The Hard-to-Pass-Down Craft of Chinese Medicine Lies in the Dosage
The Japanese say that the untransmitted secret of Chinese medicine lies in the dosage. Herbal dosage is indeed a problem, but is this secret really "untransmitted" or merely "hard to transmit"? In my view it is not that it is not transmitted, but that it is hard to transmit; and it is not so much a "secret" as a "craft."
Recently, while treating some late-stage cancer patients and some chronic patients who had failed long treatment, several had been treated by multiple physicians along every imaginable rationale without effect; after taking the medicine their stomach felt terrible, and they could not tolerate it. When I took over, I used dose reduction on some: I sharply cut many herbs from 10g down to 1–5g, using a great many at 2g and 3g, and kept administering for a week or more; many then improved.
Among my own patients, there were two notable cases. In one, whenever I prescribed a formula—no matter the rationale—the patient immediately became breathless, his central qi would not rise, and he felt wretched; a single dose sufficed to produce this effect. I finally managed to settle him with Buzhong Yiqi Wan together with Shenqi Wan, lifting up and anchoring down, until he was restored. Later, I used large amounts at the 3g dose for this patient, or made one dose last three days, and he got along safely; his condition reportedly eased.
The other patient was over-medicated: his appetite failed, and even adding spleen-strengthening, appetite-opening herbs was useless. The patient had already had a poor appetite after taking Iressa (gefitinib)—what Chinese medicine calls insufficiency of stomach qi. He who obtains stomach qi lives; he who loses stomach qi dies; poor stomach qi means a poor prognosis. Yet my medication was actually worsening his appetite—a blunder.
Although the patient's other bodily conditions improved, chronic loss of appetite is truly not a good thing. Recently the patient went off to Western treatment. This case makes me feel deeply remorseful. If a prescription is not carefully thought through and is off-target, taking it genuinely harms rather than helps. In fact, for this patient the doses should have been small: slowly regulating with low doses to gradually nurture his stomach qi.
Li Dongyuan was personally partial to small herbal doses. Many disciples of the classical-formula school criticize warm-disease school physicians for using light, scattered, disorderly medicines that, they claim, cannot work. But in my own practice I have built formulas on several of Li Dongyuan's famous prescriptions with very small doses, and the results have been excellent. Li Dongyuan's own mother died from the wolf-like, tiger-like medication of an incompetent physician; hence he felt viscerally about brutal prescribing, and every formula he created guarded the patient's spleen and stomach. This is precious experience left us by Old Master Dongyuan that we should well inherit.
On the other hand, in treating ascites, when I tuned the dose of Jisheng Shenqi Wan it became remarkably effective; small doses simply did nothing. With Xihuang Wan, when I tuned the dose to 12g at a time, I often obtained unexpected effects. These are four times the common dose—doses physicians in regular hospitals simply dare not prescribe.
In treating severe deficiency and damage, I use prepared rehmannia (Shudi), prepared polygonum multiflorum (Zhi Shouwu), and polygonatum (Huangjing), often at over 90g; the patients' mental state immediately changes after taking them, with none of the "clogging the diaphragm" side effects recorded in the books.
The craft of dosing can only be personally grasped in concrete clinical work—observing carefully and slowly groping one's way until one develops one's own set of ideas. How could a master transmit such a thing to a disciple? So herbal dosage truly is the hard-to-pass-down craft of Chinese medicine; even if a master wanted to pass it to his disciple, he could not.