Within the Water there is no Fire
Pain cases from Hé Yuánzhǎng
This week I have been spending more time (perhaps more than I should) looking at old collections of case reports. Case reports are, of course, one of the most important routes of transmission of knowledge in our medicine. Having gone through the formal process of learning to write detailed literature reviews and case studies to submit to academic journals, it is striking to note the difference in the way that cases are presented today versus how they were through much of the history of Chinese medicine. Many of the old cases are succinct and include only the barest of details. They rely heavily on context; perhaps that was one way to safeguard the knowledge from those outside the family and/or guild. Still, their terseness makes them approachable for translation novices like me, and there can be a lot of value in parsing them, even if they contain secrets yet unrevealed.
The return may be somewhat limited, of course, depending on the collection and the disease patterns covered. I have found that almost every collection has sections on coughing or urinating blood, or hernias and hiccoughs, for example. These cases, however interesting they may be, don’t much reflect the kinds of issues that patients bring to my practice.
I recently happened upon a book of cases by Hé Yuánzhǎng 何元長 (1752～1806), a Qīng era physician who was of the 19th generation in a family line of doctors. The conditions covered span the normal spectrum of internal diseases, but also include a few chapters on pain. Since I have a particular interest in supporting my pain patients with herbal medicine, I found these brief cases to be engaging.
As always, the translations are rough but hopefully serviceable and not too wide of the mark.
First, two cases from the Impediment (Bì) Pattern chapter (23):
（案2）風濕入絡，四肢浮腫，痹之漸也。及早圖治。
茅朮 歸身 木瓜 五加皮 防風 川斷 米仁 細桑枝 赤苓 防己
(Case 2) Wind dampness enters the network vessels, puffy swelling of the four limbs, gradually forming impediment. Seek to eliminate it as soon as possible.
Máo Zhú (Rz Atractylodis Maoshanense), Guī Shēn (Rx Angelicae Sinensis), Mù Guā (Fructus Chaenomelis), Wǔ Jiā Pí (Cx Acanthopanacis), Fáng Fēng (Rx Saposhnikoviae), Chuān Duàn (Rx Dipsaci), Mǐ Rén (a.k.a. Yì Yǐ Rén /Sm Coicis), Xì Sāng Zhī (Rm Mori), Chì Líng (Poria Rubra), Fáng Jǐ (Rx Stephaniae)
Mulch comments: Máo Zhú is Cāng Zhú (Rz Atractylodis) grown on Máoshān mountain in Jiāngsū province. It is considered to be the highest-grade (Wiseman & Brand, 2020). This is a pretty straight-ahead wind-damp prescription with some yáng tonics and blood movers in the mix.
（案5）下體痹痛，脈來細軟。水中無火。法當溫補。
熟地 歸身 川斷 狗脊 麥冬 鹿角 杜仲 蒺藜
(Case 5) Lower body impediment pain, the arrival of the pulse is thin and soft. Within the water there is no fire. One must treat with warming supplementation.
Shú Dì (Rx Rehmanniae Praeparata), Guī Shēn (Rx Angelicae Sinensis), Chuān Duàn (Rx Dipsaci), Gǒu Jí (Rz Cibotii), Mài Dōng (Rx Ophiopogonis), Lù Jiǎo (Cornu Cervi), Dù Zhòng (Cx Eucommiae), Jí Lí (Sm Astragali)
Mulch comments: an example of warm supplementation. Even if the disease is technically an exterior pattern, the pulse shows an underlying vacuity and therefore it is important to supplement the essence, blood, yīn, and yáng. Any wind-damp properties of the prescription are provided by skillful selection of yáng tonics which cover both areas (Gǒu Jí, Lù Jiǎo, Chuān Duàn, Dù Zhòng).
A case from the Low Back Pain chapter (29):
（案1）內熱腰痛，虛損之漸也。莫作輕視。
制首烏 歸身 川斷 鱉甲 丹皮 金狗脊 山藥 秦艽 銀柴胡
(Case 1) Interior heat low back pain, gradually turning to vacuity detriment. Don’t regard it as trivial.
Zhì Shǒu Wū (Rx Polygoni Multiflori Prep) , Guī Shēn (Rx Angelicae Sinensis), Chuān Duàn (Rx Dipsaci), Biē Jiǎ (Carapax Trionycis), Dān Pí (Cx Moutan), Jīn Gǒu Jí (Rz Cibotii), Shān Yào (Rz Dioscoreae), Qín Jiāo (Rx Gentianae Macrophyllae), Yín Chái Hú (Radix Stellariae)
Mulch comments: an interesting case of low back pain with interior heat, rather than cold. Still very focused on supplementation with some vacuity heat clearing (Dān Pí, Qín Jiāo, Yín Chái Hú) and blood moving secondary to the major functions of the medicinals (Guī Shēn, Chuān Duàn, Biē Jiǎ, Dān Pí)
Two cases from the Headache chapter (30):
（案1）頭汗畏風，不時作痛。乃衛陽虛而營陰損也。表裡兼顧。
生耆 白芍 茯神 首烏 女貞 甘菊 杞子 牡蠣 料豆衣
(Case 1) Head sweating with aversion to wind, with frequent pain. It is a vacuity of defensive yáng (wèi yáng) and damage to provisioning yīn (yíng yīn). One must take into account both the exterior and interior.
Shēng Qí (Rx Astragali Cruda), Bái Sháo (Radix Paeoniae Alba), Fú Shén (Poriae Pararadicis), Shǒu Wū (Rx Polygoni Multiflori), Nǚ Zhēn (Fr Ligustri Lucidi), Gān Jú (Fl Chrysanthemi), Qǐ Zǐ (Fr Lycii), Mǔ Lì (Concha Ostreae), Lǚ Dòu Yī (Testa Sojae Atra)
Mulch comments: a complex formula for a complex pathomechanism. Shēng Qí raises qì and checks sweating, Bái Sháo nourishes yíng. Lighter, less cloying yīn tonics are used (Shǒu Wū, Nǚ Zhēn, Qǐ Zǐ). Lǚ Dòu Yī (mung bean seed casing) nourishes yīn, calms the liver and checks sweating. Cool acrid Gān Jú clears liver heat from the head and eyes and salty cold Mǔ Lì anchors yáng and astringes sweat.
（案4）頭痛膈脹，少陽鬱熱也。治以清疏。
柴胡 赤芍 陳皮 黑梔 鬱金 石決明 連翹 蔞皮 木通
(Case 4) Headache with diaphragmatic distension, depressive heat in shǎo yáng. Treat by clearing (heat) and coursing (qì).
Chái Hú (Rx Bupleuri), Chì Sháo (Rx Paeoniae Rubra), Chén Pí (Pc Citri Reticulatae), Hēi Zhī (Fr Gardeniae Carbonisatus), Yù Jīn (Rx Curcumae), Shí Jué Míng (Concha Haliotidis), Lián Qiáo (Fr Forsythiae), Lóu Pí (Pc Trichosanthis), Mù Tōng (Caulis Akebiae).
Mulch comments: Of course, I really like this formula. Straight-up liver depression with heat, plus ascending yáng and some stuck phlegm. I would swap out Mù Tōng for Tōng Cǎo (Medulla Tetrapanacis) due to possible species adulteration and toxicity concerns.
I have been posting some of the cases I come across on Substack Notes in between the regular emails, so if you are interested in seeing more, check back periodically at the link above. And, as always, thanks for reading.
Note: this newsletter is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have.
References
Hé Yuánzhǎng yī àn. (n.d.) https://jicheng.tw/tcm/book/%E8%91%89%E5%A4%A9%E5%A3%AB%E6%9B%B9%E4%BB%81%E4%BC%AF%E4%BD%95%E5%85%83%E9%95%B7%E9%86%AB%E6%A1%88/index.html . Retrieved November 23, 2022
Wiseman, N. (2022). Chinese-English Dictionary of Chinese Medical Terms. Paradigm Publications.
Wiseman, N., & Brand, E. (2020). Comprehensive Chinese materia medica. Paradigm Publications.