Dr. Xu: A Chinese Medicine Novel

Evan has earned the driver’s attention. Now he has to explain what went wrong.

Chinese medicine required the four diagnostic methods to be considered together. Why? To reduce mistakes. If you misread a pulse, something in the other findings might alert you to the error.[1]

Evan had used the other methods first, reached a conclusion, and then questioned the patient on that basis. That was an easy way to get things wrong.

So why had he done it? Because the patient no longer trusted them. He needed to show what he could do and win the man’s confidence.

And why had he dared? For one thing, he’d spent an entire year training under Dr. Qian, who had often required him to make a diagnostic assessment without questioning the patient.

He had the experience. He had the skill.

There was another important reason: Ben had helped him. Conventional medicine called the condition oral ulcers; Chinese medicine called it kouchuang, mouth sores. In the traditional account, their causes came down to three organ systems: the Heart, Spleen, and Kidney.

Ben had already eliminated two wrong answers for him. That greatly reduced Evan’s chances of getting it wrong. He had reason to feel confident.

Yet even after ruling out two wrong answers, Ben had still managed to screw it up.

The driver was thoroughly impressed with Evan now. He wouldn’t underestimate him again. This young doctor had accurately named so many of his symptoms without asking him a single question beforehand. That was remarkable.

“Is what he said true?” the driver asked Evan.

“Well…” Evan considered his answer. “Not… entirely…”

“What?” Ben was taken aback.

His sister-in-law burst out laughing.

Ben was embarrassed at once.

Clara shook her head helplessly.

Evan was at a loss too. He’d been trying to cover for Ben, which was why he’d only said the problem lay in the Spleen and Stomach. But Ben had insisted on naming Xiehuang San. That damn formula was for hidden fire in the Spleen and Stomach.

All the symptoms Evan had just discussed pointed to deficiency cold in those systems. Hadn’t Ben heard the patient say that cold food upset his stomach?

Evan wanted to grab him by the ear and ask, “Are you deaf, damn it?”

The driver gave an angry snort and glared at Ben.

Ben was embarrassed all over again.

The driver let out a couple of breaths. Instead of going on arguing with Ben, he addressed Evan in earnest. He could see now that the young doctor knew what he was doing.

“Doctor, what’s causing these ulcers? They’ve been coming back for six years. They heal, then come back, then heal again. There are hardly any days in the whole year when I get a break.

“You have no idea what it’s like, having a mouth full of sores. I can’t eat. I can’t drink. Hot drinks hurt my mouth; cold drinks upset my stomach. How am I supposed to live like this?” He was getting worked up.

Evan hurried to reassure him. “Don’t get upset. Take your time. What were the sores like at the beginning?”

“Not too bad at first,” the driver said urgently. “They’d come every few months. Sometimes once a month. They kept coming back, but Huanglian Shangqing tablets worked then. The ulcers would clear right up.

“Later, they stopped working. I took them and nothing happened. So I went back to the hospital. They gave me some kind of vitamins, some kind of anti-inflammatory medicine. That helped, but they still kept coming back. They’d barely healed before they flared up again.

“It’s been tormenting me. You don’t know what it’s like. I don’t even dare eat chicken eggs now. I eat duck eggs instead. All day I’m drinking chrysanthemum tea, and I don’t even dare put any damn goji berries in it!”[2]

Evan made a downward motion with his hand. “In Chinese medicine, we call these ulcers mouth sores. They’re mainly associated with three organ systems: the Heart, Spleen, and Kidney.

“We’re always talking about ‘internal heat.’ But there’s excess heat and deficiency heat. There’s heat from yin deficiency, there’s deficient yang floating upward, and there are several other kinds. Generally, mouth sores begin as excess heat. What does that mean? Too much heat. Clear it, and that’s enough.

“That’s why the Huanglian Shangqing tablets worked at first. But if the illness isn’t resolved, the pattern begins to change, shifting from excess heat to deficiency heat. Then those tablets won’t work. If you keep taking them, those bitter, cold medicines will damage your Stomach qi.[3]

“So taking too much bitter, cold medicine may have contributed to the deficiency cold in your Spleen and Stomach. Add irregular meals to that. As a cab driver, you can’t always eat on time, can you?”

The driver looked a little sheepish. “Well, that’s how it is for us cabbies… That’s how it is…”

“Irregular eating can also harm the Spleen and Stomach, so your pattern changed further. But you still thought the sores meant you had too much internal heat. You kept eating cooling foods to bring it down. The more you ate, the more you weakened your Spleen and Stomach, and the colder they became. That kept the sores from healing.”

“B-but why? If I’ve got too much heat, isn’t eating something cooling the right thing to do?”

“Heat can come from deficiency or excess,” Evan explained. “Chinese medicines only work when they match the pattern. The wrong medicine may make things worse. You can’t just clear heat every time you see it.”

Ben looked embarrassed. Wasn’t that exactly what he’d done?

He was also starting to resent Evan. Why couldn’t the kid let him save a little face? Was he really trying to get him driven out of the clinic?

“As I said, the Heart, Spleen, and Kidney are closely connected with mouth sores,” Evan continued. “The Ming physician Xue Ji wrote in Kouchi Leiyao, ‘Mouth sores arise from excess heat in the upper burner, deficiency cold in the middle burner, yin fire in the lower burner, and changes transmitted through the various channels.’[4]

“Excess heat in the upper burner usually comes from fire in the Heart channel, or heat accumulating in the Heart and Spleen. The Heart opens into the tongue, so this can directly cause mouth sores. That’s why Dr. Song prescribed Daochi San for you. He was trying to clear Heart fire.”

Ben was taken aback. Huh?

The driver turned to glance at him too.

“In the five phases, the Kidney corresponds to Water,” Evan continued. “Kidney Water rises to support and restrain Heart fire. If there isn’t enough Kidney Water, that’s yin deficiency. It can’t restrain Heart fire, which can lead to mouth sores. That’s why Dr. Song gave you Zhibai Dihuang Wan.”[5]

Ben stared at Evan.

“Dr. Song wasn’t prescribing at random. Your condition was difficult to see through, and he didn’t identify the pattern correctly.”

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The driver murmured something, looking rather dazed.

“That leaves the Spleen,” Evan said. “The Spleen and Stomach open into the mouth. Hidden fire there can certainly cause mouth sores. But your problem is the opposite: deficiency cold in the Spleen and Stomach.”

The driver was startled. “How can the opposite do the same thing? If I’m already cold, I can still get mouth ulcers?”

“Yes.” Evan nodded. “The Yuan physician Zhu Danxi wrote in Danxi Xinfa, ‘When mouth sores fail to heal with cooling medicines, Earth in the middle burner is deficient, and the patient cannot eat. Ministerial fire surges upward without restraint. Use Lizhong Tang.’”[6]

“Lizhong Tang… That’s a hot formula…” Ben looked bewildered. “You treat internal heat with hot medicine?”

“What does that mean?” the driver asked, still not understanding.

“There are two kinds of fire in the body: sovereign fire and ministerial fire,” Evan explained. “Sovereign fire is housed in the Heart. It’s like the sun, hanging high above. With the sun, living things can grow, develop, and store their resources. The same applies inside us.

“Ministerial fire is generally said to be housed in the Liver, Gallbladder, and Kidney, but its root is in the Life Gate, in the Kidney.[7]

“Above it are Spleen Earth and Liver Wood. Think about why there are no plants at the North and South Poles. It’s too cold. Ministerial fire lies beneath the earth. Its warmth allows things to grow.[8]

“You can think of it as one of those charcoal braziers people use to keep warm in the countryside in winter. The coals are hot, aren’t they? You need a thick covering of ash to keep that heat down, so it isn’t too fierce.

“But if the layer of ash is too thin, won’t the heat come rushing straight up?

“That’s what’s happening. Your Spleen and Stomach are too weak. Earth can’t contain Fire. Ministerial fire surges upward unchecked, causing the sores in your mouth.”

“Oh!” The driver finally understood.

So did the others.

“Wow, you’re amazing!” Ben’s sister-in-law exclaimed.

Clara immediately frowned and fixed her eyes on the woman.

Ben licked his dry lips. Since when had this kid become so good?

“So what medicine will treat it?” the driver asked.

“As I said, Wenzhong Tang,” Evan replied.[9] “The underlying problem is deficiency cold in the middle burner. Wenzhong Tang supports the Spleen and warms the middle. Once the middle burner is working properly, with abundant original qi and warmth restored to the Spleen and Stomach, the deficiency fire and floating yang in the Kidney can settle back where they belong. We call that strengthening Earth to subdue Fire. Your mouth sores will heal.”[10]

“All right. I’ll try once more.” The driver nodded.

“Clara, get the herbs!” Evan called.

“Right!” Clara answered at once.

Reader Notes

↩︎ Four methods, considered together. Inspection, listening and smelling, inquiry, and palpation contribute different findings to a Chinese medicine assessment. Pulse examination belongs to palpation. The narrator’s point is that the findings should check one another. Evan’s unusual order is explained by his training and this patient’s distrust; it is not presented as an additional examination performed in this scene. Source: Hong Kong Department of Health — Diagnostic Methods and Features of Chinese Medicine Practitioners.↩︎ Cooling foods and everyday precautions. The driver is choosing foods and drinks according to ideas about their warming or cooling qualities in Chinese dietary medicine. These qualities do not simply mean the temperature at which something is served. His switch from chicken eggs to duck eggs, his chrysanthemum tea, and his reluctance to add goji berries show how far he has taken his own efforts to avoid “heat.” They are his reported habits; the scene does not establish that these particular dietary restrictions are necessary. Source: Hong Kong Department of Health — Managing internal heat in Chinese medicine (in Chinese).↩︎ Internal heat, cold medicines, and Stomach qi. “Internal heat” translates the familiar expression shanghuo. The term can cover different traditional patterns, which is why Evan distinguishes excess heat from deficiency heat and floating yang. “Bitter” describes taste; “cold” describes a medicine’s traditional property. Huanglian Shangqing Pian is the tablet preparation the driver names. Stomach qi refers to digestive functions in this vocabulary. Evan’s account of how this patient’s illness changed, including the possible contribution of earlier medicines, remains his clinical explanation in the novel. Sources: Hong Kong Department of Health — Managing internal heat (in Chinese); WHO — Chinese medicine terminology, entry 188.↩︎ Xue Ji and the three burners. Xue Ji was a Ming-period physician. His Kouchi Leiyao discusses disorders of the mouth and teeth. Its mouth-sores section distinguishes several patterns rather than assigning every sore to the same kind of heat. The three burners are functional regions introduced earlier in the series. Similarly, an organ system “opening into” the tongue or mouth describes a traditional functional correspondence. The quotation frames Evan’s explanation of Ben’s earlier choices; it does not mean that the driver has every pattern listed. Source: Kouchi Leiyao — “Mouth sores,” section 2 (in Chinese).↩︎ Kidney Water and Heart fire. Water, Fire, Earth, Wood, and Metal are the five phases, a system of functional correspondences. Kidney Water and Heart fire name relationships within that system, not actual water rising into the heart or literal flames. Here Evan explains one possible route to mouth sores: insufficient nourishing yin leaves fire less restrained. This explains why Ben chose Zhibai Dihuang Wan; it does not confirm that the driver has that pattern. The Spleen and Stomach reasoning follows separately. Source: WHO — Chinese medicine terminology, five-phase restraint and Kidney yin, entries 35 and 155.↩︎ Danxi Xinfa and Lizhong Tang. Zhu Danxi was a Yuan-period physician; Danxi Xinfa preserves teachings associated with him. The “Mouth and teeth” section contains the quoted passage linking persistent sores after cooling medicines with deficient middle-burner Earth and unrestrained ministerial fire. Lizhong Tang is the formula named there. “Hot” in Ben’s reply concerns the traditional warming property of a formula, rather than the temperature of a drink. The historical quotation supports the provenance of this reasoning, not a demonstrated treatment result for the driver. Source: Danxi Xinfa — “Mouth and teeth,” section 78 (in Chinese).↩︎ Sovereign fire, ministerial fire, and the Life Gate. The ruler-and-minister names distinguish roles in traditional accounts of bodily activity. Evan associates sovereign fire with the Heart, and traces ministerial fire to the Kidney’s Life Gate, or mingmen. This is the functional concept encountered earlier, not a reference to needling the acupuncture point of the same name. His sun image explains function through a comparison. Different medical writings develop these images differently; the translation preserves this speaker’s account. Sources: WHO — Chinese medicine terminology, entries 179–181; Danxi Xinfa — traditional fire discussion (in Chinese).↩︎ The polar comparison. Evan uses the poles as an image of cold preventing growth. Taken as a statement that polar regions have no plants, it is too broad: the British Antarctic Survey documents mosses and two flowering plant species in Antarctica, as well as richer vegetation on sub-Antarctic islands. His comparison is retained as spoken in the novel. It illustrates his explanation of warmth; the geographic claim is not needed to establish that explanation’s traditional terminology. Source: British Antarctic Survey — Plants of Antarctica.↩︎ A change of formula name in the source. The Chinese chapter first quotes Lizhong Tang (理中汤), which Ben repeats, but here Evan says Wenzhong Tang (温中汤), “as I said,” and repeats that name in his explanation. This draft preserves both names in their original positions. The chapter supplies no ingredients or doses with which to establish whether the change is intentional. The translation therefore does not silently identify the two names as the same prescription or supply a recipe. This note records a difference within the Chinese manuscript.↩︎ Strengthening Earth to subdue Fire. Earth refers here to Spleen and Stomach function. Evan’s brazier analogy presents weak Earth as an inadequate covering: the warming fire rises because it is no longer contained. His proposed treatment therefore supports and warms the middle rather than simply clearing heat. The ash is a comparison, not a medicine ingredient. This containment image also differs from the five-phase relationship in which Water restrains Fire. Evan’s assurance is a treatment proposal spoken to the patient, not an observed recovery. Source: Danxi Xinfa — “Mouth and teeth,” section 78 (in Chinese).