A Complete Guide to Common Toxic Chinese Medicines and Antidotes for TCM Poisoning

The core of medicine is safety and efficacy; medication safety concerns the patient's life and health and admits not the slightest negligence. Yet the treatment of many diseases cannot avoid toxic drugs.

Used well, they cure; abused, they kill. When a doctor uses toxic Chinese medicines, he must be thoroughly familiar with the drug's toxicity and the harms that may arise from combining certain drugs, and must know the emergency and management measures after TCM poisoning, so as to avoid patients being poisoned by Chinese medicines and suffering serious consequences or medical accidents.

Generally speaking, the toxic and side effects of Chinese medicines manifest in the following ways.

First, some Chinese medicines, when combined, produce serious side effects. When herbs of contrary or mutually-restraining properties are combined, serious consequences may result, such as the traditional TCM "eighteen incompatibilities" and "nineteen mutual antagonisms."

The eighteen incompatibilities state that Gancao (Licorice) conflicts with Gansui (Knoxia), Daji (Euphorbia), Haizao (Sargassum), and Yuanhua (Daphne); Wutou (Aconite: Fuzi, Chuanwu, Caowu) conflicts with Beimu (Fritillaria), Gualou (Trichosanthes), Banxia (Pinellia), Bailian (Ampelopsis), and Baiji (Bletilla); Lilu (Veratrum) conflicts with Renshen (Ginseng), Shashen (Glehnia), Danshen (Salvia), Xuanshen (Scrophularia), Xixin (Asarum), and Shaoyao (Paeonia). Historically there is a verse: "The Bencao plainly states the eighteen incompatibilities: Ban, Gualou, Bei, Lian, Ji attack Wutou; Zao, Ji, Sui, Yuan all war against Cao; the various Shens, Xin, and Shao rebel against Lilu."

The nineteen mutual antagonisms state that Liuhuang (Sulfur) antagonizes Puxiao (Mirabilite); Shuiyin (Mercury) antagonizes Pishuang (Arsenic trioxide); Langdu (Euphorbia fischeriana) antagonizes Mituseng (Litharge); Badou (Croton) antagonizes Qianniu (Pharbitis); Dingxiang (Clove) antagonizes Yujin (Curcuma aromatica); Chuanwu and Caowu antagonize Xijiao (Rhinoceros horn); Yaxiao (thenardite) antagonizes Sanleng (Sparganium); Guigui (cinnamon bark) antagonizes Chishizhi (Halloysitum rubrum); Renshen antagonizes Wulingzhi (Trogopterus dung).

The verse for the nineteen antagonisms is: "Sulfur is originally the essence of fire; once it meets Mirabilite they contend. Mercury must not see arsenic; Langdu most fears litharge. Croton's nature is fiercest of all, yet it is not at odds with Qianniu. Clove must not see Yujin; thenardite hard to join with Sparganium. Chuanwu, Caowu are not at ease with rhinoceros horn; Ginseng most fears Wulingzhi. Cinnamon bark is good at regulating cold qi, but meets Chishizhi and is then cheated. In all compounding, observe what goes with what; roasting, quenching, and charring must not be joined at will."

Whether the drugs of the eighteen incompatibilities and nineteen antagonisms may be used together has been disputed by physicians through the ages. Some hold that incompatible drugs increase toxicity and damage the body, and stress they must not be used. The Shennong Bencao Jing says "do not use the mutually-abhorring and mutually-contrary ones"; the Bencao Jing Jizhu says "if contrary, they become mutual enemies and must not be combined"; Sun Simiao says "if herbs and minerals are contrary, they confuse the person, with force greater than swords." All stress that contrary drugs must not be used together.

Some physicians, as in the Yi Shuo (Medical Tales), even described the poisoning symptoms and rescue methods from using contrary drugs together. Modern clinical and experimental research also has many reports of poisoning from using contrary drugs together, such as Beimu with Wutou. Hence the "generalities" of the 1963 edition of the Chinese Pharmacopoeia explicitly stipulated: "Noted as mutually-restraining, mutually-abhorring, or mutually-contrary means that under ordinary circumstances they should not be used together."

However, from ancient times to the present there are also many records of contrary drugs being used together, holding that such combination can achieve the effect of mutual opposition producing mutual reinforcement, and of opposing force to seize accumulations. The Medical Orthodoxy says: "Without, for great poisonous diseases, there must be great poisonous medicines to attack them, and one cannot apply ordinary principles. As in the ancient formula Ganying Wan, using Badou and Qianniu together as a medicine to attack hardened accumulations; the Siwu Decoction with Renshen, Wulingzhi and the like to treat blood clots; Zhu Danxi's twenty-four-flavor Lianxin San for consumptive consumption, using Gancao and Yuanhua together, and its subtlety lies precisely here. This is something only the wise, with true insight, may use; the dull must not rashly try it and kill people." The Bencao Gangmu also says: "Using mutually-abhorring and mutually-contrary drugs together is the hegemon's way; there is the constant and the expedient, depending on the knowledge and judgment of the user." Both stress that contrary drugs may be used together.

As above, formulas through the ages that use contrary drugs together are not rare. For example, in the Jingui Yaolüe, Gansu Banxia Tang uses Gansui and Gancao together to treat retained fluid; Chi Wan combines Wutou and Banxia to treat cold-ni reverse flow; in the Qianjin Yifang, the Da Paifeng San and Da Kuanxiang Wan both pair Wutou with Banxia, Gualou, Beimu, Baiji, and Bailian; in the Rumen Shiqin, Tongqi Wan uses Haizao and Gancao together; the Jingyue Quanshu's Tongqi San pairs Lilu with Xuanshen to treat malignant swelling of epidemic toxin and throat obstruction. Modern reports also describe using Gansui and Gancao together for cirrhosis and nephritic edema, and Yuanhua, Daji, and Gansui combined with Gancao for tuberculous pleurisy, with good results, thereby affirming that contrary drugs may be used together.

At present there are not yet enough clinical experimental data to confirm whether the eighteen incompatibilities and nineteen antagonisms truly cause adverse reactions. To be cautious, in clinical prescribing one should still avoid these incompatible combinations as much as possible.

In addition, contemporary TCM clinicians have found that Yanhusuo (Corydalis) can enhance the toxicity of Maqianzi (Strychnos); that combining Zhusha (Cinnabar) with Kunbu (Kelp) not only markedly lowers the effective components (mercuric sulfide and iodine) but also forms mercuric iodide and releases mercury ions, easily leading to mercury poisoning.

Some Chinese medicines used together with Western drugs produce similar situations; for example, calcium-containing TCM herbs such as Shigao (Gypsum), Longgu (Dragon bone), and Shijueming (Haliotidis concha) combined with cardiac glycoside drugs can enhance the latter's toxicity to the myocardium and more easily produce cardiac-glycoside toxic reactions.

Second, pregnant women taking certain Chinese medicines may suffer serious consequences; this is also a contraindication for TCM use. The verse for pregnancy contraindications:

Yuan¹, Ban², leech and horsefly; Wutou, Fuzi and Tianxiong; Yage (southern moonseed), mercury and Croton; Niuxi, Yiyi and centipede; Sanleng, Yuanhua³, Daizhe⁴, musk, Daji, Chantui, male and female arsenic⁵; Yaxiao, Mangxiao, Mudan, Gui, Huaihua, Qianniu, Zaojiao alike; Banxia, Tiannanxing and Tongcao; Qumai, Ganjiang, Taoren, Tong⁶; Naosha, Ganqi, crab claw and shell; Di dan, Maogen all are not fit.

Notes:

1. Yuan: the general term for Protura insects, a class of tiny wingless insects; also read as a type of salamander, of the family Salamandridae, feeding on various insects, small fish, or tadpoles, distributed mainly in central and eastern China, an internally-fertilizing amphibian.

2. Ban: refers to Banmao (Mylabris / blister beetle). It has strong renal toxicity and is a highly toxic substance, secreting a liquid called cantharidin to defend against enemies.

3. Yuan: refers to Yuanhua (Daphne genkwa). Aliases include Yaoyucao, Laoshuahua, Naoyuhua, Touotonghua, Mentouhua, etc.; the corolla is acrid, bitter, cold, and toxic.

4. Daizhe: i.e. Daizheshi (Hematite).

5. Male and female arsenic: i.e. Xionghuang (realgar) and Cihuang (orpiment).

6. Tong: refers to Mutong (Akebia) and Tongcao (Tetrapanax pith), both TCM herbs to be used cautiously in pregnancy.

The contraindicated herbs summarized in the Pregnancy Contraindication Verse fall into three categories:

(1) Absolutely prohibited highly toxic herbs: Yuanqing (bluebottle beetle), Banmao (blister beetle), Tianxiong, Wutou, Fuzi, Yage (southern moonseed), mercury, Croton, Yuanhua (Daphne), Daji (Euphorbia), Naosha (sal ammoniac), Didan (oil beetle), red arsenic, white arsenic.

(2) Prohibited toxic herbs: leech, horsefly, centipede, realgar, orpiment, Qianniu (Pharbitis seed), Ganqi (dried lacquer), crab claw and shell, musk.

(3) Cautious-use herbs: Maogen (cogongrass rhizome), Mutong, Qumai (Dianthus), Tongcao, Yiyiren (Coix seed), Daizheshi, Mangxiao (Mirabilite), Yaxiao, Puxiao, Taoren (peach kernel), Mudanpi (Moutan bark), Sanleng (Sparganium), Niuxi (Achyranthes), Ganjiang (dried ginger), Rougui (cinnamon), raw Banxia, Zaojiao (Gleditsia), raw Tiannanxing, Huaihua (sophora flower), Chantui (cicada slough), etc.

In addition, people have found in practice that the following herbs should also be used cautiously in pregnancy: Gualidi, Lilu, Danfan (blue vitriol), Yuli ren, honey, Gansui, Chishao (red peony), Quanxie (scorpion), Zhishi (immature bitter orange), Honghua (safflower), Wulingzhi, Moyao (myrrh), Xueshangyizhihao, Ezhu (Zedoary), Shanglu (Phytolacca), Danggui (Angelica), Chuanxiong (Ligusticum), Danshen, Yimucao (Leonurus), Taoren, Taoren, Xuejie (dragon's blood), Chuanshanjia (pangolin scales), Zelan (Lycopus), Ruxiang (frankincense), Maodongcao, Wuzhuyu (Evodia), Sharen (Amomum), Doukou (cardamom), Houpo (Magnolia bark), Muxiang (Aucklandia), Zhiqiao (ripe bitter orange), Jinlingzi, Huanglian (Coptis), Zhizi (Gardenia), Longdancao (Gentiana), Shandougen (Sophora tonkinensis), Daqingye, Banlangen (Isatis root), Kushen (Sophora flavescens), Danpi, Shengdi (raw Rehmannia), Xuanshen, Zicao (Lithospermum), Xijiao, Maogen, Huaihua, Chuanwu, Caowu, Yanhusuo, Xixin, Baishao (white peony), Baizhi (Angelica dahurica), Gancao, Suanzaoren (sour jujube seed), Hailong, Haima (seahorse), reed, Yangjinhua (Datura), Tiannanxing (Arisaema), Taizishen (pseudostellaria), Wangbuliuxing, Liuhuang, camphor, Xuanmingfen, Chansu (toad venom), Qianglang (dung beetle), Tubiechong (eupolyphaga), Hongniang (ladybug beetle), Awei (asafoetida), Zhuya zao, Lulutong, Bayue zha, Chaihu (Bupleurum), Tianxianzi, Biancao (Verbena), Baifuzi (Typhonium), Mahuang (Ephedra), Dongkuizi, castor oil, fanxieye (senna leaf), etc.

The Chinese medicines banned or used cautiously in pregnancy may be summarized as mostly blood-activating and stasis-resolving herbs, blood-cooling and detoxifying herbs, qi-moving and wind-dispersing herbs, and bitter-cold heat-clearing herbs.

In addition, when administering medicines to weak, frail patients and to the elderly and young, attention must also be paid to medication safety. Generally, for weak patients or the elderly and young, dosages should be lighter than for ordinary adult patients, because such patients are relatively frail and cannot withstand the attack of harsh herbs; when taking tonics they may also show the vacuity-not-bearing-tonic phenomenon, so dosages should be reduced for them.

Third, some drugs are inherently toxic, such as Pishuang (arsenic), Banmao (blister beetle), Maqianzi (Strychnos), Naoyanghua (Rhododendron molle), and Datura (Datura); these are highly toxic, and improper use leads to poisoning. This is the key part of TCM poisoning.

TCM poisoning falls into two categories: acute and chronic. When the dose exceeds the extreme limit and a toxic reaction occurs immediately, it is called acute poisoning; when medication over a long time accumulates and a toxic reaction gradually appears, it is chronic poisoning.

Because individuals differ in sensitivity to drugs, even a dose within the normal range may produce a toxic reaction. Some patients, after being sensitized by a certain drug, produce an antigen-antibody binding reaction upon re-exposure, causing tissue damage or physiological dysfunction; these are called allergic (hypersensitivity) reactions. Generally, an allergic reaction has a latent period of varying length.

In addition, with advances in medical technology, some Chinese medicines have been found to be carcinogenic, teratogenic, or mutagenic; these now also require the attention of clinicians. For some patients there are also idiosyncratic reactions: individual patients, at ordinary doses, may show abnormal drug reactions unrelated to the drug's pharmacologic action and different from the general population; such a reaction is idiosyncratic.

Some patients have drug dependence: after long-term use of a drug, although the therapeutic goal has been reached, they still feel a desire to continue taking it, producing psychological dependence.

Of course, in the broad sense of toxic reactions, almost all Chinese medicines have toxic or side effects; some considered safe and nontoxic, if taken in excess, can also cause adverse reactions. There are reports of patients who died after taking 40 grams of red ginseng. But by "toxic Chinese medicines" we generally mean, in the narrow sense, the more toxic herbs that produce acute poisoning when taken.

The toxic TCM varieties regulated under the State Council's Measures for the Administration of Toxic Medicines for Medical Use include: Pishi (red arsenic, white arsenic), Pishuang, mercury, raw Maqianzi, raw Chuanwu, raw Caowu, raw Baifuzi, raw Fuzi, raw Banxia, raw Tiannanxing, raw Badou, Banmao, Qingniang chong, Hongniang chong, raw Gansui, raw Langdu, raw Tenghuang (Garcinia morella), raw Qianjinzi, raw Tianxianzi, Naoyanghua, Xueshangyizhihao, Hongsheng dan, Baijiang dan, Chansu, Yangjinhua (Datura), Hongfen, Qingfen (calomel), Xionghuang (realgar), etc.

Contemporary Chinese medicine, combining written records and clinical reports with modern pharmacological experimental methods, has conducted extensive research on adverse reactions of Chinese medicines. The results show:

In terms of acute toxicity, Maqianzi, Chuanwu, Caowu, Fuzi, Xueshangyizhihao, Xixin, raw Tiannanxing, Huangyaozi, and Kudouzi easily cause toxic reactions of the central nervous system. Common poisoning symptoms include numbness of the lips, tongue, and limbs, headache, dizziness, restlessness, confusion, twitching, convulsions, coma, constricted or dilated pupils, locked jaw, and even death.

Drugs containing aconitine (such as Chuanwu, Caowu, Fuzi, Xueshangyizhihao) and drugs containing cardiac glycosides (such as Chansu, Apocynum venetum leaf, Rohdea japonica, Thevetia peruviana, and Periploca sepium bark) easily cause toxic reactions of the cardiovascular system. Common symptoms include palpitations, chest oppression, arrhythmia, raised or lowered blood pressure, circulatory failure, and even death.

Kuxingren (bitter apricot kernel), Taoren (peach kernel), Liren, Piparen, Baiguo (ginkgo nut), and Shanglu (Phytolacca) easily cause toxic reactions of the respiratory system. Common poisoning symptoms include dyspnea, cough and hemoptysis, acute pulmonary edema, respiratory-muscle paralysis, respiratory failure, and even death by asphyxiation.

Some bitter-cold herbs taken in large doses orally irritate the gastrointestinal tract; in severe cases they cause toxic reactions of the digestive system. Common toxic symptoms include nausea, vomiting, poor appetite, abdominal pain, abdominal distension, diarrhea, gastrointestinal bleeding, jaundice, hepatomegaly, hepatitis, and hepatocellular necrosis.

Huangqin (Scutellaria), Mangxiao, Chaihu, and Yinchen (Artemisia capillaris) can cause stomach discomfort. Huanglian, Kushen, Qinghao (Artemisia annua), Qinjiao (Gentiana macrophylla), and Yinchen can cause nausea. Yadanzi (Brucea), Kushen, Qinghao, raw Dahuang, and Qinjiao can cause vomiting. Raw Dahuang, raw Shengdi, fanxieye, Yuanhua, and Changshan can cause abdominal pain. Badou, Huangqin, Huanglian, Kushen, raw Shengdi, Changshan, and Beidougen can cause diarrhea. Cangerzi (Xanthium), Huangyaozi, Chuanlianzi (Melia toosendan), and Leigongteng (Tripterygium) can cause liver damage.

Banmao (blister beetle), Guanmutong (Aristolochia manshuriensis), Qingmuxiang, Madouling (Aristolochia fruit), Mufangji (Aristolochia fangchi), and Zhushalian easily cause toxic reactions of the urinary system. Common toxic symptoms include low back pain, edema, frequent urination, oliguria, anuria, uremia, and renal failure.

Yangjinhua (Datura), Yuanhua, Banmao, Langdu, and Leigongteng easily cause toxic reactions of the hematopoietic system. Common toxic symptoms include leukopenia, agranulocytosis, hemolytic anemia, purpura, aplastic anemia, and even death. Extended IV drip of Chuanhuning injection can lead to thrombocytopenia.

In terms of chronic toxicity, based on histopathological examination of long-term animal toxicity tests on 103 Chinese medicines, 44 showed pathologic damage changes. Among the target organs of long-term toxic damage from these 44 herbs, the liver, kidney, and gastrointestinal tract have the highest incidence, followed by myocardium, bone marrow, lung, central nervous system, and endocrine glands. Some of these are commonly used herbs, such as Tianhuafen (Trichosanthes root), Qingdai (indigo), Qinghao, Huzhang (Polygonum cuspidatum), Shandougen, Banxia, Dahuang (rhubarb), Duhuo (Angelica pubescens), Qinjiao, and Fangji (Stephania).

The Chinese medicines that cause allergic reactions chiefly include over a hundred such herbs as Jiangchan (Bombyx batryticatus), centipede, scorpion, Chantui, Banmao, Tubiechong, Langdu, Yadanzi, and Leigongteng, as well as compound Dilong injection, Lurongjing injection, and Tianhuafen injection.

These easily trigger allergic reactions in patients with allergic constitutions. Mild cases present as rash, urticaria, erythema, skin/mucosal blisters, and fever; severe cases may show exfoliative dermatitis and anaphylactic shock.

Teratogenic, mutagenic, and carcinogenic effects: long-term use of Leigongteng (Tripterygium), Binglang (areca bud), Kuandonghua (coltsfoot), Qianliguang (Senecio), Shichangpu (Acorus tatarinowii), Guangfangji, Guanmutong, Madouling, Xixin, Tujingjie, Xionghuang, Pishuang, Tubimu, and Yebaihe may have mutagenic or carcinogenic potential. There are also reports that Kushen, Kuxingren, Taoren, and Yuliren may be teratogenic.

Acute TCM poisoning generally has a short course with sudden onset. With a history of exposure to the toxic substance and corresponding poisoning symptoms, lung and stomach symptoms are seen early, and the heart, brain, liver, kidney, and blood vessels are easily involved. There is often organ damage and disharmony of the zang-fu and qi-blood, leading to critical signs such as sudden panting, palpitations, convulsions, coma, desertion syndrome, oliguria, and anuria, even the critical sign of yin-yang separation.

Generally, TCM poisoning presents with the following clinical manifestations:

1. Abnormal complexion and skin color: (1) Flushing is common in Datura poisoning and gas poisoning. (2) Sweating is common in physostigmine (calabar bean) poisoning and pilocarpine poisoning. (3) Burning pain with rash is mostly from blister-beetle (cantharidin) damage. (4) Skin ulceration is common in poisoning by highly toxic mineral drugs or in insect/animal bites. (5) Cyanosis is common after eating poisonous fungi by mistake or inhaling foul toxic gas. (6) Jaundice is common after eating broad beans by mistake or other poisons that injure the liver and gallbladder.
2. Abnormal changes of the pupil: (1) Constricted pupil is common in physostigmine, pilocarpine leaf, Banbianlian (Lobelia), opium, organophosphate, and insect/animal bites. (2) Dilated pupil is common in Mahuang (Ephedra), Gouwen (Gelsemium), Duqin (Cicuta), and Datura poisoning.
3. Mental (shen) abnormalities: (1) Convulsions are common in Maqianzi (Strychnos), Mashanguo (Coriaria fruit), belladonna-type, camphor, and nux-vomica poisoning. (2) Delirium is common in poisonous mushroom, flesh-poison, and Coriaria fruit poisoning. (3) Paralysis is common in curare, pufferfish, poison hemlock, spoiled meat, and Zuiyucao (Buddleja) poisoning. (4) Fainting is common after overdosing on nuts such as apricot, peach, or loquat kernels.
4. Abnormal respiration: (1) Over-deep breathing is common in opium, Gelsemium, and Rauwolfia poisoning. (2) Respiratory paralysis is common in snake venom, wasp venom, Xixin (Asarum), colchicine, Naoyanghua, Bichengqie (Litsea cubeba), Datura, Baibu (Stemona), and Gelsemium poisoning.
5. Digestive abnormalities: (1) Dry mouth is common in Datura and diguazi (sweet potato seed) poisoning. (2) Salivation and vomiting are common in Lobelia, poison hemlock, Coriaria fruit, tobacco, blister beetle, and Shisuan (Lycoris) poisoning. (3) Hematemesis is common with strongly corrosive poisons such as arsenic poisoning. (4) Diarrhea or bloody stool is common in Langdu, Daji, Yuanhua, Xanthium, Phytolacca, and ipecac poisoning.
6. Abnormalities of the heart and pulse: (1) Tachycardia is common in Datura and Ephedra poisoning. (2) Bradycardia is common in oleander, Bajiaofeng (Alangium), Chansu (toad venom), and Aconite poisoning. (3) True heart pain is common in tobacco and Ephedra poisoning. (4) Hyperactive (yang) wiry pulse is common in Ephedra, tobacco, toad venom, Rohdea japonica, and ergot poisoning, often accompanied by raised blood pressure.
7. Abnormalities of the urine: (1) Hematuria is common in Tripterygium, blister beetle, Aristolochia, and castor-seed poisoning. (2) Abnormal urine color is common in realgar and other mineral drug poisoning.
8. Other manifestations: (1) Miscarriage is common when pregnant women take poisonous fungi, Phytolacca, or saffron. (2) Colored-vision is common in Veratrum and oleander poisoning. (3) Deafness is common in cinchona bark and its preparations poisoning.

How is TCM poisoning rescued? Generally, after TCM poisoning the following management principles should be followed:

First, immediately stop eating, taking, inhaling, or contacting the poison. Second, rapidly remove the absorbed and unabsorbed poison already in the body. Third, as early as possible use effective antidotes that counteract the poison and relieve its toxic and side effects. Fourth, actively and rapidly provide emergency treatment for critical signs that arise, such as convulsions, reverse-desertion, panting, and coma, combining Chinese and Western medicine when necessary. Fifth, the poisoned patient should be kept under observation and monitoring, the course of poisoning observed in detail, symptomatic emergency and anticipatory treatment plans formulated, and special records kept.

The commonly used emergency measures for TCM poisoning are as follows.

First, reduce absorption of the poison. There are four common ways: emesis (inducing vomiting), gastric lavage, purgation, and diuresis.

Emesis (also called the emetic detoxification method) is mainly suited to cases where the amount of poison ingested is not large, the poison was taken orally within 2–3 hours, and the patient's upright qi is still robust. Common emetic formulas include:

1. Ipecac syrup: 15–20 ml added to 200 ml water, taken orally; vomiting occurs within 15–30 minutes.

2. Sansheng San: Lilu (Veratrum) 6g, Fangfeng (Saposhnikovia) 10g, Gualidi (Trichosanthes fruit stalk) 6g oralum (alum) 6g, decocted in water and taken all at once.

3. Emetic Detoxification Decoction: Gancao 60g, Gualidi 7 pieces, Xuanshen 60g, Diyu (Sanguisorba) 15g or Kushen 30g, decocted and taken all at once.

4. Raw eggs: 10–20, take the egg whites, add alum 6–30g, stir well, take orally or by gastric gavage; after vomiting, gavage again. White alum 6g, gall alum 1g, taken with warm water; or stimulate the throat with a finger or tongue depressor to induce vomiting.

Gastric-lavage detoxification is mainly suited to cases where the poison amount is large and oral ingestion was recent. If the patient is conscious, have him drink large amounts of water then induce vomiting. If unconscious, routinely insert a gastric tube and use a gastric-lavage machine with wash liquid made by decocting Gancao 20g, or light salt water, potassium permanganate, or mung-bean soup, repeatedly rinsing until the effluent is roughly the same as the inflowing liquid. This method is contraindicated in patients with convulsions, esophageal varices, aortic aneurysm, ulcer bleeding, or esophageal/gastrointestinal injury from corrosive poisons. Pregnant women should use it cautiously.

Purgative detoxification suits cases where the poison has entered the intestine but not yet been fully absorbed; use purgation to expel the poison in the stool. Common methods:

1. One packet Baohong San taken all at once; fanxieye (senna) 15g decocted and taken.

2. Dahuang (rhubarb), Fangfeng, and Gancao each 30g, decocted and taken.

3. If oral cathartics still cannot fully expel the poison, use colonic lavage, e.g. Dahuang 30g decocted to 200–300 ml and used as an enema; Dachengqi Decoction (Dahuang 12g, Houpo 24g, Zhishi 12g, Mangxiao 6g) decocted to 300–500 ml and used as an enema. This is contraindicated in patients with esophageal and gastrointestinal injury from corrosive poisons.

Diuretic detoxification suits cases where the poison has entered the blood. Cheqianzi (Plantago seed) and Baimaogen (cogon grass rhizome) each 30g may be decocted and taken. For acidic drug poisoning, sodium bicarbonate and diuretics may be used to alkalinize the urine; watch for pulmonary edema, cerebral edema, electrolyte disturbance, and acid-base imbalance in such patients. It is contraindicated in renal insufficiency.

Common antidotal Chinese medicines include:

1. Shengjiang (fresh ginger) 5g decocted and taken, or white alum 6–10g taken with boiling water, to antidote Banxia and Tiannanxing toxicity.

2. Fangfeng 10–15g decocted and taken, for arsenic poisoning.

3. Lüdou (mung bean) 250g decocted and taken, for Croton poisoning.

4. Gegen (Kudzu root) 50g, Zisu (Perilla) 50g, Guizhi (cinnamon twig) 10g, decocted and taken 2–3 times daily, for alcohol poisoning. Alternatively, Zexie (Alisma) 12g and Baizhu (Atractylodes) 12g may be decocted as a drink.

5. For spoiled-meat poisoning: one garlic bulb and Xionghuang (realgar) 2g, mixed and mashed, taken with warm water.

6. For sprouted-potato poisoning: drink an appropriate amount of vinegar.

7. For poisonous-mushroom poisoning: white alum 6g and an appropriate amount of sesame oil, taken with boiling water.

8. For alcohol poisoning: dadou (soybean) 250g decocted, taken warm.

9. For organophosphate pesticide poisoning: Gancao 240g decocted to a liquid, mixed into 60g talcum powder and an appropriate amount of soybean, clarified, then taken all at once.

10. Raw soybean 120g and raw mung bean 60g decocted, for various food and drug poisonings.

11. Xingguo antidote: Jixueteng (Spatholobus), Sanqi (Notoginseng), Qingmuxiang, Qiancao (madder) each 15g, Xiangfu (Cyperus) 10g, Bingpian (borneol) 3g, Xiaoye Fengweicao (Pteris multifida) 150–250g, decocted and taken. For poisoning by Aconite, Xanthium, Strychnos, wild poisonous mushrooms, cyanide, nitrite, and organophosphate pesticides.

12. Lüdou Gancao Jiedu Tang: mung bean 120g, raw Gancao 30g, Danshen, Lianqiao, Shihu each 30g, Dahuang 15–30g, decocted and taken, two doses daily.

Clinically there are also targeted management methods for specific common TCM poisonings.

I. Aconite-type drugs (Fuzi, Tiebangchui, Chuanwu, Caowu, Tianxiong, Jitouhua, Xiaoyelu, etc.) poisoning.

This type of poisoning is mostly alkaloid poisoning. Alkaloids have strong pharmacologic and toxic effects; the latent period is generally short, mostly presenting within 2–3 hours after ingestion. The toxic components mostly attack the central and autonomic nervous systems.

Mild cases generally present nausea, vomiting, salivation, abdominal pain, diarrhea, generalized numbness, headache, dizziness, and blurred vision. Severe cases show palpitations, shortness of breath, pale complexion, purple lips, cold limbs with sweating, a bound-scattered (irregularly intermittent) pulse, even syncope and convulsions. ECG may show various arrhythmias.

The standard management after Aconite-type poisoning is:

1. Remove the poison: within 4–6 hours of ingestion, immediately lavage with 1:5000 potassium permanganate solution; after lavage, instill 20g magnesium sulfate through the tube for catharsis, or perform high enema with 2% saline.

2. IV fluids: IV drip of 10% glucose injection or 5% glucose-normal saline, supplemented with vitamins B and C.

3. Antidotal Chinese medicine (taken after lavage):

(1) Honey 50–100 g, taken with boiling water; for frequent vomiting, take small sips often; once vomiting stops, take it all at once.

(2) Mung bean decoction as a tea, taken often.

(3) Jiang Gancao Lüdou Tang: Shengjiang and Gancao each 15–30g, mung bean 30–60g, decocted and taken.

(4) Huanglian (Coptis) 9g, heidou (black soybean) 30g, decocted and taken.

(5) Shengjiang 15g, Shenggancao 15g, Jinyinhua (honeysuckle) 15g, decocted and taken.

(6) Yinhua Gancao Sandou Tang: Jinyinhua, Gancao, heidou, lüdou, chidou (red bean) each 30g, decocted then add honey 30g, one dose daily.

(7) Huangqi (Astragalus) 30g, Yuanzhi (Polygala) 10g, Gancao 10g, decocted and taken.

(8) Kushen 30g decocted and taken.

(9) Gancao 15g, Shuiniujiao (water buffalo horn) 20g, Chuanhuanglian 3g, decocted and taken.

II. Gelsemium (Gouwen / Goudu) poisoning

Mild cases of Gelsemium poisoning show burning pain in the mouth and throat, nausea and vomiting, abdominal pain, and diarrhea. Severe cases show dizziness, limb numbness, slurred speech, fatigue, occasional tremor, difficulty swallowing, double vision, reduced vision, drooping eyelids, even coma and convulsions. Critical cases show shortness of breath or faint breathing, cold limbs with sweating, dilated pupils, and a pulse that is first slow then rapid. Laboratory tests may show elevated peripheral white-cell count and hemoglobin, and urinalysis may show protein and abnormal red and white cells.

Management of Gelsemium poisoning:

1. Remove the poison: promptly lavage and cathart to promote excretion. Lavage may use 1:5000 potassium permanganate solution, tea water, or 3% tannic acid solution; after lavage, instill magnesium sulfate solution for catharsis.
2. Oxygen therapy: for respiratory failure, immediately inject or IV drip a respiratory center stimulant; when necessary, perform endotracheal intubation and mechanical ventilation.
3. IV medication: supplement large amounts of B vitamins and vitamin C; IV drip hypertonic glucose injection for diuresis and detoxification; adrenocortical hormones may be used as appropriate.
4. Chinese medicine (taken after lavage).

(1) Sanhuang Tang (Huangqin 10g, Huanglian 10g, Huangbai 10g, Gancao 10g), decocted and administered by gavage.

(2) Jinyinhua with leaves mashed, juiced, mixed with brown sugar, and given by gavage.

(3) Three eggs, take the egg whites, mix with peanut oil, and give by gavage.

(4) Gancao decoction by gavage.

(5) The roots and stems (leaves removed) of Tongshuxin (water spinach) 500g, mashed, juiced, and given by gavage.

III. Blister beetle (Banmao) poisoning

Mild blister-beetle poisoning shows nausea and vomiting, colicky abdominal pain, diarrhea, frequent and painful urination, urethral burning, scanty dark urine, oral mucosal erosion and burning pain, dry red skin with blisters, even ecchymoses and ulceration. Severe cases show headache, dizziness, limb numbness, bloody stool, and hematuria. Critical cases show chills, high fever, delirium, coma, and convulsions. Laboratory tests may show elevated peripheral blood cell count and hemoglobin; urinalysis may show protein and abnormal red and white cells.

Management of blister-beetle poisoning:

1. Clean the mouth: keep the mouth clean; rinse with 2% boric acid water. For oral ulcers, apply Bingpeng San; for skin blisters, apply Houfeng San. Use antibiotics when necessary to prevent infection.

2. Protect the gastrointestinal mucosa: for oral poisoning, immediately take 3–4 eggs, break them and take the egg whites orally, or take 50–100 ml fresh milk, to protect the gastric and intestinal mucosa. Use gastric lavage cautiously, because blister-beetle poisoning easily forms blisters and may damage the gastric mucosa, worsen bleeding, and even cause gastric perforation.

3. IV fluids to maintain water-electrolyte balance: IV drip furosemide and mannitol to enhance toxin excretion. If renal damage and shock occur, treat promptly.

4. Chinese medicine (taken immediately):

(1) Xingguo antidote: Jixueteng, Sanqi, Qingmuxiang, Qiancao each 15g, Xiangfu 10g, Bingpian 3g, Xiaoye Fengweicao 150–250g, decocted and taken.

(2) Doujiang Liancao Tang (heidou (black soybean) 1000g, Chuanhuanglian 60g, Gancao 30g; first grind the black soybeans into soy milk, then decoct the Coptis and Gancao, strain, mix the liquid into the soy milk, stir well, and drink often).

(3) Gancao Tang (Gancao 10g, mung bean 30g, Huanglian 5g, tea 10g, talcum 30g, Hupowu (amber powder) 3g), decocted and taken; it clears heat and detoxifies, cools blood and promotes diuresis.

IV. Datura (Yangjinhua) poisoning

Datura belongs to the belladonna (atropine) group. Mild Datura poisoning shows dry mouth and throat, hoarseness, flushed skin and face, red eyes, shortness of breath, and dizziness. Severe cases show agitation, clouded consciousness, delirium, dilated pupils, convulsions, even coma.

Datura poisoning can be diagnosed by the cat-eye dilation test: take a drop of the patient's urine and drip it on a cat's eye; if it is Datura poisoning, the cat's pupil will immediately dilate. It can also be confirmed by the atropine qualitative urine test (Vitel test): heat the patient's urine to dryness; if the residue is yellow and turns purple on adding potassium hydroxide, it is Datura poisoning.

Management of Datura poisoning:

1. Remove the poison: immediately lavage with 2%–4% sodium bicarbonate, or 2%–4% activated charcoal suspension. Do not use potassium permanganate or tannic acid solution, because they cannot destroy atropine. As a cathartic, use magnesium sulfate 15–30g; when necessary, IV fluids to promote renal excretion.

2. Use atropine antagonists: e.g. pilocarpine, which excites the parasympathetic nervous system; start with small subcutaneous doses, generally once every 6 hours, 5–10 mg each time; in severe poisoning shorten to every 15–30 minutes until dry mouth and mental symptoms disappear. Physostigmine or neostigmine may also be used.

3. IV access: supplement large amounts of B vitamins and vitamin C; IV drip hypertonic glucose for diuresis and detoxification; adrenocortical hormones may be used as appropriate.

4. Chinese medicine (used after lavage):

(1) Fangfeng 6g, Guizhi 6g, decocted and taken.

(2) Shenggancao and Sheng lüdou (raw mung bean) each 30g, mashed, steeped in boiling water or decocted and taken.

(3) Tea 30g decocted to a strong brew, mixed with 250g tofu, taken at once.

(4) Drink rice vinegar and brown sugar often.

(5) Lvdouyi (mung bean skin) 200g, Jinyinhua 100g, Lianqiao 50g, Gancao 25g, decocted and taken.

(6) Compound Daqingye injection 4 ml (containing Daqingye, Dahuang, Caocheche (Paris polyphylla), Jinyinhua, Qianghuo, etc.) by intramuscular injection; also effective for Datura poisoning.

(7) Shengmao Tongcao Yin (Shengma (Cimicifuga) and Tongcao each 50g, Maimendong 30g, Shenggancao 10g) decocted to 1000 ml, taken often.

V. Leigongteng (Tripterygium wilfordii; also Hongchaigen, Licouteng) poisoning

Six hours after taking Leigongteng, there is dull abdominal discomfort or severe abdominal pain, abdominal distension and diarrhea, nausea and vomiting, poor appetite, dry mouth, dizziness, headache, body pain tender to the touch, limb numbness, fatigue, and in severe cases bloody stool, jaundice, or convulsions. By 2–3 days, oliguria, edema, low back pain, palpitations, chest oppression, shortness of breath, purple lips, and a fine weak pulse appear. By 5–7 days, urine volume increases; a few show hematuria or urinary retention. Laboratory tests may show granulocytopenia, bone-marrow suppression, elevated ALT, and liver and kidney damage.

Management of Leigongteng poisoning:

1. Expel the poison: promptly lavage and cathart to minimize absorption; because Leigongteng is absorbed slowly in the stomach, even if poisoning has lasted hours or even days, lavage thoroughly to clear residual poison from the digestive tract.

2. Use adrenocortical hormones: dexamethasone 5–10 mg added to 50% glucose 40 ml by IV injection; thereafter dexamethasone 1.5 mg orally three times daily may be used for 2–3 weeks.

3. IV access: IV fluids, diuresis; dextran 40 500 ml by IV drip; 20% mannitol 250 ml by rapid IV drip; furosemide 40 mg by IV injection, to speed toxin excretion. Watch electrolyte balance, promptly correct acidosis, and strengthen supportive therapy.

4. Oxygen; watch vital signs.

5. Chinese medicine (taken after lavage):

(1) Gancao juice or mung-bean Gancao decoction (lüdou 12g, Gancao 50g), decocted and taken in divided doses.

(2) Fresh radish juice 120 ml orally, or Laifuzi (radish seed) 250g taken at once, and fresh chive juice, all antidotal.

(3) Sanhuang Gancao Tang (Huanglian, Huangqin, Huangbai each 10g, Gancao 50g), decocted and taken in divided doses.

(4) Seven pumpkin seeds and ten river snails, mashed to a juice and taken orally.

(5) Yangmeipi (bayberry bark) 200g decocted to 200–300 ml, taken at once.

(6) Baiyan powder 5g added to egg whites (3–5), with cold boiled water 100 ml, stirred well and taken orally; stimulate the back of the throat to induce vomiting; once vomiting stops, take 10–15 egg whites.

(7) Mung bean 120g decocted to 200 ml, taken orally.

VI. Maqianzi (Strychnos nux-vomica) poisoning

Early symptoms of Strychnos poisoning generally include dizziness, restlessness, shortness of breath, facial stiffness, and difficulty swallowing. The middle stage shows clarity of mind, constricted pupils, convulsions, opisthotonus, clenched fists, and rigid limbs, each convulsion lasting 1–2 minutes. In the later stage, severe convulsions recur five or more times; patients often die of lung-qi exhaustion or heart-qi exhaustion. Laboratory tests may show elevated peripheral white-cell count and hemoglobin; urinalysis may show protein and red and white cells.

Management of Strychnos poisoning:

1. Immediately place the patient in a dark room, keep quiet, and avoid light, sound, and other external stimuli.

2. Prevent convulsions: as soon as possible use central depressants, e.g. thiopental sodium or amobarbital sodium 0.4–0.5 g by intramuscular injection, or diazepam 20–30 mg by IV injection; if convulsions are still uncontrolled, use light ether anesthesia.

3. Lavage: after convulsions are controlled, if poison is thought to remain in the stomach, lavage with 0.1% potassium permanganate solution. Drink cow's milk or egg whites to precipitate the poison and reduce absorption, but strictly avoid acidic drinks and opiates.

4. Symptomatic treatment: IV fluids, oxygen, anti-infection, etc.

5. IV access: drip large doses of vitamin C and hepatic-protectant (Glurola) to speed hepatic detoxification and protect the liver.

6. Emetic and cathartic Chinese medicine (taken after lavage):

(1) Salt 15g with warm water to induce vomiting; Mangxiao with Gancao for catharsis.

(2) Honey 60g, mung bean 30g, Gancao 30g, decocted and drunk often.

(3) Wugong (centipede) 3 strips, Quanxie (scorpion) 6g, ground to powder and taken at once.

(4) If only mild symptoms such as dizziness, spinal numbness, or tight back/lumbar muscles are seen, drink large amounts of Gancao water.

VII. Lilu (Veratrum) poisoning

Veratrum poisoning generally shows local oral and gastrointestinal irritation, along with slowed heart rate, lowered blood pressure, spasms, drowsiness, yellow vision, and even respiratory suppression.

Common management:

1. Lavage with potassium permanganate; take activated charcoal solution orally to antidote. Give atropine 0.5–1 mg subcutaneously, IV when necessary. 2. Large IV fluids to promote renal excretion of the poison; watch electrolytes; oxygen when necessary. 3. Decongestion water with scallion taken, or Xionghuang, scallion head, and lard decocted together with cold tea; there is a folk saying that scallion antidotes Veratrum.

VIII. Calabar bean (physostigmine) poisoning

Common symptoms of calabar-bean poisoning include salivation, sweating, abdominal pain, nausea, vomiting, miosis, slow pulse, lowered blood pressure, respiratory depression, and tremor.

Management of calabar-bean poisoning:

1. Lavage; take tannic acid, strong tea, or iodine tincture to antidote. 2. Subcutaneous or IV injection of atropine until pupils dilate or symptoms ease. 3. IV fluids; oxygen when necessary; respiratory failure handled by standard first aid.

IX. Opium (morphine, codeine, and derivatives) poisoning

Acute opium poisoning shows stupor or coma, shallow and irregular breathing, constricted pupils with cyanosis. The toxic action is mainly on the central nervous system, so spinal reflexes persist during coma. Severe cases die of respiratory failure. Chronic poisoning chiefly shows fatigue, poor appetite, premature aging, emaciation, and anemia.

Management of opium poisoning:

1. Lavage and catharsis. 2. For respiratory depression, use respiratory stimulants such as naloxone hydrochloride. 3. Oxygen therapy. 4. IV glucose can promote morphine detoxification. 5. Chronic poisoning requires opiate withdrawal.

X. Tiannanxing (Arisaema) poisoning

Arisaema poisoning initially shows oral and gastrointestinal irritation, numbness, stiff tongue with salivation, pharyngeal bleeding, and oral erosion. Severe cases show dizziness, palpitations, limb numbness, and in critical cases coma, asphyxiation, and respiratory arrest.

Management of Arisaema poisoning: 1. Lavage with potassium permanganate. 2. Take tannin, strong tea, and dilute acid orally. 3. Oxygen therapy. 4. Fluid support. 5. TCM antidote: (1) fresh ginger juice 5 ml orally; (2) Shengjiang 30g, Fangfeng 60g, Gancao 15g, decocted and held in the mouth or taken orally.

XI. Mahuang (Ephedra) poisoning

Ephedra poisoning chiefly shows raised blood pressure, faster heart rate, dilated pupils, and increased metabolism. Severe poisoning can lead to respiratory failure and ventricular fibrillation death.

Management of Ephedra poisoning: 1. Lavage with potassium permanganate. 2. Immediately inject atropine subcutaneously, once every 20 minutes if necessary. 3. Use sedatives. 4. Use respiratory stimulants. 5. IV fluids and symptomatic management.

XII. Kulianzi (Chuanlianzi / Jinlingzi, Melia toosendan) poisoning

The main reactions of Melia-toosendan poisoning are vomiting and diarrhea; severe cases may show dizziness, dyspnea, tremor, spasms, and paralysis.

Management of Melia-toosendan poisoning:

1. Lavage and catharsis. 2. Use egg whites or activated charcoal to protect the mucosa. 3. IV fluids and symptomatic treatment.

XIII. Baibu (Stemona) poisoning

The main manifestation of Stemona poisoning is central depression, and in severe cases respiratory failure death.

Management: 1. Lavage and catharsis. 2. Respiratory stimulants. 3. Oxygen and other symptomatic treatment. 4. Ginger juice and white rice vinegar decocted together and taken.

XIV. Wannianqing (Rohdea japonica) and oleander poisoning

The main reactions of Rohdea and oleander poisoning are gastrointestinal irritation, plus slowed heart rate, raised blood pressure, and conduction block; severe cases show chest oppression, coma, and cardiac arrest.

Management:

1. Early lavage and catharsis. 2. Use atropine or anisodamine (654-2) as antagonist. 3. IV fluids and symptomatic management.

XV. Shanglu (Phytolacca) poisoning

The main reactions of Phytolacca poisoning are vomiting, abdominal pain, diarrhea, and bloody stool; severe cases show limb convulsions, respiratory distress, lowered blood pressure, and in critical cases dilated pupils; in pregnant women it can cause miscarriage.

Management:

1. Lavage and catharsis. 2. Central stimulants. 3. IV fluids, large supplementation of vitamin C. 4. Oxygen. 5. Blood transfusion and mechanical ventilation when necessary. 6. Fangfeng, Fangji, Gancao, and Guizhi decocted and taken.

XVI. Huangyaozi (Dioscorea bulbifera) poisoning

Huangyaozi poisoning chiefly shows oral pain, salivation, nausea and vomiting, and diarrhea; severe cases may show coma, dyspnea, and cardiac arrest.

Management: 1. Lavage and catharsis. 2. Instill egg whites and activated charcoal. 3. Use respiratory stimulants. 4. IV fluids. 5. Oxygen. 6. Symptomatic treatment. 7. Large amounts of mung-bean soup, or ginger 30g juiced, white vinegar 60g, and Gancao 10g decocted together and taken.

XVII. Aloe poisoning

The main reactions of aloe poisoning are abdominal pain, diarrhea, bloody stool, and tenesmus; severe cases show low back pain, hematuria, and proteinuria, pelvic congestion, and miscarriage in pregnant women.

Management: 1. Lavage and catharsis. 2. Instill egg whites and activated charcoal. 3. Protect the kidneys. 4. Sedatives (opiates are contraindicated). 5. Symptomatic treatment. 6. Orally take Chinese medicines that percolate and drain dampness to treat the gastrointestinal symptoms.

XVIII. Qiye Yizhihua (Chonglou / Caoheche / Zaochu, Paris polyphylla) poisoning

The main reactions of Paris-polyphylla poisoning are gastrointestinal reactions, nausea and vomiting; severe cases show headache, spasms, abdominal distension, poor appetite, and indigestion.

Management: 1. Lavage and catharsis; take dilute acid internally. 2. Protect the liver. 3. Antispasmodics. 4. IV fluids, large supplementation of vitamin C. 5. Symptomatic treatment. 6. Gancao 15g decocted, then mixed with white rice vinegar and ginger juice and taken.

XIX. Yuanhua (Daphne genkwa) poisoning

The reactions of Daphne-genkwa poisoning are severe vomiting, diarrhea, dehydration, hemorrhagic dysentery, and muscle spasms.

Management: 1. Rinse the mouth with warm water. 2. Lavage and protect the gastric mucosa. 3. Use sedatives. 4. IV fluids, large supplementation of vitamin C. 5. Symptomatic treatment.

XX. Mashan (Coriaria sinica) poisoning

Coriaria poisoning is very similar to Fangji (Stephania) poisoning: both show slow heartbeat, raised blood pressure, faster breathing, and in severe cases respiratory failure, as well as tonic spasms and coma.

Management: 1. Lavage and catharsis. 2. Anticonvulsants. 3. Use respiratory stimulants. 4. IV fluids. 5. Oxygen. 6. Symptomatic treatment. 7. Lianqiao, Jinyinhua, and mung bean decocted have some antidotal effect.

XXI. Yadanzi (Brucea javanica) poisoning

The reactions of Brucea-javanica poisoning are nausea and vomiting, abdominal pain and diarrhea, headache, stupor, and limb numbness; severe cases show paralysis and dyspnea.

Management: 1. Lavage; instill egg whites and cow's milk. 2. Oxygen. 3. Use respiratory stimulants. 4. IV fluids, large supplementation of vitamin C and B vitamins. 5. Symptomatic treatment. 6. Shenggancao decocted and drunk often, or brown-sugar water and cold thin rice porridge to antidote.

XXII. Cangerzi (Xanthium) poisoning

Mild Xanthium poisoning shows headache, nausea, vomiting, and abdominal pain; moderate poisoning shows headache, fatigue and weakness, restlessness, drowsiness, hepatomegaly, jaundice, bleeding, and difficulty urinating. Severe poisoning shows coma, generalized rigidity, and respiratory-circulatory failure.

Management:

1. Lavage; instill activated charcoal. 2. Large supplementation of vitamin C. 3. Protect the liver. 4. Use glucocorticoids. 5. IV fluids, cardiac stimulants, and analgesics. 6. Symptomatic treatment. 7. Banlangen (Isatis root) 120g decocted and taken, or Gancao-mung bean water drunk often.

XXIII. Daji (Euphorbia) poisoning

The reactions of Euphorbia poisoning are mainly irritation of the skin, mouth, and gastrointestinal mucosa; severe cases show dizziness, coma, spasms, dilated pupils, and respiratory paralysis.

Management: 1. Lavage. 2. Correct electrolyte disturbance. 3. Use respiratory stimulants. 4. IV fluids. 5. Oxygen. 6. Antispasmodics. 7. Tianjiegeng (Platycodon) 30g decocted and taken, or Changpu (Acorus) juice 200 ml and Lugen (Phragmites rhizome) 120g decocted and taken to antidote.

XXIV. Badou (Croton) poisoning

Croton poisoning first shows gastrointestinal irritation and corrosion symptoms, such as stabbing pain and salivation, vomiting and diarrhea, and rice-water stool. Severe cases show dehydration, dyspnea, lowered blood pressure, dizziness, cold limbs, delirium, and cyanosis; critical cases die of respiratory-circulatory failure.

Management: 1. Within 6 hours of ingestion, lavage, but protect the gastric mucosa. 2. Instill egg whites and activated-charcoal suspension. 3. Mung bean 120g crushed, steeped in water, and taken cold. 4. Use respiratory stimulants. 5. IV fluids, cardiac stimulants, and analgesics. 6. Symptomatic treatment. 7. TCM management: (1) for incessant diarrhea, Huanglian, Hanshuishi (gypsum), and soybean juice each 10g decocted and taken. (2) Renshen and Huanglian each 5g decocted and taken. (3) For dermatitis caused by Croton, Huanglian 2g steeped in water and applied externally. (4) Folklore uses banana leaf and root juice 100 ml drunk, or peanut oil 100–200 g taken orally.

XXV. Baiguo (ginkgo nut) poisoning

The reactions of ginkgo-nut poisoning are chiefly fever, nausea and vomiting, abdominal pain and diarrhea; severe cases show dizziness and headache, extreme fear, convulsions, coma, dilated pupils, and rigid limbs; critical cases die within 1–2 days of heart failure and respiratory failure.

Management: 1. Lavage within 6 hours. 2. Use antispasmodic anticonvulsants. 3. Correct heart failure and respiratory failure. 4. Large IV fluids. 5. Symptomatic treatment. 6. Large-dose Gancao-mung bean soup decocted and taken.

XXVI. Tenghuang (Garcinia morella) poisoning

The main reactions of Garcinia-morella poisoning are vomiting, abdominal pain and diarrhea, tenesmus, dehydration, and shock.

Management: 1. Lavage and catharsis. 2. Instill egg whites. 3. Correct dehydration and shock. 4. IV fluids, large supplementation of vitamin C. 5. Haizhe (jellyfish) can antidote Garcinia-morella poisoning; folklore also uses Huaqing for treatment.

XXVII. Xixin (Asarum) poisoning

The main reactions of Asarum poisoning are nausea, vomiting, restlessness, rapid breathing, raised blood pressure, neck stiffness, locked jaw, opisthotonus, clouded consciousness, convulsions, and coma; severe cases die of respiratory paralysis.

Management: 1. Control convulsions; use sedatives. 2. Instill Angong Niuhuang Wan. 3. For anuria, catheterize. 4. IV fluids. 5. Oxygen. 6. Use respiratory stimulants. 7. After stopping spasms and opening the orifices, decoct and take Renshen, Maimendong, Wuweizi, Shengshigao, Gancao, Lingyangjiao (antelope horn), and mung bean.

XXVIII. Chan Chu (toad / toad venom) poisoning

Toad-poisoning symptoms resemble digitalis poisoning: frequent vomiting and borborygmus, abdominal pain and diarrhea, chest oppression, arrhythmia, cold limbs, cyanosis, and lowered blood pressure; severe cases show headache and dizziness, limb numbness, drowsiness, slow responses, and convulsions.

Management: 1. Lavage and catharsis. 2. IV atropine. 3. Central stimulants. 4. Antiarrhythmic drugs. 5. Shengmai injection and Shenfu injection may be used.

Understanding the reactions to common TCM poisonings and mastering the management protocols for them is a basic quality every TCM clinician must possess. When using Chinese medicines, watch the patient's reactions and try to avoid serious poisoning.

Toxic Chinese medicines have outstanding efficacy in treating certain stubborn diseases; to dare not use them because they are toxic is to stop eating for fear of choking. The key is to control the dosage of toxic herbs and use the appropriate processing methods to remove their toxicity. After processing, the toxicity of most toxic herbs is well controlled.

For example, blister beetle is stir-fried with glutinous rice over a gentle fire until the rice turns yellow; during heating, part of the cantharidin sublimes and its toxicity is reduced. Strychnos is stir-fried with sand; after hot-sand roasting, the strychnine and brucine content of the Strychnos is markedly reduced and its toxicity weakened. After Cishi (magnetite) is calcined in fire, the arsenic (toxic element) content is only 1/12 that of raw magnetite, greatly reducing toxicity. Xionghuang, Zhusha, Luganshi, and Shijueming have reduced toxicity after water-grinding (feishui). After wine-processing Changshan and honey-processing Yingsuke (poppy husk), the vomiting effect is markedly reduced. Croton is pressed for its oil and made into cream; Gansui and Daji are vinegar-processed; Chuanwu and Caowu are boiled with Gancao and Jinyinhua; Banxia and Tiannanxing are processed with ginger-alum water; and Fuzi is processed with gall-alkali water (waste water from salt manufacture containing MgCl, etc.)—all can markedly reduce toxic and side effects.

To prevent TCM poisoning, first of all, pattern differentiation must be accurate and medication correct; with wrong medication, even commonly used tonics like Renshen and Baizhu can cause harm.

Second, strictly control dosage and duration. The Shennong Bencao Jing says: "If using poisonous drugs to treat disease, begin with a tiny amount; once the disease is gone, stop; if not gone, double it; if still not gone, increase it tenfold, stopping when it is gone." This gradual increase of dosage is an important guarantee of medication safety.

The Huangdi Neijing says: "Great poison treats disease, removing nine parts in ten; ordinary poison removes seven; small poison removes eight; non-poisonous removes nine. Grains, meat, fruit, and vegetables are used to nourish and finish it. Do not let it go too far, lest it damage the upright qi." Clearly, whether the drug is toxic or not, the duration of use must be controlled.