Reflections on a Case of Insomnia

Two weeks ago, a young friend messaged me on WeChat asking what to do about trouble sleeping. After analyzing the situation, I figured he’d probably need some medicine, so I had him come to the clinic on Sunday.

Three years ago, when this young man returned from abroad, he had come to me with palpitations. At the time, he was cured with Roasted Licorice Decoction (Zhi Gan Cao Tang). But since the beginning of this year, he had developed difficulty falling asleep, accompanied by increasingly vivid dreams. In recent days, he was dreaming every single night and waking up without fail. His sleep quality had deteriorated sharply. I prescribed him the following formula:

My rationale for this prescription was twofold:

First, his tongue tip was slightly red, with a yellow, thick, greasy coating — especially in the mid-to-posterior region, where it was beginning to take on a putrid appearance.

Second, he sometimes experienced a feeling of fullness and stuffiness in his abdomen, though without any other obvious discomfort.

The prescription was filled as a pre-decocted preparation. After writing it up, I still had some reservations. But when I followed up later, he reported that just two packets had produced excellent results — he was already sleeping soundly.

This formula must not be casually imitated. The 2015 “Zhang Xi case,” which sent shockwaves through the TCM community, taught us that using Ban Xia (Pinellia) in excess can land you a five-million-yuan lawsuit. This was, in fact, one of the thoughts that crossed my mind after writing the prescription.

Looking back at it now, Huanglian Wendan Decoction would likely have worked as well. Why didn’t I think of it at the time?

I won’t discuss that question today. Instead, my real line of thinking is this: are the usage restrictions that pervade China’s medical institutions essentially toothless?

Under current laws and prescribing regulations, most institutions impose restrictions on traditionally “toxic” Chinese medicinals or those shown through experimental research to possess toxicity. If a doctor’s prescription exceeds the standard dosage, the pharmacy will not dispense it.

But there’s another regulation: if a doctor provides a “dual signature” for restricted-dosage medicinals, the pharmacy can dispense them.

What exactly is such a self-contradictory rule trying to express? Perhaps it is simply an act of helpless compromise.

According to the Chinese Pharmacopoeia, the usage and dosage of Ban Xia is: “For internal use, generally administered after processing, 3–9 g.” In other words, when a doctor prescribes processed Ban Xia, the amount per dose should generally not exceed 9 g. For someone like me using seven times that amount, three signatures would be required.

In reality, the Pharmacopoeia’s language is quite ambiguous. On the question of dosage, its explanation is: “When necessary, the dosage may be adjusted up or down according to clinical need.”

That is to say, from a legal standpoint, how much to use is the doctor’s call. Nobody is restricting you, and certainly nobody is saying that prescribing outside the recommended range constitutes a violation or illegal act.

So why all these complications now?

I’ve thought about this carefully, and it really comes down to fear — fear that reckless practitioners like myself might cause incidents that would tarnish the reputation of Chinese medicine. The intention is genuinely good, but the approach is flawed.

Based on the materials I’ve gathered, no one has yet conducted systematic, in-depth research on the question of dosage. Take Ban Xia, for example — its toxicity profile remains unclear to this day. How much causes harm? Under what circumstances does harm occur? What is the actual mechanism of injury? These questions still lack complete answers. And so, people simply rely on their “experience” to propose a reference dosage range.

Is this scientific?! It only serves to deepen public misunderstanding of TCM.

I hope that insightful members of the TCM community will step up and conduct the necessary research — and let the evidence speak for itself.

两周前，小友某某在微信问我睡不好觉咋办，我分析了一下，估计得吃点药才行，遂让其周日来门诊。

这位小同志三年前从国外回来时曾因心悸怔仲来找我看过，当时用炙甘草汤愈之，但自今年开始出现入睡困难，多梦，日益严重，近几日甚至出现夜夜有梦，每夜必醒，睡眠质量急剧下降，然后我给开了这个方：

我开这个方动机主要是两个：

一是当时他的舌尖偏红，且舌苔黄厚腻，尤其是中后部舌苔，已有腐苔之意

二是他有时感觉腹中满焖，但又无其他明显不适

此方为代煎，开完之后我还心里还有些想法，不过后来询问说吃完两包效果就很好，已经能睡得很踏实了

此方切不可轻易模仿，2015年，震惊中医界的”张喜案”告诉我们，超量用半夏搞不好会赔500万，这也是我开完方之后的想法之一。

现在重新研究一下，其实黄连温胆汤应该也可以，为什么当时突然没想起来呢？

今天不讨论这个问题，我的思考是，中国医疗机构中普遍存在的的限制使用规定到底是不是鸡肋？

根据当前的法律和处方规定，大部分机构都会对传统”有毒”中药或经实验研究”有毒性”的中药进行使用限制，如果医生处方超过限量，药房不予配发

但是另一条规定是，如果医生对限量中药采取”双签名”，药房就可以配发

这种出尔反尔的规定，到底是想表达什么意思呢？可能就是一种无奈的权衡吧

根据中国药典规定，半夏的用法用量是：”内服一般炮制后使用，3～9g”，也就是说，医生开具炮制过的半夏，每付药用量一般不得超过9g，像我这样超7倍使用的，得签三个名字才行

但实际上，药典的规定很模棱两可，对于用量的问题，药典的解释是：必要时可根据需要酌情增减

也就是说，从法律层面讲，用多用少医生说了算，谁也没给你限制使用，更没说你不在用量范围内就是违规违法

那现在为什么要搞出这么多事情？

其实我曾仔细思考过，无非就是怕某些像我这样的猛浪之徒出事情，给中医药抹黑，其实这个出发点确实是好的，但是做法不好。

从目前我收集到的资料看来，尚没有人对剂量问题开展系统而深入的研究，就拿半夏来说，毒性问题到现在都没搞清楚，用多少会有损伤？什么情况下会有损伤？到底是什么造成的损伤？这些问题至今仍没有给出完整的答案，于是乎，大家就根据自己的”经验”，给出了这么个参考的用量范围

这很科学么？！！这只会在很大程度上增长吃瓜群众对中医的误解

希望中医药界有识之士赶紧把试验做了，用事实来说话