On Dosing

(With Cinzia Scorzon MSc)

Some time ago, in what now seems the distant past, we went on a trip through the Kimberley, a remote and stunningly beautiful wilderness area in Western Australia. Our guide, Liam (not his real name), looked, dressed, and acted so naturally like Crocodile Dundee that it seemed the film character had been modelled on him rather than vice versa. Despite Liam’s obvious disappointment that we were no beer drinkers, we greatly enjoyed our time together. He took it upon himself to singlehandedly down all of the Fosters he had brought along for the trip, but one night he strained his back while lifting all that beer out of his jeep. As we carried some acupuncture needles, we offered to treat him. He gladly accepted, but only under the condition that we used lots of needles, the thicker and longer the better, and that we would make him feel every one of them. All very much in line with the Crocodile Dundee character and a world away from the London patients we were used to treating.

Besides being an enduring holiday memory for ourselves, this short anecdote raises essential questions for all Chinese medicine practitioners. Namely, what is the correct dosage of any intervention, and how might we establish this? As teachers of acupuncture and herbal medicine, we get asked this question by novices and experienced practitioners alike. Our answer, invariably, is that everyone has to learn to make that decision for themselves. Students who seek certainty from their teachers do not like such an answer. Yet, it is the most honest answer we can give.

In this blog post, we want to highlight the “truth” of our statement through two herbal medicine cases (we could provide many more) that responded extremely well to what most practitioners might consider minimal or even non-therapeutic dosages. The very opposite of the dosage Liam, aka Crocodile Dundee, being treated in the Australian outback required to get better. In the concluding section, we will return to the broader question of dosing in light of these cases.

Case 1: Female, 60 years old

This patient consulted us for help with breathing difficulties. She had a history of asthma that had first started fifteen years ago and gradually got worse. She initially took steroid inhalers in the past, but she was able to come off them after she started acupuncture. She still can get occasional asthma attacks, especially when she is stressed and tired, but she can usually prevent them by slowing down. She has a very demanding and emotionally draining job working with young women who have behavioural problems. In this context, her breathing over recent months has become shallow, and her chest feels tight. She also complained about pain in the right back around Bl-13, but this improved with massage and acupuncture.

She thinks that the true cause of her asthma is being surrounded by all the pain, sorrow, and hopelessness she is confronted with at work. She has therefore finally decided to change her job. She is currently pursuing an MA in art therapy, which will eventually enable her to work in a different environment. For the time being, however, this adds yet more stress to what she already has, which may account for her recent aggravation.

Overall, she appears to have quite a strong constitution. When asked to indicate her energy levels on a scale between 1 and 10, she said they were now around 7, but that in the past, they had been 15(!) She sometimes has difficulty falling asleep. She wakes up once or twice during the night to urinate, and it then takes her some time to fall back asleep again. She suffers from cold hands and feet and needs to keep her neck warm.

As this was a video-based consultation, there is no information on the pulse. The tongue was slightly puffy, more narrow at the tip, with a very thin dry slightly yellow and sticky coating

Our diagnosis was deficiency of the gathering (zong) qi with inability of the Lungs to descend and the Kidneys to hold. Therefore, she was prescribed Tonify the Lungs Decoction (bǔ fèi tāng) in concentrated powders as follows:

Ginseng Radix (rén shēn) 9g, Astragali Radix (huáng qí) 30g, Rehmanniae Radix praeparata (shú dì huáng) 24g, Schisandrae Fructus (wǔ wèi zǐ) 6g, Asteris Radix (zǐ wǎn) 9g, Mori Cortex (sāng bái pí) 12g

She was instructed to take 5g of the powder twice daily. However, during a follow-up consultation after one week, we discovered that she had taken less than half of this dosage (around 30g over the course of the week). Still, her breathing problems had disappeared, and she no longer felt any pain or tightness in her chest. The quality of her sleep had also improved. She still woke up once per night to urinate, but she was able to fall asleep again immediately. Despite staying up longer at night to complete coursework for her MA degree, she had noted a considerable improvement in her energy.

Case 2: Female, 74 years old

This patient presented with a diagnosis of psoriasis from her dermatologist. The condition had started in June 2024 in the wake of a second Covid-19 infection. Unlike her first infection, this time, she had felt quite ill, eventually suffering from bronchitis, which was treated with antibiotics. The psoriasis developed after the chest infection had subsided. It started on the legs, but then spread over the entire body. At the time of her consultation, the condition was still quite active, continuing to produce new lesions that now involved the eyes, lips, anus, vagina, and soles of her feet. The latter were particularly painful and made it difficult for her to walk.

The lesions were reddish-purplish with clearly defined borders. They itched day and night, and there was some scaling. Ice packs relieved the itching. She currently used a topical cortisol cream, which provided some short-term relief but had not been able to slow down the spread of the lesions.

Since the infection, the patient had been extremely tired. She felt she had to rest after any exertion. This was exacerbated by bad sleep, as she was constantly woken by the itching of her skin.

The patient felt cold overall but sometimes got hot and sweaty at night. Her appetite was normal but she could not eat large amounts. She had frequent and sometimes explosive bowel movements in the mornings. Initially, the stools would be loose, becoming harder and smaller during the course of the day. She also experienced urgency, without being able to pass any stools. She reported that she had a constant need to urinate but would pass only small amounts. There was no pain or burning on urination. She was not thirsty and she said she had to remind herself to drink.

This also was a video-based consultation, so we have no information regarding the pulse. The tongue was narrow, and had a purplish body with a curdly coating.

In our experience, Covid-19 infections frequently manifest with cold leading to stasis in the network vessels. In the present case, this had caused her wei (or yang) qi to become constrained, producing internally generated pathogenic fire, which the body tried to eliminate via the skin and intestines. We, therefore, prescribed the following formula aimed at unblocking the network vessels and venting constraint fire from the nutritive aspect as granulated powders, which the patient took at a dosage of 5g per day. (1)

Rehmanniae Radix (shēng dì huáng) 15g, Angelicae sinensis Radix (dāng guī) 15g, Paeoniae Radix rubra (chì sháo) 8g, Chuanxiong Rhizoma (chuān xiōng) 5g, Persicae Semen (táo rén) 5g, Carthami Flos (hóng huā) 5g, Cinnamomi Ramulus (guì zhī) 5g, Glycyrrhizae Radix praeparata (zhì gān cǎo) 5g, Zingiberis Rhizoma recens (shēng jiāng) 5g, Jujubae Fructus (dà zǎo) 5g, Polygoni multiflori Radix (hé shǒu wū) 10g, Arnebiae/Lithospermi Radix (zǐ cǎo) 8g, Moutan Cortex (mǔ dān pí) 8g, Dictamni Cortex (bái xiān pí) 15g, Tribuli Fructus (cì jí lí) 15g, Cicadae Periostracum (chán tuì) 15g

At a one-week follow-up, the patient reported a significant improvement in almost all of her symptoms. The lesions on the arms and legs had almost entirely cleared. The lips and the skin around the eyes were still swollen and irritated. The bowels were now solid in the mornings and more liquid in the afternoons. She did not feel cold anymore, but the fatigue and tiredness remained. As she still had most of the herbs left at the time, we advised her to continue until she had used up all of the prescription.

At a second follow-up two weeks later, almost all of the skin lesions had disappeared. What remained were spots and itchiness around the back of the neck, and heat sensations in the tips of her fingers and toes. Bowel movements were now normal, urination had decreased, sleep had significantly improved, and so had her energy. These changes were reflected in her tongue, which was no longer purplish with a much-reduced coating that was more smooth in consistency.

So what is the correct dosage?

Our intention in documenting these cases is not to argue that low dosing is best. What we do want to argue, however, is that the correct therapeutic dosage is highly contextual. We have chosen two cases where very low dosages proved highly effective to make this argument because, in our experience, the case for such low dosages is rarely put forward today.

We often hear that skin diseases can only be treated effectively using decoctions with high dosages of individual herbs. Likewise, the high dosages of formulas used in the Treatise on Cold Damage are often portrayed as models that must be followed. There exists an equally important tradition within Chinese medicine, however, that has long emphasised working with low dosages. This is most famously represented by the Suzhou style of prescribing embodied by physicians like Ye Tianshi 葉天士 (1664-1746) and Xue Shengbai 薛生白 (1681-1770), or modern era physicians like Cheng Menxue 程門雪 (1902-1972) or Qin Bowei 秦柏未 (1901-1970). For many reasons, this tradition no longer receives as much attention as those advocating large dosages. Not that these physicians ever shied away from using larger dosages and harsh herbs when this is what they thought was needed. (2)

Practitioners tend to view the question of dosing almost exclusively in clinical and pharmacological terms. In that sense, they are not all that different from biomedical physicians, for whom dosage boils down to biochemistry. From a historical perspective, however, it is clear that prescribing preferences have always been shaped by contextual factors on both the patients’ and physicians’ side. Many of the literati patients treated by elite physicians in late imperial China considered themselves to possess frail bodies that could not tolerate harsh herbs like Aconiti Radix lateralis praeparata (zhì fù zǐ), Ephedrae Herba (má huáng), or Rhei Radix et Rhizoma (dà huáng.(3)

In Republican China the pendulum swung back in the other direction. A predilection for ancient formulas that contained precisely these herbs and disparaging criticisms of an earlier generation of “peppermint and fritillary” doctors following in the footsteps of Ye Tianshi expressed the desire of progressive Chinese intellectuals at the time to strengthen their nation to shed the image of the sick man of the East. Harsh formulas prescribed in large dosages matched that desire.(4)

The history of Chinese medicine in the twenty-first century remains to be written. When it eventually will be, I am sure that the forgetting of Cheng Menxue and Qin Bowei, prominent figures still in the 1990s, and the revival, once again, of a more “macho” ancient formula medicine will be linked to the changing self-image of China itself: wolf warrior diplomacy re-enacted in the domain of medicine.

What we are discovering instead, often by accident and to our own surprise, is that our own urban millennial patients frequently respond better to low doses and very few needles. However, as the case of Liam in the Kimberley demonstrates, sometimes the very opposite is needed. Hence, the correct therapeutic dosage cannot be found in books, and our teachers’ preferences and experiences are just that. Like so much else, the proper therapeutic dosage must emerge organically at the bedside from a conjunction of many different factors, among which biology and biochemistry are just two. The more sensitive we can become to all the others involved, from historically specific imaginaries of medical practice to how our patients engage with their own bodies and selves, the more often we are likely to hit the mark.

Notes

1. This formula is based on Zaocys Skin‑Nourishing Decoction (wu she rong pi tang 乌蛇荣皮汤) by the famous contemporary physician Li Ke.

2. Biographies of Cheng Menxue and Qin Bowei and a discussion of their prescribing practices can be found in Scheid, Volker. Currents of Tradition in Chinese Medicine, 1626 - 2006. Seattle: Eastland Press, 2007.

3. I discuss the nexus between literati self-images and medical prescribing in Scheid, Volker. “Depression, Constraint, and the Liver: (Dis)assembling the Treatment of Emotion-Related Disorders in Chinese Medicine.” Culture Medicine and Psychiatry 37, no. 1 (2013): 30–58.

4. For an excellent discussion of this issue see Karchmer, Eric. “Ancient Formulas to Strengthen the Nation: Healing the Modern Chinese Body With the Treatise on Cold Damage.” Asian Medicine: Tradition and Modernity 8, no. 2 (2013): 394–422.