Original Case by:

[Patient] Gu (age 44) had already greying whiskers and hair on the temples. His facial complexion though was bright. He was emotionally worried and irritable. [There was] yang ascending and agitating [the spirit] with phlegm and thin mucus also ascending and overflowing.  The divine pivot says, when yang qi descends, joins and enter the yin, then the yang qiao vessel is full and one is able to sleep. [At this moment though] qi was disseminating and discharging outward and yang was not entering yin. He would drink alcohol in hopes of muddling his consciousness enough so he could sleep. This was not a good method for managing this disease. In middle age and afterwards, men’s lower base is the first to become depleted. [The treatment] was to use Eight-Ingredient Pill (ba wei wan) in the morning and Pinellia and Millet Decoction (ban xia shu mi tang) in the evening. (yang qiao vessel deficiency).

Translated by: Jason Blalack

Original Chinese: 顾（四四） 须鬓已苍。面色光亮。操心烦劳。阳上升动。痰饮亦得上溢。灵枢云。阳气下交入阴。阳跷脉满。令人得寐。今气越外泄。阳不入阴。勉饮酒醴。欲其神昏假寐。非调病之法程。凡中年已后。男子下元先损。早上宜用八味丸。晚时用半夏秫米汤。（阳跷脉虚）

Source: Case from the Insomnia chapter of Case Records as a Guide to Clinical Practice (临证指南医案 lin zheng zhi nan yi an).

Commentary: This case shows one approach to dealing with complex patterns of excess and deficiency, giving separate formulas at different times of day.  Ye uses his typical style of focusing on the pathodynamics and uses little in the way symptomatic “sleep” herbs. Brilliant! Eight-Ingredient Pill (ba wei wan) is another name for Kidney Qi Pill (shen qi wan). Pinellia and Millet Decoction (ban xia shu mi tang) is from the Divine Pivot and contains Pinelliae Rhizoma preparatum (zhi ban xia) and  Setariae Fructus (shu mi).

Comments? Questions? Mistakes?

New Post / article + Recent Posts: For those that might have missed some recent posts:

1. Some issues in warm disease Three essays from Qin Bo-Wei (秦伯未). Originally published in The Lantern, Volume VIII, Issue: 2 — (Australia) (May 2011). The three essays are spereated below, so that if one desires they may post comments on them.
   1. A restructuring of Warm Disease names by Qin Bo-Wei
   2. The issue of newly contracted pathogens and lurking pathogens by Qin Bo-Wei
   3. The relationship between warm disease (温病, wen bing) and cold damage (伤寒, shang han) by Qin-Wei
2. Case studies:
   1. Duck Butt
   2. Lurking-warmth case study by Liu Bao-Yi (Liu Baoyi) (柳宝诒)

The names in the warm disease current are extremely complicated. Besides the name, warm disease itself, there is wind-warmth, spring-warmth, summerheat-warmth, autumn-warmth, winter-warmth, damp-warmth, warm-epidemic, warm-toxin, warm-malaria, as well as lurking summerheat, autumn-dryness etc. All of these are within the scope of warm disease.

I think that these should be restructured with some added explanation. Only after we rectify these terms will we be able to perform some judicious pruning.

1. Spring-warmth: Warmth is the qi of spring and the onset of warm disease mostly occurs in the spring season. In the Inner Classic it clearly points out that “[if the disease occurs] before the summer solstice then it is warm disease.” This shows that spring warmth is a seasonal disease of springtime, but one that has been influenced by “damage from cold during winter”; most people regard spring warmth as a lurking pathogen warm disease.
2. Wind-warmth is a newly contracted warm disease that occurs in spring. Ye Tian-Shi said “Wind warmth is a result from the contraction of wind during the spring months, when the wind’s qi is already warm.” In fact, “wind-warmth” is the true springtime warm disease, since “spring warmth” was the name used for the lurking pathogen that manifested in the springtime. They had to have a new name (e.g. “wind warmth”) for a simple exposure to warm pathogen in the springtime because [the most logical name] “spring warmth” was already taken.
3. Summerheat-warmth is a warm disease that occurs in the summer. It is caused by summerheat combined with damp heat. Therefore summerheat that has a tendency towards warmth is called summerheat-warmth. Summerheat that has a tendency towards  damp is called damp-warmth. These are different than the general warm disease outline.
4. Autumn-warmth is a newly contracted warm disease that occurs in the autumn.
5. Winter-warmth is a newly contracted warm disease that occurs in the winter. It commonly comes about because of seasonal qi warmth.
6. Damp-warmth is a pattern related to a warm pathogen confined with dampness.
7. Warm-epidemic is a heat type presentation related to seasonal epidemics.
8. Warm-toxin is a pattern related to wind-warmth that manifests with local redness, swelling, and heat type pain, such as swollen face epidemic (大头瘟 da tou wen), epidemic parotitis (蛤蟆瘟 ha ma wen) etc..
9. Warm-malaria is a warm pathogen that forms into malaria.
10. Lurking summerheat refers to a summerheat-warmth disease that erupts in the autumn, and is actually a pattern of autumn-warmth confined with dampness.
11. Autumn-dryness refers to a pattern of dry heat in autumn that actually has nothing to do with warm disease.

If this type of explanation is correct then my opinion is that after we resolve newly contracted and lurking pathogen issue, then spring-warmth, wind-warmth, summerheat-warmth, autumn-warmth and winter-warmth all can be unified. Damp-warmth, warm-epidemic, warm-toxin can be preserved [as their own disease]. Lurking-summerheat and autumn-dryness should belong to the scope of summerheat disease and dry disease [respectively]. Warm-malaria should be in the scope of malaria. Our forefathers  realised that these all belong to externally contracted heat diseases. However, their classification methods were fairly problematic.

Hence, if we could unify cold damage and warm disease theory, systematise warm disease theory, sort out the summerheat, autumn dryness and epidemic pestilence patterns, then Chinese medicine’s externally contracted disease theory could be integrated.

In regard to the issue of warm disease systematisation, the beginning of the book. The Importantly Revised and Expanded Discourse on Warm-Heat Disease (Zhong Ding Guang Wen Re Lun) points out “five methods for differentiating warm-heat diseases”. Immediately  following are the “treatment methods for the fundamental warm-heat disease pattern”, “treatment methods for concurrent warm-heat disease patterns” and “treatment methods for warm-heat complicated patterns”. That is, this “fundamental warm-heat disease pattern” is caused by a single basic warm disease pathogen. The book presents this fundamental presentation and its transmutations.

Thus there is the basic pattern with its possible associated pathogens (e.g. wind, dampness, toxin), as well as conditions that may complicate this basic pattern such as phlegm-water, by blood amassment, or by Spleen deficiency or Kidney deficiency. This type of organisational method enables one to understand the overall picture, as well as aiding in differentiating the primary and secondary issues.

By using such academic thinking and analysis of these issues, we have a relatively more advanced understanding as [compared to the past].

This article was originally published in The Lantern, Volume VIII, Issue 2 — 2011, as part of a larger essay entitled Some issues in warm disease Three essays from Qin Bo-Wei. Three essays from Qin Bo-Wei.

Original Essay from: Some Ideas I Have Learned About Warm Disease published in 1963.

[Patient] Zhao (44) [suffered from] chronic constraint and clumping. The five emotions had lead to ascending qi fire. There was Stomach qi counterflow resulting in a stifling sensation of the gastric cavity and no appetite. [This was a pattern of] excessive ascendant Liver yang and wind fire intimidating the orifices. Inevitably there was dizziness and painful obstruction of the throat. There was a feeling of cold, but this was not true cold. All of these signs are due to qi painful obstruction and lack of free flow. This disease [can be understood] from [the classic] phrase, “All clenching, shuddering, and chattering [of the jaws] belongs to fire.” [In addition] Dan Xi said, qi that ascends is from Liver and Gallbladder ministerial fire that does not have a place to reside.

sheng di huang (Rehmanniae Radix)
e jiao (Asini Corii Colla)
xuan shen (Scrophulariae Radix)
mu dan pi (Moutan Cortex)
shi hu (Dendrobii Herba)
hei dou pi (black bean skin)

Translated by: Jason Blalack

Original Chinese: 赵（四四） 郁勃日久。五志气火上升。胃气逆则脘闷不饥。肝阳上僭。风火凌窍。必旋晕咽痹。自觉冷者。非真寒也。皆气痹不通之象。病能篇以诸禁鼓栗属火。丹溪谓上升之气。从肝胆相火。非无据矣。 生地 阿胶 玄参 丹参 川斛 黑 豆皮

Source: Case from the constraint chapter of Case Records as a Guide to Clinical Practice (Lín zhèng zhî nán yï àn) 《临证指南医案》.

Commentary: I found this case quite instructive. This is a classic Ye Tian-Shi case in that there are multiple symptoms that can be viewed in many ways (secondary patterns) yet Ye focuses on the underlying pathodynamic, addressing all of them in a simple elegant formula.

The way I like to read such cases is to examine how these “other” symptoms can be caused from the pathodynamic that is addressed. That is,we know that such a patient could have red eyes, dry mouth, thirst, a rapid and thin pulse, etc. These are not mentioned because they are obvious. However, the key unusual symptoms are mentioned and this is what we focus our learning on. For example, a question to ask is, why is there low appetite, painful obstruction of the throat, stifling sensation in the gastric cavity, a sensation of cold and how is it related to the diagnosis, the pathodynamic, and addressed in this formula? One can assume that Ye believes that these symptoms will be eliminated with the above formula, which is addressing the root.

Hence from such cases, we can learn that we need not load our formulas with unnecessary symptomatic herbs (that may even be counterproductive) if we properly address the underlying pathodynamic, consequently, teaching us how to keep our formulas small and compact.

Therefore we see a focus on yin and blood deficiency with heat even though there is ascending wind, yang, and fire.  Ye only uses the mild hei dou pi (black bean skin) to calm and descend the Liver yang, which also nourishes yin and blood (and enriches the Kidney yin). {BTW, this is also called 穭豆衣 (lu dou yi) and I have used this herb and idea successfully often in the clinic.}

We also learn that a fire condition can produce a sensation of cold and one does not need to warm the patient. This is often occurs  from constraint. I also find it interesting that there are clear signs of stomach involvement (low appetite, stifling sensation) and Ye does not move qi (which would damage to yin). The only moving herb is mu dan pi. He also does not try to tonify qi (with warm medicinals) just because there is a low appetite. Hence we learn that the Stomach involvement (even the stifling sensation) can arise from yin deficiency. If one addresses the root and the symptoms improve. Clearly, there was not enough evidence to lead Ye to believe that there was a true underlying Spleen and Stomach deficiency which might make the digestion of yin tonic herbs difficult. This is of course inferred.

The phrase “qi that ascends is from Liver and Gallbladder ministerial fire that does not have a place to reside” simply illustrates the need to build yin (place to reside) to control yang. Also “painful obstruction of the throat” is not only painful but often red and swollen.

I would love to hear what others see in this case…

[Patient] Ni had lots of pain and ascending yang. The yin fluids were endlessly pouring out from the upper part of the body. The tongue was dried-up and red-crimson colored. There was irritability and inability to sleep. It was suitable to augment the Kidney water in order to control Heart fire.

xian sheng di (fresh Rehmanniae Radix)
xuan shen (scrophularia, ningpo figwort root)
mai men dong (Ophiopogonis Radix)
lu dou pi (Phaseoli Radiati Testa)
jin yin hua (Lonicerae Flos)
zhu ye xin (Lophatheri Folium Immaturum)

Translated by: Jason Blalack

Original Chinese: 倪 多痛阳升。阴液无以上注。舌涸赤绛。烦不成寐。当益肾水以制心火。（心火）鲜生地 元参 麦冬 绿豆皮 银花 竹叶心

Source: Case from the Insomnia chapter of Case Records as a Guide to Clinical Practice (Lín zhèng zhî nán yï àn) 《临证指南医案》.

Commentary:

lu dou pi (Phaseoli Radiati Testa) is cold and sweet. It resolves heat toxin, clears wind-heat, eliminates eye screen (目翳), transforms maculopapular eruption, and disperses swelling and distention. From: 《纲目》& 《随息居饮食谱》

Comments?

Original Case by:

[Patient] Gu (age 44) had already greying whiskers and hair on the temples. His facial complexion though was bright. He was emotionally worried and irritable. [There was] yang ascending and agitating [the spirit] with phlegm and thin mucus also ascending and overflowing.  The divine pivot says, when yang qi descends, joins and enter the yin, then the yang qiao vessel is full and one is able to sleep. [At this moment though] qi was disseminating and discharging outward and yang was not entering yin. He would drink alcohol in hopes of muddling his consciousness enough so he could sleep. This was not a good method for managing this disease. In middle age and afterwards, men’s lower base is the first to become depleted. [The treatment] was to use Eight-Ingredient Pill (ba wei wan) in the morning and Pinellia and Millet Decoction (ban xia shu mi tang) in the evening. (yang qiao vessel deficiency).

Translated by: Jason Blalack

Original Chinese: 顾（四四） 须鬓已苍。面色光亮。操心烦劳。阳上升动。痰饮亦得上溢。灵枢云。阳气下交入阴。阳跷脉满。令人得寐。今气越外泄。阳不入阴。勉饮酒醴。欲其神昏假寐。非调病之法程。凡中年已后。男子下元先损。早上宜用八味丸。晚时用半夏秫米汤。（阳跷脉虚）

Source: Case from the Insomnia chapter of Case Records as a Guide to Clinical Practice (临证指南医案 lin zheng zhi nan yi an).

Commentary: This case shows one approach to dealing with complex patterns of excess and deficiency, giving separate formulas at different times of day. I often give a daytime and nighttime formula for insomnia. Ye uses his typical style of focusing on the pathodynamics and uses little in the way symptomatic “sleep” herbs. Brilliant! Eight-Ingredient Pill (ba wei wan) is another name for Kidney Qi Pill (shen qi wan). Pinellia and Millet Decoction (ban xia shu mi tang) is from the Divine Pivot and contains Pinelliae Rhizoma preparatum (zhi ban xia) and  Setariae Fructus (shu mi).

(Case 6) – from Understanding Case Records Pt. 2

A 10 year-old presented with a mild cough and tidal fever. This was caused by childhood yin exhaustion and qi aspect heat.

Di Gu Pi 3 qian (Lycii Cortex)
Qing Hao 1 qian (Artemisiae Annuae Herba)
Zhi Mu 1 qian (Anemarrhenae Rhizoma)
Gan Cao 3 fen (Glycyrrhizae Radix)
Nan Sha Shen 1 qian (Adenophorae Radix)
Shi Hu 3 qian (Dendrobii Herba)

Qin Bo-Wei’s Commentary:

This case is also a cough with Lung heat and yin exhaustion, but there is a tidal fever which in general shows that the yin exhaustion has progressed. There is incessant heat that is certainly resulting in more and more consumption of the qi and yin. This is important to consider. Nan Sha Shen (Adenophorae Radix), Gan Cao (Glycyrrhizae Radix) and Shi Hu (Dendrobii Herba) not only moisten the Lungs, but with Di Gu Pi (Lycii Cortex), Qing Hao (Artemisiae Annuae Herba) and Zhi Mu (Anemarrhenae Rhizoma) also clear heat and reduce steaming. The “mild” in “mild cough” illustrates that this is a chronic disease with an infrequent cough. Therefore he did not use Xing Ren (Armeniacae Semen) or Chuan Bei Mu (Fritillariae cirrhosae Bulbus).

Translated by: Jason Blalack

Original Chinese: 十岁，嗽缓，潮热，稚年阴亏，气热所致。地骨皮(三钱)、青蒿(一钱)、知母(一钱)、生甘草(三分)、南沙叁(一 钱)、川斛(三钱)。

按:此案亦咳嗽肺热阴亏，但有潮热则比一般阴亏更进一步，热不止，势必气阴愈受消耗，所以特别提出。并用沙参、甘草、石斜润肺外，加入地骨皮、青莆、知母清热退蒸。咳缓的缓字，说明病已经久，咳己不繁，故不用杏仁、川贝之属。

Source: Case from the Cough chapter of Case Records as a Guide to Clinical Practice (lín zhèng zhî nán yï àn) 《临证指南医案》. Commentary from Complete Famous Medical Works of Qin Bo-Wei.

Comments?

(Case 5) – from Understanding Case Records Pt. 2

There was exhausted yin existing in conjunction with contraction of a warm pathogen. There was a cough and head distention. It is suitable to use a light formula.

sang ye (Mori Folium)
xing ren (Armeniacae Semen)
chuan bei mu (Fritillariae cirrhosae Bulbus)
bei sha shen (Glehniae Radix)
sheng gan cao (Glycyrrhizae Radix)
tian shui li pi (Pyri Exocarpium) (pear peel)

Qin Bo-Wei’s Commentary:

This and the previous case’s symptoms and cause of disease are identical. In this case there was constitutional yin exhaustion, and moreover the condition is not occurring in conjunction with wind or damp. Therefore Ye used Sang Ye (Mori Folium), Xing Ren (Armeniacae Semen), and Chuan Bei Mu (Fritillariae Cirrhosae Bulbus) to clear and transform the upper burner phlegm heat while simultaneously using Bei Sha Shen (Glehniae Radix), Gan Cao (Glycyrrhizae Radix), and Li Pi (Pyri Exocarpium) to clear and moisten. This “light formula” refers to the idea that “when the condition is located in the upper burner treat like a feather; unless one’s touch is light, one will be unable to grasp it.” It does not refer to dosages.

Translated by: Jason Blalack

Original Chinese: 阴亏挟受温邪，咳嗽、头胀，当以轻药。桑叶 杏仁 川贝 白沙参 生甘草 甜水梨皮

Source: Case from the Cough chapter of Case Records as a Guide to Clinical Practice (Lín zhèng zhî nán yï àn) 《临证指南医案》. Commentary from Complete Famous Medical Works of Qin Bo-Wei.

Comments?

A warm pathogen assaulted the outer body. There was a cough and head distention. It is appropriate to clear the upper burner. [The prescription given was]

Xing Ren (Armeniacae Semen)
Sang Bai Pi (Mori Cortex)
Jie Geng (Platycodi Radix)
Zhe Bei Mu (Fritillariae Thunbergii Bulbus)
Tong Cao (Tetrapanacis Medulla)
Lu Gen (Phragmitis Rhizoma)

Qin Bo-Wei’s Commentary: This case’s only presenting symptoms are cough and head distention, making it difficult to come up with a clear diagnosis. However since we are given the diagnosis of “warm pathogen assaulting the outer body” we can deduce additional symptoms that are related to wind warmth. From the section of Ye Tian-Shi’s text entitled “Externally-contracted Warm Heat” we get a better idea of what this means. For example,

When a warm pathogen assaults the outer body, it first accosts the Lungs.”

Also there is,

The Lungs govern the qi and connect with the skin and body hair. Therefore [the Lungs] reside in the exterior. When the pathogen is in the exterior one should first use an acrid, cool, and light prescription. If occurring in conjunction with wind then one should add Bo He (Menthae haplocalycis Herba) and Niu Bang Zi (Arctii Fructus). If occurring in conjunction with damp one should add Lu Gen (Phragmitis Rhizoma) and Hua Shi (Talcum). This will, respectively, vent the wind to the outside of the heat, or leach the damp away from under the heat, so that [neither of these pathogens] interacts with the heat, and it will be isolated.”

It can be seen that in this case that the cough is the chief patho-condition, but there also should be concurrent symptoms such as headache, phlegm that is difficult to cough up, dry mouth, scanty yellow urination etc. The pulse and tongue was not given, but it ought to be something along the lines of a slippery and rapid pulse with a yellow greasy coat. Therefore the formula uses Xing Ren (Armeniacae Semen), Zhe Bei Mu (Fritillariae Thunbergii Bulbus), and Jie Geng (Platycodi Radix) to dispel wind [by diffusing the Lungs and transforming] phlegm. Sang Bai Pi (Mori Cortex) was used to clear heat. All of these focus on the Lungs. In addition Tong Cao (Tetrapanacis Medulla) and Lu Gen (Phragmitis Rhizoma) were added to clear heat and leach out dampness through their bland flavor.

Translated by: Jason Blalack

Original Chinese: 案四:温邪外袭，咳嗽、头胀，当清上焦。杏仁、桑皮、桔梗、象贝、通草、芦根.

Source: Case from the Cough chapter of Case Records as a Guide to Clinical Practice (Lín zhèng zhî nán yï àn) 《临证指南医案》. Commentary from Complete Famous Medical Works of Qin Bo-Wei.

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).