Understanding Case Records Pt. 1
Further 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:
- Many of the cases are extremely terse, giving only one or two symptoms and then a formula (and sometimes not).
- There is no mention of follow-through or results of the case.
- He does not seem to follow a system and his formulas show little resemblance to standard formulas.
- 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.
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.
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.
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.
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.