Essentials of Complementary and Alternative Medicine (June 1999)

Table 6.6. Levels of Mercury and Arsenic (per product unit) Detected in Certain Traditional Chinese Medicines
Table 6.7. Metal Poisoning by Traditional Chinese Medicines
Table 6.8. Adulteration of Traditional Chinese Medicines with Western Pharmaceuticals

Kampo Medicines
Chinese herbal medicines are also widely used in Japan, where they are known as Kampoyaku. The number of case reports about the adverse reaction potential of 
these Kampo medicines is steadily growing. For instance, the use of Sho-saiko-to (which consists of Bupleuri radix, Ginseng radix, Glycyrrhizae radix, Pinelliae tuber, 
Scutellariae radix, Zingiberis rhizoma, and Zizyphi fructus) has been repeatedly associated with cases of allergic pneumonitis and/or hepatitis (
302
, 
303
, 
304
, 
305
, 
306
, 
307
, 
308
 and 
309
).
Individual Herbs
The following is a summary of the known and reported adverse effects of some traditional Chinese medicinal herbs and products. See also the introductory part of this 
section for data on additional plants.
When faced with a patient using these products, the practitioner should find the summary of known adverse effects of those products. This will provide an indication of 
the adverse effects known for that plant and help guide the practitioner in monitoring for possible adverse effects in that patient. It will also help the practitioner inform 
the patient about possible risks.
Alocasia macrorrhiza
Ingestion of the raw root tuber of this Chinese medicinal plant can result in neurological and gastrointestinal symptoms (e.g,. severe pain and numbness in the 
perioral area and throat, nausea, vomiting, and abdominal pain) (
310
).
Coptis spp.
Due to the presence of the alkaloid berberine, these medicinal herbs entail a risk of jaundice in infants who are deficient in glucose-6-phosphate dehydrogenase (
34
, 
35
 and 
36
).
Dictamnus dasycarpus
This herb is among the common ingredients of the complex traditional Chinese herbal medicines that have been associated with liver damage, but a causal role 
remains to be established (
311
, 
312
, 
313
 and 
314
).
Gossypol
Occurs in certain Gossypium species, mostly in the seeds and root bark. Clinical studies have confirmed its efficacy as a male contraceptive agent. Reported side 
effects include fatigue, changes in appetite, transient elevation of ALT levels, and hypokalemia. Hypokalemic paralysis may occur with muscular weakness and 
severe fatigue as prodromal signs (
315
). Further assessment seems to be needed to determine to what extent gossypol entails a risk of irreversible sterility.
Lentinus edodes
This edible mushroom has been occasionally associated with skin reactions (
316
, 
317
).
Polygala spp.
Polygalae radix (the dry root of  Polygala tenuifolia or P. sibirica) is known in traditional Chinese medicine under the name of Yuanzhi. It contains 
1,5-anhydro-D-glucitol and can thus interfere with laboratory tests, which measure diabetes-related changes in the blood level of this compound (
318
).
Polygonum multiflorum
Shou-Wu-Pian (a proprietary Chinese medicine prepared from this herb) has been associated with a case of hepatitis (
319
).
Sauropus androgynus
An outbreak of bronchiolitis obliterans in Taiwan was associated with the ingestion of this herb. It is normally cooked before being eaten as a vegetable, but in this 
case the numerous victims had all consumed uncooked leaf juice as an unproven method of weight control (
320
).
Salvia miltiorrhiza
In China, the root (Danshen) has been used traditionally for the treatment of coronary diseases. A pharmacodynamic and pharmacokinetic study in rats suggests 
that this traditional agent may enhance the anticoagulant activity of warfarin when both drugs are taken together. This animal study was initiated because of 
observations in Hong Kong that patients on routine warfarin therapy experienced an adverse drug interaction when they self-medicated with a freely available 
Danshen preparation (
321
).
Sinomenium acutum
Ingestion of this Chinese herb (known in Japan as Boi) has been associated with a case of systemic edematous erythema with itching (
322
).
Taxus celebica
This plant, which contains the flavonoid sciadopitysin, is traditionally used in China as an herbal treatment of diabetes mellitus. In two cases, the ingestion of a 
massive dose was followed by acute renal failure. Both patients initially presented with gastrointestinal upset and fever (
323
).
Tetrahydropalmatine
l-Tetrahydropalmatine has been identified as the active constituent in Chinese Jin Bu Huan Anodyne tablets on the Western market. The package insert suggested 
Polygala chinensis as the source plant, but in reality this alkaloid comes from a  Stephania species. Both l-tetrahydropalmatine and its racemic dl-form are used in 
Chinese medicine as analgesic and hypnotic agents. Reported side effects include vertigo, fatigue, nausea, and drowsiness, which could make users unfit for 
driving. Case reports have documented life-threatening bradycardia and respiratory depression in small children following unintentional overdosing and acute 
hepatitis in adult users (
324
, 
325
 and 
326
).
Tripterygium wilfordii
Extracts from the root (Leigongteng) are used in China for the treatment of various disorders, such as rheumatoid arthritis, ankylosing spondylitis, systemic lupus 
erythematosus, and glomerulonephritis. The potential benefits in such serious diseases should be weighed carefully against a substantial risk of adverse reactions, 
including gastrointestinal disturbances, skin rashes, amenorrhea, leukopenia, and thrombocytopenia. In male users, prolonged use can induce oligospermia and 
azoospermia and a decrease in the size of the testis (
327
, 
328
 and 
329
). In addition, the immunosuppressive properties of Leigongteng may promote the 
development of infectious diseases (
330
).

Extracts from the root (Leigongteng) are used in China for the treatment of various disorders, such as rheumatoid arthritis, ankylosing spondylitis, systemic lupus 
erythematosus, and glomerulonephritis. The potential benefits in such serious diseases should be weighed carefully against a substantial risk of adverse reactions, 
including gastrointestinal disturbances, skin rashes, amenorrhea, leukopenia, and thrombocytopenia. In male users, prolonged use can induce oligospermia and 
azoospermia and a decrease in the size of the testis (
327
, 
328
 and 
329
). In addition, the immunosuppressive properties of Leigongteng may promote the 
development of infectious diseases (
330
).
Ziziphus jujuba
The fruit (Dazao) is often consumed in Eastern Asia as food or as a tonic and sedative. A case of angioneurotic edema following the oral ingestion of dazao 
preparations has been described (
331
).
Traditional Indian and Pakistani Medicines
Unani and Ayurvedic preparations are another type of non-Western herbal medicines increasingly being introduced into Western health markets. These preparations 
have a long tradition of medicinal use in India and Pakistan. A survey of the availability of such medicines in the United Kingdom identified as many as 320 different 
herbal ingredients (
332
). This inventory comprised several well-known potent herbs and herbs with well-known potentially toxic constituents (
Table 6.9
). Among the 
other Indian herbs with established toxic potential are  Androcephalus kadamba (which contains salicylic acid) (
333
), Canscora decussata (a CNS depressant), and 
Indigo tinctoria (which causes headaches and is a known teratogen in rats) (
336
).
Table 6.9. Examples of Herbal Ingredients in Traditional Indian and Pakistani Medicines in the United Kingdom
The botanical identity of herbal medicines from India may present problems (
336
, 
337
), and adulteration with Western pharmaceuticals is also occasionally reported 
(
338
, 
339
 and 
340
). An even greater cause of concern is the accidental or intentional presence of toxic metals (
336
, 
337
), because this has repeatedly resulted in 
clinical poisonings (see the section on toxic metals in 
Chapter 7
).
C
HAPTER
 R
EFERENCES
1.
Sperl W, Stuppner H, Gassner I, et al. Reversible hepatic veno-occlusive disease in an infant after consumption of pyrrolizidine-containing herbal tea. Eur J Pediatrics 1995;154:112–116.
2.
De Smet PAGM. Drugs used in non-orthodox medicine. In: Dukes MNG, Beeley L, eds. Side effects of drugs - Annual 13. Amsterdam: Elsevier, 1989:442–473.
3.
Schier W, Sachsa B, Schultze W. Aktuelle Verfälschungen von Arzneidrogen. 5. Mitteilung - Birkenblätter, Orthosiphonblätter, Besenginsterblüten, Wohlriechendes Gänsefusskraut und 
Isländisches Moos. Dtsch Apoth Ztg 1994;134:4569–4576.
4.
Greinwald R, Lurz G, Witte L, Czygan F-C. A survey of alkaloids in  Spartium junceum L. (Genisteae-Fabaceae). Z Naturforsch Sect C Biosci 1990;45:1085–1089.
5.
Barboni L, Manzi A, Bellomaria B, Quinto AM. Alkaloid content in four  Spartium junceum populations as a defensive strategy against predators. Phytochemistry 1994;37:1197–1200.
6.
De Smet PAGM. Should herbal medicine-like products be licensed as medicines. Special licensing seems the best way forward. BMJ 310:1023–1024.
7.
Tyler VE. Herbal remedies. J Pharm Technol 1995;11:214–220.
8.
Hsu CK, Leo P, Shastry D, Meggs W, et al. Anticholinergic poisoning associated with herbal tea. Arch Intern Med 1995;155:2245–2248.
9.
De Smet PAGM. Toxicological outlook on the quality assurance of herbal remedies. In: De Smet PAGM, Keller K, Hänsel R, Chandler RF, eds. Adverse effects of herbal drugs. Volume 1. 
Heidelberg: Springer-Verlag, 1992:1–72 .
10.
Anonymous. European pharmacopoeia, 3rd ed. Strasbourg: Council of Europe, 1996.
11.
Oliver MR, Van Voorhis WC, Boeck H, et al. Hepatic mucormycosis in a bone marrow transplant recipient who ingested naturopathic medicine. Clin Infect Dis 1996;22:521–524.
12.
Abeywickrama K, Bean GA. Toxigenic  Aspergillus flavus and aflatoxins in Sri Lankan medicinal plant material. Mycopathologia 1991;113:187–190.
13.
Abeywickrama K, Bean GA. Cytotoxicity of  Fusarium species mycotoxins and culture filtrates of  Fusarium species isolated from the medicinal plant  Tribulus terrestris to mammalian cells. 
Mycopathologia 1992;120:189–193.
14.
Ros JJW, Pelders MG, De Smet PAGM. Positive doping case associated with the use of an ephedra-labeled health food product. Unpublished manuscript.
15.
De Smet PAGM, Smeets OSNM. Potential risks of health food products containing yohimbe extracts. BMJ 1994;309:958.
16.
De Smet PAGM. Yohimbe alkaloids—general discussion. In: De Smet PAGM, Keller K, Hänsel R, Chandler RF, eds. Adverse effects of herbal drugs. Volume 3. Heidelberg: Springer-Verlag, 
1997:181–205.
17.
Anonymous. Ostrich fern poisoning - New York and Western Canada, 1994. MMWR 1994;43:677–684.
18.
Lai R-S, Chiang AA, Wu M-T, et al. Outbreak of bronchiolitis obliterans associated with the consumption of  Sauropus androgynus in Taiwan. Lancet 1996;348:83–85.
19.
Haynes RL. Carbon-monoxide poisoning from non-tobacco cigarettes. J Med Assoc Ga 1983;72:553-5
20.
King M. Nontobacco cigarettes. Can Med Assoc J 1985;133:13
21.
Bloom JW, Kaltenborn WT, Paoletti P, et al. Respiratory effects of non-tobacco cigarettes. BMJ 1987;295:1516-8
22.
Sherrill DL, Kryzanowski M, Bloom JW, Lebowitz MD. Respiratory effects of non-tobacco cigarettes: a longitudinal study in the general population. Int J Epidemiol 1991;20:132-7
23.
Nahas G, Latour C. The human toxicity of marijuana. Medi J Aust 1992;156:495-7
24.
Polen MR, Sidney S, Tekawa IS, Sadler M, Friedman GD. Health care use by frequent marijuana smokers who do not smoke tobacco. West Med J 1993;158:596-601
25.
Kumar A, Aitas AT, Hunter AG, Beaman DC. Sweeteners, dyes, and other excipients in vitamin and mineral preparations. Clin Pediatr 1996;35:443–450.
26.
Eun HC, Lee AY. Contact dermatitis due to Madecassol. Contact Dermatitis 1985;13:310.
27.
Cronin E. Contact dermatitis. Edinburgh: Churchill Livingstone, 1980.
28.
Bruynzeel DP, Van Ketel WG, Young E, et al. Contact sensitization by alternative topical medicaments containing plant extracts. Contact Dermatitis 1992;27:278–279.
29.
Ali SA, Blume H. Pestizidrückstände in Adeps Lanae anhydricus und Babycremes. Pharm Ztg 1986;131:1638–1640.
30.
Coplenad CA, Raebel MA, Wagner SL. Pesticide residues in lanolin. JAMA 1989;261:242 .
31.
De Jong CAJ. Melisana, voor uw broodnodige rust? Ned Tijdschr Geneeskd 1978;122:82–83.
32.
Pradeepkumar VK, Tan KW, Ivy NG. Is ‘herbal health tonic' safe in pregnancy, fetal alcohol syndrome revisited. Aust N Z J Obstet Gynaecol 1996;36:420–423.
33.
Anonymous. Over-the-counter drug products intended for oral ingestion that contain alcohol. Fed Reg 1995;60:13590–13595.
34.
Yeung CY, Lee FT, Wong HN. Effect of a popular Chinese herb on neonatal bilirubin protein binding. Biol Neonate 1990;58:98–103.
35.
Chan E. Displacement of bilirubin from albumin by berberine. Biol Neonate 1993;63:201–208.
36.
Chan TYK. The prevalence use and harmful potential of some Chinese herbal medicines in babies and children. Vet Hum Toxicol 1994;36:238–240.
37.
Newton BW, Benson RC, McCarriston CC. Sparteine sulphate: a potent capricious oxytocic. Am J Obstet Gynecol 1996;94:234–241.
38.
De Smet PAGM, Brouwers JRBJ. Pharmacokinetic evaluation of herbal remedies: basic introduction, applicability, current status and regulatory needs. Clin Pharmacokinet 1997;32:427–436.
39.
Zhou H-H, Adedoyin A, Wood AJJ. Differing effects of atropine on heart rate in Chinese and white subjects. Clin Pharmacol Ther 1992;52:120–124.
40.
Carbo M, Segura J, De la Torre R, et al. Effect of quinolones on caffeine disposition. Clin Pharmacol Ther 1989;45:234–240.
41.
Harder S, Fuhr U, Staib AH, Wolff T. Ciprofloxacin-caffeine: a drug interaction established using in vivo and in vitro investigations. Am J Med 1989;87:89S-91S.
42.
Healy DP, Polk RE, Kanawati L, et al. Interaction between oral ciprofloxacin and caffeine in normal volunteers. Antimicrob Agents Chemother 1989;33:474–478.
43.
Mahr G, Soergel F, Granneman GR, et al. Effects of temafloxacin and ciprofloxacin on the pharmacokinetics of caffeine. Clin Pharmacokin 1992;22(Suppl 1):90–97.
44.
Gram LF, Debruyne D, Caillard V, et al. Substantial rise in sparteine metabolic ratio during haloperidol treatment. Br J Clin Pharmacol 1989;27:272–275.
45.
Gram LF, Brosen K, Danish University Antidepressant Group. Moclobemide treatment causes a substantial rise in the sparteine metabolic ratio. Br J Clin Pharmacol 1993;35:649–652.
46.
Schellens JH, Ghabrial H, van der Wart HH, et al. Differential effects of quinidine on the disposition of nifedipine, sparteine, and mephenytoin in humans. Clin Pharmacol Ther 
1991;50:520–528.
47.
Anonymous. Adverse events associated with ephedrine-containing products—Texas, December 1993–September 1995. MMWR 1996;45:689–693.
48.
Leatherdale BA, Panesar RK, Singh G, et al. Improvement in glucose tolerance due to  Momordica charantia (karela). BMJ 1981;282:1823–1824.
49.
Aslam M, Stockley IH. Interactions between curry in gredient (karela) and drug (chlorpropamide). Lancet 1979;1:607.
50.
De Smet PAGM, D'Arcy PF. Drug interactions with herbal and other non-orthodox drugs. In: Wellington PJ, D'Arcy PF, eds. Drug interactions. Heidelberg: Springer-Verlag, 1996:327–352.
51.
Ljunggren B. Severe phototoxic burn following celery ingestion. Arch Dermatol 1990;126:1334–1336.

52.
Boffa MJ, Gilmour E, Ead RD. Celery soup causing severe phototoxicity during PUVA therapy. Br J Dermatol 1996;135:330–345.
53.
De Smet PAGM. Alternatieve middelen en verkeersveiligheid. Arts en Auto 1987;53:1684–1686.
54.
De Smet PAGM, Elferink F, Verpoorte R. Linksdraaiend tetrahydropalmatine in Chinese tablet. Ned Tijdschr Geneesk 1989;133:308.
55.
Anonymous. Definition of doping and list of doping classes and methods. International Olympic Committee Medical Commission. Paris, September 5, 1994.
56.
Hiller K. Ephedra. In: Hänsel R, Keller K, Rimpler H, Schneider G, eds. Hagers Handbuch der Pharmazeutischen Praxis. 5th edn. Fünfter Band: Drogen E-O. Berlin: Springer-Verlag, 
1993:46–57.
57.
Anonymous. Het eeuwige gevecht tegen de kilo's. Consumentengids 1995;5:296–300.
58.
De Smet PAGM. Drugs used in non-orthodox medicine. In: Dukes MNG, Beeley L, eds. Side effects of drugs - Annual 14. Amsterdam: Elsevier, 1990:429–451.
59.
De Smet PAGM. Drugs used in non-orthodox medicine. In: Dukes MNG, ed. Side effects of drugs. 11th ed. Amsterdam: Elsevier, 1992:1209–1232.
60.
De Smet PAGM. Legislatory outlook on the safety of herbal remedies. In: De Smet PAGM, Hänsel R, Keller K, Chandler RF, eds. Adverse effects of herbal drugs. Volume 2. Heidelberg: 
Springer-Verlag 1993:1–90.
61.
Ernst E, De Smet PAGM. Risks associated with complementary therapies. In: Dukes MNG, ed. Side effects of drugs. 13th ed. Amsterdam: Elsevier, 1996:1427–1454.
62.
De Smet PAGM, Keller K, Hänsel R, Chandler RF, eds. Adverse effects of herbal drugs. Volume 1. Heidelberg: Springer-Verlag, 1992.
63.
De Smet PAGM, Keller K, Hänsel R, Chandler RF, eds. Adverse effects of herbal drugs. Volume 2. Heidelberg: Springer-Verlag, 1993.
64.
De Smet PAGM, Keller K, Hänsel R, Chandler RF, eds. Adverse effects of herbal drugs. Volume 3. Heidelberg: Springer-Verlag, 1997.
65.
Tyler VE. The new honest herbal. A sensible guide to the use of herbs and related remedies. 3rd ed. Binghamton: Pharmaceutical Products Press, 1993.
66.
Bisset NG, Wichtl M, eds. Herbal drugs and phytopharmaceuticals. A handbook for practice on a scientific basis. Stuttgart: Medpharm Scientific Publishers, 1994.
67.
Newall CA, Anderson LA, Phillipson JD. Herbal medicines. A guide for health-care professionals. London: The Pharmaceutical Press, 1996.
68.
Leung AY, Foster S. Encyclopedia of common natural ingredients used in food, drugs, and cosmetics. 2nd ed. New York: John Wiley & Sons, Inc., 1996.
69.
Hänsel R, Keller K, Rimpler H, Schneider G, red. Hagers Handbuch der Pharmazeutischen Praxis. 5th edn. Vierter Band: Drogen A-D. Berlin: Springer-Verlag, 1992.
70.
Hänsel R, Keller K, Rimpler H, Schneider G, red. Hagers Handbuch der Pharmazeutischen Praxis. 5th edn. Fünfter Band: Drogen E-O. Berlin: Springer-Verlag, 1993.
71.
Hänsel R, Keller K, Rimpler H, Schneider G, red. Hagers Handbuch der Pharmazeutischen Praxis. 5th edn. Fünfter Band: Drogen P-Z. Berlin: Springer-Verlag, 1994.
72.
Roth L, Daunderer M, Kormann K. Giftpflanzen - Pflanzengifte: Wirkung, Vorkommen, Wirkung, Therapie; allergische und phototoxische Reaktionen. 4. Auflage, Landsberg: Ecomed, 1994.
73.
Teuscher E, Lindequist U. Biogene Gifte. Biologie - Chemie -Pharmakologie. 2. Auflage. Stuttgart: Gustav Fischer, 1994.
74.
Wichtl M, red. Teedrogen und Phytopharmaka. Ein Handbuch für die Praxis auf wissenschaftlicher Grundlage. 3. Auflage. Stuttgart: Wissenschaftliche Verlagsgesellschaft, 1997.
75.
Frohne D, Pfänder HJ Giftpflanzen. Ein Handbuch für Apotheker, Ärzte, Toxikologen und Biologen. 4. Auflage. Stuttgart, Wissenschaftliche Verlagsgesellschaft, 1997.
76.
Mitchell J, Rook A. Botanical dermatology. Plants and plant products injurious to the skin. Vancouver: Greengrass, 1979.
77.
Longerich L, Johnson E, Gault MH. Digoxin-like factors in herbal teas. Clin Invest Med 1993;16:210–218.
78.
Malinow MR, Bardana EJ Jr, Goodnight SH Jr. Pancytopenia during ingestion of alfalfa seeds. Lancet 1981;1:615.
79.
Roberts JL, Hayashi JA. Exacerbation of SLE associated with alfalfa ingestion. N Engl J Med 1983;308:1361.
80.
Kaufman WH. Alfalfa seed dermatitis. JAMA 1954;155:1058–1059.
81.
Ossenkoppele PM, Van Der Sluis WG, Van Vloten WA. Fototoxische dermatitis door het gebruik van de Ammi majus-vrucht bij vitiligo. Ned Tijdschr Geneeskd 1991;135:478–480.
82.
De Smet PAGM, Vulto AG. Drugs used in non-orthodox medicine. In: Dukes MNG, Beeley L, eds. Side effects of drugs - Annual 12. Amsterdam: Elsevier, 1988:402–415.
83.
DeSmet PAGM. Heal risks of herbal remedies. Drug Safety 1995;13:81–93.
84.
Siegers C-P, Von Hertzberg-Lottin E, Otte M, Schneider B. Antrhanoid laxative abuse—a risk for colorectal cancer? Gut 1993;34:1099–1101.
85.
Kommission E. Aufbereitungsmonographien. Dtsch Apoth Ztg 1993;133:2791–2794.
86.
Anonymous. Anthranoid-haltige Humanarzneimittel. Pharm Ztg 1994;139:2432.
87.
Anonymous. Humanarzneimittel. Pharm Ztg 1996;141:2716–2717.
88.
DeSmet PAGM.  Aristolochia species. In: DeSmet PAGM, Keller K, Hansel R, Chandler RF, eds. Adverse effects of herbal drugs. Volume 1, Heidelberg: Springer-Verlag, 1992:79–89.
89.
Mengs U, Stotzem CD. Renal toxicity of aristolochic acid in rats as an example of nephrotoxicity testing in routine toxicology. Arch Toxicol 1993;67:307–311.
90.
Pena JM, Borras M, Ramos J, Montoliu J. Rapidly progressive interstitial renal fibrosis due to a chronic intake of a herb ( Aristolochia pistolochia) infusion. Nephrol Dial Transplant 
1996;11:1359–1360.
91.
Kelly KJ, Neu J, Camitta BM, Honig GR. Methemoglobinemia in an infant treated with the folk remedy glycerited asafoetida. Pediatrics 1984;73:717–719.
92.
Caravaca Magariños F, Cubero Gomez JJ, et al. Afectación renal y hepática en la intoxicación por Atractylis gummifera. Nefrologia 1985;5:205–210.
93.
Nogue S, Sanz P, Botey A, et al. Insuffisance renale aigue due a une intoxication par le chardon a glu (Atractylis gummigera-L). Presse Méd 1992;21:130.
94.
Müller AH. Über Vergiftung mit Besenginster (Sarothamnus scoparius). Dtsch Med Wschr 1951;75:1027.
95.
Rodriguez P, Blanco J, Juste S, et al. Allergic contact dermatitis due to burdock (Arctium lappa). Contact Dermatitis 1995;33:134–135.
96.
Widgren S, De Peyer R, Geissbühler P, Stalder H. Enterocolite due à un médicament contenant des saponines. Schweiz Med Wschr 1994;124:313–318.
97.
Landa N, Aguirre A, Goday J, et al. Allergic contact dermatitis from a vasoconstrictor cream. Contact Dermatitis 1990;22:290–291.
98.
Bluhm R, Branch R, Johnston P, Stein R. Aplastic anemia associated with canthaxanthin ingested for 'tanning' purposes. JAMA 1990;264:1141–1142.
99.
Angelini G, Vena GA, Filotico R, et al. Allergic contact dermatitis from  Capparis spinosa L. applied as wet compresses. Contact Dermatitis 1991;24:382–383.
100.
Tuncok Y, Kozan O, Cavdar C, et al. Urginea maritima (squill) toxicity. J Toxicol Clin Toxicol 1995;33:83–86.
101.
Anonymous. Poisoning associated with herbal teas—Arizona, Washington. MMWR 1977;26:257–259.
102.
Bain RJI. Accidental digitalis poisoning due to drinking herbal tea. BMJ 1985;290:1624.
103.
Koopmann H. Tödliche Schöllkraut-Vergiftung (Chelidonium majus). Vergiftungsfälle 1937;8:93–98.
104.
Pinto Garc
a V, Vicente PR, Barez A, et al. Anemia hemol
tica inducida por Chelidonium majus. Observación cl
nica. Sangre 1990;35:401–403.
105.
Subiza J, Subiza JL, Hinojosa M, et al. Anaphylactic reaction after the ingestion of chamomile tea: a study of cross-reactivity with other composite pollens. J Allergy Clin Immunol 
1989;84:353–358.
106.
Subiza J, Subiza JL, Alonso M, et al. Allergic conjunctivitis to chamomile tea. Ann Allergy 1990;65:127–132.
107.
Balslev T, Moller AB. Forbraendinger hos born forarsaget af kamillete. Ugeskr Laeg 1990;152:1384.
108.
Gordon DW, Rosenthal G, Hart J, et al. Chaparral ingestion. The broadening spectrum of liver injury caused by herbal medications. JAMA 1995;273:489–490.
109.
Batchelor WB, Heathcote J, Wanless IR. Chaparral-induced hepatic injury. Am J Gastroenterol 1995;90:831–833.
110.
Katz M, Saibil F. Herbal hepatitis: subacute hepatic necrosis secondary to chaparral leaf. J Clin Gastroenterol 1990;12:203–206.
111.
Anonymous. Chaparral-induced toxic hepatitis—California and Texas, 1992. MMWR 1992;41:812–814.
112.
Smith BC, Desmond PV. Acute hepatitis induced by ingestion of the herbal medication chaparral. Aust NZ J Med 1993;23:526.
113.
Alderman S, Kailas S, Goldfarb S, et al. Cholestatic hepatitis after ingestion of chaparral leaf: confirmation by endoscopic retrograde cholangiopancreatography and liver biopsy. J Clin 
Gastroenterol 1994;19:242–247.
114.
Grice HC, Becking G, Goodman T. Toxic properties of nordihydroguaiaretic acid. Food Cosmet Toxicol 1968;6:155–161.
115.
Goodman T, Grice HC, Becking GC, Salem FA. A cystic nephropathy induced by nordihydroguaiaretic acid in the rat. Light and electron microscopic investigations. Lab Invest 1970;23:93–107.
116.
Gardner KD Jr, Evan AP, Reed WP. Accelerated renal cyst development in deconditioned germ-free rats. Kidney Int 1986;29:1116–1123.
117.
Smith AY, Feddersen RM, Gardner Jr KD, Davis Jr CJ. Cystic renal cell carcinoma and acquired renal cystic disease associated with consumption of chaparral tea: a case report. J Urol 
1994;152:2089–2091.
118.
Cahill DJ, Fox R, Wardle PG, Harlow CR. Multiple follicular development associated with herbal medicine. Hum Reprod 1994;9:1469–1470.
119.
Eisele JW, Reay DT. Deaths related to coffee enemas. JAMA 1980;244:1608–1609.
120.
Green S. A critique of the rationale for cancer treatment with coffee enemas and diet. JAMA 1992;268:3224–3227.
121.
Berrut C, Bisetti A, Widgren S, et al. Colite pseudomembraneuse causée par l'ingestion de coloquinte. Schweiz Med Wschr 1987;117:135–138.
122.
Al Faraj S. Haemorrhagic colitis induced by Citrullus colocynthis. Ann Trop Med Parasitol 1995;89:695–696.
123.
Cox D, O'Kennedy R, Thornes RD. The rarity of liver toxicity in patients treated with coumarin (1,2-benzopyrone). Hum Toxicol 1989;8:501–506.
124.
Hogan III RP. Hemorrhagic diathesis caused by drinking an herbal tea. JAMA 1983;249:2679.
125.
Glaeser S, Hecker E. Drugs from Euphorbiaceae and Thymelaeaceae as possible health hazards: phytotherapeutics derived from  Croton tiglium—an iatrogenic risk of cancer? Planta Med 
1991;57(Suppl.2):A50–A51.
126.
Stadler HW, Dietzel U, Sauer R. Erfahrungen mit einem “Onkophytotherapeutikum”. Dtsch Med Wchschr 1985;110:1184–1185.
127.
Dietzel U, Sauer R, Reichardt U. Erfahrungen mit Carnivora. Fortschr Med 1985;103:760–761.
128.
Anonymous. Carnivora
(R)
—Masznahmen des Bundesgesundheits amtes. Pharm Ztg 1986;131:109–110.
129.
Hecker E, Gläser S, Gminski R. Konditionalkanzerogene als eine neuartige Kategorie vorn Krebsrisikofaktoren am Beispiel der Tumorpromotoren des Diterpenestertyps. Pharm Ztg Wiss 
1991;4(5/6):1–16.
130.
Anonymous. Immunallergische Reaktionen nach Echinacea-Extrakten (Echinacin, Esberitox N u.a.). Arznei-Telegramm 1991;4:39.
131.
Anonymous. Wie verträglich sind Echinacea-haltige Präparate? Deutsches Ärzteblatt 1996;93:2723.
132.
Schilcher H. Ätherische Öle—Wirkungen und Nebenwirkungen, Dtsch Apoth Ztg 1984;124:1433.
133.
Tisserand R, Balacs T. Essential oil safety. A guide for health care professionals. Edinburgh: Churchill Livingstone, 1995.
134.
Schaller M, Korting HC. Allergic airborne contact dermatitis from essential oils used in aromatherapy. Clin Exp Dermatol 1995;20:143–145.
135.
Bilsland D, Strong A. Allergic contact dermatitis from the essential oil of French marigold ( Tagetes patula) in an aromatherapist. Contact Dermatitis 1990;23:55–56.
136.
Gminski R, Hecker E. Drugs from Euphorbiaceae and Thymelaeaceae as possible health hazards: homeopathics derived from  Euphorbia cyparissias and Daphne mezereum—an iatrogenic risk 
of cancer? Planta Med 1991;57(Suppl.2):A50.
137.
German K, Kumar U, Blackford HN. Garlic and the risk of TURP bleeding. Br J Urol 1995;76:518.

138.
Burnham BE. Garlic as a possible risk for postoperative bleeding. Plast Reconstruct Surg 1995;95:213.
139.
Rose KD, Croissant PD, Parliament CF, Levin MB. Spontaneous spinal epidural hematoma with associated platelet dysfunction from excessive garlic ingestion: a case report. Neurosurgery 
1990;26:880–882.
140.
Lee TY, Lam TH. Contact dermatitis due to topical treatment with garlic in Hong Kong. Contact Dermatitis 1991;24:193–196.
141.
Garty B-Z. Garlic burns. Pediatrics 1993;91:658–659.
142.
Canduela V, Mongil I, Carrascosa M, et al. Garlic: always good for the health? Br J Dermatol 1995;132:161–162.
143.
Rowin J, Lewis SL. Spontaneous bilateral subdural hematomas associated with chronic Ginkgo biloba ingestion. Neurology 1996;46:1775–1776.
144.
Rosenblatt M, Mindel J. Spontaneous hyphema associated with ingestion of  Ginkgo biloba extract. N Engl J Med 1997;336:1108.
145.
Koren G, Randor S, Martin S, Danneman D. Maternal ginseng use associated with neonatal androgenization. JAMA 1990;264:2866.
146.
Awang DVC. Maternal use of ginseng and neonatal androgenization. JAMA 1991;266:363.
147.
Quatrehomme G, Bertrand F, Chauvet C, Ollier A. Intoxication from  Veratrum album. Hum Exp Toxicol 1993;12:111–115.
148.
Rubin HR, Wu AW. The bitter herbs of Seder: more on horseradish horrors. JAMA 1988;259:1943.
149.
De Smet PAGM, Vulto AG. Drugs used in non-orthodox medicine. In: Dukes MNG, ed. Side effects of drugs - Annual 11. Amsterdam: Elsevier, 1987:422–431.
150.
Hulbert DC, Thorpe PJ, Winning AJ, Beckett MW. Fatal bronchospasm after oral ingestion of isphagula. Postgrad Med J 1995;71:305–306.
151.
Pye KG, Kelsey SM, House IM, Newland AC. Severe dyserythropoiesis and autoimmune thrombocytopenia associated with ingestion of kelp supplements. Lancet 1992;339:1540.
152.
Perron AD, Patterson JA, Yanofsky NN. Kombucha “mushroom” hepatotoxicity. Ann Emerg Med 1995;26:660–661.
153.
Anonymous. Kombucha tea. Aust Adv Drug React Bull 1997;16(2):6.
154.
Currier RW, Goddard J, Buechler K, et al. Unexplained severe illness possibly associated with consumption of kombucha tea—Iowa 1995. MMWR 1995;44:892–900.
155.
Stormer FC, Reistad R, Alexander J. Glycyrrhizic acid in liquorice—evaluation of health hazard. Food Chem Toxicol 1993;31:303–312.
156.
Chandler RF. Glycyrrhiza glabra. In: De Smet PAGM, Keller K, Hänsel R, Chandler RF, eds. Adverse effects of herbal drugs. Volume 3. Heidelberg: Springer-Verlag, 1997:67–87.
157.
BGA-Pressedienst. Widerruf der Zulassung für Krappwurzelhaltige Arzneimittel angeordnet. Berlin: Bundesgesundheitsamt, 1993.
158.
De Smet PAGM, Stricker BHC. Meekrapwortel in Duitsland niet langer toegestaan. Pharm Weekbl 1993;128:503.
159.
Cassidy DE, Drewry J, Fanning JP. Podophyllum toxicity: a report of a fatal case and a review of the literature. Clin Toxicol 1982;19:35–44.
160.
Dobb GJ, Edis RH. Coma and neuropathy after ingestion of herbal laxative containing podophyllin. Med J Aust 1984;140:495–496.
161.
Chan TH, Wong KC, Chan JCN. Severe salicylate poisoning associated with the intake of Chinese medicinal oil (Red Flower Oil). Aust NZ J Med 1995;25:57.
162.
Pichler WJ, Angeli R. Allergie auf Mistelextrakt. Dtsch Med Wschr 1991;116:1333–1334.
163.
Harvey J, Colin-Jones DG. Mistletoe hepatitis. BMJ 1981;282:186–187.
164.
Kurz G, Rapaport MJ. External/internal allergy to plants (Artemisia). Contact Dermatitis 1979;5:407–408.
165.
Mansfield LE, Ting S, Haverly RW, Yoo TJ. The incidence and clinical implications of hypersensitivity to papain in an allergic population, confirmed by blinded oral challenge. Ann Allergy 
1985;55:541–543.
166.
Bernstein DI, Gallagher JS, Grad M, Bernstein IL. Local ocular anaphylaxis to papain enzyme contained in a contact lens cleansing solution. J Allergy Clin Immunol 1984;258–260.
167.
Sagona MA, Bruszer GV, Lin L, et al. Evaluation of papain/chymopapain cross allergenicity. J Allergy Clin Immunol 1985;76:776–781.
168.
Anderson IB, Mullen WH, Meeker JE, et al. Pennyroyal toxicity: measurement of toxic metabolite levels in two cases and review of the literature. Ann Intern Med 1996;124:726–734.
169.
Bakerink JA, Gospe Jr SM, Dimand RJ, Eldridge MW. Multiple organ failure after ingestion of pennyroyal oil from herbal tea in two infants. Pediatrics 1996;98:944–947.
170.
Sasseville D, Nguyen KH. Allergic contact dermatitis from Rhus toxicodendron in a phytotherapeutic preparation. Contact Dermatitis 1995;32:182–183.
171.
Hamilton RJ, Shih RD, Hoffman RS. Mobitz type I heart block after pokeweed ingestion. Vet Hum Toxicol 1995;37:66–67.
172.
Dechamp C. Anaphylaxis following pollen ingestion. Allerg Immunol (Paris) 1986;18:2.
173.
Mirkin G. Can bee pollen benefit health? JAMA 1989;262:1854.
174.
Chivato T, Juan F, Montoro A, Laguna R. Anaphylaxis induced by ingestion of a pollen compound. J Investig Allergol Clin Immunol 1996;6:208–209.
175.
Suhonen R, Kantola I, Björksten F. Anaphylactic shock due to ingestion of psyllium laxative. Allergy 1983;38:363–365.
176.
Lantner RR, Espiritu BR, Zumerchik P, Tobin MC. Anaphylaxis following ingestion of a psyllium-containing cereal. JAMA 1990;264:2534–2536.
177.
Bah M, Bye R, Pereda-Miranda R. Hepatotoxic pyrrolizidine alkaloids in the Mexican medicinal plant  Packera candidissima (Asteraceae: Senecioneae). J Ethnopharmacol 1994;43:19–30.
178.
Mattocks AR. Chemistry and toxicology of pyrrolizidine alkaloids. New York: Academic Press, 1986.
179.
Anonymous. Pyrrolizidine Alkaloids. Environmental Health Criteria 80. Geneva: World Health Organization, 1988.
180.
Westendorf J. Pyrrolizidine alkaloids—general discussion. In: De Smet PAGM, Keller K, Hänsel R, Chandler RF, eds. Adverse effects of herbal drugs. Volume 1. Heidelberg: Springer- Verlag, 
1992:193–205.
181.
Stuart KL, Bras G. Veno-occlusive disease of the liver. Quart Med J 1957;26:291–315.
182.
McGee J, Patrick RS, Wood CB, Blumgart LH. A case of veno-occlusive disease of the liver in Britain associated with herbal tea consumption. J Clin Pathol 1976;29:788–794.
183.
Ortiz Cansado A, Crespo Valades E, Morales Blanco P, et al. Enfermedad venooclusiva hepatica por ingestion de infusiones de  Senecio vulgaris. Gastroenterol Hepatol 1995;18:413–416.
184.
Roulet M, Laurini R, Rivier L, Calame A. Hepatic veno-occlusive disease in newborn infant of a woman drinking herbal tea. J Pediatr 1988;112:433–436.
185.
Spang R. Toxicity of tea containing pyrrolizidine alkaloids. J Pediatrics 1989;115:1025.
186.
Anonymous. Vorinformation Pyrrolizidinalkaloidhaltige Humanarzneimittel. Pharm Ztg 1990;135:2532–2533,2623–2624.
187.
Anonymous. Aufbereitungsmonographien Kommission E. Pharm Ztg 1990;135:2081–2082.
188.
El Sayed F, Manzur F, Marguery MC, et al. Urticarial manifestations due to  Raphanus niger. Contact Dermatitis 1995;32:241.
189.
Participating Veterans Administration Medical Centers. Low doses  v standard dose of reserpine. A randomized, double-blind, multiclinic trial in patients taking chlorthalidone. JAMA 
1982;248:2471–2477.
190.
Freis ED. Mental depression in hypertensive patients treated for long periods with large doses of reserpine. N Engl J Med 1954;251:1006–1008.
191.
Goodwin FK, Bunney Jr WE. Depressions following reserpine: a reevaluation. Sem Psychiatry 1971;3:435–448.
192.
De Smet PAGM. Een alternatieve olie met een luchtje. Pharm Weekbl 1994;129:258.
193.
Arzneimittelkommission der Deutschen Apotheker. Vorinformation Sassafras-haltige Arzneimittel. Dtsch Apoth Ztg 1995;135:366–368.
194.
Mengs U. Toxic effects of sennosides in laboratory animals and in vitro. Pharmacology 1988;36(Suppl.1):180–187.
195.
Sandnes D, Johansen T, Teien G, Ulsaker G. Mutagenicity of crude senna and senna glycosides in  Salmonella typhimurium. Pharmacol Toxicol 1992;71:165–172.
196.
Lydén-Sokolowski A, Nilsson A, Sjöberg P. Two-year carcinogenicity study with sennosides in the rat: emphasis on gastro-intestinal alterations. Pharmacology 1993;47(Suppl 1):209–215.
197.
Mengs U. Reproductive toxicological investigations with sennosides. Arzneim Forsch 1986;36:1355–1358.
198.
Faber P, Strenge-Hesse A. Relevance of rhein excretion into breast milk. Pharmacology 1988;36(Suppl.1):212–220.
199.
Beuers U, Spengler U, Pape GR. Hepatitis after chronic abuse of senna. Lancet 1991;337:372–373.
200.
Prior J, White I. Tetany and clubbing in a patient who ingested large quantities of senna. Lancet 1978;2:947.
201.
Armstrong RD, Crisp AJ, Grahame R, Woolf DL. Hypertrophic osteoarthropathy and purgative abuse. BMJ 1981;282:1836.
202.
Hausen BM. Sesquiterpene lactones. In: De Smet PAGM, Keller K, Hänsel R, Chandler RF, eds. Adverse effects of herbal drugs. Volume 1. Heidelberg: Springer-Verlag, 1992:227–260.
203.
Hausen BM, Breuer J, Weglewski J, Rücker G. a-Peroxyachifolid and other new sensitizing sesquiterpene lactones from yarrow ( Achillea millefolium L., Compositae). Contact Dermatitis 
1991;24:274–280.
204.
Beier RC, Norman JO, Reagor JC, et al. Isolation of the major component in white snakeroot that is toxic after microsomal activation: possible explanation of sporadic toxicity of white snakeroot 
plants and extracts. Natural Toxins 1993;1:286–293.
205.
Plouvier B, Trotin F, Deram R, et al. Concombre d'ane ( Ecabalium elaterium) une cause peu banale d'oedème de Quincke. Nouv Presse Méd 1981;10:2590.
206.
Vlachos P, Kanitsakis NN, Kokonas N. Fatal cardiac and renal failure due to  Ecbalium elaterium (squirting cucumber). J Toxicol Clin Toxicol 1994;32:737–738.
207.
Yesilada E, Tanaka S, Sezik E, Tabata M. Isolation of an anti-inflammatory principle from the fruit juice of  Ecballium elaterium. J Nat Prod 1988;51:504–508.
208.
Geier J, Fuchs T, Wahl R. Anaphylaktischer Schock durch einen Mariendistel-Extrakt bei Soforttyp-Allergie auf Kiwi. Allergologie 1990;13:387–388.
209.
Woelk H, Burkard G, Grünwald J. Benefits and risks of the Hypericum extract LI 160: drug monitoring study with 3250 patients. J Geriatr Psychiatry Neurol 1994;7(suppl 1):S34-S38.
210.
Axelsson IGK, Ihre E, Zetterström O. Anaphylactic reactions to sunflower seed. Allergy 1994;49:517–520.
211.
Knight TE, Hausen BM. Melaleuca oil (tea tree oil) dermatitis. J Am Acad Dermatol 1994;30:423–427.
212.
Anonymous. Kontaktallergie gegen Teebaumöl (MELALEUKA u.a.). Arznei-Telegramm 1997;2:23.
213.
Elliott C. Tea tree oil poisoning. Med J Aust 1993;159:830–831.
214.
Seawright A. Tea tree oil poisoning. Med J Aust 1993;159:830–831.
215.
Garcia-Estrad H. Fischman CM. An unusual case of nicotine poisoning. Clin Toxicol 1977;10:391–393.
216.
Dieckmann H. Untersuchungen zur Pharmakokinetik, Metabolismus und Toxikologie von Baldrinalen. Inaugural-Dissertation. Berlin: Freie Universität, 1988.
217.
Del Pozo MD, Gastaminza G, Navarro JA, et al. Allergic contact dermatitis from  Verbena officinalis. Contact Dermatitis 1994;31:200–201.
218.
Castot A, Larrey D. Hépatites observées au cours d'un traitement par un médicament ou une tisane contenant de la germandrée petit-chêne. Bilan des 26 cas rapportés aux Centres Régionaux 
de Pharmacovigilance. Gastroenterol Clin Biol 1992;16:916–922.
219.
Laliberté L, Villeneuve J-P. Hepatitis after the use of germander, a herbal remedy. Can Med Assoc J 1996;154:1689–1692.
220.
Mostefa-Kara N, Pauwels A, Pines E, et al. Fatal hepatitis after herbal tea. Lancet 1992;340:674.
221.
Loeper J, Descatoire V, Letteron P, et al. Hepatotoxicity of germander in mice. Gastroenterology 1994;106:464–472.
222.
Kouzi SA, McMurtry RJ, Nelson SD. Hepatotoxicity of germander (Teucrium chamaedrys L.) and one of its constituent neoclerodane diterpenes teucrin A in the mouse. Chem Res Toxicol 
1994;7:850–856.
223.
Mattei A, Rucay P, Samuel D, et al. Liver transplantation for severe acute liver failure after herbal medicine ( Teucrium polium) administration. J Hepatol 1995;22:597.
224.
Granlund H. Contact allergy to witch hazel. Contact Dermatitis 1994;31:195.

225.
Winterhoff H.  Lycopus species. In: De Smet PAGM, Keller K, Hänsel R, Chandler RF, red. Adverse effects of herbal drugs. Volume 2. Heidelberg: Springer-Verlag, 1993:245–251.
226.
De Smet PAGM. Yohimbe alkaloids— Pausinystalia species. In: De Smet PAGM, Keller K, Hänsel R, Chandler RF, eds. Adverse effects of herbal drugs. Volume 3. Heidelberg: Springer-Verlag, 
1997:211–214.
227.
De Smet PAGM. Yohimbe alkaloids— Corynanthe species. In: De Smet PAGM, Keller K, Hänsel R, Chandler RF, eds. Adverse effects of herbal drugs. Volume 3. Heidelberg: Springer-Verlag, 
1997:207–209.
228.
Schultes RE, Hofmann A. The botany and chemistry of hallucinogens. 2nd ed. Springfield: Charles C.Thomas Publisher, 1980.
229.
De Smet PAGM. Ritual enemas and snuffs in the Americas. Ph.D. Thesis. Latin America Studies no.33, Centro de Estudios y Documentacion Latinoamericanos, Amsterdam. Dordrecht: Foris 
Publications, 1985.
230.
Spoerke DG, Hall AH. Plants and mushrooms of abuse. Emerg Med Clin North Am 1990;8:579–593.
231.
Hovin AW, Marten GC. Distribution of specific alkaloids in reed canarygrass cultivars. Crop Science 1975;15:705–707.
232.
Gander JE, Marum P, Marten GC, Hovin AW. The occurrence of 2-methyl-1,2,3,4,-tetrahydro-b-carboline and variation in alkaloids in  Phalaris arundinacea. Phytochemistry 1976;15:737–738.
233.
Grinspoon L, Bakalar JB. Psychedelic drugs reconsidered. New York: Basic Books, 1981.
234.
Guharoy SR, Barajas M. Atropine intoxication from the ingestion and smoking of jimson weed (Datura stramonium). Vet Hum Toxicol 1991;33:588–589.
235.
Coremans P, Lambrecht G, Schepens P, et al. Anticholinergic intoxication with commercially available thorn apple tea. Clin Toxicol 1994;32:589–592.
236.
Anonymous. Jimson weed poisoning—Texas, New York, and California. MMWR 1995;44:41–44.
237.
Koevoets PFM, Van Harten PN. Doornappel-intoxicatie. Ned Tijdschr Geneeskd 1997;141:888–889.
238.
Abernethy MK, Becker LB. Acute nutmeg intoxication. Am J Emerg Med 1992;10:429–430.
239.
Taylor RFH, Al-Jarad N, John LME. Betel-nut chewing and asthma. Lancet 1992;339:577–578.
240.
Deahl M. Betel nut-induced extrapyramidal syndrome: an unusual drug interaction. Mov Disord 1989;4:330–333.
241.
Pickwell SM, Schimelpfening S, Palinkas LA. 'Betelmania'. Betel quid chewing by Cambodian women in the United States and its potential health effects. West J Med 1994;160:326–330.
242.
Siegel RK, Elsohly MA, Plowman T, et al. Cocaine in herbal tea. JAMA 1986;255:40.
243.
Siegel RL. Herbal intoxications: psychoactive effects from herbal cigarettes, tea, and capsules. JAMA 1976;236:473–476.
244.
Levine R, Taylor WB. Take tea and see. Arch Dermatol 1986;122:856.
245.
Suess R, Lehmann P. Haematogenes Kontaktekzem durch pflanzliche Medikamente am Beispiel des Kavawurzel-extraktes. Hautarzt 1996;47:459–461.
246.
Ruze P. Kava-induced dermopathy: a niacin deficiency? Lancet 1990;335:1442–1445.
247.
Widler P, Mathys K, Brenneisen R, et al. Pharmacodynamics and pharmacokinetics of khat: a controlled study. Clin Pharmacol Ther 1994;55:556–562.
248.
Kristiansson B, Abdul Ghani N, Eriksson M, et al. Use of khat in lactating women: a pilot study on breast-milk secretion. J Ethnopharmacol 1987;21:85–90.
249.
Zhang JS, Zhen T, Zhi-cen L. Simultaneous determination of six alkaloids in Ephedrae Herba by high performance liquid chromatography. Planta Med 1988;54:69–70.
250.
Zhang JS, Tian Z, Lou ZC. Quality evaluation of twelve species of Chinese  Ephedra (Ma huang). Acta Pharm Sin 1989:24:865–871.
251.
Liu Y-M, Sheu S-J, Chiou S-H, et al. A comparative study on commercial samples of Ephedrae herba. Planta Med 1993;59:376–378.
252.
Chua SS, Benrimoj SI. Non-prescription sympathomimetic agents and hypertension. Adverse Drug Exp 1988;3:387–417.
253.
Anonymous. Botanical ephedrine supplements cause alarm. Scrip OTC News 1996;28:8.
254.
Catlin DH, Sekera M, Adelman DC. Erythroderma associated with ingestion of an herbal product. West J Med 1993;159:491–493.
255.
Capwell RR. Ephedrine-induced mania from an herbal diet supplement. Am J Psychiatry 1995;152:647.
256.
Doyle H, Kargin M. Herbal stimulant containing ephedrine has also caused psychosis. BMJ 1996;313:756.
257.
Nadir A, Agrawal S, King PD, Marshall JB. Acute hepatitis associated with the use of a Chinese herbal product, Ma-Huang. Am J Gastroenterol 1996;91:1436–1438.
258.
ElSohly HN, ElSohly MA, Stanford DF. Poppy seed ingestion and opiates urinalysis. A closer look. J Anal Toxicol 1990;14:308–310.
259.
Kaplan R. Poppy seed dependence. Med J Aust 1994;161:176.
260.
Unnithan S, Strang J Poppy tea dependence. Br J Psychiatry 1993;163:813–814.
261.
Chang H-M, But PP-H, eds. Pharmacology and applications of Chinese materia medica. Volume 1. Singapore: World Scientific Publishing, 1986.
262.
Chang H-M, But PP-H, eds. Pharmacology and applications of Chinese materia medica. Volume 2. Singapore: World Scientific Publishing, 1987.
263.
Tang W, Eisenbrand G. Chinese drugs of plant origin. Chemistry, pharmacology, and use in traditional and modern medicine. Heidelberg: Springer-Verlag, 1992.
264.
Bensoussan A, Myers SP. Towards a safer choice. The practice of traditional Chinese medicine in Australia. Campbelltown: University of Western Sydney Macarthur, 1996.
265.
Tai YT, But PP, Young K, Lau CP. Cardiotoxicity after accidental herb-induced aconite poisoning. Lancet 1992;340:1254–1256.
266.
Chan TY, Tomlinson B, Critchley JA. Aconitine poisoning following the ingestion of Chinese herbal medicines: a report of eight cases. Aust NZ J Med 1993;23:268–271.
267.
Hikino H, Yamada C, Nakamura K, et al. Change of alkaloid composition and acute toxicity of  Aconitum roots during processing. Yakugaku Zasshi 1977;97:359–366.
268.
Kao W-F, Hung D-Z, Lin K-P, Deng J-F. Podophyllotoxin intoxication: toxic effect of Bajiaolian in herbal therapeutics. Hum Exp Toxicol 1992;11:480–487.
269.
Chan JCN, Chan TYK, Chan KL, et al. Anticholinergic poisoning from Chinese herbal medicines. Aust NZ J Med 1994;24:317–318.
270.
Deji D, Qingtian Z. Shancigu. In: Chang H-M, But PP-H, eds. Pharmacology and applications of Chinese materia medica. Volume 1. Singapore, World Scientific Publishing Co, 1986:117–123.
271.
Songbai Y. Zangqie. In: Chang H-M, But PP-H, eds. Pharmacology and applications of Chinese materia medica. Volume 2. Singapore, World Scientific Publishing Co, 1987:1250–1255.
272.
Vanherweghem JL, Depierreux M, Tielemans C, et al. Rapidly progressive interstitial renal fibrosis in young women: association with slimming regimen including Chinese herbs. Lancet 
1993;341:387–391.
273.
Vanherweghem JL. Une nouvelle forme de nephropathie secondaire a l'absorption d'herbes chinoises. Bull Mem Acad Roy Med Belg 1994;149:128–135.
274.
Vanhaelen M, Vanhaelen-Fastre R, But P, Vanherweghem JL. Identification of aristolochic acid in Chinese herbs. Lancet 1994;343:174.
275.
Van Ypersele De Strihou C, Vanherweghem JL. The tragic paradigm of Chinese herbs nephropathy. Nephrol Dial Transplant 1995;10:157–160.
276.
Depierreux M, Van Damme B, Vanden Houte K, Vanherweghem JL. Pathologic aspects of a newly described nephropathy related to the prolonged use of Chinese herbs. Am J Kidney Dis 
1994;24:172–180.
277.
Vanherweghem J-L, Abramowicz D, Tielemans C, Depierreux M. Effects of steroids on the progression of renal failure in chronic interstitial renal fibrosis: a pilot study in Chinese herbs 
nephropathy. Am J Kidney Dis 1996;27:209–215.
278.
Cosyns J-P, Jadoul M, Squifflet J-P, et al. Urothelial malignancy in nephropathy due to Chinese herbs. Lancet 1994;344:188.
279.
Vanherweghem JL, Tielemans C, Simon J, Depierreux M. Chinese herbs nephropathy and renal pelvic carcinoma. Nephrol Dial Transplant 1995;10:270–273.
280.
Schmeiser HH, Bieler CA, Wiessler M, et al. Detection of DNA adducts formed by aristolochic acid in renal tissue from patients with Chinese herbs nephropathy. Cancer Res 
1996;56:2025–2058.
281.
Wu G, Yamamoto K, Mori T, et al. Improvement by Guan-mu-tong ( Caulis aristolochiae manshuriensis) of lactation in mice. Am J Chin Med 1995;23:159–165.
282.
Anonymous. Drug development from natural products. Pharm J 1995;255:430–431.
283.
Quansheng C. Mutong. In: Chang H-M, But PP-H, eds. Pharmacology and applications of Chinese materia medica. Volume 1. Singapore: World Scientific Publishing, 1986:195–198.
284.
But PP. Herbal poisoning caused by adulterants or erroneous substitutes. J Trop Med Hyg 1994;97:371–374.
285.
Chan TY. Anticholinergic poisoning due to Chinese herbal medicines. Vet Hum Toxicol 1995;37:156–157.
286.
Jin Y, Berry MI, Chan K. Chinese herbal medicine in the United Kingdom. Pharm J 1995;255:R37.
287.
Liu XM, Meng ZH. Pseudomonas contamination of Chinese herbal drug,  Tremella fuciformis. Chin J Prev Med 1993;27:227–229.
288.
Shaw D, House I, Kolev S, Murray V. Should herbal medicines be licensed? BMJ 1995;311:451–452.
289.
Espinoza EO, Mann M-J, Bleasdell B. Arsenic and mercury in traditional Chinese herbal balls. N Engl J Med 1995;333:803–804.
290.
Chi Y-W, Chen S-L, Yang M-H, Hwang R-C, Chu M-L. Heavy metals in traditional Chinese medicine: Ba-Pao-Neu-Hwang-San. Acta Paediatr Sin 1993;34:181–190.
291.
Schaumburg HH, Berger A. Alopecia and sensory polyneuropathy from thallium in a Chinese herbal medication. JAMA 1992;268:3430–3431.
292.
Kang-Yum E, Oransky SH. Chinese patent medicine as a potential source of mercury poisoning. Vet Hum Toxicol 1992;34:235–238.
293.
Markowitz SB, Nunez CM, Klitzman S, et al. Lead poisoning due to  Hai Ge Fen. The porphyrin content of individual erythrocytes. JAMA 1994;271:932–934.
294.
Gertner E, Marshall PS, Filandrinos D, et al. Complications resulting from the use of Chinese herbal medications containing undeclared prescription drugs. Arthritis Rheum 1995;38:614–617.
295.
Van der Stricht BI, Parvais OE, Vanhaelen-Fastré RJ, Vanhaelen MH. Remedies may contain cocktail of active drugs. BMJ 1994;308:1162.
296.
Nelson L, Shih R, Hoffman R. Aplastic anemia induced by an adulterated herbal medication. J Toxicol Clin Toxicol 1995;33:467–470.
297.
Floren AE, Fitter W. Contamination of urine with diazepam and mefenamic acid from an Oriental remedy. J Occup Med 1991;33:1168–1169.
298.
Diamond JR, Pallone TL. Acute interstitial nephritis following use of Tung Shueh pills. Am J Kidney Dis 1994;24:219–221.
299.
Abt AB, Oh JY, Huntington RA, Burkhart KK. Chinese herbal medicine induced acute renal failure. Arch Intern Med 1995;155:211–212.
300.
Joseph AM, Biggs T, Garr M, et al. Stealth steroids. N Engl J Med 1991;324:62.
301.
Graham-Brown RAC, Bourke JF, Bumphrey G. Chinese herbal remedies may contain steroids. BMJ 1994;308:473.
302.
Kubo K, Watanabe F, Sakuma S, et al. Hypersensitive hepatic injury induced by Shosaikoto, a liver-supporting herb medicine. IRYO (Jap J Nat Med Serv) 1986;40:205–206,257–260.
303.
Tsukiyama K, Tasaka Y, Nakajima M, et al. A case of pneumonitis due to Sho-saiko-to. Jap J Thoracic Dis 1989;27:1556–1561.
304.
Daibo A, Yoshida Y, Kitazawa S, et al. A case of pneumonitis and hepatic injury caused by a herbal drug (Sho-saiko-to). Jap J Thoracic Dis 1992;30:1583–1588.
305.
Imokawa S, Sato A, Taniguchi M. A case of Sho-Saiko-to induced pneumonitis and the review of literature. Jap J Chest Dis 1992;51:53–58.
306.
Takada N, Arai S, Kusuhara N, et al. A case of Sho-Saiko-to-induced pneumonitis, diagnosed by lymphocyte stimulation test using bronchoalveolar lavage fluid. Jap J Thorac Dis 
1993;31:1163–1169.
307.
Itoh S, Marutani K, Nishijima T, et al. Liver injuries induced by herbal medicine, Syo-saiko-to (xiao-chai-hu-tang). Dig Dis Sci 1995;40:1845–1848.
308.
Kawasaki A, Mizushima Y, Kunitani H, et al. A useful diagnostic method for drug-induced pneumonitis: a case report. Am J Chin Med 1994;22:329–336.
309.
Tojima H, Yamazaki T, Tokudome T. Two cases of pneumonia caused by Sho-saiko-to. Jap J Thorac Dis 1996;34:904–910.
310.
Chan TY, Chan LY, Tam LS, Critchley JA. Neurotoxicity following the ingestion of a Chinese medicinal plant,  Alocasia macrorrhiza. Hum Exp Toxicol 1995;14:727–728.
311.
Pillans P, Eade MN, Massey RJ. Herbal medicine and toxic hepatitis. NZ Med J 1994;107:432–433.

312.
Kane JA, Kane SP, Jain S. Hepatitis induced by traditional Chinese herbs; possible toxic components. Gut 1995;36:146–147.
313.
Vautier G, Spiller RC. Safety of complementary medicines should be monitored. BMJ 1995;311:633.
314.
Perharic L, Shaw D, Leon C, et al. Liver damage associated with certain types of traditional Chinese medicines used for skin diseases. Vet Hum Toxicol 1995;37:562–566.
315.
Woerdenbag HJ. Gossypol. In: De Smet PAGM, Keller K, Hänsel R, Chandler RF, eds. Adverse effects of herbal drugs. Volume 2. Heidelberg: Springer-Verlag, 1993:195–208.
316.
Nakamura T, Kobayashi A. Toxikodermie durch den Speisepilz Shiitake ( Lentinus edodes). Hautarzt 1985;36:591–593.
317.
Nakamura T. Shiitake (Lentinus edodes) dermatitis. Contact Dermatitis 1992;27:65–70.
318.
Kato C, Morishita Y, Fukatsu T. False-positive increase in 1,5-anhydro-D-glucitol due to Kampo (Japanese herbal) medicine. Jap J Clin Pathol 1996;44:396–399.
319.
But PP, Tomlinson B, Lee KL. Hepatitis related to the Chinese medicine Shou-wu-pian manufactured from  Polygonum multiflorum. Vet Hum Toxicol 1996;38:280–282.
320.
Lai R-S, Chiang AA, Wu M-T, et al. Outbreak of bronchiolitis obliterans associated with the consumption of  Sauropus androgynus in Taiwan. Lancet 1996;348:83–85.
321.
Lo ACT, Chan K, Yeung JHK, Woo KS. The effects of Danshen ( Salvia miltiorrhiza) on pharmacokinetics and pharmacodynamics of warfarin in rats. Eur J Drug Metab Pharmacokin 
1992;17:257–262.
322.
Okuda T, Umezawa Y, Ichikawa M, et al. A case of drug eruption caused by the crude drug Boi (Sinomenium stem/Sinomeni caulis et Rhizoma). J Dermatol 1995;22:795–800.
323.
Lin JL, Ho YS. Flavonoid-induced acute nephropathy. Am J Kidney Dis 1994;23:433–440.
324.
Horowitz RS, Gomez H, Moore LL, et al. Jin Bu Huan toxicity in children—Colorado 1993. MMWR 1993;42:633–636.
325.
Woolf GM, Petrovic LM, Rojter SE, et al. Acute hepatitis associated with the Chinese herbal product Jin Bu Huan. Ann Intern Med 1994;121:729–735.
326.
Horowitz RS, Feldhaus K, Dart RC, et al. The clinical spectrum of Jin Bu Huan toxicity. Arch Int Med 1996;156:899–903.
327.
Yu D-Y. Clinical observation of 144 cases of rheumatoid arthritis treated with glycoside of Radix Tripterygium wilfordii. J Tradit Chin Med 1983;3:125–129.
328.
Tao X-L, Sun Y, Dong Y, et al. A prospective, controlled, double-blind, cross-over study of  Tripterygium wilfordii Hook f in treatment of rheumatoid arthritis. Chin Med J 1989;102:327–332.
329.
Qian SZ. Tripterygium wilfordii, a Chinese herb effective in male fertility regulation. Contraception 1987;36:335–345.
330.
Guo J-L, Yuan S-X, Wang X-C, et al.  Tripterygium wilfordii Hook f in rheumatoid arthritis and ankylosing spondylitis. Preliminary report. Chin Med J 1981;94:405–412.
331.
Chan TYK, Chan AY, Critchley JA. Hospital admissions due to adverse reactions to Chinese herbal medicines. J Trop Med Hyg 1992;95:296–298.
332.
Aslam M. Asian medicine and its practice in Britain. In: Evans WC, ed. Trease and Evans' Pharmacognosy. 14th edn. London: WB Saunders Company Ltd, 1996:488–504.
333.
Thatte UM, Rege NN, Phatak SD, Dahanukar SA. The flip side of Ayurveda. J Postgrad Med 1993;39:179–182.
334.
Maurice PDL, Cream JJ. The dangers of herbalism. BMJ 1989;299:1204.
335.
Vanherweghem J-L. Aristolochia sp. and chronic interstitial nephropathies in Indians. Lancet 1997;349:1399.
336.
Aslam M, Shaw J. A case study—dangers of transcultural medicine in the U.K. J Clin Pharm Ther 1995;20:345–347.
337.
Aslam M, Shaw J. Problems of identity with traditional Asian remedies. Pharm J 1992;248:20–23.
338.
Barnes AR, Paul CJ, Secrett PC. Adulteration of an Asian alternative medicine. Pharm J 1991;247:650.
339.
Thatte U, Ucchil D, Dahanukar S. Screening Ayurvedic drugs. Essential Drugs Monitor 1996;22:12.
340.
Raman A, Jamal J. 'Herbal' hay fever remedy found to contain conventional drugs. Pharm J 1997;258:105–106.

CHAPTER 7. T
HE
 S
AFETY OF
 N
ONHERBAL
 C
OMPLEMENTARY
 P
RODUCTS
Essentials of Complementary and Alternative Medicine