The Hermeneutics of a Song Dynasty Case Record

By Stephen Boyanton, Ph.D.

The genre of medical cases (yi’an 醫案) did not become widespread in China until the Ming (1368-1644), but medical cases were recorded long before. Arguably, the records of ritual healing found on oracle bones are the earliest medical case records found in China—and among the earliest examples of writing in China as well. Later examples, such as the cases of Chunyu Yi (淳于意, b. 216 or 206 BCE) contained in Records of the Historian (Shiji 史記) are both more detailed and more in line with what we now understand as “medicine”—a system of healing possessed of a textual corpus and largely eschewing ritual practice in favor of physical interventions and pharmaceutical therapy—but were preserved, like their oracle bone predecessors, for reasons mostly unrelated to their medical content. In the Song (960-1279), although the term “medical cases” was not yet in use, records of clinical interactions first began to be compiled as a major or sole component of books. The reasons for this development are complex and beyond the scope of this post. Instead, I would like to query the hermeneutics of the Song case record literature. How were these records meant to be understood? What purposes did they serve? To begin answering these questions, I look at an example from one of one of the pioneers of this genre, Xu Shuwei (許叔微, 1080-1154)—a member of the literati-elite, holder of the prestigious jinshi degree, and avid proponent of the Han Dynasty (206 BCE-220 CE) medical text, the Treatise on Cold Damage (Shanghan lun 傷寒論). Xu produced the first book completely devoted to case records, Ninety Discourses on Cold Damage 傷寒九十論, and included many such records in his other works, most notably Efficacious Formulae for Universal Aid (Puji benshifang 普濟本事方). The case I translate and examine below is taken from the ninth fascicle of Efficacious Formulae. It follows a description of a formula from the Treatise on Cold Damage, Minor Bupleurum Decoction (Xiao chaihu tang 小柴胡湯). Throughout this book, Xu frequently followed a formula with a case record including its use. Their position clearly indicates that their purpose is explanatory and pedagogical, but their content is often far from straightforward. Translation and Commentary Xu opens this case record by describing the circumstances in which he found the patient:

            I recall that there was a person who had suffered from cold damage for five or six days. He was sweating from his head, but from the neck downward there was no sweating. His hands and feet were cold; he felt fullness and oppression in his epigastrium, and he was constipated. Another [physician], seeing the cold extremities and also the sweating and fullness, took it to be a yin pattern [of illness]. I diagnosed the patient’s pulse and found it to be sunken and tight.

            I said, “This pattern can certainly give rise to doubt. However, the stool is bound, and it is not a vacuity-bind. How can take it as a yin [pattern]? Although a sunken and tight pulse indicates a lesser yin pattern, they are mostly patterns of spontaneous diarrhea. There has never yet been a case of constipation [with this diagnosis]. Know that this pattern is half in the interior, half in the exterior. Prescribe Minor Bupleurum Decoction and you will obtain a cure.

A common feature of Xu’s cases is the attention he pays to his arguments with other physicians present. Well-off families frequently consulted more than one healer and often made use of more than one healing modality. Even a very elite physician like Xu had to argue down the other physicians present in order to win the confidence of the patient’s family, but unlike some of Xu’s other case records, the emphasis here is not on the ignorance of his opponents so much as it is on content of Xu’s resolution of the “doubts” surrounding this case:

            “Zhongjing said, ‘In cold damage after four or five days, there is sweating from the head, slight aversion to cold, cold hands and feet, and fullness of the epigastrium. [The patient’s] mouth does not wish to eat, and his stool is hard. The pulse is fine. This is debilitation and binding of the yang. There must be [illness] in both the exterior and the interior. A sunken pulse also indicates [an illness in] the interior. Sweating indicates debilitated yang. If it were completely binding of the yin, it could not also have an external pattern. It would completely enter into the interior. This is half in the interior and half in the exterior. Even if the pulse is sunken and tight, it cannot be taken as a lesser yin [pattern]. Why is this so? Yin [patterns] cannot have sweating. Now the head is sweating, therefore we know that it is not a lesser yin [pattern]. You can give Minor Bupleurum Decoction. If [the patient] does not recover completely, obtain a bowel movement and [the illness] will resolve.’ This pattern of illness is the same; therefore, if we obtain a bowel movement [the illness] will resolve.

In defense of his position, Xu quotes from the Treatise at length (this is line 148). Throughout his case records this is the most common tactic he uses to overcome objections to his proposed treatments. In this case, the match between the patient’s symptoms and the line from the Treatise on Cold Damage is precise and nearly complete. In the original Chinese, the similarity is so pronounced the reader could be forgiven for thinking a scribe had accidentally copied the same passage twice. Xu’s reading of this particular line, however, is somewhat idiosyncratic. The terms I have translated as “debilitation and binding of the yang (yang wei jie 陽微結) are read by most commentators as “mild binding of the yang.” Both readings are grammatically possible, but I have found no other commentator who agrees with Xu’s interpretation.

            One person objected, “Zhongjing said, ‘If the yin and yang of the patient’s pulse are both tight, but contrary to expectations he is sweating, the yang has perished, this pertains to lesser yin.’ How can you now say that ‘Yin patterns cannot have sweating?’ How is it that [seeing] sweating from the head you can then know that it is not a lesser yin pattern?”

In most of Xu’s case records, his opponents are depicted as ignorant and unable to quote the medical classics—particularly the Treatise on Cold Damage. In this record, however, at least one of his opponents has a solid knowledge of the Treatise and accurately quotes from it (line 283) disputing Xu’s conclusions.

            I said, “This passage is truly one of the places where Zhongjing critically analyzes [a clinical situation]. The significance [of this passage] is that cold of the four limbs, a sunken and tight pulse, and fullness are all similar to lesser yin [patterns]; however, hard stools and [only] sweating from the head cannot be lesser yin [patterns]. Since the head is where the three yang [channels] gather together while the three yin [channels] turn back on reaching the chest, it must be that when there is sweating from the head [alone], it is naturally [due to] yang vacuity. Therefore, [Zhongjing] says, ‘Sweating indicates debilitated yang.’ This is [the meaning of] ‘Yin cannot have sweating.’ As for a lesser yin [pattern], if there were sweating from [only] the head, [the patient] would die. Thus, in the ‘Treatise on Evaluating the Pulse’ [chapter of the Treatise on Cold Damage], Zhongjing says, ‘[In the five phases], the heart is fire. It is named lesser yin. … If there is no sweating from the head, [the patient] can be treated; if there is sweating, he will die.’ It must be because the heart [channel] is hand lesser yin and the kidney [channel] is foot lesser yin. Relative to one another they are above and below. Only by using judgement to trace it back can you obtain it.

“Critical analysis (yilun 議論)” refers to a discussion of the finer points of what is and is not so in a given situation (in Chinese shi zhi shifei 事之是非), and Xu immediately delves into just such an analysis. The problem, he informs us, with this clinical situation is that some of the signs and symptoms seem to clearly indicate a lesser yin pattern while others equally clearly argue against it. A key issue was why sweating from the head alone cannot be present in a yin pattern. Xu’s explanation draws on the fundamental ambiguity of the terms yin and yang within the Treatise on Cold Damage. The Treatise labels the primary six diseases or stages of cold damage with the names of the six categories of acupuncture channels. While many later authors drew a clear distinction between the diseases of the Treatise and the acupuncture channels that shared the same name, Song authors like Xu did not. For them, cold damage diseases were diseases of the channel for which they were named. Xu could therefore freely conflate diseases, patterns of illness, and channels. Xu reasons that since only yang acupuncture channels directly reach the head, only an illness of the yang channels could cause sweating from the head alone. Thus, this could not be a lesser yin pattern, as his interlocutor had suggested. To secure his victory, Xu quotes from the Treatise again, noting that in illnesses of the heart, patients who sweat from the head will die. Lesser yin disease in the Treatise is usually associated with the kidneys, but both the heart acupuncture channel and the kidney acupuncture channel are named lesser yin (one for the hands and one for the feet). Xu's final comment, "Only by using judgement (yi 意) to trace it back can you grasp it 惟以意逆者，斯可得之," is somewhat vague. It closely resembles a passage from the Mencius (Mengzi 孟子) in which Mencius gives instruction on how to understand one of the Odes (Shi 詩): "We use our understanding (yi 意) to trace it back to what was [originally] in the writers mind (zhi 志)—this is how to grasp it 以意逆志，是為得之." (Mencius V.A.4.ii, translated by Stephen Owen [1]). This quote was one of the mainstays of Chinese literary theory, and Xu would certainly have been familiar with it. The parallel is interesting. It suggests that Xu is giving advice for understanding medical texts in general, and that advice is very similar to the traditional method for understanding literature: use your judgement/understanding (yi 意) to understand the author's intention (by Xu's time also written yi 意). This advice would be given and applied more explicitly two centuries later by Zhu Zhenheng (朱震亨, styled Danxi 丹溪, 1281-1358, e.g., Gezhi yulun 格致餘論, "Douchuang Chenshi fang lun 痘瘡陳氏方論") and his student Wang Lü (王律, fl. mid-late 14th c., e.g., Yijing suhui ji 醫經溯洄集, "Zhang Zhongjing shanghan lifa kao 張仲景傷寒立法考“). Discussion What are we to make of this case record? The clinical details of the case receive far less space than the argument between Xu and the opposing physicians, but given the pedagogical intent of the record, attention to the reasoning behind Xu’s choices is understandable. It is also typical of Xu’s cases in general. Likewise, citing the medical classics in medical arguments—though less common than it would become—was not uncommon in the Song and was almost ubiquitous in Xu’s cases. However, the particular quotation chosen and the way in which Xu used it reveal important aspects of Xu’s general approach and his purposes in writing this case record. To understand what Xu was doing in this case record, we need to answer three questions. First, why does Xu’s description of the patient’s signs and symptoms match almost word for word the quotation from the Treatise? Second, this quote is one of the most difficult and debated lines of the Treatise. Commentators have argued over it’s meaning from Xu’s time to today and failed to reach consensus. If this case record was meant to illustrate the use of Minor Bupleurum Decoction, why did he choose such a problematic example? Finally, why in this case—unlike almost all of Xu’s others—are his opponents depicted as being conversant with the text of the Treatise on Cold Damage? For Xu, the words of the classics, properly understood, correspond exactly to clinical reality. They are not merely doctrinal principles but detailed clinical guidance. In looking to them, he did not seek general ideas but concrete diagnoses and treatments. We see this throughout his medical writings, but most especially in his case records, where he goes to great length to demonstrate that what one sees in clinical practice is identical to what one reads in the classics—particularly in the Treatise on Cold Damage. The line Xu quoted, obscure and difficult to explain, was therefore a challenge. If his approach was sound, Xu had to be able to show that even this line could be understood in a way that would make it’s clinical application straightforward. Presenting a case record in which he used this line as the basis for his treatment was an ideal way of demonstrating its clinical utility. Unfortunately, part of this line—the statement, “Yin [patterns] cannot have sweating”—appears to directly contradict other parts of the Treatise, which, in fact, frequently mention sweating as a symptom of lesser yin disease. Xu had to resolve this contradiction in order to maintain his claim that the classics were sources of practical clinical advice. A knowledgeable opponent provided the perfect opportunity to both raise this objection and defeat it. Xu’s analysis thus emphasizes the similarity of the illness pattern described by this line to lesser yin patterns of disease—cold limbs, abdominal fullness, a sunken and tight pulse—but reveals how a handful of symptoms—constipation and sweating from the head—guide us away from that diagnosis and towards a very different one. In so doing, he not only rescues this line but also gives it a proper place in the system of cold damage diagnosis and treatment. It has become one of the many lines that discuss patterns that superficially appear to be one kind of illness but on deeper investigation are found to be something else entirely. Taken as a whole, this case record vindicates both the clinical applicability of this line and the overall usefulness of Xu’s approach to medicine. An obvious question is whether this is really a case record at all. Did Xu present events that actually occurred or did he just invent them to suit his purposes? We have no way of knowing with certainty. Xu’s cases include a large amount of clinical and social detail that seem unlikely to be completely fictional. At times he identifies his patients and surely would not have falsified the basic details of their cases in so public a fashion. However, the dialogues between himself and other physicians often appear somewhat too convenient for the arguments Xu wants to make. It is possible that these debates were embellished or invented by Xu to suit his purposes. Regardless, what this example shows us is that case records could be used for a variety of purposes: self-promotion, instruction, doctrinal polemics, clinical innovation, or even exegesis. Notes [1]: Stephen Owen, Readings in Chinese Literary Thought (Cambridge: Harvard University Press, 1992), 24.