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14. What are the contraindications and cautions when using Chinese herbal medicine?

In order to ensure the therapeutic effects of Chinese herbal medicine and the safety of the patients, it is important to know the contraindications of using Chinese herbal medicine so as to avoid mistakes and accidents.

The contraindications of Chinese herbal medicine can be divided into contraindications of particular syndromes, caution about herb combinations, caution during pregnancy and caution about diet.

Contraindications of particular syndromes

Some herbs should not to be used in certain syndromes. Apart from herbs that gently harmonize the functions of the internal organs, most herbs have specific actions and can be used in only certain pathological conditions. It is very important to learn contraindications by heart. The contraindications of each herb are usually mentioned after the functions of individual herbs. However, there are some general principles, as follows.

• When treating Cold syndromes, herbs with a cold nature should not be used; equally, hot herbs should not be used in Heat syndromes When the Qi, Yang or Fire and Wind are ascending in a pathological condition (e.g. in hypertension), herbs that move upwards and outwards should not be used; if the Qi and Yang are sinking (e.g. in diarrhea), herbs that move downwards should not be used. However, these contraindications apply only to the use of single herbs; they may be used in certain herb combinations, or formulas in some conditions.

For instance, Ma Huang (Ephedrae herba) is a pungent and hot herb, it can strongly disperse the Lung-Qi, expel Wind-Cold and is able to treat Exterior syndrome and asthma. It is forbidden to use it in patients suffering from Wind-Heat syndrome; it is also forbidden to be used alone for patients with shortness of breath due to Heat in the Lung so the Lung-Qi is not able to descend (e.g. in asthma, asthmatic bronchitis or pneumonia). However, in the latter condition it can be used with Shi Gao (Gypsum), which is cold and able to direct the Lung-Qi to descend and clear the Heat. In this case, the two substances are used in a ratio of 1 (Ma Huang) to 4 (Shi Gao), so overall the combination has a cooling and descending action.

• If there is an Exterior syndrome then sweet, cloying, tonifying herbs and sour or astringent herbs should not be used because they will keep the pathogenic factors in the body and reduce the strength of the herbs that expel the exogenous pathogenic factors. This mistake is called ‘closing the door and keeping your enemy in. This contraindication applies to single herbs as well as to the main actions of herbal combinations. If the body resistance of the patient is too weak, a small amount of herbs that strengthen the body resistance and tonify the Qi can be used in combination with a larger amount of herbs that expel the exogenous pathogenic factors, in order to assist the herbs that expel exogenous pathogenic factors.

• If the patient sweats easily during the course of an Exterior syndrome, this suggests that the pores are open at that moment; therefore herbs that induce sweating and expel exogenous pathogenic factors should not be used at that time because they are too strong and may cause over dispersion of the Qi and Body Fluids. For instance, if a patient with asthma catches a cold and the asthma is worsening and also the patient’s Defensive Qi is weak, although the syndrome is caused directly by Wind-Cold the patient may sweat and feel dry in the mouth, so Ma Huang (Ephedrae herba) cannot be used alone in this condition. However, it can be used with Shi Gao (Gypsum) but the dosage of Shi Gao must be much higher than that of Ma Huang.

• Before tonifying herbs and astringent herbs are applied, the body should be comparatively clean; that is, there should be no accumulations of Phlegm, water, food, Fire, Qi and Blood, because most of the sweet tonifying and the astringent or sour herbs may retain the pathogenic factors in the body and complicate the syndrome. The correct procedure is first to remove pathogenic factors, and especially the substantial pathogenic factors, and then start treatment with tonifying herbs. There are some exceptions, however. If accumulations are caused by deficiency of Qi, Blood, Yin or Yang, it is impossible to remove these pathogenic factors completely at first. In this case, tonifying herbs should be added in combination with the reducing herbs. The ratio between the two sorts of herbs must also be varied depending on the change of strength in the pathogenic factors and the person’s resistance.

• If the Stomach of the patient is weak or sensitive, then harsh herbs should not be chosen, such as very hot or very cold herbs or herbs with strong tastes. In TCM, the Stomach and Spleen are regarded as the foundation of life, not only in physiology but also in pathology. ‘If there is only one percent Stomach-Qi, there is still one percent chance of recovery of the patient’ is a saying found in many classics. Restoring the Stomach to a good condition is considered as the first step in achieving different therapeutic results. In other words, protecting and strengthening the transportation and transformation functions of the Stomach and Spleen will allow the herbs to be absorbed by the body.

Cautions about herb combinations

There are three groups of herbs that are forbidden to be used together; otherwise toxicity and side effects may occur.

1. Gan Cao (Glycyrrhizae radix) may not be used with Gan Sui (Euphorbiae  kansuiradix), Da J Jıˇ (Knoxiae radix), Yuan Hua (Genkwa flos) or Hai Zao (Sargassum).

2. Wu Tou (Aconiti radix) may not be used with Chuan Bei Mu (Fritillariae cirrhosae bulbus), Zhe Bei Mu (Fritillariae thunbergii bulbus), Gua Lou (Trichosanthis fructus), Ban Xia (Pinelliae rhizoma), Bai Lian (Ampelopsitis radix) or Bai Ji (Bletillae tuber).

3. Li Lu (Veratri nigri radix et rhizoma) may not be used with Ren Shen (Ginseng radix), Bei Sha Shen (Glehniae radix), Nan Sha Shen (Adenophorae radix), Ku Shen (Sophorae flavescentis radix), Xuan Shen (Scrophulariae radix), Dan Shen (Salviae miltiorrhizae radix), Xi Xin (Asari herba), Bai Shao Yao (Paeoniae radix lactiflora) or Chi Shao Yao (Paeoniae radix rubra).

As Gan Cao (Glycyrrhizae radix) and Wu Tou (Aconiti radix) are very commonly used, the first two groups of the herbs should be learnt by heart. There are also nine pairs of herbs that are traditionally forbidden to be used together. It is believed that such combination can minimize or even neutralize the therapeutic effects:

• Liu Huang (Sulfur) antagonizes Po Xiao (Glauberis sal)

• Shui Yin (Hydrargyrum) antagonizes Pi Shuang (Arsenicum)

• Lang Du (Euphorbiae fischerianae radix) antagonizes Mi Tuo Seng (Lithargyrum)

• Ba Dou (Crotonis fructus) antagonizes Qian Niu Zi (Pharbitidis semen)

• Wu Tou (Aconiti radix) antagonizes Xi Jiao (Rhinoceri cornu)

• Ya Xiao (Nitrum) antagonizes San Leng (Sparganii rhizoma)

• Ding Xiang (Caryophylli flos) antagonizes Yu Jin (Curcumae radix)

• Ren Shen (Ginseng radix) antagonizes Wu Ling Zhi (Trogopterori faeces)

• Rou Gui (Cinnamomi cassiae cortex) antagonizes Chi Shi Zhi (Halloysitum rubrum).

Among these nine pairs, the first five are rarely used in clinical practice because their functions are so different that they can hardly be combined to treat one syndrome and some of them are very poisonous so they are also hardly used nowadays. However, the last four pairs would possibly be combined to treat one syndrome, so these must be memorized by heart.

Cautions during pregnancy

During pregnancy, herbs can influence physiological changes in both the pregnant woman and the fetus, especially during the first 3 months. Generally speaking, it is better to keep the pregnancy as natural as possible, and try to avoid all kinds of treatment if they are not really necessary at that moment.

According to the strength and characteristics of the herbs, there are some herbs which are forbidden to be used during pregnancy and others that should be used with caution.

Herbs that are forbidden include poisonous or harsh herbs which are used for breaking up congealed Blood and draining downwards, such as Ba Dou (Crotonis fructus), Qian Niu Zi (Pharbitidis semen), Da Jı ˇ (Knoxiae radix), Shang Lu (Phytolaccae radix), Ban Mao (Mylabris), She Xiang (Moschus), San Leng (Sparganii rhizoma), E Zhu (Curcumae rhizoma), Mang Chong (Tabanus) and Shui Zhi (Hirudo).

If it is really necessary, some herbs can be used during the pregnancy, such as in conditions of tumor, bleeding due to stagnation of Blood, severe deficiency of Qi and Blood and severe internal coldness, where if the pathological situation is not treated it may injure the woman and the fetus; however, the dosage and treatment course must both be controlled carefully.

Herbs that are to be used with caution include all the substances that promote Qi movement and Blood circulation, especially in the Lower Jiao, and herbs that remove the obstruction of food and Phlegm, promote bowel movement and promote urination and have pungent or lubricating properties; examples include Tao Ren (Persicae semen), Hong Hua (Carthami flos), Da Huang (Rhei rhizoma), Zhi Shi (Aurantii fructus immaturus), Fu Zi (Aconiti radix lateralis preparata), Gan Jiang (Zingiberis rhizoma), Rou Gui (Cinnamomi cassiae cortex), Dong Kui Zi (Malvae semen), Hua Shi (Talcum), Fu Ling (Poria) and Ze Xie (Alismatis rhizoma).

Cautions about diet

Caution about diet means, on the one hand, that certain kinds of food should not be taken in certain syndromes or diseases and, on the other hand, that certain kinds of food should not be taken when certain herbs are used.

Generally speaking, during herbal treatment, all cold, raw, heavy and spicy food should be avoided. It is wise to suggest that patients drink light tea instead of coffee, do not take fresh drinks and fruits directly from the refrigerator, and eat lightly cooked vegetables rather than salads.

If heavy food is eaten, it is better to take some tea or orange juice afterwards to remove the fat, or to take semi skimmed milk and to take less candy, sugar, chocolate and alcohol.

For Cold syndromes, raw and cold food should be avoided; for Heat syndromes or syndromes of Liver-Yang rising, spicy and heavy food, coffee and alcohol should be avoided. For syndromes of Damp-Phlegm or Damp-Heat accumulation, sweet, heavy food, milk products, nuts and alcohol should be avoided. For skin disorders or wounds characterized by itching, weeping and redness, seafood, spicy food and alcohol should be avoided.

For some herbs mentioned in the classics, certain foods are contraindicated. For all of the substances that tonify the Blood, strong tea should be avoided. Dan Shen (Salviae miltiorrhizae radix) and Fu Ling (Poria) are contraindicated with vinegar; Sheng Di Huang (Rehmanniae radix), Shu Di Huang (Rehmanniae radix praeparata) and He Shou Wu (Polygoni multiflori radix) are contraindicated with onion, garlic and radish; Gan Cao (Glycyrrhizae radix), Huang Lian (Coptidis rhizoma), Jie Geng (Platycodi radix) and Wu Mei (Mume fructus) are contraindicated with pork; Tu Fu Ling (Smilacis glabrae rhizoma) and Shi Jun Zi (Quisqualis fructus) are contraindicated with tea; Chang Shan (Dichroae febrifugae radix) is contraindicated with onion.

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