Chapter 132: The Telltale Exception

Evan asks his students to look beyond the obvious signs.

Evan said to the group, “There's an old saying: ‘The tongue doesn't lie; a yellow coating indicates fire.’ In most cases, that's true. But the coating is formed by Stomach qi steaming upward. The Spleen and Stomach are like a cauldron, and Kidney qi is the fire beneath it. If that fire is weak, there's no power to steam and transform. Then the tongue findings may fail to reveal the true pathomechanism.”^[1]

Everyone frowned.

“Dr. Xu, do you mean her Life Gate fire is declining?” one of them asked. “That this is a cold pattern?”

Alex immediately perked up. Declining Life Gate fire—he knew this one.

“Don't rush. Look more carefully,” Evan said. “For now, I'm only telling you that tongue findings can often mislead you. Look at her dry, bitter mouth, her restlessness and thirst. Don't those all look like heat signs too?”

They nodded.

“But observe closely. The areas at Guanyuan and Shenque are extremely cold and hard to the touch. Check her knees: they're icy cold as well. That's evidence of cold in the lower burner.”^[2]

Everyone looked at the woman on the bed.

Leo was taken aback too. Was that so?

Even Guo looked curious and turned to look.

“Zhang Jingyue spoke of ‘the culprit hiding in the sign that stands alone,’” Evan continued. “When one or two excess signs appear amid a host of deficiency signs, those excess signs are often what matters most. When one or two deficiency signs appear amid a host of excess signs, the deficiency often reveals the underlying mechanism.

“The same applies to cold and heat. If nearly every sign points to heat, but one or two point to cold, that cold is often the key to the pathomechanism. That's what the saying means. You must be extremely careful in clinical practice. If the outward signs are unclear, what should you do?”^[3]

They hesitated.

Evan called on Alex again. “Alex. You tell me.”

“Uh…” His mind had gone blank.

Evan shook his head slightly. “Didn't I tell you yesterday? If the other three examinations don't settle it, use the pulse examination as your guide. That's why you can never take too much care over the pulse.”^[4]

The others stared at Alex in astonishment. His face went bright red.

Unbelievable. They were all supposed to be hopeless students together. He'd sneaked off for extra tutoring, then come back to show off. The nerve!

Alex tipped his head back to look at the ceiling. If he held his head high enough, nobody would see how embarrassed he was.

“The patient's pulse is fine and almost hidden,” Evan went on. “That tells us her yang qi is severely weakened. She seems to drink because a heat pattern has made her desperately thirsty, but after drinking, she brings up frothy saliva.

“Her mouth is bitter and she's restless and thirsty, yet she prefers hot water. The dry, bitter mouth and thirst make the upper burner look full of fire and heat, while the lower burner shows cold. This is a typical case of false heat above and true cold below.^[5]

“Her symptoms grew worse after you gave her Xiao Chengqi Tang. That should have told you it probably wasn't an excess-heat pattern. Otherwise, it would certainly have helped to some extent.

“The mechanism here is cold directly invading Jueyin, with cold and blood stasis binding together. Cold contracts and draws tight, causing pain. That's the cause of her five years of intestinal spasms. That's the root of the mechanism.

“But the mistaken use of a cold purgative like Xiao Chengqi Tang made her worse and caused Chong qi to surge upward. It's now become bentun qi. Look at the qi surging back and forth in her lower abdomen, below the navel. During the pain, she feels as though a lump rushes straight up into the center of her upper abdomen. Even my light pressure caused unbearable pain.”^[6]

The other young Chinese medicine doctors listened eagerly.

Leo was almost sweating. Had they really misdiagnosed and mistreated her? He couldn't help blaming Evan too. Why did the kid have to be so honest? Couldn't he see Director Guo was still here?

He cautiously checked Guo's expression. There was no anger on his face. He was watching Evan intently.

“The Chong Vessel is one of the eight extraordinary vessels,” Evan continued. “It's the sea of the twelve channels and governs their qi and blood. Disorders of the Chong Vessel often involve irregular menstruation, infertility, miscarriage, shortness of breath, abdominal colic and bentun qi.^[7]

“The Qing materia medica Depei Bencao summarizes medicines for the eight vessels. Tortoise and softshell turtle shells and zishiying are important medicines for calming the Chong Vessel, often used for the Ren and Chong Vessels. There's also wangbuliuxing, baji, xiangfu, chuanxiong, danggui and wuzhuyu. Read the book when you get back.”

Alex had nothing to say. More homework.

“Oh, right,” Evan asked him. “Have you finished copying out the Qianjin Yaofang and the Suwen?”^[8]

Alex nearly cried. It had only been one night. How much could he possibly have copied?

The others looked at him with disdain. The idiot had even been made to copy books as punishment. And he still had the nerve to show off!

Evan gave another slight shake of his head. “The treatment should warm and nourish the innate true fire of the Life Gate, supplement fire so it can generate earth, nurture the Chong Vessel, guide fire back to its origin and subdue bentun. We can use Wen Shi Bentun Tang.

“It's a formula left by Wen Biquan, the renowned Shanxi physician. It was developed through modifications involving dried ginger from Renshen Sini Tang, baizhu from Guifu Lizhong Tang, and prepared rehmannia, danpi and shanyurou from Guifu Bawei Wan, with chenxiang, sharen and niuxi added.

“It's a remarkable formula, purely yang in nature, strengthening fire to rescue those in desperate straits. Its warming action moves freely through all twelve channels, through exterior and interior alike. It can clear cold accumulations in the five zang organs, expel congealed cold from the six fu organs, remove cold impediment in the bones and vessels, break up deep, stubborn cold, and disperse cold and move qi to treat all kinds of pain.

“It treats cold patterns of the three yin systems—the Liver, Spleen and Kidney—as well as bentun qi, cold-type huoluan, epigastric and abdominal colic, and qi surging upward in counterflow. The key to using it is counterflow qi attacking upward: the surging movement captured by bentun. Study this formula carefully. Once you've learned it, you'll find endless ways to use it.”^[9]

Dr. Li had held this formula in particularly high regard during his lifetime and had often used it to treat patients. Wen Biquan had taught him by correspondence and had been his first teacher in medicine.

A provenance note: the author's published chapter was copied here without permission; reading it at the source supports the creator.

Evan began writing the prescription.

“Use a low-dose Wen Shi Bentun Tang. Add 30 g of danggui and 30 g of calcined zishiying to calm the Chong Vessel, and 15 g of wuzhuyu. Wuzhuyu is especially good at relieving spasms. What Western medicine calls spasm is the same as what we call cold causing contraction and tightening.”

He finished writing and handed it to Leo. “That's the complete prescription.”

Leo glanced over it, and a thought occurred to him. He handed it to Guo.

“Director, please have a look. Is there anything wrong with the prescription?”

Guo took it and read it with a frown. “Why are your doses so small this time? Only 10 g of fuzi, well within the pharmacopoeia's limits. Is that because I'm here?”

Evan looked puzzled. “Her underlying problem is weak fire. That amount of fuzi is enough to kindle it and dispel cold in the lower burner. For warming and nourishing in a mild case, 10 g is enough. In serious illness with declining yang, I use 15 to 30 g. Only in a critical case, with icy-cold limbs and yang on the verge of collapse, would I use more. Who starts out with such large amounts?”^[10]

This time it was Guo who was taken aback.

Evan gave him a curious look. This official from the health authorities didn't seem to understand Chinese medicine very well.

“Dr. Cao, have the prescription filled right away,” he said. “I'll come back and check on her after she's taken one batch of the decoction.”

“Ah…” Leo answered. He had more sense than that. He knew to ask the official first.

“Director Guo, what do you think?”

Guo looked at the prescription, then at his wife, who lay on the bed looking much more comfortable. He frowned, considered briefly, and said, “Go ahead with this prescription.”

Leo took it back and hurried to have the pharmacy dispense and decoct the herbs.

“Dr. Cao, didn't you say there was another patient?” Evan asked.

“Uh…” Leo glanced at Guo. “Yes, yes. Director Guo, shall I take Dr. Xu over to have a look?”

Guo nodded slightly. “Go ahead. Get on with your work.”

“All right. Goodbye, Director Guo. We'll be off.”

“All right.” Guo gave Evan a long look.

The group left the room.

They hadn't gone far when Leo's startled voice rang out in the corridor.

“Where's the patient?”

“What? Heart failure and respiratory failure? They've been taken for emergency treatment?”

Hearing this from inside the room, Guo frowned and went out too.

Reader Notes

Reader Notes

1. ↩︎ The fire beneath the cauldron. Stomach qi and Life Gate fire belong to the traditional account of bodily function. The cauldron image links the Spleen and Stomach's processing of food and fluids with the Kidney system's warming support. Here, the Life Gate, or mingmen, is a functional concept, rather than an instruction to treat the acupuncture point of the same name. Evan uses the analogy to explain why a tongue sign might conflict with other findings; it does not describe literal fire or steam inside the body. Source: WHO — International standard terminologies, entries 156, 179–180 and 188.
2. ↩︎ Abdominal points and the lower burner. Guanyuan is an acupuncture point below the navel; Shenque is at the navel itself. Evan is describing the feel of those areas, rather than inserting needles there. The lower burner is one of the three functional divisions called sanjiao. In this framework it covers the region below the navel and its associated functions. “Cold in the lower burner” is a traditional interpretation of the findings, rather than a measured core temperature. Sources: Zhenjiu Dacheng — Guanyuan, primary-text transcription (in Chinese); Shandong University of Traditional Chinese Medicine — Shenque (in Chinese); WHO — Entries 207–210.
3. ↩︎ The sign that stands apart. The saying directs attention to a finding that differs from the overall picture. In his Jingyue Quanshu, the Ming physician Zhang Jingyue discusses an exceptional pulse location, quality or organ-associated pattern that may disclose the underlying problem. The text uses the image of a hidden culprit where something is amiss. Evan applies that reasoning to deficiency and excess, then cold and heat. These are traditional diagnostic categories: deficiency and excess concern insufficiency or overabundance, while cold and heat describe a different dimension of the pattern. Source: Jingyue Quanshu, volume 5 — “Discussion of the Exceptional,” primary-text transcription (in Chinese).
4. ↩︎ The other three examinations. The four traditional methods are inspection, listening and smelling, inquiry, and palpation. Pulse examination belongs to palpation. Evan's “other three” refers to the remaining categories, rather than three additional pulse positions. His advice about which finding to rely on in this difficult case remains part of his teaching; the broader framework combines information from the different methods. Source: Hong Kong Polytechnic University — Four Diagnostic Methods.
5. ↩︎ False heat and true cold. In this traditional distinction, heat-like appearances can mask what the physician judges to be an underlying cold pattern. “False” describes the interpretation of the signs; it does not mean that the patient's discomfort is imaginary. The fine pulse has a thin, threadlike feel, while a hidden pulse is difficult to reach without deep pressure. Evan combines these qualities with the preference for hot drinks and the cold lower body. His conclusion is a case-specific interpretation, rather than a laboratory confirmation. Source: WHO — Entries 408–411, 896, 912 and 2271.
6. ↩︎ Jueyin, cold and bentun qi. Jueyin is a name within traditional channel and six-division theory; it is not an anatomical organ or a synonym for yin deficiency. Evan attributes the pain to cold, contraction and blood stasis within that framework. Bentun, conventionally translated “running piglet,” names a sensation of qi rushing upward from the lower abdomen, using the animal's sudden rush as an image. It does not mean a pig or a confirmed physical mass is moving inside the patient. Evan's comparison with intestinal spasm is his explanation of this case. Source: WHO — Entries 26, 299–300 and 2170.
7. ↩︎ The Chong Vessel. The extraordinary vessels form a traditional functional network alongside the twelve main channels. “Sea” is an image for gathering and regulating; it does not identify an extra anatomical blood vessel. Chong and Ren are closely associated with reproductive functions, but Evan also connects Chong counterflow with abdominal symptoms here. The list of possible disorders is general teaching, rather than a claim that this patient has every condition listed. “Calming” the Chong Vessel describes the treatment's intended control of that counterflow. Source: WHO — Chong meridian pattern, entry 1376, and extraordinary meridian terminology.
8. ↩︎ Medical books as homework. The Depei Bencao is a Qing materia medica: a work about medicinal substances, their properties and combinations. The Qianjin Yaofang, or Essential Prescriptions Worth a Thousand Gold, is a medical compendium associated with Sun Simiao. The Suwen, or Basic Questions, is part of the Yellow Emperor's Inner Canon. Alex's copying assignment concerns these substantial medical texts; the joke is the amount of work he has been given, followed by its public exposure. Sources: Depei Bencao — Preface and editorial principles, primary-text transcription (in Chinese); Qianjin Yaofang — Primary-text transcription (in Chinese); Suwen — Primary-text transcription (in Chinese).
9. ↩︎ Wen's formula and its warming strategy.Wen Shi Bentun Tang names Wen Biquan's formulation; it differs from the classical formula also called Bentun Tang. Tang identifies a decoction formula. Supplementing fire to generate earth links warming support with the Spleen's transforming function; guiding fire to its origin describes restraining upward-floating yang. The Liver, Spleen and Kidney here are traditional yin systems. Cold-type huoluan is a historical pattern label associated with acute vomiting, diarrhea and abdominal distress, rather than a diagnosis of bacteriologically confirmed cholera in this patient. Sources: Wen Shi Bentun Tang — Reproduced primary clinical account (in Chinese); WHO — Entries 2587 and 2598.
10. ↩︎ Medicines, processing and quantities. The pinyin words identify medicinal substances; they are not instructions to substitute similarly named foods or plants. Fuzi refers to the processed lateral root of aconite, distinct from the mother root called chuanwu. Processing and decoction matter to its toxicity. Calcined records the specified processing of zishiying. The gram quantities and severity-based distinctions remain Evan's prescription and explanation. Guo's reference to the pharmacopoeia does not identify an edition, and the passage does not supply a complete preparation regimen. Source: Hong Kong Department of Health — Aconite roots, processing and toxicity (in Chinese).