Understanding Case Records Pt. 1

 In Misc. CM articles

YTS_01Further thoughts on understanding Ye Tian-Shi’s case records.

By: Jason Blalack

Ye Tian-Shi is quite arguably one of the most important clinicians in Chinese medical history. His most important contribution, Case Records as a Guide to Clinical Practice (lin zheng zhi nan), is a compilation of case records by his students. It should be noted that, for a period of time in the Qing Dynasty that doctors/students would only study this book while ignoring the “classics.” Although criticized for this by their teachers, it definitely demonstrates the impact that Ye’s case records had on medicine.

Many often complain about the complexity and the difficulty in understanding Ye’s cases. Some of the issues that I have encountered are:

  1. Many of the cases are extremely terse, giving only one or two symptoms and then a formula (and sometimes not).
  2. There is no mention of follow-through or results of the case.
  3. He does not seem to follow a system and his formulas show little resemblance to standard formulas.
  4. His formulas often do not “seem” to address the chief complaint.

Fortunately, through talking with people much smarter than me, translating numerous cases, as well as working with doctors in China, I am starting to get an idea of how to resolve these issues and approach his works. Actually, these ideas can be applied to most case studies. Here are a few thoughts.

1) Why so terse?

These cases were recorded and compiled by his students. Observing doctors in modern Chinese clinics can give some further insight into what this means and how this can be applied to understanding Ye’s cases.

To elaborate, herbal consults are usually of short duration (sometimes only five minutes). Most seasoned Chinese doctors are very good at asking only the key questions needed to make a diagnosis. Students, therefore, only have a limited amount of information to write down. This is most likely not unlike Ye’s students and hence reflected in the cases we read. On a side note, understanding why these few symptoms (or questions) are significant can be incredibly helpful in perfecting our intake and diagnostic skills.

Furthermore, doctors usually only say a few words (if any) about cases, which is mostly dependent on time (or interest).

Therefore, when a case record does not say something it means very little, yet when it does it is very significant.”

Apart from the one or two symptoms that are the most distinguishing features of the case, an important skill to develop is learning how to properly deduce other possible symptoms based on the formula or other cases.

Hence, an important strategy is comparing multiple case studies with similar formulas. However, we must not make the mistake of assuming that because a specific comment (e.g. diagnosis) is in one case and does not appear in another that it is meaningful. For example, we may have a case that has a diagnosis of “damage to the eight extraordinary vessels” and a similar case that mentions nothing about the extraordinary vessels. We cannot assume that the latter case was not originally considered an eight extraordinary vessels case. This lack of information is not helpful.

2. Results / Outcome?

Most case studies do not mention results nor follow-up visits. This is also true with many cases that we see in China. However, fixating on the result is far from the issue. Understanding and learning the thinking from a specific doctor is the issue. Obviously, we do not want to follow a doctor that does not get results. But I think we can safely assume that Mr. Ye has stood the test of time enough for us to learn from his thinking.

3. Did Ye Tian-Shi have a system?

Ye was extremely educated in classical texts and he certainly had a thinking process when writing his formulas. He quite simply, had grasped the underlying principles of Chinese medicine and classic formulas and applied them flexibly to individual patients that he saw. He certainly was not opening up an internal medicine textbook and picking a pattern/formula that matched a specific disease.

He was an eclectic who was not afraid of using newly developed theories Warm Disease (wen bing) as well as old classic Cold Damage (shang han) ideas. Eclectics are always difficult to follow, since they pull ideas from multiple places and essentially do not follow one school of thought. It should be noted that the Systematic Differentiation of Warm Pathogen Diseases (wën bìng tiáo biàn) by Wu Tong was created by systematizing many of Ye’s cases and creating famous formulas that we now find in our modern textbooks such as yinqiaosan.

However, because he isn’t just following a set system we must give some liberty into possible “inconsistencies” that may be contained within formulas due to differences in time and development of his own ideas. This really hit home after watching a 75-year-old Chinese doctor practice over many years time. One might think that even a seasoned professional has figured out what he likes to do and just does it. However, over many years time I would notice that he had new ideas and was constantly shifting things around to better his formulas. He is far from ossified. Therefore leaving out a specific medicinal (or including it) might not be as significant as we think because at that point in time he might just have not been using it. We cannot be too rigid in our conclusions and be open to learning from the broad base of his case records.

As noted above, looking at cases in context of other similar cases is essential. Essentially, one has to learn how a specific doctor thought about a given herb by when he uses or omits it in different circumstances. For example, note the removal of bai zhu in this Xiao Yao San case. This becomes increasingly more difficult to understand when the doctor does not use standard formulas. At first glance, Ye’s cases, although usually only containing a few number of medicinals, are difficult to relate to a “common” formula.

4. How important is the chief complaint?

I feel that the difficulty many of us have with this style is our inherent methodology for determining a formula. For example, we often put the chief complaint/disease at the forefront of our thinking process, opening up our modern textbooks, which is organized by disease, pick the closest pattern and consequently a formula. Even Ye’s case record books are organized by disease. Although obviously the chief complaint is important, it is also clear that Ye rarely gets fixated on this issue. He really is treating the person in front of him and a pattern(s) that present. Hence, the appeal (and difficulty) that many people find in studying his cases.

Furthermore, Ye clearly knew classical formulas that came before him. In a few instances he actually gives them unmodified. However, the majority of the time he is treating based on the principles of these classic formulas using medicinals that many times were not even around when these formulas were written.

The important thing to grasp is Ye’s understanding of pathodynamics underlying the complaint. Notice the case, Constraint Harming the Heart yang, the chief complaint takes backseat to the underlying pattern. Such an approach is far from an anything goes mentality (just making up theory) but firmly rests on a sound understanding of human physiology. That is not to say, he always addresses the root cause and not the branch. But, his ability to see the core pathodynamic is one reason people like Ye’s cases so much.

Finally, the key to understanding case studies in general is not how it fits into our paradigm of thinking but more importantly how the given doctor is conceptualizing the case. We really need to ask, what is this case trying to teach us, not, “how do I understand this case”, or ” I would have done it this way…”

Also check out, the previous post, Understanding Ye Tian-Shi Case Studies.

Please feel free to make any comments or criticisms on this essay.

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Showing 7 comments
  • Gabriel Fuentes

    Great post Jason!

  • Thomas Avery Garran

    Thanks for being such a proponent of reading these old case studies. Not sure where you find the time to have a life outside of all the stuff you do, but keep it up, it is very much appreciated!

  • Ruth Neely

    A thought that runs through my mind reading this: How much of what herbs he choose had to do with what he had on hand at the time, rather than simply thinking he had all choices available at all times. We are used to buying whatever we want whenever we want from anywhere in the world. That was not the case in the times we are discussing here, although never part of the thought process when examining ancient practitioners (so far as I have ever seen).

  • Sharon Sherman

    Thank you very much for taking the time to post these cases. It’s really great to try and bend one’s mind around new ideas, interpretations and applications. Thanks again for sharing the information!

  • Thomas Avery Garran

    Ruth, this is a good point and one I have thought about. I would say that in the case of many of these “famous” physicians they had most of what they wanted, most of the time, although there is no way (or it would be extremely difficult if not impossible) to know how well stocked Ye Tian-shi’s pharmacy was at any given moment. So, although we can discuss this and it would make for some very interesting research, it is probably mute because there is likely no way to find the answer to that question. Also, even if we knew the answer for a particular time, say the Summer of 1740, we would need to connect written case histories to that period. While it sure would shed some light on the subject, I don’t think you’re going to find too many people willing to spend the amount of time that would be necessary trying to find those answers.

  • Michael Tierra

    Jason, i appreciate your trying to explain Ye Tian shi’s case studies — but either there’s something I’m missing or I don’t see how no 1 and no 2 together add up to an approach one can emulate, duplicate or whatever one can say.

    For me no. 1 explains why Ye’s cases are terse not whether the terseness points to anything that can be emulated by clinicians today.

    Of course it is true that “Therefore, when a case record does not say something it means very little, yet when it does it is very significant.” — but not having read any of Ye’s cases (where are these available in English), does he only describe the symptom i.e. named TCM disease? I can’t see how it can be very practically useful if there is no explanation why a particular pattern or symptomology is observed or notable.

    As to no 2 — it gives a lot to say that one prescribes a treatment protocol but does not follow up with the results.

    On the face of it I maintain a more questioning (I don’t know that I mean skeptical) attitude towards theory. The history of medicine is rife with elitist doctors who sequester themselves in chambers to discuss the application of their theories usually on selected cases often at the expense of attending to the trenches of relieving the suffering of patients.

    Medicine during the European renaissance was famous for this. Doctors spoke in Latin not only because it was a common professional language but also to keep the knowledge of healing an elitist art, and to keep common approaches, plants and substances used away from the masses — in other words — to protect their profession. I suspect that this tendency is true in the case of the use of TCM jargon and Ayurvedic jargon. What’s at risk is that just as common phrases and words are capable of misunderstanding — uncommon phrases, terms and jargon is even more capable of misunderstanding. I think this is why TCM process stresses giving a treatment principle — it’s at least partially to clarify what is intended by the diagnosis.

    I’m very interested in your own and other’s thoughts on this.

    • Jason Blalack

      Thanks for the post. These are good questions which I will try to address the best I can.

      1) Reading these case studies takes a certain amount of patience and the development of a skill. Certainly, things are not spelled out in significant detail and consequently one must essentially learn “how to read” these case studies. I’m currently working on a formal essay detailing how to do this with specific examples etc.; it should be ready for publication soon.

      But essentially it is like a code, once one knows how to decipher it, then things become much clearer. However, if you have never spent time with such case studies then at first it may be very difficult to use. It takes work and contemplation. Please feel free to ask any specific questions about any case and we can try to decipher things together. One useful strategy is to compare similar case studies. For example, I have posted 15 Ye Tian-Shi case studies on constraint.

      FTR, most pre-modern / classical case studies were written in this terse fashion and a) they first required the reader to have a certain level of proficiency, and b) required the reader to figure things out for themselves. Although this is not easy, there is great reward in struggling through this process. When one contemplates complex issues one gains an understanding that is much deeper than if the answers were just given to them. This seems to be a common theme in Chinese medicine literature. But in the end, yes (you are right) there is no explanation.

      However, we know that Chinese doctors have been successfully using Ye Tian-Shi’s cases for hundreds of years now. Many famous doctors have written about them, designed formulas around them, and base their style around them. For example, as you may all know, Wu Ju-Tong created formulas such as yin qiao san and sang ju yin from Ye’s cases. So we know that these cases, even though terse, can be successfully applied by clinicians today.

      For the record, I’ve been applying Ye’s ideas successfully for some time now. For example, two out of the four of my case studies that I recently posted have formulas that were taken directly from ideas from Ye’s case studies. They were only in my mind because I had been studying and thinking about them. (1-10, 5-26).

      The more one reads the more one can start to think in this “direct” manner. There is unfortunately very little published by Ye in English, hence why I have decided to start putting them on my website. To date I have translated hundreds of his case studies and plan to put them up one at a time. This idea of posting them slowly is so that people can digest them. So if you would like to follow along on the ride we all can try to learn together. Here is a list of all the current Ye Tian-Shi case studies.

      2) To address your second question: It is my opinion that the actual “result” is really not the issue. The issue is how to learn to think like Ye. Unless Ye has duped hundreds of thousands of Chinese medical doctors (for 100s of years) we can be fairly certain that his methods (way of thinking) are effective. They work for me!

      We also know that he was not some elitist doctor. He was in the trenches seeing patients and many believe he didn’t write a single book or essay etc. because of this fact. His case studies were recorded by his students and then later published. Many famous *clinicians* have emulated him and we find this in their case studies and writings. Therefore, one of the major points of studying someone like Ye is that he is extremely practical and not overburdened with excess theory, although it is clear that he is very well educated. But I do agree with you, that there are many examples of Chinese medical books and theory that are more from the hands of elitists than the actual doctors, but I do not think this is one of those cases.

      For further reading check out my previous post, Understanding Ye Tian Shi’s Cases.

      If I missed something, something was not clear, or you just disagree, please let me know…

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