Chapter 105 Removing the Firewood

The doctors have heard Evan’s diagnosis. Now they want to know how he reached it.

One case was enough to show the differences in skill among the doctors in the room.

The younger doctors had been given the answer, yet still couldn't understand the reasoning.

Dr. Zhong had some idea, but wasn't sure.

Professor He had worked it out as soon as he read the earlier prescription.

The gap between them was plain.

What he couldn't understand was how Evan had reached the same conclusion without seeing the previous doctor's prescription. Had he guessed?

The young doctors looked at one another, murmuring, “Retained food can cause a cough?”

“The patient ate too much, which led to food retention,” Evan replied. “The food remained in the Large Intestine and couldn't be passed. Excess heat accumulated there, producing a bowel excess pattern. Coughing may not be listed under yangming bowel excess, but you can't treat a textbook as the whole story! In Chinese medicine, you have to differentiate the pattern by considering the whole body. Have you forgotten that the Lung and Large Intestine form an exterior–interior pair?”^[1]

The young doctors were taken aback.

“The Lung governs the descending movement of qi,” Evan continued. “If excess heat in the bowel transfers to the Lung, it interferes with that function. Naturally, coughing follows. In clinical practice, we also find that this kind of cough tends to be more violent than an ordinary one.”

The young doctors exchanged glances.

Evan continued explaining. “This is why some children who have retained food and have been constipated for several days develop fever, coughing, and inflammation of the respiratory tract. Simply clearing heat from the upper burner isn't enough.

“Even conventional medicines, such as anti-inflammatory drugs, often don't work well. The reason is simple: the excess heat in the Large Intestine is still there. It's like a fire beneath a cauldron. With a fire burning so fiercely underneath, of course it's hot above.

“You can keep cooling the top, but that won't bring the heat down. You have to put out the fire underneath. That's the root of the problem. In Chinese medicine, we call it removing the firewood from beneath the cauldron.”^[2]

At last, everyone understood.

Dr. Zhong still had a question. “But Dr. Xu, how could you tell straightaway that this was yangming bowel excess? Phlegm-heat obstructing the Lung was entirely possible too. All the patient's symptoms fit.”

The others nodded. That was what had been puzzling them as well.

Professor He also looked at Evan. He hadn't worked out how Evan had identified it so directly either.

The “Treatise on Cough” in the Suwen stated: “All five zang and six fu can cause coughing, not only the Lung.”^[3]

Coughs were difficult to treat. Any of those organ systems could be involved, and both internal causes and external pathogens could bring one on. If the underlying mechanism was missed, a cough could persist through treatment after treatment.

This was where a doctor's skill mattered. The pulse had been slippery and rapid. Several patterns could produce that combination, including phlegm-heat and food retention.

The patient also had a cough with phlegm, a flushed face of the kind often seen with phlegm-heat obstruction, and tongue findings that indicated heat. All the evidence pointed toward phlegm-heat obstructing the Lung and causing the cough.

Many doctors would therefore go straight to a formula to relieve coughing, transform phlegm, and clear heat. It wouldn't work.

Only when the patient returned might the doctor think of food retention and change the prescription.

But often, if the first treatment didn't work, the patient never came back. The doctor might assume the patient had recovered. How could he improve that way?

An experienced doctor would be more cautious. On finding a slippery, rapid pulse, he would certainly ask about both phlegm and food retention.

But suppose the questioning did turn up food retention.

Here, another group of doctors would fall short. Was retained food causing the cough, or was it phlegm-heat obstructing the Lung? Which should the prescription focus on? Anyone who still couldn't decide would have to try a treatment and see.

A more skilled doctor would look for further evidence.

“Didn't you hear the family say the boy starts coughing once he goes to sleep?” Evan asked. “Why doesn't he cough during the day? Why only when he's sleeping at night?”

Everyone paused.

“If phlegm-heat were obstructing the Lung, why wouldn't he cough during the day?” Evan went on. “Besides, the phlegm brought up in that pattern is usually yellow. Were you listening carefully? What he's spitting out is white saliva. He hasn't brought up any phlegm at all.

“And according to the daily rhythms of the twelve channels, coughing caused by yangming bowel excess generally occurs at night. It becomes particularly severe in the early hours.”^[4]

“Yes, yes, exactly!” the grandmother said quickly. “It's worst in the second half of the night. He keeps all of us awake.”

Now everyone understood completely.

Only Professor He was still frowning. He understood the case. He had worked it out after reading the prescription: medicines to restore the Lung's dispersing function and relieve coughing had failed, and so had conventional drugs.

The problem probably wasn't in the upper burner.

He had based his judgment on experience and skill.

Dr. Zhong had read the same prescription, but hadn't dared draw that conclusion. He had wondered whether the medicines hadn't matched the pattern, perhaps because they hadn't placed enough emphasis on clearing heat. He remained uncertain.

What Professor He couldn't understand was that Evan hadn't read the prescription. He had already decided the cough was caused by retained food after examining the pulse.

He hadn't simply asked about food retention. He had identified yangming bowel excess and kept asking questions about that specific pattern, as though he already knew the answer.

Was it coincidence? Had he read a case like this before?

Professor He was puzzled.

Someone in the group ventured, “But the patient has been passing watery stools. Does that still count as bowel excess?”

Evan looked at this hopeless student, almost at a loss for words. “The section on stools in Wenyi Lun says, ‘In overflow diarrhea from heat-bound stool, there is excess in the Stomach system. Internal heat blocks it: first the stool is bound, then diarrhea follows—nothing but foul-smelling water, with no feces at all.’ Didn't I already tell you it was overflow diarrhea? Passing foul water without stool can still be a bowel excess pattern.”^[5]

A simple distinction: this copy was made without approval, while the chapter on the author's official page supports their work.

The doctor's expression froze.

“So what formula should we use?” Evan asked him.

The doctor thought for a moment. “Since it's caused by retained food… Baohe Wan?”^[6]

“Baohe Wan is fine for relieving food retention, or for fever caused by food retention in children,” Evan said. “But this child already has yangming bowel excess. Your prescription would take too long to work.”

Embarrassment showed on the doctor's face.

Evan looked at him. “And yangming bowel excess can occur in severe illness. It can even be life-threatening. Aren't you worried about treating it so slowly?”

During the current epidemic, for instance, many patients had shown epidemic toxin blocking the Lung and yangming bowel excess early in the illness: high fever, coughing, difficulty passing stool, labored breathing, and shortness of breath. Their conditions then changed rapidly. Within two or three days, they developed such life-threatening patterns as pathogenic heat trapped in the interior and sudden collapse of yang qi.^[7]

Once the pattern had been correctly identified, treatment had to be decisive. That was how to halt its progression and save the patient's life!

“What? It's that serious?” Evan's words frightened the grandmother.

“Your grandson won't get to that stage,” Evan replied.

She was a little reassured.

“The Jinkui Yaolue says, ‘A rapid, slippery pulse indicates excess. There is retained food; purging it brings recovery. Da Chengqi Tang is appropriate,’” Evan continued. “Don't be afraid of a strong purgative like this. If you've differentiated the pattern correctly, you can use it. The Medical Sage's guidance won't lead you astray.”^[8]

Professor He looked at him. “Write a prescription, then.”

“All right.” Evan nodded and began writing.

Da Chengqi Tang was a strong purgative. Many doctors feared its power and wouldn't use it, afraid of damaging the patient's healthy qi.

But yangming bowel excess could sometimes endanger a patient's life. At such a critical moment, only a purgative this forceful could save them.

That was why doctors often said that only someone who had truly mastered the clinical use of this decoction could be called a mature practitioner, capable of treating illness. You had to know how to use it—and dare to use it.

Evan finished writing and handed the prescription to Professor He. “Please have a look, Professor.”

The professor took it and frowned slightly as he read. Evan had added several medicinals to Da Chengqi Tang: some to clear Lung heat, and xuanshen to support the body's healthy qi.^[9]

Professor He looked at Evan in surprise and uncertainty. They hadn't seen each other for a little over half a year. Had Evan improved this much? If he had stayed at the hospital and studied clinical practice properly, the professor would have expected rapid progress. He was confident of that.

After all, he had given Evan an exceptionally solid foundation. Once Evan began clinical work, he should improve quickly. But he had been dismissed more than half a year ago and had ended up in that little clinic. Who had been teaching him?

Or had he happened to read an identical case? Evan's theoretical grounding was excellent, after all, and reading and understanding case records was part of that grounding.

Just then, several knocks sounded at the door.

Hannah pushed it open. “Professor He, Dr. Qi would like you to join him for a consultation.”

Reader Notes

Reader Notes

1. ↩︎ The Lung–Large Intestine pair. Chinese medicine pairs these two functional systems through the channel network; “exterior–interior” names that relationship, rather than placing one organ outside the body. The Lung's “descending” function concerns the downward movement of Lung qi. Evan connects the bowel pattern to coughing through this relationship. The traditional definitions explain the terms he uses; they do not independently establish that retained food caused this child's cough. Source: WHO — International standard terminologies on traditional Chinese medicine, entries 95 and 109.
2. ↩︎ Removing the firewood. The “upper burner,” or upper jiao, is a traditional functional region above the diaphragm that includes the Heart and Lung. It forms part of a three-region model, not a literal heating apparatus. Evan's cauldron image distinguishes cooling the affected upper region from removing the heat accumulation he identifies below. The expression therefore describes a treatment principle in this passage. The accompanying claim about conventional medicines remains his clinical argument. Sources: WHO — International standard terminologies on traditional Chinese medicine, entries 207–210; Hong Kong Baptist University — Da Cheng Qi Tang, pathogenesis discussion (in Chinese).
3. ↩︎ The “Treatise on Cough.” This is chapter 38 of the Suwen, the Basic Questions portion of the Huangdi Neijing. Its opening extends the discussion of cough beyond the Lung to the five zang and six fu functional systems. The sentence is translated here from the Chinese quoted in the novel. It recalls the framework introduced in the previous chapter, rather than supplying a modern diagnosis. Source: Suwen — “Treatise on Cough,” Chinese transcription.
4. ↩︎ The twelve channels and time of day. Traditional channel theory includes daily changes in the activity of qi, associated with twelve two-hour periods. This provides the background for Evan's reference to a daily rhythm. He does not name an exact hour or a particular channel here, so none is supplied in the translation. The more specific inference—that the timing distinguishes this child's bowel-related cough—is his reasoning in the scene, rather than a diagnostic rule established by the background source. Source: Hong Kong Baptist University — The twelve-period daily health cycle (in Chinese).
5. ↩︎ Wenyi Lun and overflow diarrhea. Wu Youxing's Wenyi Lun, or Treatise on Epidemic Diseases, discusses this presentation in its section on stools. In the quoted traditional account, watery discharge follows an initial binding of stool; watery output therefore need not exclude internal accumulation. The term continues the explanation given in the previous chapter. The quotation describes the classical pattern, and does not add a newly established period of constipation to this boy's reported history. Source: Wenyi Lun — Upper volume, “Stools,” Chinese transcription.
6. ↩︎ Baohe Wan. This is a named compound formula traditionally used to promote digestion and address food accumulation; wan identifies a pill preparation. The database also discusses preparing the formula as a decoction, but the novel specifies no preparation or dose here. The young doctor's suggestion begins a discussion about the distinction between food retention and the more severe bowel pattern Evan has identified. Evan's assessment of how quickly it would work belongs to that discussion. Source: Hong Kong Baptist University — Bao He Wan, classification, action, and pathogenesis.
7. ↩︎ Pattern progression and collapse. “Epidemic toxin,” internal trapping of pathogenic heat, and collapse of yang qi belong to traditional descriptions of disease and its progression. Collapse here means a critical loss of bodily function within that theoretical vocabulary, not a person simply falling over. The narrator's reference to the “current epidemic” names no pathogen, location, or year in this passage. Its two- or three-day course is retained as narrated; the terminology source does not verify that account or identify the outbreak. Source: WHO — International standard terminologies on traditional Chinese medicine, entries 414 and 1049.
8. ↩︎ Jinkui Yaolue and Da Chengqi Tang. The Essentials from the Golden Cabinet is associated with Zhang Zhongjing, the physician honored as the “Medical Sage.” The quoted passage appears in its chapter on abdominal fullness, cold hernia, and retained food. Da Chengqi Tang is a decoction traditionally classified as a forceful purgative for heat-bound accumulation. “Healthy qi” refers broadly to normal bodily functions and the capacity to resist illness and recover. The scene retains both the concern about damaging it and Evan's confidence in using the formula when the pattern fits. Sources: Jinkui Yaolue Fanglun — Chapter 10, Chinese transcription; Beijing University of Chinese Medicine Museum — Zhang Zhongjing, the Medical Sage (in Chinese); Hong Kong Baptist University — Da Cheng Qi Tang (in Chinese); WHO — International standard terminologies on traditional Chinese medicine, entry 365.
9. ↩︎ Xuanshen. This medicinal is figwort root, distinct from ginseng despite the shared syllable shen in their Chinese names. The university's specimen database lists it among heat-clearing medicinals. In this passage, “support the body's healthy qi” preserves the novel's description of its role in Evan's modified formula. It does not rename the material or specify an additional dose. The other added medicinals are not named in the source, and remain unnamed here. Source: Hong Kong Baptist University — Xuan Shen / Figwort Root, specimen D00316.