Chapter 92 The Question of Dosage

A prescription leaves Evan searching for words. Dr. Li begins to explain what the numbers mean.

It wasn't that Evan was uneducated. At that moment, he simply couldn't think of a better expression of admiration than “Holy shit.”

Looking at the prescription in his hands, he marveled at the ingenuity of the formula and the boldness of the doses.

No wonder people said that Dr. Li's treatments showed results after one batch and finished the cure after two.

The man had an almost godlike command of medicines.

“This formula can treat acute abdomen in general,” Dr. Li continued. “If there's intestinal obstruction, combine it with Xiaofu Tongjie Tang to break up stagnant qi. Once the bowel excess is relieved, the toxins pass out with the stool, and the stubborn illness is cured.

“For acute pancreatitis, combine it with Da Chaihu Tang, using a heavy dose of chaihu—125 g—and add Jinlingzi San, taken as a powder mixed into liquid. In my experience, it can usually halt the disease within 40 minutes: the pain stops, the swelling subsides, and the blood count is more or less back to normal.”^[1]

Evan was filled with admiration.

Dr. Li smoked as he went on at his leisurely pace. “I've been using Western medical disease names to help you understand. You students coming out of school have learned so much Western medicine, after all.

“But remember this: when you're treating a patient, don't let Western disease names or test results lead you astray. Far too many patients have been misdiagnosed and mistreated that way. You must be very, very careful.”

Evan nodded solemnly. When he had helped at the county Chinese medicine hospital, Dr. Simon Liu had been misled by Western disease names and misdiagnosed two patients in succession.

“In Chinese medicine, always remember to treat according to the pattern,” Dr. Li said. “Whenever a pattern in Chinese medicine conflicts with the symptoms identified by modern medicine, follow the pattern without hesitation.

“Chinese medicine has never been a matter of treating only the head when the head hurts, or only the foot when the foot hurts. We see a person as a whole, never as separate pieces. If your head hurts, something in the whole is out of balance. Find where the imbalance lies and what caused it: that's the Chinese medical pattern. Correct it, and the headache will go away.

“When treating illness, you mustn't simply accept a Western disease name. Sometimes you needn't dwell on the Chinese disease name either. Remember Zhongjing's twelve-character principle: ‘Examine the pulse and signs, understand what has gone wrong, and treat according to the pattern.’”^[2]

Dr. Li dropped the cigarette butt on the ground, took out another cigarette, and lit it.

“Still, you've done well. To have developed your pulse examination to this level at your age—and your acupuncture and moxibustion too—those two skills are far better than many old Chinese physicians'.”

Evan felt a little sheepish. He had put no small amount of work into those two skills. Who knew how many summers and winters he had spent with those two masters in the clinical training room?

“But when it comes to medicines…” Dr. Li looked at him. “Your foundations are sound enough, but you're still very immature in combining ingredients and choosing doses. There's a great deal you lack.”

Evan nodded earnestly. That was indeed his weak point.

“But that's a good thing too.” Dr. Li smiled faintly.

Evan looked puzzled.

Dr. Li smiled as he let out a mouthful of smoke. “If you were already good at everything, what would I have left to teach you?”

Evan froze for a few seconds. Then delight filled his heart.

“You… you mean… are you saying…”

Dr. Li smiled and nodded. “It's rare to find someone with your determination. If a youngster like you isn't afraid, it would be wrong of me to keep standing on my dignity.”

Overjoyed, Evan immediately started to kneel and acknowledge him as his master.

“Up you get, up you get.” Dr. Li hurried to help him. “Why make such a ceremony of it? People don't do that anymore.”

But Evan was entirely serious. “When you become a master's apprentice to study medicine, you must observe the proper rites.”

Dr. Li was visibly taken aback. Then he smiled, let go of Evan, and settled into his chair, watching him with a gentle gaze.

With the utmost respect, Evan touched his forehead to the ground three times before Dr. Li. As he had said, the rites must be observed.^[3]

Dr. Li was so moved that his eyes glistened. He quickly wiped the corners of his eyes.

“I never imagined that someone like me could still have an apprentice like you,” he said, holding back his emotion.

“This is the greatest good fortune of my life,” Evan said earnestly.

“But I don't know whether I'll be doing you harm.” Dr. Li was deeply moved too.

“A physician must have the compassion of a bodhisattva, feeling another person's suffering as his own. In treating illness, he must not hesitate over the consequences, worry about his own fortune or misfortune, or cling to his own safety.

“From the day I began studying medicine, I resolved to relieve the suffering of all living beings. The Great Physician's Skill and Sincerity has always meant more to me than words I can recite.”^[4]

Dr. Li gazed at him.

“Good! Good! Having you as my apprentice is my good fortune.”

He went over and helped Evan to his feet. Then he took out another cigarette and lit it.

There in that remote mountain village, master and apprentice spoke openly to each other for the first time.

Sitting on the little chair, Dr. Li said, “My doses often exceed the prescribed limits. Everyone calls my prescribing outrageously bold. But I believe I'm the one who's right, because the results are the strongest proof.”

Evan inclined his head slightly.

Dr. Li took a drag and slowly released a few smoke rings.

“I taught myself Chinese medicine in adversity and began treating patients after I came out of prison. Before the 1960s, I had already treated some severe cases of heart failure.

“I followed Zhongjing's classical formulas and used Sini Tang. It's a principal formula for strengthening the heart. Heart failure is always a severe yin-cold condition, and Sini Tang restores yang and rescues collapse, bringing people back from death's door. Many heart failure patients have not only failing yang qi but exhausted yin fluids, so I added Renshen Tang and treated them with Renshen Sini Tang.^[5]

“The formula greatly replenishes the original qi. In addition to restoring yang and rescuing collapse, it nourishes yin, harmonizes yang, supplements qi, and generates fluids, making it more complete. Even so, in severe heart failure the chances of life and death were still about equal.

“Before the 1960s, I treated six severe heart failure cases with low doses of Renshen Sini Tang. Five died. Only one survived. I failed repeatedly with it afterward too. I couldn't understand it.”

Dr. Li took another drag and exhaled heavily.

“I wondered whether Zhongjing, the Sage of Medicine, could have been wrong. But the old records said this formula had been used for a thousand years and had worked wonders time and again.

“I was at a loss. All I could do was increase the fuzi, the chief ingredient for restoring yang and rescuing collapse—from 10 g to 15 g, then to 45 g. Still it had no effect. By then, I was already using more than five times the amount specified in the pharmacopoeia.^[6]

“Then there was a friend of mine whose mother had suffered from cor pulmonale for 20 years. She became critically ill in hospital. They gave up trying to save her and she went home for the family to prepare for her death.^[7]

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“He asked me to make one last attempt, to do whatever was humanly possible. When I went, her whole body was cold except for a little warmth at her chest. She was unconscious and gasping. Her blood pressure couldn't be measured, and she'd lost control of both bladder and bowels.

“The pulses at the six wrist positions were barely there. Only the Fuyang, Taixi, and Taichong pulses hadn't disappeared. No wonder modern medicine had given up. Someone that close to death was terribly hard to save.^[8]

“But I was a doctor. I still prescribed three batches for one last attempt, each containing 45 g of fuzi. After writing the prescription, I left. I had no hope either.

“The household was in utter confusion that day. They had to get burial clothes ready, prepare the room for mourning, and receive friends and relatives who kept coming to see the patient one last time.

“My friend's wife—the patient's daughter-in-law—couldn't read a word, and she'd completely forgotten my instructions. With the whole house in such a state, in her hurry she tipped all three batches in together and boiled them down to a thick liquid.

“By then the zi hour had passed. She gave her mother-in-law some every few minutes, and in just over 40 minutes she'd finished giving her that half bowl of concentrated medicine. Then a miracle happened. The unconscious patient suddenly woke up. She even knew she was hungry and asked for food. The next day she could get out of bed and walk. She lived another 19 years before dying of old age.”^[9]

Dr. Li shook his head and gave a couple of quiet chuckles.

“A heart failure patient with barely a breath left, so critically ill that modern medicine had given up—and she came back from death's door in such a dramatic way.

“That was when I finally understood. It wasn't that Chinese medicine couldn't treat these desperate cases. The dose was wrong! The Sage of Medicine's unspoken secret was dosage. Every earlier failure had come down to getting the dose wrong.”

He sighed again, looking desolate.

“After that, I worked hard at dosage and saved one critically ill patient after another. But outsiders said my prescribing was dangerous, a deviant practice. It also violated the pharmacopoeia. I could have been sentenced and sent to prison at any time.

“I believed I was right, that I was the one who understood Zhongjing's classical formulas. But I had no evidence. I couldn't prove what the actual doses in ancient times had been.”

“No,” Evan said. “Now there is evidence.”

“Hm?” Dr. Li looked up in surprise.

“Not long ago, archaeologists discovered an Eastern Han tomb,” Evan said. “They excavated an Eastern Han standard weight, the bronze weight issued by the Grand Minister of Agriculture. It established that one liang in the Eastern Han was equivalent to 15.625 g today.”

Dr. Li stared. “Really?” he asked, scarcely able to believe it.

Evan nodded earnestly. “It's only just been discovered. The news may not have reached here yet.”^[10]

Dr. Li leaned back heavily in his chair, his expression caught between grief and joy.

“I knew I wasn't wrong. I knew I wasn't wrong!”

He lifted his head. The usually good-natured Dr. Li suddenly burst into an angry curse.

“Goddamn Li Shizhen! He's led Chinese medicine astray for more than four hundred years!”^[11]

Reader Notes

Reader Notes

1. ↩︎ Combining formulas and taking a powder. Xiaofu Tongjie Tang continues from the previous chapter; Da Chaihu Tang is a different classical formula. Here Dr. Li proposes combining formulas rather than substituting one disease name for another. Jinlingzi San is a powder formula associated with moving constrained qi and relieving pain in traditional practice. Chongfu means mixing the powder into liquid for administration, rather than necessarily boiling it with the other ingredients. The 125 g of chaihu and the claimed changes within 40 minutes are Dr. Li's account, not findings established by the formula reference. Source: Hong Kong Baptist University — Jin Ling Zi San, Method and Action.
2. ↩︎ Pattern, symptom, and the twelve-character maxim. A pattern, zheng (证), is a traditional interpretation of a person's presentation; a symptom, also pronounced zheng (症), is a manifestation of illness. Neither is simply interchangeable with a biomedical disease name. The maxim comes from the Shanghan Lun in a passage about illness altered by inappropriate treatment. Its twelve characters become a longer sentence in English; the translation follows Chapter 66. Dr. Li's instruction to prefer the pattern is his own teaching here. The cited definitions and classical passage do not establish that a test result or disease diagnosis should always be disregarded. Sources: WHO — TCM terminologies, entries 546, 548, and 550; Ke Qin — Shanghan Lun Zhu Lai Su Ji, lower section on Guizhi Tang presentations (in Chinese).
3. ↩︎ The formal acknowledgment of a master. Baishi establishes a personal teacher–disciple relationship, beyond simply learning from an experienced physician. A kowtow is a kneeling bow in which the forehead touches the ground. Evan performs three to mark that relationship. Such a ceremony appears in first-person accounts of medical apprenticeship, but it is not a universal requirement for studying Chinese medicine. Dr. Li initially considers it unnecessary; Evan insists on the respect it expresses. The scene makes their apprenticeship explicit, after the village doctor's assumption in the preceding chapter. Source: Shanxi University of Chinese Medicine's affiliated acupuncture hospital — a physician recalls his own apprenticeship (in Chinese).
4. ↩︎ Compassion and The Great Physician's Skill and Sincerity. Evan joins the idiom “a bodhisattva's heart,” meaning a compassionate disposition, to language from Sun Simiao's essay on medical conduct in the Qianjin Yaofang. Its concern includes feeling a sufferer's distress as one's own and responding without putting personal advantage or safety first. The novel rearranges and abbreviates the classical wording; the English translates this passage afresh. Evan is answering Dr. Li's concern about taking him as an apprentice. This is an ethical commitment within their conversation, not a new clinical finding. Sources: Ministry of Education dictionary — the compassion idiom (in Chinese); Sun Simiao — Qianjin Yaofang, opening chapter on the great physician (in Chinese).
5. ↩︎ Sini Tang and the ginseng addition. Sini Tang belongs to the classical tradition of warming the interior and restoring yang in collapse. “Yin fluids” refers to the body's nourishing and moistening substances in traditional theory; “original qi” describes a foundational sustaining function. They are not names of laboratory measurements. The source text names Renshen Tang and Renshen Sini Tang. These names are retained; the university reference lists the related Sini Jia Renshen Tang, but does not resolve precisely which preparation Dr. Li means. His classification of all heart failure as yin cold remains his statement. Source: Hong Kong Baptist University — Si Ni Tang and the ginseng-containing associated formula.
6. ↩︎ Fuzi and the pharmacopoeia. Fuzi is an aconite-root medicine whose constituents can be seriously toxic. Preparation, the material used, and dose all matter; “fuzi” alone does not specify every one of these details. A pharmacopoeia is a collection of medicinal standards. Dr. Li recalls exceeding its limits, but the novel does not identify an edition for this earlier period. Modern safety information cannot verify that historical limit, or establish the safety of his doses. A batch here means one prescription's quantity, not one mouthful. Sources: Hong Kong Department of Health — aconitum-containing medicines (in Chinese); WHO — what pharmacopoeias are.
7. ↩︎ Cor pulmonale. This term describes failure of the right side of the heart associated with disease affecting the lungs and their circulation. It connects the mother's long history of lung-related heart disease with Dr. Li's discussion of heart failure; it does not mean cardiac arrest. The chapter gives her condition as he recalls it, without specifying the underlying lung disease or supplying hospital records. No additional diagnosis, test, or treatment is implied by the English medical name. Source: MedlinePlus — Cor pulmonale, definition and causes.
8. ↩︎ Wrist pulses and the lower pulse sites. The six wrist positions are the three traditional positions at each wrist, not six separate hearts or six different heart rates. Fuyang, Taixi, and Taichong name sites in the foot and ankle region, discussed in Chapter 88. Dr. Li is describing palpation, not acupuncture at these sites. The terminology reference describes wrist positions and lower pulse examination; it does not establish this woman's likelihood of survival from the reported pulses. Source: WHO — TCM terminologies, entries 855–856 and 919.
9. ↩︎ The zi hour and the remembered recovery. Zi is the traditional two-hour period spanning approximately 11 p.m. to 1 a.m.; the narrative's wording is retained without supplying an exact clock time. The three batches, half bowl, repeated administration over more than 40 minutes, next-day walking, and further 19 years all belong to Dr. Li's retrospective account. The time reference explains the hour, not the treatment's efficacy, and does not independently verify the case. Source: Academia Sinica — Taiwan Social Change Survey report, PDF p. 96, traditional-hour coding table.
10. ↩︎ A Han liang and a standard weight. Liang is a historical unit whose value has varied. Researchers have used the Eastern Han bronze standard associated with the agricultural administration to argue for a value around 15 g; 15.625 g is one published reconstruction. Other reconstructions differ, and converting an ancient prescription also raises questions about preparation and the material weighed. Evan's exact value and report of a newly excavated tomb are preserved as dialogue. The cited research does not independently confirm the novel's discovery story or make the conversion a clinical dose recommendation. Sources: Shi et al., 2019 — questions in classical-prescription research, §4 (in Chinese); Zhou et al., 2022 — classical literature on Houpu Mahuang Decoction, §2.2 (in Chinese).
11. ↩︎ Li Shizhen and the final outburst. Li Shizhen was the Ming physician who compiled the Bencao Gangmu, the Compendium of Materia Medica. The dose debate concerns, among other things, a passage in that work allowing a smaller contemporary quantity to stand for an ancient liang. The 2019 discussion below places that approach among several historical conversions. Dr. Li's charge that Li Shizhen misled Chinese medicine for four hundred years is his emotional judgment in the novel, rather than a conclusion established by these sources. Sources: UNESCO — nomination dossier for the Compendium, summary on p. 1; Shi et al., 2019, §4.2 (in Chinese).