A Touch of Ling: Learning from ancient case records

This article originally appeared in The Lantern, Volume 7, No.3 September 2010.

by Jason Blalack

Studying Chinese medicine case records is an invaluable way to enhance one’s clinical skills beyond basic textbook knowledge.

Qin Bo-Wei, one of the most important educators and clinicians of the 20th century, strongly advocated detailed study of case records, and said that they are the “intimate integration between theory and practice.” Their study enables one to learn from the thought processes of great physicians, thereby increasing one’s clinical repertoire and developing inspiration (灵感, ling gan) in the clinic.

Unfortunately, due to a lack of emphasis, lack of translated material, and lack of training in how to read case records, their importance is often missed in the educational process in the West, and their value unrecognized. Consequently, much of our clinical training ends up relying on formulated textbook approaches and research-based strategies, which, in most students’ experience, rarely yield the purported results.

Thus, an often heard criticism among TCM students and practitioners is that textbooks only present simplified patterns, whereas our real life patients are more complex and do not match what we study. Although there is some truth to this complaint, it really demonstrates a misunderstanding of the educational process and the full potential of TCM. Furthermore, it highlights the major gap that exists in material in the West: case records. Case records are a missing link in the educational process in the West, and all physicians should make analyzing them a lifelong practice.

Quite simply, our textbooks are full of stock formulas that represent the first step in the educational process and are really only meant as guidelines. The second step is learning how to transcend this basic material and flexibly apply these ideas in the clinic. This is the essence and art of Chinese medicine. Case records essentially demonstrate how master practitioners have done this and brought Chinese Medicine’s theory alive in the clinic.

We have almost 1000 years of case records documenting the thought processes of some of the most important clinicians in Chinese medicine’s history. We see that they rarely gave formulas straight from the book, but instead wrote individual formulas for each presenting clinical situation.

For example, we study the formula Yin Qiao San (Honeysuckle and Forsythia Powder). This formula was crafted and written down in a “textbook”, but it was modeled after case records from Ye Tian-Shi. Ye actually never gave this formula as we read about it, but various permutations of the formula are contained in many of his cases. These cases ideas were then combined into one formula /design.

Therefore, although Yin Qiao San (Honeysuckle and Forsythia Powder) is sometimes useful as it stands, it is more useful as an idea or demonstration of principles, which can be tailored for the individual.

We learn these nuances, e.g. how to give the most important components of a formula, by studying case records.

It was said by Hua Xiu-Yun, the compiler of the most well-known of Ye Tian-Shi’s case histories, that “the art of medicine lies in three critical points: recognizing patterns, constructing methods, and writing formulas.” Case records help with all three of these points.

1. Case studies sharpen one’s diagnostic skills by, for example, highlighting how master physicians recognized patterns. It is interesting to see patterns diagnosed with symptoms that are often routinely attributed to other patterns. Learning these “exceptions” widens one’s clinical view, preventing the tendency toward an ‘X symptom equals Y pattern’ type of thinking. We also see elegant ways of managing complex cases, such as addressing one core pathodynamic instead of five or more patterns.
2. From the pattern, one must formulate the treatment principles or methods. Most case records mention this overlooked step. Using treatment principles correctly not only clarifies our own thinking, but helps us understand specific herb choices in a given case record.
3. Finally, the specific herb choices often give us a different way of approaching a problem. Quite simply, people use herbs in different ways. Many pre-modern case records illustrate usages of herbs that differ from our modern understanding. Hence, we cannot assume that the physician was using a medicinal the same way as discussed in our modern materia medica. Moreover, from the analysis of herbs we can reverse-engineer additional information to further round out a case study.

There are a few points one should keep in mind when studying case records. First, the bulk of Chinese medicine case records are dramatically different than our modern day case records. That is, they often lack outcomes, are very terse, and require special type of approach to decode and interpret them.

A large percentage of case records, especially pre-modern ones, mention no results and contain no follow-up visits. This is not considered problematic because the purpose is to grasp the thinking method behind the choices and not just “find” a formula that works.

In addition, most pre-modern case records are very concise and straight to the point, sometimes only one or two lines long. They forgo presenting detailed narratives and simultaneously occurring symptoms and focus on the underlying diagnostic pattern and individualized treatment. In the end, the key information is usually given, such as the chief manifestation, pattern/diagnosis, treatment principle, and formula. In some cases the etiology and pathodynamics are explained.

Nonetheless, reading these case records requires a certain approach and skill set because of the lack of information presented. For example we can learn to reverse-engineer information using TCM theory. That is, we know that when a pattern was originally determined there was a certain level of theoretical understanding. For example, a case may only mention a pattern such as “yang yellowing (jaundice)” without any manifestations. This specifically refers to a series of symptoms such as yellowing of the eyes, yellow urination, and bright yellow skin color that is related to a damp-heat yellowing pattern.

There are also important clues that can be obtained when the absence of a manifestation is mentioned. For example, it may be pointed out that the “urine is not yellow” or “bowel movements are not sloppy.” These statements are used to illustrate that there is not internal heat or Spleen deficiency, which becomes key information for the prescribing of herbs.

In addition, most case records highlight something unique. One will rarely see generally understood treatment methods for common disease/patterns. For example, there is no point in documenting a case where Gui Zhi Tang (Cinnamon Twig Decoction) was given to a patient with fever and chills unrelieved by sweating, headache, nasal congestion, no particular thirst, a thin, white, and moist tongue coating, and a floating lax pulse. More common are interesting, difficult, complex or serious conditions, special disease patterns, or a unique variation of a “standard” treatment approach.

This is not to say that case records represent only fringe occurrences. They more commonly document frequent deviations from the textbook approaches, which correspond to a large percentage of the patient population. Hence, if we look at the case records, such as those, for example, that Yin Qiao San (Honeysuckle and Forsythia Powder) originated from, we see a full spectrum of wind-heat presentations with nuanced selections of herbs to match the patient’s individualized condition. Noting when Ye used or did not use specific herbs found in Yin Qiao San (Honeysuckle and Forsythia Powder) can be instructive.

More times than not, Chinese medicine case record discussions bring up Ye Tian-Shi. That is because he is one of the most important clinicians in Chinese medical history, and his case records are an invaluable contribution to our medicine. His cases are some of the most laconic and direct, yet some of the most instructive if one learns how to read them.

Ye’s style is characterized by a small number of ingredients, small dosages, and the favoring of mild and neutral medicinals.

He had an unparalleled ability to focus directly on the root pathodynamic, thereby, for example, treating a cough without any cough medicinals[1]. His ability to prescribe so accurately for each individual presentation essentially came from his deep understanding of Chinese medicine theory, his intricate understanding of herbs, and critical diagnostic skills. Thus, he has influenced generations of doctors and his style offers a useful contrast to the larger ingredient, larger dosage formulas of many modern practitioners.

When reading these types of case records there are some additional things to keep in mind. It is suggested that one not ask how we would have approached the situation, but do everything we can in trying to figure out how this doctor is thinking and why (s)he made the decisions (s)he did.

Furthermore, clinicians like Ye were not sitting around writing down his case studies for us to study. His case records, in particular, were recorded by his students and published after his death. Consequently, they represent his real-time clinical decisions.

The short-hand style that they are written in is emblematic of Qing Dynasty physicians who required readers to have a certain level of proficiency in understanding the deep structure of such formulas, and skill at decoding medical shorthand. This is something we all must work towards to understand such case records.

Below are six case records from Ye Tian-Shi’s Lin Zheng Zhi Nan Yi An (Case Records as a Guide to Clinical Practice). Following each is commentary from Qin Bo-Wei. Three of them are wind-stroke (zhong feng中风) patterns and three of them are cough patterns. In general, a useful strategy is to compare and contrast similar case records, but without fixating on minor differences. For example, cases occurred in different time periods and certainly different ideas were going through the physician’s mind. This is no different than how our own clinical choices are influenced by what we are reading at the time. Therefore, looking at both overall trends as well as detailed analysis of individual cases is important when analyzing case records.

Hopefully the following examples will provide some exposure to this important tradition as well as some insight into how to start deciphering such case records.

Case 1: Hemilateral withering

Case 2: Wind Stroke – Blood deficiency

Case 3: Wind-stroke – Qi & blood deficiency

Case 4: Cough – Warm pathogen

Case 5: Cough – Warm Pathogen with exhausted yin

Case 6: Cough – Childhood yin exhaustion with qi aspect heat

* please post any comments or questions

** For further reading please see Understanding Case Records Pt. 1 and Understanding Ye Tian Shi’s Cases.

[1] For example, notice the herbal prescription from one of Ye’s cough cases, Gan Cao (Glycyrrhizae Radix), Sheng Di Huang (Rehmanniae Radix), Mai Men Dong (Ophiopogonis Radix), Huo Ma Ren (Cannabis Semen), E Jiao (Asini Corii Colla), Bai Shao (Paeoniae Radix alba), and Tang Jiang (Sacchari Syrupus).

A six-year or old girl came in with chronic eczema located symmetrically around the elbows, back of the knees, on the legs, and on the upper back. The areas were dry, itchy, had mild erosion and lichenification, only mild erythema in areas, and had scabs and scratch marks. She had a history of persistent runny nose, felt hot, restless sleep, talking in her sleep, allergies (e.g. cats, pollen, possible food intolerances), and would easily get sinus and ear infections since the age of four. Her pulse was fast and slippery and her tongue body was red with red prickles and a slightly thicker coat.

Diagnosis: This was wind predominate chronic childhood atopic eczema due to damp collecting, transforming to heat, with an  underlying Spleen qi deficiency.

Prescription:

fú líng pí (Poriae Cutis) 6
bái xiān pí (Dictamni Cortex) 9
bái zhú (Atractylodis macrocephalae Rhizoma) 9
yì yǐ rén (Coicis Semen) 12
gǔ yá (Setariae (Oryzae) Fructus germinatus) 6
mài yá (Hordei Fructus germinatus) 6
fáng fēng (Saposhnikoviae Radix) 9
chán tuì (Cicadae Periostracum) 6
cì jí lí (Tribuli Fructus) 9
gān cǎo (Glycyrrhizae Radix)  6

1 bag over 7 days.

Visit #2 – Eczema looked slightly better and there was less itching. Her sinus problems had been eliminated. Although she still felt hot her sleep was better, meaning it was less restless and not waking up as much. The tongue coat was also slightly less thick.

The previous formula was given plus sāng yè (Mori Folium) 9 and xī xiān cǎo (Siegesbeckia) 6.

Visit #3 – Itching was reduced. She also caught a very mild cold which left very quickly (much quicker than in the past and did not go into the usual sinus infection). The overall body temperature was less hot, and sleep was good. The previous formula was given again.

Visit #4 – There was less itching, no new breakouts for weeks, upper back was completely clear, sinuses were clear, no problem with cats, temperature had normalized, sleep was good. The tongue body was less red with a thin slightly thicker white coat.

Working towards a more maintenance formula, the previous prescription was given minus fáng fēng (Saposhnikoviae Radix) and xī xiān cǎo (Siegesbeckia) with the addition of bái biǎn dòu (Lablab Semen album) 9 and chì xiǎo dòu (Phaseoli Semen) 9, with the reduction of bái xiān pí (Dictamni Cortex) 6.

Visit #5 – Symptoms remain improved; however the tongue coat was still thick. I added zhì bàn xià (Pinelliae Rhizoma preparatum) and chén pí (Citri reticulatae Pericarpium), used châo bái zhú (dry-fried Atractylodis macrocephalae Rhizoma) and châo yì yî rén (dry-fried Coicis Semen) and removed sāng yè (Mori Folium) and gǔ yá (Setariae (Oryzae) Fructus germinatus).

Commentary: I do not find anything overly strange or exciting about my approach for this case. It is a straightforward approach I often take for skin conditions especially when itching is a predominant sign. That is, at the beginning I focus on reducing the symptoms and fundamental pathodynamic, then as the symptoms reduce, I slowly modify the formula to address more of the root problem. As long as the symptoms stay at bay, I will, for example, remove all stop itching type herbs such as chán tuì (Cicadae Periostracum), fáng fēng (Saposhnikoviae Radix), cì jí lí (Tribuli Fructus), bái xiān pí (Dictamni Cortex) etc. and focus more on the internal cause, e.g. strengthening the Spleen and eliminating dampness and any heat that remains.

However, the one thing interesting about this case is that the skin presentation (dry, itchy, no vesicles, pustules, or oozing) which might suggest a blood deficiency type, was treated through a damp and heat pattern. This choice was made due to a proper differentiation of pattern identification, and not fixating on one single element. This formula is based on one of Zhao Bing-Nan’s core eczema formulas; fú líng pí (Poriae Cutis), bái xiān pí (Dictamni Cortex), bái zhú (Atractylodis macrocephalae Rhizoma), and yì yǐ rén (Coicis Semen).

Location: Boulder, Colorado: Case of childhood eczema treated with Chinese medicine

The patient presented with a chief complaint of chronic migraines, which were preceded by a sensation of heat rising to the head. She also felt warm overall, had red eyes that could easily become swollen with yellow discharge, painful and bleeding gums, difficulty falling asleep and would wake up with her mind racing, a long history of menstrual cramps and pain with clots, alternating bowels (constipation and loose) that had a tendency towards a strong smell that were occasionally sticky. Her abdomen was sore to the touch, her pulse was deep, wiry, and jumpy, and her tongue had a yellow coat.

She had tried many formulas in the past including tian ma gou teng yin as well as bitter, cold, descending and purging methods with no success. This is a pattern of fire due to Liver constraint. The treatment method was to follow the Inner Classic’s “when there is fire from constraint discharge it (火郁发之)”

mǔ dān pí (Moutan Cortex)        9
gōu téng (Uncariae Ramulus cum Uncis)               12
sāng yè (Mori Folium)                    6
lu dòu yī (Glycinis Testa)                               6
bò hé (Menthae haplocalycis Herba)       6
màn jīng zǐ (Viticis Fructus)          12
jú huā (Chrysanthemi Flos)         9
zhī zǐ (Gardeniae Fructus)             9
gǎo běn (Ligustici Rhizoma)         6
cì jí lí (Tribuli Fructus)     9

1 bag=2days.

Location: Boulder, Colorado

Commentary: This formula eliminated all migraines, which was the first time this had occurred. Also her sleep and many other heat related symptoms improved. After stopping the herbs a sense of a migraine would occasionally arise that could be headed off quickly after taking the herbs.

Although I like this formula for the headaches and addressing the basic pathodynamic, I do think there is a deeper level to treat to attempt to “cure” the problem. The patient has expressed interest in pursuing a deeper treatment, and if anything interesting arises I will post the progress.

A 35 year-old female on Wednesday, March 31, 2010 presented with a chief complaint of cough and a hot tongue.

The previous day she had a runny nose and felt like she was getting a cold. She also reported that both of her kids had strep throat, which in the past she would get a couple times a year.

Currently she had a dull and achy sore throat. Her cough was mildly productive with congealed thick discolored phlegm. She felt like she was breathing fire, felt hot, irritable, had a dry mouth, no sweat, no chills, and had some eyelid twitching. Her bowels were not moving and when they did they were black and hard. She had a sensation of abdominal bloating and had no appetite.

Upon further inquiry she reported having some dental work on 3/24/10 where she was given a course of Clindamycin 300mg TID, Flagyl 500mg q 6 hours taken with Phenergan, and Diflucan due to some infectious complications. She noticed a red dry rash appear on the dorsal part of her hands after taking these meds.

Tongue: very red body with no coat

Pulse: Slippery and rapid

Diagnosis: Heat in the qi and nutritive level, clumping of the stools.

Treatment principles: Open the bowels, facilitate resolution of heat via the urine, vent the pathogen from the nutritive aspect, and enrich the fluids.

Prescription:

dà huáng (Rhei Radix et Rhizoma) (add) 9g  
máng xiäo (Natrii Sulfas) (add)  6g    
chì sháo (Paeoniae Radix rubra) 6g                             
mǔ dān pí (Moutan Cortex) 6g    
shuǐ niú jiǎo (water buffalo horn) 15g                          
shēng dì huáng (Rehmannia root, Chinese foxglove root) 15g    
dàn zhú yè (Lophateri Herba) 6g   
lián qiào (Forsythiae Fructus) 15g    
dēng xīn cǎo (Junci Medulla) 1g    
huáng lián (Coptidis Rhizoma) 2g

Cooking Instructions: 1 bag=2 days. Cook time =45 minutes. Taken between  meals 2-3 times a day.

Outcome: After taking two bags of herbs all of her symptoms were resolved except for a slightly warm feeling on the tongue and slight thirst. We then switched to a constitutional formula. Note: she stopped all pharmaceuticals after initial consultation.

Commentary: Although many consider antibiotics and other similar pharmaceuticals as cold one must always observe what is happening in the body and treat what they see. In this situation the multiple pharmaceuticals seemed to have pushed the heat pathogen deep into the qi and nutritive level. One clue was the rash on the hands, even though this was “caused by the pharmaceuticals.” An aggressive approach was needed to evict the pathogen and prevent damage to the yin and possibly entering the pericardium. Of note, there were no herbs in the formula to directly treat the chief complaint of the cough. Although this seemed to be the most pressing sign to the patient, there was clearly a bigger fish to fry.

Questions or comments?

Location: Boulder, Colorado

Intro: This is a somewhat informal presentation of a recent case that I found quite educational for myself. It is definitely not the cleanest case (easy success) but that is why I like it. I am still working out the best way to present these cases and if anyone has any suggestions please let me know. I also welcome others to submit their cases for us to learn from. I hope you enjoy it and welcome any feedback or criticisms.

Case: 55 year old male presented with testicular and perineal pain, sensation of “peeing glass”, strong sensation heat in the lower burner, unable to sit due to the pain, and frequent urination in both night and day. This had persisted for many months and had been labeled “chronic prostatitis.” He also presented with a painful left big toe, dry mouth, and very strong emotions (anger, anxiety, fear etc.). The pulse was cloudy (模糊,mó hú mài) and wiry, and his tongue was dark red/purple with a thick coat. The diagnosis was damp-heat stasis in the lower with the treatment principle of transform damp, clear heat, promote urination, and promote the movement of blood.

Long dan cao     6
Che qian zi           9
Huang qin            9        
Zhi zi                      9
Sheng di                9         
Ze xie                     9
Dang gui               6        
Mu tong                6
Chai hu                 6         
Gan cao                6
Huang bai            6
Ku ding cha         2

Instructions: 1 bag=2 days. Cook time =45 minutes. Take 2-3 times a day.

Visit #2: Heat was 40-50% better. Pain had improved. Started a course of Cipro for 1 month. Tongue was red.

Visit #3: In the previous three days the pain was severe. Dx: damp heat + toxin pouring into the lower burner.

Visit #4: Feels very hot, insomnia, urine is yellow, very angry, dry mouth, thirst, and feels energy shooting up. Uncomfortable sensation over his liver. Red tongue, wiry pulse. Diagnosis: Liver Fire.

Visit 5-6: more of the same.

Commentary: Throughout all of these visits a modified Gentian Decoction to Drain the Liver (lóng dân xiè gän täng) was used with various additions to emphasize more blood invigorating (e.g. Vaccariae Semen (wáng bù liú xíng), Manitis Squama (chuän shän jiâ)), pain relieving (e.g. Corydalis Rhizoma (yán hú suô)), toxin clearing (e.g. Patriniae Herba (bài jiàng câo),Taraxaci Herba (pú göng yïng)) , cooling the blood (e.g. Paeoniae Radix rubra (chì sháo)), protecting the yin (e.g. Dendrobii Herba (shí hú)), and descending the yang and calming the spirit (e.g. Fossilia Ossis Mastodi (lóng gû), Poriae Sclerotium pararadicis (fú shén)). But the overall presentation had hardly budged. Pain and heat was certainly still an issue as well as the severe emotions (anger, fear, sadness etc.). Other modalities were also used at this time by other practitioners.

Visit 7: Due to unclear results, I decided to switch to a more modern prostatitis formula:

Huang qi                     10
Yan hu suo                  6
Di long                        4.5      
Zhi gan cao                 6
Hu zhang                     9         
Bai hua she she cao     9
Huang bai                    9         
Sheng di huang           12
He huan pi                   9         
Wang bu liu xing         9
Nu zhen zi                   12       
Ze xie                          6

Visit 8-9: “prostate” seems better. He has noticed that stress makes it worse. Anxiety is less. Pain is 5/10 (was 8/10). Feels like the muscles are very tight/pulled muscle around the perineum. Added 20 grams of Paeoniae Radix alba (bái sháo).

Visit 10: Urethral pain is still severe, pelvic pain is getting better. Lots of emotion. Pulse is very tight and wiry. Fatigue (mentioned that had been going on for awhile).

Chao Chuan lian zi      6
Mai dong                     9
Bai zi ren                     9         
Tao ren                        9
Dang gui                     6         
Huang bai                    9
Yan hu suo                  9         
He huan pi                   9

Commentary: Over the last 10 visits the pain had gone up and down many times. However even though the pain had decreased it was still significantly present. The heat was also very obvious. Due to the unclear results from the above more straightforward approaches. I decided to consider the underlying mechanism for the fire/heat. Taking inspiration from Ye Tian-Shi, I prescribed the above formula (see his constraint case). Notice the more softening approach.

Visit 11: significant improvement, pain and pelvic floor tension was much less. 3 bags of previous. Of Note: Almost all of the previous formulas contained Corydalis Rhizoma (yán hú suô).

Visit 12: + Paeoniae Radix alba (bái sháo) 25.

Visit 13: It was unclear if Paeoniae Radix alba (bái sháo) made any difference) – feeling much better.

Visit 14: Common cold / flu (gan mao), stopped herbs, pain became worse. Thought there might be a lurking pathogen and switch strategies to a yin deficient venting idea. (I was wrong)

Visit 15: Pain became much worse, went back to previous formula (visit 12-13) and pain continued to decrease once again. This confirmed that addressing the underlying mechanism, causing the fire was actually effective. Over the next few weeks the pain completely resolved.

Visit 16: Although no pain remained, there was anxiety, fear, pressure in the chest, and palpitations. This had been going on for many years since the death of his wife. He (and I) thought that this was the underlying cause of all his problems including the fire/prostatitis. This was qi and blood stagnation in the collaterals. The treatment principle was to dredge the liver and open the collaterals. I decided to use a modified Inula Decoction (xuán fù huä tang) from the Essentials from the Golden Cabinet.

Xuan fu hua                9
Hong hua                    6
Tao ren                        9         
Dang gui wei               6
Ze lan                          3         
Lu lu tong                   3
Wang bu liu xing         6         
Mei gui hua                 3

Note: Carthami Flos (hóng huä) sub for New crimson (xïn jiàng).

Emotional symptoms, energy, sensation in the chest all dramatically improved over the next couple weeks.

Location: Boulder, Colorado