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.
- 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.
- 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.
- 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. 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 4: Cough – Warm pathogen
* please post any comments or questions
 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).