Chapter 111 Sharing the Responsibility

Evan begins writing the prescription as the doctors weigh clinical experience against the risks of acting on it.

Ever since the discovery of an Eastern Han tomb in 1981 had established the actual doses in Zhongjing's classical formulas, the argument over dosage in Chinese medicine had never stopped.^[1]

Dr. Li had spent a great deal of his later years campaigning on the issue. Many other older physicians had done the same.

Some practitioners had begun trying different doses, gradually introducing them into clinical practice with excellent results. But very few dared touch the potent, toxic medicines.

The reason was simple: the pharmacopoeia was the law.

If something went wrong within the stated dose, it was treated as an individual incident, and the pharmacopoeia protected the doctor. Exceed that dose, and the doctor would be held responsible if anything happened.^[2]

In the 1960s, Dong Wei, a renowned cardiovascular specialist who had returned from studying at Japan's Imperial Medical College, was sent down to work as a school doctor at a secondary school in Dr. Li's county. He had once watched Dr. Li use Poge Jiuxin Tang to save a patient with heart failure.

He was astonished by the results and praised Dr. Li's ability to rescue critically ill heart-failure patients as surpassing modern medicine. But he also feared that doses like those would land Dr. Li in prison if anything went wrong.

Dr. Li carried on regardless, intent on saving lives without considering his own gain or loss. Fortunately, he had supportive leaders. The hospital director would sign for him and take responsibility. When the director was away, even the local head of public security would sign.^[3]

For years, people in Chinese medicine had been pushing for reform of the pharmacopoeia. There wasn't a practitioner who didn't curse it. Unfortunately, they had achieved very little. Chinese medicine practitioners had long since lost the final say over the Chinese materia medica pharmacopoeia.

…

Evan sat down to write the prescription.

“The patient's pattern is quite clear,” he said. “Yang deficiency with congealing cold, deep-seated, stubborn cold, and obstruction from blood stasis. Yin cold has trapped him from within, leading to true Heart pain and tuoju.^[4]

“The obstruction comes from cold congealing and blood stasis, so we must invigorate the blood and resolve the stasis. And since qi is the commander of blood—when qi moves, blood moves—we need huangqi, astragalus root, as the chief ingredient, in a large dose. We must strongly replenish his qi so that it can drive the blood forward.

“Raw huangqi is particularly good at bringing toxins out and draining pus, closing sores and promoting tissue growth. It is an essential medicine for abscesses and deep-seated sores, and a first choice for tuoju. But its action is mild. Without an unusually large dose, it will be difficult to get results. So we'll use 240 g of raw huangqi.”^[5]

The young practitioners glanced at one another. Without much hesitation, they all started taking notes again. Evan was explaining the principles of treatment and the strategy behind his prescription. This was invaluable clinical experience.

“Yin cold has trapped the patient from within,” Evan continued. “The pathogenic cold lies deep in the channels and has entered the blood level, causing true Heart pain and ice-cold limbs. That calls for Danggui Sini Tang to restore yang and reverse collapse.

“Danggui Sini Tang nourishes the blood and opens the vessels. It treats ice-cold hands and feet with a thready pulse on the verge of disappearing—exactly this patient's symptoms. His dorsalis pedis pulse is already absent, and his wrist pulse is deep, thready, slow, and faint. We'll need 60 g each of fuzi and danggui.

“His hands and feet are numb, the cold has entered the channels and collaterals, and he has severe, electric-shock-like pain in both legs. We need Wu Zhuyu Shengjiang Tang. Wuzhuyu is particularly good at relieving spasms. Combined with Danggui Sini Tang, it will restore yang and reverse collapse, easing his pain and relieving the numbness and spasms in his hands and feet.^[6]

“Finally, he has been ill for far too long. His blood is deficient and stagnant, and the cold within him has congealed as though it were frozen solid. At this stage, only Wutou Tang—strongly acrid and hot, reaching all twelve channels, exterior and interior alike—can overcome it and drive out the cold.

“So we must combine it with Wutou Tang and follow Zhongjing's intention. The dose of prepared licorice root must be twice the chuanwu dose: 60 g of prepared licorice root for 30 g of chuanwu. That amount of licorice is enough to restrain the toxicity of fuzi.

“We'll also add 30 g each of black xiaodou beans and fangfeng. They are important medicines for counteracting the toxicity of wutou and fuzi, although neither appears in Zhongjing's Wutou Tang.

“When I try fuzi and chuanwu myself, I often use a decoction of these two medicines to counteract the poison. Materia medica texts also record that they can counteract the toxicity of wutou and fuzi. I've used the decoction to save someone poisoned by chuanwu.

“Adding them makes the prescription more secure and ensures that the fuzi and chuanwu won't cause harm. These days, it's difficult for pharmacies to obtain raw chuanwu. We can't process it the way Zhongjing did, but adding 150 g of honey to the decoction does the same thing.^[7]

“All of this comes from earlier physicians' experience with aconite medicines. Only by learning how to command these fierce generals will Chinese medicine have weapons capable of defeating critical illness.

“Remember this: what you see as exceptional use of these potent, toxic medicines isn't recklessness. It calls for the utmost care. Only by trying them yourselves can you really know what you're dealing with. I suggest you try chuanwu and fuzi after work, too. Find out what it feels like to be poisoned, then have the poison counteracted.”

The young practitioners drew sharp breaths.

“Many older physicians require their students to try wutou, fuzi, and other medicines themselves,” Evan said. “If you don't dare take them yourself, how can you dare give them to a patient?”

They exchanged uneasy looks.

Several doctors practicing Western medicine glanced at one another, unimpressed. What Evan called caution was still far too crude by their standards.

A new drug went through an enormously complex testing process before it reached clinical practice: repeated verification, pharmacological research, animal experiments, and multiple rounds of testing in people. Only after going through all those procedures would anyone dare use it clinically.^[8]

And he thought a couple of mouthfuls himself were enough to justify giving it to a patient?

That was reckless.

There was no assurance of safety at all.

The department heads from Western medicine shook their heads. They had serious objections, but kept them to themselves.

Even Henry Zhong and Leo Cao were frowning deeply.

…

Evan sighed softly.

“I know you think it's unscientific to determine doses from your own experience of taking a medicine. After all, you're healthy and the patient is critically ill. The two can't be treated as equivalent.”

The young practitioners nodded.

“It's right to question earlier physicians' experience,” Evan said resignedly. “Having you take fuzi and chuanwu, become poisoned, and then use medicines to counteract the poison is simply meant to show that those medicines can control aconite toxicity, so that the fuzi and chuanwu won't cause harm when used in patients.

“We have to be more careful than anyone when using medicines like these. I'd welcome reliable conclusions from pharmaceutical research institutes. But among the institutions studying Chinese medicines, hardly anyone understands Chinese medicine.

“Medicine is a practical discipline. We mustn't prize empty talk and look down on clinical practice. Pharmacological research in those institutes can't fully represent Chinese medicines. We can only test the poisons and the medicines on ourselves.

This chapter appears on NovelPhoenix under the author's publication; the text here was taken without permission.

“Once you've tried them, you'll find that Zhongjing was right. His classical formulas have more than eighteen hundred years of clinical experience behind them. Isn't that more reliable than a pharmaceutical research institute? Isn't it enough to establish their safety and effectiveness?”

The young practitioners looked at one another. They wanted to take notes, but didn't know what to write.

Professor He gave a soft sigh too.

Evan looked at them.

“I'm strongly opposed to your using large doses of wutou and fuzi as soon as you start practicing. That would be irresponsible toward your patients.

“I suggest you study under experienced older physicians. Only after you've seen enough, learned enough, and tried enough yourselves should you use them clinically. We're here to save people, not harm them.

“But once you have the relevant clinical experience, and your pattern differentiation is correct, you can use the actual doses and combinations in Zhongjing's classical formulas with confidence. Because Zhongjing couldn't be wrong.”

Henry and Leo exchanged rueful smiles. Zhongjing wasn't wrong, but the pharmacy still had to agree to dispense the medicines. Zhongjing wasn't wrong, but if the patient made trouble, the doctor who wrote the prescription would have to answer for it.

Evan continued writing.

“The pathogenic cold entered from the exterior and moved into the interior. It has remained latent for years. The weaker his healthy qi became, the deeper the cold invaded. Now it has reached the blood level and become a life-threatening illness.

“Since it entered through the exterior, that's how it should be released. The way it came in is the way it must leave. Chinese medicine has never been about killing pathogenic factors. We must strengthen healthy qi and expel them.

“Support healthy qi and drive out pathogenic qi. So releasing the exterior must come first, bringing the pathogenic factor out. Without that, even if we use hot medicines like wutou and fuzi to drive out the cold, it will still have no way to leave the body. We have to open the doors to drive out the thieves. Otherwise, a cure will be difficult. That's why we should add acrid, warm exterior-releasing medicines such as mahuang and guizhi.^[9]

“Xixin is a powerful general for supporting healthy qi and drawing pathogenic factors out. It can bring the deep, stubborn cold hidden in the three yin divisions from the interior to the exterior. We must use the full basic dose given in the Shanghan Lun. We mustn't follow Chen Cheng of the Song dynasty or Li Shizhen in saying xixin must never exceed one qian.^[10]

“Add a few insect-derived medicines to open the collaterals and relieve pain, and that's the complete prescription.”

Evan finished writing and looked calmly at them all.

“I'll take responsibility for every consequence.”

The words shook every Chinese medicine practitioner in the room.

Evan picked up the sheet, but Professor He suddenly snatched it from his hand.

Evan froze.

So did everyone else.

Professor He laid the prescription on the desk, took out a pen, and signed his name on it.

“Professor… you…” Evan was astonished.

Professor He shook his head and gave a rueful smile.

“I can't talk you out of it. I'll just have to help you shoulder the responsibility.”

Reader Notes

1. ↩︎ Reconstructing ancient doses. Zhongjing's formulas use historical measures such as the liang. Recovering their weight involves archaeological objects, textual transmission, and changes in weighing systems. The chapter presents the 1981 discovery as settling the question. Published scholarship records several competing reconstructions, rather than one universally accepted conversion. Establishing an ancient weight is also a different question from establishing an appropriate modern clinical dose. The precise tomb and discovery report behind this opening have not been identified for this adaptation. Source: Cui and colleagues — Comparative Study on the Original Dose of Classical Formula between China and Japan, section 4.1 (in Chinese).
2. ↩︎ The pharmacopoeia and responsibility. A pharmacopoeia sets standards for medicines; this chapter invokes it in a dispute over dose limits. “The pharmacopoeia is the law” conveys the categorical view expressed in the story. It does not by itself establish automatic protection within a stated dose or automatic criminal liability outside it. China's 2007 prescription rules discuss exceptional use above usual labeled doses, requiring the reason to be recorded and the prescription signed again. Those rules alone do not determine whether this proposed prescription is permissible. Source: National Health Commission — Prescription Management Measures, Article 6(9), p. 4 (PDF, in Chinese).
3. ↩︎ Dr. Li and the earlier account. “Dr. Li” retains the respectful form used in the Chinese passage. Poge Jiuxin Tang is a named formula already discussed in the novel; its name is kept distinct from a modern emergency-care procedure. “Sent down” describes Dong Wei's reassignment to a local school in the 1960s. The passage supplies neither a more precise political classification nor an identifiable institutional name beyond “Japan's Imperial Medical College.” The specific episode, institutional identification, and signatures described here remain unverified historical details in the source narrative.
4. ↩︎ Cold, stasis, and the named conditions. These are Chinese medicine categories within Evan's explanation. Yang deficiency concerns impaired warming and supporting functions; blood stasis describes obstructed blood movement without by itself establishing a blood clot. “True Heart pain” and tuoju retain the terms used earlier in the consultation: a severe cardiac-pain category and a traditional category involving painful, cold limbs and possible digital gangrene. Using these names here does not add a newly observed infarction, necrosis, or examination finding. Source: WHO — TCM Terminologies, entries 1030, 1092, 1578, and 1932.
5. ↩︎ Qi, blood, and the chief ingredient. “Qi is the commander of blood” summarizes qi's traditional role in blood formation, movement, and containment. The chief, or monarch, ingredient is the medicine assigned the leading role against the principal pattern; it is a prescribing role, not a rank of physician. Huangqi is a medicinal root. “Raw” distinguishes the form named here from specially prepared forms. Evan's claims about pus, sores, and tissue growth describe its traditional uses; the references do not establish that 240 g is effective or safe for this patient. Sources: WHO — TCM Terminologies, entries 250–253 and 2768; Hong Kong Baptist University — Huangqi, specimen D00565.
6. ↩︎ The formula names. Danggui Sini Tang is a classical formula for nourishing blood and warming channels, distinct from Sini Tang. A recorded extension adds wuzhuyu and fresh ginger. The source passage calls its added component Wu Zhuyu Shengjiang Tang; that wording is retained rather than silently replaced with Wu Zhuyu Tang or the longer classical name. Danggui is Chinese angelica root; shengjiang means fresh ginger. Fuzi is not in the university's base Danggui Sini Tang ingredient list; Evan is describing his combined prescription here. Source: Hong Kong Baptist University — Danggui Sini Tang, F00065, including associated formula 1.
7. ↩︎ Aconite materials and the claimed safeguards. Chuanwu and fuzi are related aconite medicines, respectively associated with the main root and the lateral root; wutou is also used in the discussion. Processing and formulation affect toxicity, but these terms are not interchangeable names for a harmless substance. Prepared licorice, fangfeng, black xiaodou beans, and honey are preserved as Evan names them. His assurances that they prevent harm and his later proposal to test poisoning on oneself remain character claims; the official information describes poisoning risks and toxicity reduction, not a guaranteed antidote. Sources: Hong Kong Department of Health — Aconitum Alkaloids (in Chinese); Nanjing University of Chinese Medicine — Wutou, origin and harvesting sections (in Chinese).
8. ↩︎ Testing medicines. The doctors' objection distinguishes an individual's experience of taking a medicine from systematic investigation of its safety and effectiveness. A standard drug-development account includes laboratory work, preclinical investigation, and clinical studies in people, followed by regulatory review and continuing safety monitoring. The FDA source provides an accessible example of that framework; the consultation remains in China and is not being placed under American jurisdiction. Neither a personal trial nor a long history of use is the same kind of evidence as those investigations. Source: FDA — The Drug Development Process.
9. ↩︎ An outward route for pathogenic factors. “Healthy qi” and “pathogenic factors” describe supporting functions and harmful influences in traditional theory. “Releasing the exterior” is a treatment category, here combined with supporting healthy qi; the door and thieves are Evan's metaphor. Mahuang is ephedra, and guizhi is cinnamon twig. The blood level is a traditional depth category already invoked in this consultation, rather than a bloodstream-infection finding. The three yin divisions mentioned next are Taiyin, Shaoyin, and Jueyin within the six-division framework; they do not mean three kinds of yin deficiency. Source: WHO — TCM Terminologies, entries 26, 2258, and 2282–2283.
10. ↩︎ Xixin and an old dose maxim. Xixin is a medicinal root-and-rhizome material. Qian is a historical weight unit; no gram equivalent or xixin dose is supplied here. The maxim is often shortened to “xixin must not exceed one qian.” A government-hosted historical study discusses an earlier warning attributed to Chen Cheng specifically concerning the medicine taken alone as powder, with different wording and quantity. That distinction is recorded without rewriting Evan's speech. The insect-derived medicines he mentions next are left unnamed, as in the source. Sources: Hung — Study of Classical Records of Edible Chinese Herbs, printed p. 372, PDF p. 34 (in Chinese); Hong Kong Baptist University — Danggui Sini Tang, ingredient list.