Chapter 83 Concurrent Shaoyang and Yangming Patterns

Evan begins the treatment with Alex at his side.

“All right.” Evan handed Alex the container of alcohol-soaked cotton. Alex took it and crouched beside him.

Evan took a piece of cotton and disinfected the patient's leg. “Acute appendicitis comes under intestinal abscess in Chinese medicine,” he told Alex. “It usually develops when the Spleen and Stomach lose their ability to regulate properly, with another trigger such as irregular eating or a sudden run.

“At first, healthy qi and pathogenic factors contend within the intestines. Trapped heat adds to the problem, obstructing qi and blood until they accumulate and form an abscess. If the heat can't disperse, the flesh and blood decay and turn to pus. That's how the condition progresses.^[1]

“We treat acute appendicitis as an intestinal abscess. Chinese medicine can use needling, oral medicines, or external applications. Needling is the fastest way to deal with an emergency. We can use the appendix point, Zusanli, and the right Tianshu point.

“The appendix point is often tender. We need to insert the needle right at the tender spot. This patient has an excess-heat pattern, so we use the draining method, preferably with strong stimulation.”

Evan inserted the needle. A twitch followed almost immediately: deqi, obtaining qi.^[2] His acupuncture was now at the level of a provincial specialist. This condition was well within his abilities.

The stubborn old man began groaning quietly, saying that he felt a painful fullness.

“The strength of stimulation depends on the patient's condition and constitution,” Evan continued. “Don't use strong stimulation if the illness is mild or the patient is very weak. But this patient is robust, so we can go straight to Toutianliang—Heaven-Piercing Coolness.”^[3]

“What?” Alex was stunned.

“Heaven-Piercing Coolness?” Henry and Leo were dumbfounded too. He knew that technique as well?

The Western medicine doctors looked blank. What was that supposed to be? Something from a martial-arts novel?

Ms. He gave a contemptuous snort. Chinese medicine doctors did love their mystical theatrics.

Evan used the Heaven-Piercing Coolness technique. The patient felt a strong needling sensation. He had succeeded.

The old man bore the painful fullness. The aching, tingling numbness from such strong stimulation was very uncomfortable, and he continued to groan.

Several times Ms. He almost spoke, then swallowed her words. The old man had chosen this himself. He had brought it on himself!

The young Western medicine doctors glanced at Dr. Qi, only to find him watching with great interest. Well, then. They had nothing to say either.

Still lying on the bed, the old man let out a long breath when Evan withdrew the needle.

Unlike the current acupuncture standard of retaining needles for thirty minutes, both Setting the Mountain on Fire and Heaven-Piercing Coolness called for immediate withdrawal once the manipulation was complete.^[4]

Evan continued. After disinfecting the skin, he used the same technique at Zusanli.

The old man kept groaning.

“Appendicitis usually causes pain in the lower right abdomen,” Evan explained to Alex. “Ordinarily, we can needle the corresponding spot on the lower left. That's called miuci, contralateral needling. You know it?”

“Yes. The Suwen's ‘Discourse on Miuci’: ‘For the left, treat the right; for the right, treat the left.’”

“Right. But this patient is a little different. His pain is in the upper right abdomen, so using the right Tianshu point will work too.”^[5]

Evan inserted the needle and performed the technique again.

“If there's fever, nausea, and vomiting, we can add Quchi, Hegu, and Neiting.” With that, he continued needling.

The old man had been lying there groaning from the pain for two days. He had still been very uncomfortable when Evan first began, because the stimulation was so strong.

But as Evan worked, the groans grew quieter and quieter, until they stopped altogether.

Ms. He grew anxious, afraid that something had happened to him. But his face seemed less strained with pain, so she said nothing.

After treating all the points, Evan asked, “How is it? Any better?”

The old man gave a long, relieved sigh, his furrowed brow relaxing. “Ah… much better. So much better. I haven't felt this comfortable in two days. It doesn't hurt. Not at all.”

Everyone stared.

Ms. He could hardly believe it either. Her already large eyes opened wider.

Evan nodded and put away his acupuncture case.

The others had nothing left to say. With such an obvious response, wasn't that enough to show that it was appendicitis in an unusual position?^[6] The woman resident stared at Evan, dazed.

So did the others. What they couldn't understand was whether Chinese medicine really was this powerful. Could it work this fast?

“I told you Chinese medicine worked,” the old man kept saying. “I told you. Didn't I tell you it worked?”

Ms. He kept her face rigid.

Evan stood. “Let's write a prescription. Dr. Zhong, where's the one you wrote earlier?”

“Oh, I have it ready.” Henry came out of his daze and handed over the prescription.

Evan took it and glanced through it.

“Was there anything wrong with my prescription?” Henry asked.

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“No. This really was a difficult condition to uncover. The usual pattern differentiation wouldn't work here. Although Western medicine diagnosed acute cholecystitis, you still prescribed Da Chaihu Tang based on the patient's signs and symptoms. It did fit his pattern.

“It's just that his main problem is an intestinal abscess, so the effect wouldn't be particularly marked. He clearly has a shaoyang pattern, but the doses in your Da Chaihu Tang were a little low. If you'd used larger doses then, the effect would probably have been better.”

“Thank you for explaining.” Henry nodded.

“Now that we've confirmed an intestinal abscess with concurrent shaoyang and yangming patterns, the natural choice is Da Chaihu Tang combined with Dahuang Mudanpi Tang,” Evan said.^[7]

“All right. I'll write it down.”

Evan dictated; Henry wrote.

The prescription was soon finished.

Holding it, Henry turned to Dr. Qi. “Qi, this is the prescription from our Chinese internal medicine consultation. Would you take a look?”

Henry had taken responsibility for it.

Dr. Qi accepted the prescription and glanced through it. “This is what our hospital's Chinese medicine doctors have prescribed,” he told the patient. “Do you want to take it?”

“Of course I do!” the old man said without hesitation.

Dr. Qi looked at Ms. He.

She turned her head away and said nothing.

Since the patient agreed, that settled it. “I have no objection, then,” Dr. Qi told Henry. “We'll proceed with conservative treatment using Chinese medicine.”

“All right.” Henry went off to put in the prescription.

Evan sat on a chair, a little tired.

Standing beside him, Alex looked very embarrassed. “Dr. Xu, I called my teacher last night.”

“How is Dr. Liu?” Evan asked.

“He's well. He had a lot to say to me, too. So I'd like to apologize today. I was rash. I'm sorry, Dr. Xu.”

Ashamed, Alex bowed to him.

Evan waved it off. “Oh, don't worry about offending me. What matters is studying medicine seriously and doing your best to treat people and save lives. Learn from your teacher. Make sure you become a good, responsible doctor. Your teacher is a good doctor who deserves respect.”

“Yes. I'll remember,” Alex answered respectfully.

At those words, Ms. He kept looking Evan over.

The pharmacy sent the medicine up shortly afterward.

After taking it, the old man suddenly felt unbearable abdominal pain. He went to the toilet and passed a large amount of stool: hard lumps first, then watery diarrhea.

Afterward, his abdomen felt much easier. The unbearable, distending pain was gone.

At that, no one had anything left to say.

So it was probably appendicitis with an unusually placed appendix. The young Western medicine doctors looked at Evan with astonishment and uncertainty. Dr. Qi regarded him differently too.

Alex and the others lifted their heads proudly. Who said Chinese medicine couldn't treat an acute abdomen?

Much reassured, Evan prescribed two more doses for the patient.

He was just about to leave when someone called from behind.

“Hey, wait.”

Evan turned. It was Ms. He.

Reader Notes

Reader Notes

1. ↩︎ Intestinal abscess and the traditional explanation. Changyong, translated here as “intestinal abscess,” is a Chinese medical category associated with accumulated heat in the intestines. Evan's account uses Spleen and Stomach in their traditional functional sense, along with healthy qi, pathogenic factors, and obstructed qi and blood. The progression he describes belongs to that explanatory system. It does not mean that an abscess has been demonstrated by imaging, or that irregular eating and running are established causes of acute appendicitis. Source: WHO — Standard TCM terminologies, entry 1668.
2. ↩︎ Draining and deqi. In acupuncture, “draining” means a manipulation intended, in traditional theory, to reduce an excess pattern. It does not mean drawing fluid out through a needle or inducing a bowel movement. Deqi is associated with characteristic sensations experienced by the patient or practitioner, including aching, numbness, fullness, or a gripping sensation around the needle. This edition retains the novel's distinction between obtaining qi and the arrival of qi discussed earlier, even though some terminology sources use those expressions interchangeably. Source: WHO — Standard TCM terminologies, entries 3040–3047.
3. ↩︎ Heaven-Piercing Coolness. Toutianliang is a named compound draining manipulation associated with a cooling sensation; its warming counterpart, Shaoshanhuo, appeared earlier as “Setting the Mountain on Fire.” These are traditional technique names, which explains why they sound like martial-arts moves to the onlookers. The imagery concerns relative levels of needling and intended sensations, rather than actual fire or supernatural cold. The narrative reports a strong sensation here; it does not say that the patient felt cold. Source: Beijing University of Chinese Medicine — Reinforcing and reducing manipulations (in Chinese), final two sections.
4. ↩︎ How long a needle remains. The narrator's contrast is preserved, but thirty minutes is not a universal rule for acupuncture. A review of practitioners' views describes immediate withdrawal, commonly used twenty-to-thirty-minute retention, and other durations. There is also a specific source discrepancy: the university teaching material cited above describes retaining the needle at the end of both named techniques. It therefore does not verify this chapter's statement that immediate withdrawal is inherent to them. Sources: Chen and colleagues — Appraisal of the Deqi Concept, section 3.4.3; BUCM — Reinforcing and reducing manipulations (in Chinese).
5. ↩︎ Treating the opposite side. Miuci is a classical term for a form of contralateral needling discussed in the Suwen, part of the Yellow Emperor's Inner Canon. Alex quotes its left-right principle. Evan then chooses the right Tianshu point despite the right-sided pain; that is the original dialogue's stated exception, not an anatomical correction supplied by the translation. The classical passage supports the quotation and traditional terminology, rather than establishing this choice as a diagnostic or treatment rule for appendicitis. Source: Suwen — Discourse on Miuci (in Chinese), opening exchange.
6. ↩︎ Response and confirmation. The observers take the relief of pain as evidence for their suspected diagnosis. That inference belongs to the scene. Contemporary assessment of appendicitis combines the history and physical examination with laboratory tests and imaging as needed; improvement after needling is not, by itself, confirmation of an unusually located appendix. A clinical response and an anatomical diagnosis are different kinds of evidence. Usual treatment involves appendectomy and antibiotics, with antibiotics alone considered for selected mild cases. Those options do not establish the equivalence of the treatment portrayed here. Sources: NIDDK — Diagnosis of Appendicitis; NIDDK — Treatment for Appendicitis.
7. ↩︎ Two patterns and two formulas. Shaoyang and yangming are classifications within six-division pattern differentiation; “concurrent” does not mean two infections. Da Chaihu Tang combines harmonizing shaoyang with clearing internal heat accumulation. Dahuang Mudanpi Tang is the source text's fuller name for the formula commonly catalogued as Dahuang Mudan Tang, a purgative formula traditionally associated with intestinal abscess. These references explain Evan's choice without supplying a dose or demonstrating that the combination treats this patient's suspected condition. Sources: HKBU — Major Bupleurum Decoction; HKBU — Rhubarb and Cortex Moutan Decoction.