Learning to Think like Ye Tianshi

Ye Tianshi 葉天士 (1664-1746) was one of the most famous and innovative physicians in the long history of Chinese medicine. Born into a family of doctors and obviously blessed with great intelligence and talent he studied with many different teachers to become what one might call a ‘masterless’ physician: someone who did not attach himself to any existing style of practice even as he honoured the different traditions of which he became a heir. Ye Tianshi practiced in Suzhou, then China’s most prosperous city, where his skills as a physician quickly made him very famous and bestowed on him the status nowadays reserved for pop stars and football players. He remains a legend to this day who is regularly celebrated in Chinese movies and soap operas.

Within the Chinese medicine community Ye Tianshi has long been recognised for his many innovative contributions to the development of the discipline, in particular that of warm disease (wenbing 溫病) therapeutics. Usually portrayed as a kind of supplement to the long established cold damage (shanghan 傷寒) way of treating fevers, I agree with those commentators who argue that Ye Tianshi’s innovations in fact go beyond it. That is, Ye Tianshi’s warm disease therapeutics contain all of Zhang Zhongjing’s (張仲景) cold damage approach but add something else on top. In the Buddhist terminology of Zhang Nan 章楠’, a nineteenth century physician and admirer, Ye Tianshi was Zhang Zhongjing’s true dharma heir.

Unfortunately, Ye Tianshi did not leave behind any writings that directly outline his ideas. What access we have to his way of thinking and practicing medicine is contained, instead, in case records and a few brief essays collected by later admirers from his many patients and disciples. Beginning with Wu Jutong’s 吳鞠通 (1758-1836) Systematic Differentiation of Warm Diseases (Wenbing tiaobian 溫病條辨) later scholars attempted to extract from these cases a systematic theory and standardised prescriptions but in doing so invariably introduced into it their own ideas and biases.

Ever since I first came across Ye Tianshi’s case records in the early 1990s I have been fascinated by his way of practicing Chinese medicine, his flexible choice of treatment strategies, his ability to draw on all aspects of the tradition and move beyond them when necessary. Aesthetically I find his minimalist style of composing prescriptions that often consist of only five or six herbs and sometimes even less very attractive. He never shied away, though, from using twice as many herbs if circumstances demanded it and regularly used two different formulas morning and night. Diagnostically Ye Tianshi was equally flexible. His cases show that sometimes all that is needed to write a prescription is the pulse. More often it is the careful analysis of presenting symptom and signs that leads to the correct diagnosis and treatment strategy and pulse or tongue do not feature at all. He quite obviously was finely attuned to the role that climate, seasons and the social context of a patient’s life might play in the development of a disorder. As often, however, such information is entirely absent from his records and, one must assume, irrelevant to how he viewed the case. All of that has made him a model to me not just of practicing Chinese medicine but of how to become a good physician.

Following in his footsteps is a different issue though. Most of Ye Tianshi’s cases are brief and lack explanations as to the clinical reasoning behind his diagnosis, choice of treatment strategy or use of herbs and formulas. Here is an example:

Before and after episodes of stomach pain the heart (epigastrium) feels cold. There is also vomiting: bland Evodiae Fructus (dàn wú zhū yú), dry-fried Pinelliae Rhizoma (chǎo bàn xià), Piperis longi Fructus (bì bá), bland Zingiberis Rhizoma (dàn gān jiāng), Alpiniae katsumadai Semen (cǎo dòu kòu), Magnoliae officinalis Cortex (hòu pò), Citri reticulatae viride Pericarpium (qīng pí), woody Cinnamomi Ramulus (guì zhī mù)

And here another one:

Taste insipid, shortness of breath, slight pain in the stomach cavity (yang deficiency): Ginseng Radix (rén shēn), bland Aconiti Radix lateralis (dán fù zǐ), Cinnamomi Ramulus (guì zhī), dry-fried Polygalae Radix (chǎo yuǎn zhì), roasted Zingiberis Rhizoma recens (wēi jiāng)

Provided one has a reasonable understanding of pathology, herbs and formulas it is not all that difficult to relate the prescription in each case to the presenting symptoms. If one carefully compares the two cases above with each other, for instance, one sees that the first one is one of cold in the stomach leading to an accumulation of phlegm-fluids with secondary stagnation of qi and blood, while the second one is one of pure deficiency with no yang to warm the Stomach. Even on the assumption that one were as discriminating in one’s analysis of symptoms it is still a long way from there to the same elegant combination of herbs.

Both cases raise many other questions besides. What, for instance, is the exact difference between the gastric cavity (guǎn 脘) and the Heart/epigastrium (xīn 心) both in terms of anatomy and their diagnostic significance? Why does Ye Tianshi choose Polygalae Radix (yuǎn zhì), a herb associated with the Heart and spirit, to treat Stomach pain? What is the precise role of Cinnamomi Ramulus (guì zhī) in both prescriptions?

If one takes the time to compare many of Ye Tianshi’s cases with each other, not just those from the chapter on Stomach pain but also from the gynaecology chapters (because of the Stomach’s relation to the Penetrating Vessel), the chapters on vomiting and diarrhoea or on phlegm-fluids and bulging disorder (because of their relationship of the Stomach to fluid pathologies) it gradually becomes possible to formulate answers to these questions, to grasp patterns in his choice of herbs, to understand relationships between symptoms, signs and diagnoses, and to slowly get some idea of his clinical reasoning.

To give just a few examples, Cinnamomi Ramulus (guì zhī) is Ye Tianshi’s key herb for stagnation from cold in the Stomach networks. The combination of Gardeniae Fructus (zhī zǐ), Moutan Cortex (mǔ dān pí) and Mori Folium (sāng yè) is his go-to tool for treating ascendant Liver yang, which can cause pathologies almost anywhere in the body. In the treatment of stomach pain Moutan Cortex (mǔ dān pí) is substituted, however, by Toosendan Fructus (chuān liàn zǐ), often but not always in combination with Corydalis Rhizoma (yán hú suǒ), while Mori Folium (sāng yè) is omitted. The combination of Ginseng Radix (rén shēn) and Pinelliae Rhizoma praeparatum (zhì bàn xià), taken from Major Pinellia Decoction (dà bàn xià tāng), is his core combination for treating Stomach deficiency often also combined with Poria (fú líng). However, in the second case above Pinelliae Rhizoma praeparatum (zhì bàn xià) is substituted by Polygalae Radix (yuǎn zhì), while in the first case Ginseng Radix (rén shēn) is omitted because there is obviously no deficiency.

And so on, and so on …

Over the last ten years I have been blessed with the opportunity to explore Ye Tianshi’s approach to clinical practice with a group of dedicated students from Germany, Switzerland and Austria. Once a year in September we meet for a week to do nothing else than read and think Ye Tianshi. We initially spent three years looking at how Ye Tianshi employed and built upon the formulas contained in Zhang Zhongjing’s Treatise on Cold Damage and Essentials from the Golden Casket (Jinkui yaolüe 金匱要略). After that we began reading his case records, slowly and carefully. It is difficult, hard and often frustrating work, though the beautiful environment in which we meet and the supportive atmosphere in the group make it enjoyable and fun, too.

This year, we moved from merely discussing cases to experimenting in how we might do ourselves in moving independently from a case as it is presented in the original text to a treatment strategy and a prescription. Here is one of the cases we discussed in this way:

On palpation the pulse feels wiry and rough. Stomach pain that goes around to the back and is improved by eating grains (i.e. solid food). The disease has already lasted several years and entered into the Stomach networks.

Amazingly, some participants succeeded in coming up with Ye Tianshi’s precise formula for treating this case: sweet Cinnamomi Ramulus (tían guì zhī), Corydalis Rhizoma (yán hú suǒ), Pinelliae Rhizoma praeparatum (zhì bàn xià), Poria (fú líng), Alpiniae officinarum Rhizoma (gāo liáng jiāng), Zingiberis Rhizoma recens (shēng jiāng) steamed in honey-water. I must confess I was blown away. Chinese medicine practitioners in 21st century Europe having learnt to diagnose and think like Ye Tianshi. How impressive is that?

To be clear, the goal of our meetings and my teaching is not to turn participants into little Ye Tianshis. We do not just read Ye’s cases but bring them into conjunction with the ideas of later commentators like Wu Jutong, Zhou Xuehai 周學海 or Zhang Xichun 張錫純. We explore what herbs and formulas modern physicians like Cheng Menxue 程門學, Zhu Liangchun 朱良春 or Gong Shideng 龔士澄, who I know to have achieved excellent clinical results, would have used in similar cases. We also draw on participants’ own clinical experiences and the diverse resources they bring to the table. Our group includes western medicine doctors able to relate Ye’s cases to biomedical understandings of pathology, an expert on the Yijing, a midwife and an external medicine specialist. Ultimately, we want to learn how to best help our patients and engaging with Ye Tianshi is for the moment simply a way we think may help us get there.

Having taught Chinese medicine for over two decades several schools have told me that they will no longer invite me to teach because I do not deliver what their customers are looking for: something that course participants can apply in their own clinic the very next day. To me that is not teaching but selling, not learning but buying a product. Or, to use another analogy, how can one ever learn to become a good cook if all one does is heating up ready made products in a microwave. Learning, to me, is something else altogether. It is the process of gaining familiarity with the new and different at the cost of letting go of what one once thought to be true. It is about gaining critical distance and in the course of doing so edging ever closer to what one is looking for. It is about walking the path of transformation, one of the nicest translation of Dao I have come across.

I must confess that when I initiated the above course of study I had doubts that this kind of learning Chinese medicine was still relevant and productive. I now know it is. For if, after many years of studying course participants have learned to think like Ye Tianshi, one of the greatest physicians in the history of Chinese medicine, they most certainly have become skilful physicians in their own right, too.