Chapter 76 No Clear Pattern

A stubborn cough offers Evan few clues, while the visiting doctors wait for an answer.

Leo lowered his voice. “Henry, what's wrong with the patient?”

“How would I know?” Henry replied evenly.

“Come on. You're keeping it from me too? Earlier, I could understand—you were afraid I'd tip him off. But Dr. Xu's already examining him. You still won't tell me?”

Henry glanced at him. “I really don't know.”

“What?” Leo was startled. “Even you don't know?”

Henry's brow was deeply furrowed. He spoke quietly. “I can't be sure.”

“Damn, Henry. You're setting him up! You don't know what's wrong, and you still sent him to Dr. Xu? How can you put him on the spot like this? He's barely out of medical school!”

“He's been throwing his weight around, hasn't he? He dressed Simon Liu down more than once. Think I didn't hear about it? He gives one of my people an earful, then talks him into leaving. Does he think I'll just take it?”

Henry's tone remained level, but the anger in his words was plain.

Leo didn't know what to say. He knew some people at their hospital had a problem with Evan. He hadn't realized Henry was this angry.

“I was wondering when I'd get a chance,” Henry went on. “Then along comes a difficult case, asking for the young man by name. How could I not come and have a look?”

Leo had no answer.

His heart sank. This could end with Evan making a complete fool of himself.

Evan had certainly been impressive on those earlier occasions. Even the city specialist, Dr. Raymond Liu, hadn't been able to get the better of him. But there had been special circumstances each time.

Raymond had been careless. He had identified the wrong pattern, misdiagnosed the patient, and prescribed the wrong formula. Evan had made the right diagnosis because he was more attentive. That didn't necessarily make him the better doctor.^[1]

And yes, Evan had cured those patients at the Chinese medicine hospital. But they, too, had all been misdiagnosed. He had been more cautious and thorough than the others.

Leo didn't doubt his medical skills. Still, Evan was young. He might not even be Raymond's equal, let alone Henry's—the best Chinese medicine doctor in their hospital.

And even Henry couldn't be sure what was wrong with this patient.

A genuinely difficult case!

This was it. Evan was going to embarrass himself.

Doctors failed to cure illnesses all the time. There were plenty that medicine still couldn't cure, and plenty whose causes remained unknown.

This man had seen so many doctors and still hadn't recovered after two months. Clearly a difficult case. No one could reasonably blame Evan if he couldn't cure him. Under ordinary circumstances, everyone would have understood. But these weren't ordinary circumstances anymore.

Leo could only hope Evan knew how to bluff his way through with as little loss of face as possible.

Evan was puzzled by the patient's treatment records too. The man had seen plenty of doctors and tried all sorts of medicines. Nothing had worked.

After looking through the records, he put them aside and raised his head. “Does anything else bother you?”

The man wasn't coughing just then. “No. Just this dry cough. As soon as my throat starts itching, I cough. I can't stand it anymore.”

Evan asked more questions. The man's bowel movements and urination were normal. He had no chills or fever. The cough showed no clear variation with the time of day; it went on from morning to night.

Evan's expression grew more serious. There was very little to go on. Just a cough.

Leo looked even more worried.

Young Alex, meanwhile, couldn't find anything to like about Evan. He kept casting sidelong looks at him.

Clara, on the other hand, was perfectly calm. No one could have been calmer.

Still filming discreetly, Lily asked her in a cautious whisper, “Do you think Dr. Xu can handle this?”

“Relax. The great Dr. Xu never slips up,” Clara said calmly.

Her confidence in Evan was inexplicable.

The questions had yielded no useful clues. Evan studied the man's face. His complexion was dull and dark. “Stick out your tongue for me.”

The man did.

Evan examined it carefully, but the tongue offered no useful information either.

None of the signs pointed clearly to anything!

He frowned.

Henry looked as though his suspicions had been confirmed. He had examined the patient himself and found no answer. He didn't believe Evan would find one either. That was why he had come along. He wanted to watch Evan embarrass himself.

Chinese medicine had an old saying: “A cough is a physician's adversary.” In Western medicine, a cough was generally traced to a problem in the respiratory tract. In Chinese medicine, however, any of the five zang and six fu organ systems could give rise to coughing.^[2] So could the six external pathogenic influences: wind, cold, summer-heat, dampness, dryness, and fire.^[3]

There were so many possible causes that distinguishing the pattern could be difficult. And this patient offered almost no signs from which to distinguish one. A difficult case indeed.

The author's publication on www. was copied without permission. Reading the story there helps sustain their writing.

When no pattern could be discerned, the prescription had to depend on the pulse alone.

Evan slowly let out a breath. “Give me your hand. I'll examine your pulse.”

The man held it out.

Evan exhaled slowly, settled his mind, and placed his fingers on the pulse.

Pulse diagnosis was a sharp blade that could cut through layers of fog. When outward symptoms misled, or offered no discernible pattern, the pulse was needed to uncover the truth.

He kept feeling the pulse at the cunkou site on the man's wrist. At the same time, he applied the method he had learned from the Nanjing, gauging the pulse's course by the breath: one exhalation and one inhalation, six cun of progress.^[4]

Evan believed that “whatever lies within must show on the surface.” If there was illness inside the body, it had to reveal itself outside. Through those outward signs, he intended to reach the very heart of the problem.^[5]

Pressure like the weight of three beans, at the skin and body hair: examine the Lung.

Pressure like the weight of six beans, at the blood vessels: examine the Heart.^[6]

…

Evan examined the pulse with great care. Since any of the five zang and six fu could cause coughing, he would examine them all, along with the channels throughout the body. Wherever there was illness, there had to be a corresponding change in the pulse.

Ten minutes or more passed with his fingers on the man's wrist.

The others were growing impatient.

Alex frowned at Evan. “Dr. Zhong, why is he taking so long? Is he trying to think up a way to bluff us?”

Henry frowned too. Once again, he couldn't be sure—this time about Evan rather than the patient. He, too, thought Evan might be stalling. Yet the young man's concentration as he felt the pulse didn't look like an act.

Henry had only seen such lengthy pulse examinations from truly accomplished Chinese medicine clinicians. Most doctors were finished in a few minutes.

In fact, the more skilled a doctor was at pulse diagnosis, the longer the examination took, and the more focused and serious the doctor became. Only those with no real skill at it spent a mere three to five minutes, chatting away with the patient as they went.^[7]

Henry began to wonder.

Leo was bewildered. Could Evan be trying to stall? Would that really work?

Another ten minutes or more went by. It was almost half an hour now.

Alex scratched his head and fidgeted, unable to keep still. If his department head hadn't been standing there, he would have demanded to know what Evan was playing at.

Even Leo's mouth had gone dry from waiting.

Clara kindly brought him a cup of water. He was the only one who got one. Leo accepted it, feeling awkward. Should he drink it or not?

At last, Evan finished examining the pulses at both wrists and let out a breath.

The patient was worn out too. “Cough, cough, cough… Well, Doctor?”

“Oh, Dr. Xu, I didn't dare interrupt you just now,” his wife said. “You spent so long taking his pulse. You must have been very thorough, mustn't you?”

Alex rolled his eyes. Did taking a long time mean you were thorough?

“Dr. Xu really takes his work seriously,” the wife went on. “No wonder you cured Evie. You're different from those young doctors in the hospitals. You've got a much better sense of how a doctor ought to behave.”

Alex was ready to explode. Damn it, why was she taking another swipe at him?

“There's nothing seriously wrong,” Evan said. “I'll write you a prescription. Drink the medicine at home and see how you do. It should bring some relief. Once you've finished it, come back for a follow-up, all right?”

Before the patient could answer, Henry spoke.

“Dr. Xu, aren't you going to tell us where the trouble lies?”

Leo sighed. Of course. He'd known it wouldn't end that easily.

Reader Notes

Reader Notes

1. ↩︎ A pattern is more than a symptom. In Chinese medicine, pattern differentiation means interpreting a combination of findings to identify the nature, location, and causes of an illness at a particular stage. A cough is a symptom; it does not, by itself, supply a complete pattern. “No clear pattern” therefore means that the available clues do not distinguish one, rather than that the patient has no symptoms or no illness. Source: WHO — International standard terminologies, entry 550.
2. ↩︎ Cough beyond the Lung. The Suwen's discussion of cough, Chapter 38, states that the five zang and six fu can all produce coughing, rather than the Lung alone. These are categories in a traditional framework of organ functions and relationships. This explains why Evan considers more than one system. The passage's contrast with Western medicine is a simplified narrative comparison: biomedical accounts also recognize causes such as reflux and medication effects. Neither source identifies the cause of this patient's cough. Sources: Suwen — Chapter 38, “Discussion of Cough” (in Chinese); U.S. National Library of Medicine — Cough, “Causes”.
3. ↩︎ The six external influences. This traditional group comprises wind, cold, summer-heat, dampness, dryness, and fire, understood as influences capable of causing illness. The names describe Chinese medicine categories, rather than six identified microorganisms or six weather conditions that have been established in this case. The list broadens the possibilities Evan must distinguish; it does not reveal which, if any, accounts for the cough. Source: WHO — International standard terminologies, entry 281.
4. ↩︎ The breath and the pulse's course. Cunkou is the wrist pulse-taking site used here. Difficulty One of the Nanjing, the Classic of Difficult Issues, describes three cun of progress during exhalation and three during inhalation, making six for a complete breath. Cun is the classical length unit retained here. This recalls Evan's recent training in a traditional circulation model, rather than a modern measurement of blood velocity; he is not sliding his fingers six cun along the patient's arm. Source: Nanjing Benyi — Difficulty One (in Chinese).
5. ↩︎ Reading the inside from the outside. The Danxi Xinfa's discussion of complexion and pulse describes examining outward signs to understand what is happening within, using the same maxim Evan recalls. “Outside” includes findings felt by touch, such as pulse qualities, as well as visible appearance. The quotation explains his diagnostic reasoning here. It does not establish that every illness produces an unmistakable surface sign, or that pulse examination alone will always uncover it. Source: Danxi Xinfa — section on complexion and pulse (in Chinese).
6. ↩︎ Pressure described in bean weights. Difficulty Five of the Nanjing compares finger pressure to the weight of beans: three for the level associated with the Lung and six for that associated with the Heart. These are traditional depth and pressure correspondences, not organs physically lying underneath the wrist. No beans are put on the patient, and the novel gives no conversion into grams. Capital letters distinguish the traditional organ systems in this translation. Source: Nanjing Benyi — Difficulty Five (in Chinese).
7. ↩︎ Time and thoroughness. This passage ranks doctors by how long and intently they examine a pulse. That ranking belongs to the novel's narration. The Hong Kong Department of Health describes pulse-taking as one part of palpation, alongside inspection, listening and smelling, and questioning, with the findings assessed together. Its account does not make a particular number of minutes a test of competence. Here, the long wait also changes how the observers judge Evan. Source: Hong Kong Department of Health — Diagnostic Methods and Features of Chinese Medicine Practitioners.