Fù zî (附子) : Dosing & Countering heat and toxicity (III).

Dr.Daniel L.Altschuler

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Dosing

One of the biggest problems in prescribing any herb is knowing the proper doses. Many students give up on herbs because of this alone. With fù zî, because of its heat and toxicity, proper dosing is essential. Experienced practitioners will feel comfortable within a particular range, and this will differ among practitioners. It is not uncommon to see fù zî prescribed at anywhere between 1g and 80g. A more common range is between 3 and 20g. Students tend to be at the low end, dosing timidly between 1 to 6g; those experienced with prescribing fù zî, such as Dr. Lee, tend to have average starting doses around 12 to 20 grams.

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If fù zî is being prescribed to a patient with mixed heat and cold symptoms, or if you are not yet confident with fù zî, I recommend beginning with 2g and increasing the dose by 2 to 3g each week until the condition starts to improve. If you reach a dose where the fù zî begins to exacerbate the heat signs, then back off 2-3g.

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Upper limits of fù zî can commonly reach as high as 30-40g or more. Dr. Lee and some other experienced practitioners I have observed will use as much as 60 to 80g in certain appropriate circumstances. But usually they have built up the dose carefully over many weeks. Proponents of the ‘Fire-God’ School will use up to 100 to 200 grams of fù zî, but nobody should use these doses unless they have studied the decoction, preparation and administration methods and have thoroughly learned through observation of a qualified practitioner the clinical applications. Very few cases require fù zî past 15 to 20 grams.

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Using granules is generally safe as the fù zî is usually already boiled and tested for toxicity. I will usually prescribe 0.5 to 2 grams of fù zî per 3-4g dose. I mostly find 1g is sufficient.

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Classically, one of the methods used to prevent fù zî toxicity is to have the patient take a small taste of the formula first. If the patient feels tingling or numbness on the tongue, then the fù zî is too strong. Generally, I think even this degree of fù zî toxicity is avoidable, unless there is a problem with the fù zî preparation, or the practitioner has dosed too high too quickly.

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Countering heat and toxicity

As mentioned, the toxicity of fù zî must be considered when adding it to a formula. There are several traditional methods to curb its toxicity.

1、Decocting in water. When fù zî is boiled in water, the toxic alkaloid, aconitine, is broken down. Current instructions taught in schools is to boil any fù zî 30 to 60 minutes prior to boiling any other herbs. If you are used to a double cook, then this is a good practice. My teacher does one 60-minute boil with all herbs together and has not encountered any problems, but he is careful to add such herbs as shëng jiäng (Zingiberis Rhizoma recens), gän câo (Glycyrrhizae Radix) and huáng qín (Scutellariae Radix) to counter the toxicity in the decoction process.

2、Include (raw) ginger and gancao. These two herbs are able to counteract fù zî toxicity. Gancao can be added to fù zî on a 1:2 ratio. Thus, if you prescribe 10 grams of fù zî, then add 5 grams of sheng (raw) gancao. Usually 3-4 slices of raw ginger is sufficient. Note that these three herbs, fù zî, gancao and raw or dried ginger are the ingredients of Si Ni Tang.

3、Include huang qin, huáng lián (Coptidis Rhizoma) or huáng bâi (Phellodendri Cortex) to counter fù zî’s heat. When Dr. Lee includes fù zî to Huáng qí Jiàn Zhöng Täng (Astragalus Decoction to Construct the Middle) for upper body joint pain, he usually adds huangqin at half the amount of the dose of fù zî. I believe this works well for his clinic in Taiwan which is hot and humid. This may not be necessary in other environments. However, combining fù zî with huangqin (or huang lian or huang bai) has precedent in the Shang Han Lun, notably the formula Da huang Fu zi Xie Xin Tang.

4、Avoid using fù zî in ground raw herb powders. Some practitioners take the herbs and coarse grind them in a formula. This can have two problems with toxic herbs. First is the herbs are usually prepared by a short 10 minute or so boiling. This may not be enough to break down the toxins. Second, the grinder often heats up to the point where it can cause further toxicity of some herbs.

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Conclusion

Fù zî is one of the most potent, life saving herbs in Chinese herbal medicine. It is a shame to not use it due to lack of familiarity or timidity. As one of the lifesaving herbs, I have seen it save patients from collapse and possible death following severe and prolonged diarrhea, acute pericardial effusion, severe weakness from cancer and chemotherapy and so on. Becoming familiar with fù zî, gram by gram, will enrich your clinical effectiveness by making formulas come to life.