Evan checks Lily’s pulse again, taking his time.
The last thing a doctor needed during a pulse examination was a patient chatting. It was far too easy to break the doctor's concentration.
“Don't talk just yet,” Evan Xu told Lily Li. “Keep calm and let me finish checking your pulse.”
Lily paused. Was this handsome young doctor really that serious?
Evan had been a little dazed when he first returned to the present. Now that he had a patient to examine, he was completely absorbed in his work.
At Lily's cunkou, the pulse site at her wrist, he used five techniques: lifting, pressing, searching, pushing, and tracing. Lifting, pressing, and searching were used to examine floating, deep, and relaxed pulses; pushing was for the hollow pulse, and tracing for long and short pulses. There were more than twenty other pulse qualities, but these were the five basic techniques.[1]
Lily watched his serious, melancholy face while he kept varying the pressure of his fingers on her wrist. She felt a flutter of attraction and let out a little chuckle now and then.
Evan frowned deeply and released her hand. “Come on. Go lie down on the bed.”
“Huh? Isn't that a bit fast?” Lily blurted out.
“I mean—” She hastily corrected herself. “Why do I need to lie down?”
“Your qi and blood flow more smoothly when you're lying down, and the pulse is clearer.”
“All right.” She could only agree.
They went into the treatment room. Lily lay on her back on the examination bed, her arm extended naturally, her wrist resting on a soft pulse cushion. Evan sat beside her and carefully examined her pulse.
Ben Song looked up at Evan with curiosity, then went back to Dou Dizhu. He didn't follow them in to watch.
Chinese medicine took pulse examination very seriously. The Suwen chapter “The Subtle Essentials of Pulse Diagnosis” said:
“Examination is ordinarily performed at daybreak, before yin qi has stirred and yang qi has dispersed, before food or drink has been taken, before the channels have become full, while the connecting vessels are evenly regulated and qi and blood remain undisturbed. Only then can an abnormal pulse be examined.”[2]
In the old days, patients were supposed to have their pulses examined first thing in the morning, without even eating breakfast—rather like fasting before a blood test for liver function today. That naturally gave the most precise reading. The requirement was impractical, though, and in time people stopped observing it.
There were requirements for the duration too. The Lingshu chapter “Roots and Knots” said:
“In one day and one night there are fifty circuits, with the circuits regarded as the essence of the five zang. Those who do not correspond to this number are called kuangsheng.”
So each pulse position had to be observed for at least fifty beats. There were three positions at each wrist—cun, guan, and chi—making six across both hands. Add the time spent pressing with all three fingers together at the start, and even a skilled older doctor needed at least five minutes.[3]
A less skilled practitioner needed ten minutes or more, checking repeatedly to reach an accurate conclusion.
If a doctor spent less than five minutes on both hands combined, forget it. He certainly didn't know how to examine a pulse; he was only going through the motions. Or he was overconfident, taking a rough reading at each wrist without carefully examining the individual cun, guan, and chi positions.
And those martial-arts dramas—and even some historical dramas—with doctors reading a pulse through a suspended thread? They were making a damn mockery of Chinese medicine. What a load of crap.
Without that year studying under Dr. Qian, Evan wouldn't have known how to examine a pulse either.
Ten minutes later, he finished examining both wrists and breathed out at length. He had his findings: a deep, thready pulse. A deep pulse indicated an interior pattern; a thready pulse indicated dampness, and also deficiency![4]
A thready pulse was fine and small, like an unbroken silk thread. Under the fingers it felt thin, straight, and soft. A faint pulse, on the other hand, was extremely fine and lacked force, almost imperceptible, as if about to fade away. One remained continuously perceptible; the other seemed barely there.
It was easy to confuse them.
A wiry pulse could also resemble a thready one. But a wiry pulse felt like pressing a bowstring, whereas a thready pulse felt like a silk thread. Differences that small really tested a doctor's skill.
There were twenty-eight pulse qualities, each with three or four others that closely resembled it. How could anyone distinguish them in a hurry?
Evan had checked again and again before deciding that this was a deep, thready pulse.
A thready pulse indicated dampness or deficiency. But Lily's condition was cold congealing with blood stasis. Cold congealing was clearly an excess pattern, so how could this be deficiency? And a thready pulse could mean dampness. Dampness?
Had his earlier judgment been wrong?
Evan sank into thought.
Lily got up from the bed. “Dr. Xu, how is it?”
Menstrual pain could arise from either an excess or a deficiency pattern. Pain before or during menstruation was usually an excess pattern: obstruction caused pain, so excess had to be drained. If pain continued after the period ended, it was usually a deficiency pattern: lack of nourishment caused pain, so deficiency had to be supplemented.[5]
Evan thought for a moment. “Do you still have pain after your period starts?”
“Sometimes it hurts before it starts. Sometimes it still hurts once it's started.”
He nodded slightly.
“Stick out your tongue and let me have a look.”
Lily did so.
Dr. Qian placed great importance on tongue inspection. During that year under his guidance, Evan's skill in it had improved rapidly too.
Yesterday, he had only noticed a pale-red tongue and a thin white coating—findings that could have belonged to a healthy person. Looking today, though, he saw something wrong. The tongue itself was enlarged. He had missed that before.[6]
An enlarged tongue with a thin white coating pointed to Spleen deficiency, with water, dampness, and phlegm-fluid retention.
“Lift your tongue up.”
Lily obediently did that too.
“The veins under the tongue are dilated and tortuous! That's usually a sign of blood stasis.”
“I understand now.” It suddenly became clear to him.
A thready pulse could indicate both deficiency and dampness. The Spleen governed transportation and transformation; if it was deficient, those functions suffered and dampness naturally followed. Her tongue findings confirmed it. The diagnosis wasn't cold congealing with blood stasis, but Spleen deficiency with cold in the womb. Deficient qi led to stagnation, which in turn led to blood stasis.[7]
Yes, she had a cold pattern. Her lower abdomen felt distended and painful, and the pain had a cold quality that eased with warmth: pathogenic cold had lodged in the lower burner. But cold wasn't the most important part. Her Spleen deficiency was.[8]
The Spleen was the source from which qi and blood were produced. Spleen deficiency meant weakness of qi and blood. If the source stopped producing them, how could they be plentiful?
Water and dampness also encumbered the Spleen, which explained her fatigue and reluctance to talk. Her qi and blood were already weak; during menstruation she lost a great deal of both, leaving the womb without nourishment. That made the pain from lack of nourishment worse, so she also hurt after her period ended.
Spleen deficiency also meant qi deficiency. Qi was the commander of blood: it governed the healthy movement of blood through the body. Yes, she had cold, and cold made blood congeal. But it was deficient qi that left it stagnant.
That was why so many women could take cold showers and eat raw or cold foods without having menstrual pain. Their qi and blood were plentiful. Even if cold made the blood congeal, qi still governed its movement; blood stasis would not linger in the channels.
When healthy qi remained within, pathogenic factors could not invade![9]
Spleen deficiency also caused disharmony between the Spleen and Stomach. The Stomach lost its harmonious downward movement, so Stomach qi rose instead. That explained her dry heaving.[10]
The Spleen raised the clear, and the Stomach lowered the turbid. One rose and the other descended in an orderly balance. Now Spleen deficiency had caused Stomach qi to rise, making her feel like vomiting. Turbid qi failed to descend and stagnated in the middle, producing fullness in the upper abdomen and constipation.
That was why her stools were dry and she only had a bowel movement every two or three days.
All of it came from Spleen deficiency.
Her pattern was therefore interior, deficient, and cold. Unmistakably a yin pattern.[11]
Chinese medicine used pattern differentiation by the eight principles, with yin and yang as the overarching categories. Interior, deficiency, and cold belonged to yin; exterior, excess, and heat belonged to yang. A skilled diagnostician observed the complexion, palpated the pulse, and first distinguished yin from yang.
Use yang medicines for yin illness and yin medicines for yang illness, and you wouldn't go far wrong.
That was why a doctor of Chinese medicine had to know how to differentiate patterns. Without pulse examination and tongue inspection, inquiry alone would have made it hard for Evan to identify the Spleen deficiency accurately, and then hard to cure the condition at its root.
Unauthorized duplication: this tale has been taken without consent. Report sightings.
It also explained why so many people saw a doctor of Chinese medicine and found the treatment ineffective. Chinese medicine wasn't the problem. The doctor they had seen couldn't differentiate patterns. He didn't know how to treat illness!
Evan tapped his head in frustration. He really had got the pattern wrong yesterday, taking it for cold congealing, an excess cold pattern. Still, Shaofu Zhuyu Tang was appropriate for that part. It warmed the channels and dispelled blood stasis; taking it would help her.
But it couldn't address her nausea, urge to vomit, constipation, fatigue, reluctance to talk, or bloating—the signs of Spleen deficiency. Cold congealing with blood stasis was only the branch. Spleen deficiency was the root.[12]
Treating the cold congealing and blood stasis meant treating only the branch. Unless the Spleen deficiency was addressed, the next exposure to cold would leave blood stagnant in the lower burner again.
The symptoms would return. If he had given her only Shaofu Zhuyu Tang yesterday, it would merely have relieved her menstrual pain; next month she might very well have been back where she started. Treatment could go on and on without a cure, with poor results.
A doctor who left the Spleen deficiency at the root untreated could hardly be called a good physician.
That was the difference between having a mentor and having none. Left to himself, Evan really would have been lost in clinical practice.
He breathed out. “Yesterday's medicine didn't fit your pattern. Let me prescribe something else. Oh, don't drink the Siwu Tang I prescribed yesterday yet. Finish the new medicine first, then drink it.”
He reproached himself inwardly too. He had got the pattern wrong yesterday. Siwu Tang contained chuanxiong, a qi-moving herb. You couldn't keep moving qi when it was deficient; moving it indiscriminately would only deplete it further. First supplement qi, then move it—or move it while supplementing it![13]
“All right,” Lily agreed, though she was thinking about what to eat for dinner.
Ben was a little surprised to see Evan about to write another prescription. Was this guy going to prescribe Siwu Tang again?
Evan put both hands on the keyboard. His expression grew tense again as those cold, mocking looks returned to assail him.
“Heh…” He shook his head with a little laugh, and the images vanished at once.
Evan shook his head and typed. “I'll give you a different prescription: Shaofu Zhuyu Tang combined with Liujunzi Tang, with modifications. Because of the qi stagnation and constraint, and the water and dampness encumbering the Spleen, I'll leave out the baizhu and gancao from Liujunzi Tang. For the constipation, I'll add dahuang, scorch-roasted areca seed—jiao binglang—and Xiaopi San. The hot-natured herbs in the formula balance these bitter, cold-natured medicines, so you don't need to worry about them damaging your yang qi.”[14]
Before, Evan had only been able to recite the classics. He hadn't known how to combine medicines according to a patient's actual condition. Now that had changed.
Lily looked a little crestfallen. “How long will I have to take it this time before it works?”
Evan gave her a small, confident smile. “When the medicine fits the pattern, even a stubborn illness should yield at once—as promptly as a drum sounds when struck.”
Translator's Notes
Reader Notes
↩︎ Feeling the pulse. Cunkou is the radial pulse region near the wrist, examined at the adjacent cun, guan, and chi positions. Lifting, pressing, and searching involve changes in finger pressure and contact. “Tracing” provisionally renders the novel's jing, associated here with assessing length; historical discussions also describe movements along the pulse. The text's association of the first three techniques with floating, deep, and relaxed pulses is retained. Relaxed, or huan, is a named pulse quality; it is not the name for an intermediate pressure level. Sources: WHO — Chinese medicine terminology, entries 856–860, printed p. 84; Jiangxi University of Chinese Medicine — Historical pulse techniques, section 2 (in Chinese).
↩︎ The classical setting for examination. The Suwen, or Basic Questions, is one of the received texts of the Huangdi Neijing, the Yellow Emperor's medical classic. Its chapter Mai Yao Jing Wei Lun describes daybreak as a time before eating and ordinary activity disturb the state being examined. Yin qi, yang qi, channels, and connecting vessels belong to that traditional account of bodily function. The quotation is translated from the Chinese wording in this novel. The narrator's comparison with a modern liver-function test does not establish preparation requirements for all such tests. Source: Chinese Text Project — Leijing, volume 5, commentary on Suwen chapter 17 (in Chinese).
↩︎ Circuits and counted beats. The Lingshu is the other principal received text of the Huangdi Neijing. Its Gen Jie chapter discusses fifty daily circuits in traditional physiology, then counting pulse arrivals to observe interruptions. The novel's wording about the five zang is retained; the linked text has a small wording variation. Kuangsheng remains transliterated. WHO's “fifty beats” entry concerns observing intermittent pulses. Counting fifty at every wrist position and rejecting all examinations under five minutes are the narrator's conclusions. A later national standard gives a different duration: at least one minute per hand, with three minutes for both preferred. Sources: Chinese Text Project — Lingshu, Gen Jie (in Chinese); WHO — Terminology, entry 865, printed p. 85; GB/T 40665.4–2021 — Pulse palpation, section 4.3.3, printed p. 3 (in Chinese).
↩︎ Depth and texture. A deep pulse is most perceptible with firm pressure. A thready pulse feels fine and soft but can still be followed under the fingers. Depth and texture are separate dimensions, so “deep, thready” describes a combination. The traditional meanings of interior, dampness, and deficiency guide Evan's reasoning here. They are pattern categories, rather than measurements of blood pressure or confirmation of a modern disease. The following comparisons retain the novel's distinction between a continuously perceptible thready pulse and an almost imperceptible faint pulse. Source: WHO — Terminology, entries 890, 895–896, and 904, printed pp. 89–91.
↩︎ Obstruction and insufficient nourishment. As in the earlier case discussions, excess and deficiency describe traditional patterns. Obstruction can involve cold, stagnant qi, or blood stasis; deficiency concerns insufficient support from qi, blood, or other functions. “Drain” and “supplement” name contrasting treatment principles, not simply losing or replacing fluid. The narrator uses the timing of pain to distinguish these mechanisms, while Evan also checks the pulse and tongue. Lily's answer says pain may continue after menstruation starts; it does not explicitly specify when bleeding ends. Source: WHO — Terminology, entries 994–995, printed p. 104, and 1980, printed p. 279.
↩︎ Tongue body and coating. Tongue inspection considers the body of the tongue separately from its surface coating. Pale-red describes the body; thin and white describe the coating. An enlarged tongue is another observation, so the earlier record of color and coating could miss it. This passage says Evan failed to notice enlargement yesterday. It does not say that the tongue grew overnight. The clinical interpretation belongs to the story's traditional diagnostic framework. Source: WHO — Terminology, entries 634–636 and 655, printed pp. 59–61.
↩︎ Spleen deficiency, dampness, and stasis. The capitalized Spleen denotes the traditional functional system involved in transforming food and distributing nourishment and fluids. Impaired function can be described as dampness or phlegm-fluid retention; these terms need not mean environmental humidity or coughed-up mucus. Qi deficiency and qi stagnation are distinct, but the theory also describes blood stasis when insufficient qi fails to move blood. Blood stasis is not synonymous with a diagnosed clot. Evan brings those ideas together with his pulse and tongue findings to revise his diagnosis; the terminology source defines the ideas rather than verifying his conclusion. Source: WHO — Terminology, entries 116, 440–441, 1195, and 1736, printed pp. 11, 38, 140, and 240.
↩︎ The lower burner and the womb. The three burners, or jiao, divide bodily functions and regions into upper, middle, and lower groupings. The lower burner refers broadly to the region below the navel. Here the term locates Evan's discussion of lower abdominal pain and the womb; it does not refer to a literal heater. “Cold in the womb” is a traditional pattern description associated in this passage with cold-type pain relieved by warmth. It does not report a measured uterine temperature or a newly performed test. Source: WHO — Terminology, entries 207–210, printed p. 18.
↩︎ Healthy qi and pathogenic factors. Zheng qi, translated as healthy qi, gathers the body's normal functions and its capacity to adapt, resist illness, and recover. Xie qi names pathogenic influences within the traditional theory; xie does not mean a demon or moral evil. The saying contrasts the body's resources with those influences. It should not be read as equating qi with a single immune measurement. The preceding explanation of cold foods, cold showers, and menstrual pain is the narrator's application of that theory, rather than a result established by this terminology reference. Source: WHO — Terminology, entries 274 and 365, printed pp. 23 and 31.
↩︎ Ascending and descending. The Spleen's “raising the clear” concerns distributing useful nourishment; the Stomach's “lowering the turbid” concerns moving digested material onward. These are paired functions in traditional physiology. Stomach qi moving upward instead is counterflow, associated with nausea, vomiting, hiccups, or belching. Earlier chapters linked disrupted descent to the Liver; here Evan links it to Spleen deficiency. The change in the proposed cause matters to his reasoning. Clear and turbid are functional descriptions, not judgments about a patient's cleanliness. Source: WHO — Terminology, entries 118, 193–194, and 1214, printed pp. 11, 17, and 144.
↩︎ The eight principles. This framework groups observations through four pairs: yin and yang, exterior and interior, cold and heat, deficiency and excess. Yin and yang serve as the broad categories; interior, cold, and deficiency are conventionally associated with yin. The terms classify a pattern, rather than naming eight separate diseases. Evan's combination of findings leads him to the yin category here. The subsequent statement about using opposite-natured medicines is the narrator's simplified treatment maxim, not a complete prescription rule. Source: WHO — Terminology, entries 931 and 989–997, printed pp. 93 and 103–104.
↩︎ Root and branch. In Chinese, ben is the underlying problem and biao its manifestations. The translation uses the plant metaphor “root and branch”; some terminology standards render biao as “tip.” Their relationship shapes treatment priorities: addressing a manifestation can relieve it while leaving the proposed cause unresolved. Here Evan considers blood stasis the branch and Spleen deficiency the root. His discussion of relief followed by recurrence is a prediction. The chapter has not shown Lily taking the new prescription or reported its effect. Source: WHO — Terminology, entries 2252–2254, printed p. 325.
↩︎ Supplementing and moving qi. Supplementing, or tonifying, aims to support a deficient function; moving qi aims to address stagnation. They describe different actions, even when used together. Evan is reconsidering which action should come first in this patient's pattern. Chuanxiong is a medicinal rhizome, retained here by its Chinese name. His judgment about its place in Siwu Tang and the timing of Lily's medicines belongs to his clinical reasoning in the novel. The sources identify terminology and material, rather than establish a universal prohibition or verify this prescription. Sources: WHO — Terminology, entries 2722 and 2874, printed pp. 376 and 394; National Research Institute of Chinese Medicine — Herbal catalogue, NHP-01068 (in Chinese).
↩︎ Two formulas with modifications. Shaofu Zhuyu Tang and Liujunzi Tang retain their separate names; tang traditionally denotes a decoction. Here Evan combines and modifies them. Baizhu is white atractylodes rhizome, gancao is licorice root, and dahuang is medicinal rhubarb root and rhizome. Jiao binglang names a scorch-roasted preparation of areca seed. Xiaopi San is retained by name because the passage does not identify a specific version or its ingredients. Hot and cold describe traditional medicinal properties. Evan's assurance about balancing them is his statement; no treatment result follows it here. Sources: WHO — Terminology, entries 2746 and 2777, printed pp. 379 and 382; NRICM — Herbal catalogue, NHP-00127, NHP-00099, and NHP-00030 (in Chinese); Hong Kong Baptist University — Binglang, B00158; Guangdong Drug Administration — Binglang, processed forms (in Chinese).