Understanding Ye Tian Shi’s Cases

Charles Chace recently brought this following passage to my attention. We both found it interesting in helping to understand Ye Tian-Shi’s case studies and putting into context the shorthand style that his cases are presented in. It is an excerpt from Thinking with Cases — Specialist Knowledge and Chinese Cultural History(2007) by Charlotte Furth. A great read.

“… the admirers of Ye Gui (1666-1745) saw to it that after his death some of this legendary doctor’s personal clinical records found their way into best-selling collections. Of these, Medical Cases as a Guide to Clinical Practice (Lin zheng zhinan yi’an), published in 1768, was the most authoritative and enduringly popular (there survive thirty-nine editions printed before tlIe end of the imperial era). A clinically oriented innovator from a hereditary medical family in Suzhou, Ye established a model style of case history that continues to be admired and imitated even today. Stripped of storytelling flourishes or social detail concerning the patients’ identities, Ye’s cases offered a laconic narrative that cut through the presenting symptoms to an underlying diagnostic pattern and concentrated on a customized prescription formula. The “Organizing Principles” (Fanli) that introduced the first edition of the collection help explain its thinking. They warn of the limitations of the nosological categories that constitute the surface organization of the section headings. By the selection and arrangement of cases within each category, the reader is being taught to distinguish between easily recognizable symptoms and syndromes (zheng, clusters of symptoms) and the more subtle “diagnostic patterns” (zhenghou) that identify the disorder at the most fundamental level.

Thus the nosological problem of pattern versus sign – of difference underlying similarity and similarity masking difference – is tackled head on.

Diagnostic patterns are complex: if you wish to investigate them, it is difficult to generalize. Undeterred by my ignorance, I have divided cases into sections and classes [fen men lei]. But multiple patterns are common: for example “depletion exhaustion,” “cough,” “spitting up blood” can all manifest one underlying diagnostic pattern. To divide these into different sections is to separate what belongs together. Then a cough may be a case of repletion or depletion, it may be a superficial symptom or a fundamental problem, or it may be caused by anyone of the six seasonal forms of qi. To unite these into one section is to unite what should be separate. When “summer damp” is combined with “periodic fever and dysentery,” or “Spleen function disorder” is combined with “vomiting and abdominal swelling” the overall problems multiply, and finding a satisfactory analytic category is not easy.”

Within each nosological label Ye’s collection gathered a large selection of seemingly similar cases illustrating different underlying disease patterns. Even small differences remaining [between cases] are full of significance and … if [the number of cases were] subtracted still more, one would not be able to show the master’s unerring touch, or the beauty of the myriad variations in his prescription art.”

Ye had a signature style of prescribing, preferring formulas featuring a relatively small number of mild and neutral ingredients, and he displeased traditionalists by dropping some old nosological categories like Fire, popular in the Ming dynasty. In particular he reorganized the venerable Cold Damage category, which he clearly believed overgeneralized a wide variety of syndromes marked by symptoms of heat and fever. What mattered most was the way these case histories showed distinct, deep diagnostic patterns at work in superficially similar cases and the way an informed expert could read those patterns back from the materia medica selected for a cure. Significantly, Ye’s case records did not report outcomes, being content to demonstrate the underlying principles linking disorder and remedy in each instance. Cutting to the core this way, Ye’ s cases left out the discursive fabric of social life-the contingent situations and social relations of healing. It even left out the symptomatic noise-changing manifestations of a messy clinical encounter that a practitioner needed to consider in determining what clue mattered most to a diagnosis. The case was pared down to a demonstration of the hermeneutics of prescriptions themselves.

Some of Ye’s enduring prestige came from innovations that were later identified with a modernist school of Warm Factor disorders. Some of the laconic quality of his cases reflected the Qing-dynasty setting where famous physicians more and more received patients in their clinics and had students and junior disciples take case notes that were copied for the client to take away (and therefore highlighted the prescription but did not record the outcome). His style of thinking with cases is also evidence for the increasing professionalization of medicine – a process no less genuine for being expressed through lineage affiliation, discipleship, and social networks of “scholarly currents” rather than the formal organizations of Western social theory. While clients took away prescription formulas to be filled, these eighteenth-century case records demanded initiated readers who understood the deep structure of such formulas. Rather than pleading for more careful record keeping, Qing physicians expected an audience of specialists skilled at decoding medical shorthand. Medicine was still personal, the literati physician was still important as a moral ideal, and many case collections still featured anecdotes and stories. But as doctrinal controversies in the eighteenth century and after shifted to questions of the value of medical classicism itself, case history collections following those of Yu Zhen and Ye Gui can be seen as textual vehicles for busy clinicians and teachers, medical modernists and innovators. Further, in this way the record of medical cases themselves came gradually to represent medicine’s recent history. The case genre, always especially well adapted to the model of disease as situational and of medical qualification as a kind of virtuosity vested in persons and revealed in action, in the long run was a mode of producing specialist knowledge that also fostered the modern twentieth-century definition of Chinese medicine as above all a “practice” whose essence was to be found in the clinical experience of eminent “senior physicians”.”

Note: Original endnotes have been omitted.

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