Toxic BotanicalsIs the Poison in the Plant or its Regulation?

Eric Yarnell, N.D., and LisaMeserole, M.S., R.D., N.D.

A number of safety concerns cloudthe safe use of botanicalmedicines in today's market-

place. The general lack of a consistent,efficient regulatory system for medicinalplants in the United States has greatlyhampered consumer and health careprovider knowledge about the safety ordanger of these plants. Unfortunately, theappropriate way to develop this regulato-ry system has only begun to emerge. Nogovernment department yet exists thatcould handle this problem, in part due tothe lack of a clear ability to work withnongovernmental experts and organiza-tions that need to have a say in the pro-cess. The relative safety of herbalmedicines, compared particularly to syn-thetic drugs, is often ignored in debateson these medicines. Herbal medicineshave been, and will continue to be,extremely safe in the vast majority of situ-ations.The safety issues of botanical medicines

go beyond the actual toxic properties ofeach plant. Adulteration, contamination,product labeling, advertising, uninformedprescribing, and varying strengths of spe-cific forms of herb extracts should all beconsidered. The situation is admittedlycomplex and involves many players. Pub-lic health safety and benefit issuesdeserve to have a larger role in phy-tomedicine use than they have in theUnited States.

The safety of homeopathic preparationsof herbs and other substances will not beconsidered here although there may beother safety issues regarding these sup-plements. Information on the safety ofhomeopathic drugs may be obtained fromthe American Institute of Homeopathy.

Specific Plantswith Specific Dangers

Most commonly used botanicalmedicines are safe. A long history (overfive millennia) of safe human use as wellas numerous scientific studies validatebotanical medicines' safety. However,specific plants are extremely dangerous.Deadly nightshade (Atropa belladonna) is awell-known example. Some of the dan-gerous plants may be used, however, togreat advantage when they are meticu-lously prescribed and monitored by atrained and credentialed phytomedicinepractitioner. Responsible herbal self-careobviously dictates strict avoidance of dan-gerous plants, including herbal abortifa-cients. Practitioners should stronglyadvise patients to ask trained practition-ers if specific plants are safe or toxic. Dis-eases and conditions that lend themselvesto herbal self-care do not require the useof toxic plants.The herbs that most definitely should

not be taken unless prescribed by a quali-fied health care practitioner includeAtropa belladonna (deadly nightshade),Convallaria majalis (lily-of-the-valley),Datura stramonium (thorn apple), Gelsemi-um sempervirens (gelsemium, yellow jas-mine), Hedeoma pulegoides (pennyroyal),

Podophyllum peltatum (mandrake), Rau-wolfia serpentina (Indian snakeroot, rau-wolfia), Veratrum viride (false hellebore),and Viscum album (European mistletoe). Amore complete list is included in the boxentitled Some Herbs Only You ShouldPrescribe. A brief discussion of the moretoxic of these plants is provided below.Rauwolfia was one of the first treat-

ments for hypertension recognized in thetwentieth century. However, it has verycommon side effects and thus is usuallyunsafe for long-term use. Rauwolfia cancause or aggravate depression in someindividuals. The herb may also causenasal congestion, headache, constrictionof the pupils, and diarrhea. However,rauwolfia may be prescribed by a trainedpractitioner in low doses for some people.Belladonna was historically used as a

versatile medicine as well as to causepupil dilation, once considered a sign ofbeauty. Excessive doses of this medicinalherb can block the functioning of part ofthe autonomie nervous system. The symp-toms of this are dry eyes and a dry mouth.Later, giddiness, a rapid heartbeat, confu-sion, and even a coma may occur. Further-more, this herb should not be taken withdrugs that have similar side effects,including certain antidepressants and theheart medicine quinidine. Only a highlyskilled health professional familiar withpatient symptoms, signs, tolerance, anddisease monitoring should prescribe it.

The "Dangerous If..." HerbsGelsemium is another medicinal herb

with possible toxic effects. Some signs of13

14 ALTERNATIVE & COMPLEMENTARY THERAPIES—FEBRUARY 1997

Dangerous herbs, which are unsafe if taken internally forextended periods of time, include those that containvarying amounts of the liver-damaging chemicals knownas pyrrolizidine alkaloids — comfrey, liferoot, coltsfoot,Western coltsfoot, etc.

toxicity include doubled vision, dizziness,depression, and paralysis. Caffeine andbelladonna taken concurrently withgelsemium may increase these negativeside effects. Gelsemium is relatively safe if

taken under supervision at specific dosesfor short periods of time. High doses cancause severe symptoms or death.Another category of dangerous herbs

includes those which are unsafe if taken

internally for extended periods of time.These include herbs that contain varyingamounts of the liver-damaging chemicalsknown as pyrrolizidine alkaloids (Sym-phytum officinale [comfrey], Senecio spp.[liferoot], Tussilago fárfara [coltsfoot], Peta-sites officinalis [Western coltsfoot], etc.).These medicinal plants are most danger-ous to people with pre-existing liver dis-ease. Several case studies have shownthat long-term (months or years) intake ofcomfrey pills or tea can cause a severeand sometimes lethal liver disease.1,2 Thetime of plant collection, harvesting, partof the plant collected, and specific prepa-ration can increase or reduce the contentof these alkaloids. Repeated topical appli-cation over broken skin can lead to sys-temic absorption and thus toxicity.The comfrey poisoning case studies

point out an important problem aboutmedicinal plant toxicity. None of thesereports analyzed or identified the actualproduct the patients took to rule out adul-teration. Exact dose was often not investi-gated and pre-existing patient conditionssometimes not investigated or reported.Most medical doctors and poison controlcenter personnel are not trained in botani-cal medicine. Their reporting protocolsmay be incomplete or even misinformed.Larrea tridentata (chaparral) has also

received some media attention as a causeof liver disease. Case reports exist sup-posedly documenting liver damage inpeople taking chaparral products.3'4 In atleast one of these situations, the patientswere simultaneously taking known hepa-totoxic drugs. This makes it unclear what,if any, role chaparral had in these

Use vs. Abuse: A Few G

Nutritional and tonic herbs used forsimple conditions are safe for self-carefollowing appropriate education of yourpatients. Herbs included in this category areTaraxacum officinale (dandelion), Nepetacataría (catnip), Rosmarinus officinalis(rosemary), Thymus valgaris (thyme), Rubusidaeus (raspberry), and many others.Offer your patients the following

guidelines:• Using stronger herbs for treatment ofnon-self-limiting conditions requiresconsultation with a trained practitioner.Practitioners should discuss all issues withyou about safety and promote safe andeffective use.

• Some herbs should never be taken withoutprofessional advice.

• Do not take herbs on the advice ofsomeone whose credentials or trainingare not established in some reputable way.

• Do not take herbs based on reading onething about them.

• If one article mentions an herb as atreatment or prevention for a condition,investigate further.

• If a wide variety of sources all seem toagree, then the herb is more likely to besafe, but check with a trained professionalanyway.

• Note that any claim that an herb is an"instant cure" or a "miracle" is not to betrusted.

idelines for Your Patients

• Do not take large doses of herbs unlessprescribed.

• Take moderate doses for short ormoderate periods of time.

• If you have started taking an herb or herbson your own, and are considering takingthem for a long period of time, consultwith knowledgeable persons first.

• Note that homeopathic dilutions of anyplant are safe if taken as prescribed.

• Use properly stored, nonmoldy, preferablyorganic or home-grown (whenappropriate, such as parsley or thyme)

.

preparations.• Purchasing from small growers andcompanies bound by local accountability isa reasonably good way to acquire high-quality herbal products.

• Do not assume that just because somethingis a natural product it is safe under allconditions. (Some plants have traditionallybeen used specifically as poisons inhunting, such as the dried bark extractfrom Strychnos castelnaei [woorari]. Thisextract was the source of the poisonousconstituent known as curare. Obviouslythis plant, though natural, is not safe foruse as medicine or food.)

• If you suspect you are having a badreaction to an herb, consult a practitionerwho is familiar with botanical medicinesright away. If the reaction is serious, call911 for emergency help without delay.

ALTERNATIVE & COMPLEMENTARY THERAPIES—FEBRUARY 1997 15

Some Herbs Only You Should PrescribeNOTE: This list is not exhaustively complete, but covers only the most likely dangerous plants your patients might encounter.

Part Used Potential ToxicitAdonis vernalis (pheasant's eye) herb sudden heart paralysisAnemone pulsatilla (pasque flower) herb heart and nervous system damageArnica montana (arnica) herb damage to stomach and muscles (but safe for external use)Atropa belladonna (belladonna) root or herb nervous system depression; respiratory depressionBryonia dioica (bryony) root damage to stomach and lungsCephaelis ipecacuanha (ipecac) root violent vomitingConvallaria majalis (lily-of-the-valley) herb heart and nervous system damageDatura stramonium (thorn apple) leaves nervous system damage; liver damageDigitalis purpurea (foxglove, digitalis) leaves, flowers heart and nervous system damage; potentially lethalDryopteris filix-mas (male fern) root nervous system, eye, and heart damageGelsemium sempervirens (yellow jasmine) root impaired breathing and heart function; loss of consciousnessHedeoma pulegoides (pennyroyal) oil of leaves stomach bleeding; shock; toxic to fetusesHyoscyamus niger (henbane) leaves nervous system depression; respiratory depressionPausinystalia yohimbe (yohimbe) bark high blood pressure; heart damage; nervous system damagePodophyllum peltatum (mandrake) root stomach damage; immune system damage; teratogenicRauwolfia serpentina (Indian snakeroot, rauwolfia) root depression; sedation; stomach damage; nervous system damageUrginea marítima (squill) bulb stomach and kidney damage; nervous system damageVeratrum viride (false hellebore) root low heart and lung function; nervous system damageViscum album (European mistletoe) herb gastrointestinal bleeding; nervous system and heart damage

patients' liver problems. Some patientsalso had previous liver disease. No mech-anism of injury has been proposed or dis-covered that would explain chaparral asan etiologic agent in hepatotoxicity. Pru-dent advice to give patients about self-care is that internal use of chaparralshould be avoided. A special line toreport negative effects from chaparral hasbeen set up by the American Herbal Prod-ucts Association: (512) 469-6344.

Other ProblemsWith Medicinal Herbs

Some common and very safe herbsmust be processed first in order to beacceptable for human consumption. Twoexamples of this are Ginkgo biloba (ginkgo)and Urtica dioica (stinging nettle). Ginkgoleaves can be quite toxic unless theginkgolic acids are removed. Note that inTraditional Chinese Medicine, the berriesand not the leaves are used. Stinging net-tle's name speaks for itself—the freshleaves can inflict painful stings. Actually,this property has been used historically totreat arthritis. This practice is not recom-mended without supervision by a knowl-edgeable health care professional.Internal use of fresh nettle leaves can bedangerous. Small spring fronds should beharvested and fully boiled or processed toavoid negative effects.The most gentle, harmless herbs can

cause problems in patients who are aller-gic to them. Such reactions are often obvi-ous, such as the appearance of hives orsevere nausea. It is best for patients toavoid use of known allergenic plants;encourage patients to consult a trainedpractitioner if they are confused byexpected side effects to common, safe,medicinal plants. In a similar vein, somepeople react differently to certain herbsthan other people do. These idiosyncraticreactions may be highly individual andunpredictable. Severe reactions such asthese occur but are rare. Nevertheless,advise patients with allergic tendencieswho are considering taking herbs forhealth problems or disease prevention toseek professional guidance.When weighing the allergic risks of a

plant, it is important to weigh the inci-dence of the problem. The number of peo-ple suffering allergic reactions toMatricaria recutita (German chamomile) isexceedingly low compared with the rela-tively high level of use. Many medicaldoctors, however, continue to regard it asa high risk allergen despite the smallnumber of reports of allergic reactions.5

Quality Assurance IssuesQuality assurance issues are impor-tant when considering the safety ofbotanical medicine. These include adul-teration, plant identification, and con-

tamination. Adulteration involves theintentional or accidental addition of sub-stances to a product inconsistent with itslabeled ingredients. Contaminationrefers to the presence of pesticides, her-bicides, or other chemicals related togrowing, processing, or packaging ofmedicinal herbs.Adulteration of innocuous herbal

products with toxic herbs may be thecause for a large percentage of thereports of poisonings by herbalmedicines. For example, one report of apoisoning by Viscum album (Europeanmistletoe) was most likely due to con-tamination with Teucrium chamaedrys(germander).6 Another report of liverdisease in a newborn occurred after themother drank an herbal tea. The motherbelieved the tea contained Tussilago fár-fara (coltsfoot). It had probably beenadulterated by a similar plant containinghigh levels of pyrrolizidine alkaloids.7Mislabeling of adulterated products is

another problem. A letter to The New YorkTimes details this problem regardingproducts labeled as containing Pausinys-talia yohimbe (yohimbe).8 Actually, oneproduct had no yohimbine, the activeconstituent in the herb, and another had 1mg of yohimbine per capsule with a rec-ommended dose of 8-10 capsules daily.This dose could cause severe problems inpatients with autonomie nervous systemproblems or bipolar disorder.

16 ALTERNATIVE & COMPLEMENTARY THERAPIES—FEBRUARY 1997

ResourcesAmerican Botanical CouncilP.O. Box 201660Austin, TX 78720(512)331-8868Fax (512) 331-1924

The American Herbalist GuildP.O.Box 1683Sequel, CA 95073

U.S. News and World Report reported in 1988 that, ofthe 1.2 million reports of exposure to poisons in theUnited States, 7 percent (84,400) involved some kindof plant. Of the 12 most reported plants related topoisoning, only one, Phytolacca decandra (pokeweed),is used as a medicinal plant.

The I.D. Dilemma:When Naming Systems CollideThere is a lack of organization of names

of herbs, as well as difficulty in identify-ing some herbs. Two systems of namesfor herbs exist—the botanical name (givenin Latin and always italicized or under-lined) and the common name (given inEnglish). Neither naming system is entire-ly clear. Common plant names are themost unreliable—often different namesfor the same plant are used in differentareas. For example, chaparral is alsoknown as creosote bush and greasewood.Alternatively, several different plantsmay have the same common name. Thegeneric term ginseng is used to describeseveral different plants including Panaxginseng (Chinese ginseng), Eleutherococcussenticosus (eleuthero, Siberian ginseng),and Panax quinquefolium (American gin-seng). Although they are somewhat simi-lar, each of these plants possessesdifferent properties and clinical indica-tions. There are also different commonnames in other languages. Dandelion inEnglish (also called lion's teeth and fairyclock) is known as Löwenzahn in Germanand chicoria or diente de león in Spanish.The botanical name system leaves room

for possible error in plant identification.There is a single international body thatsets the official name of plants, but whenan official name is changed it is difficultto ensure dissemination of the new nameto all parties. There is also a tendency forsome people to continue to use the old,familiar name. Finally, many species orvarieties of a plant may be difficult to dis-

tinguish yet possess distinct properties.There are several species of echinacea orpurple coneflower {Echinacea purpurea,Echinacea augustifolia, Echinacea pallidum,etc.). Most of the research has been doneon Echinacea purpurea and it is unclear towhat extent it can be extrapolated to otherspecies. Interestingly, £. augustifolia wasthe species primarily used by NativeAmericans; E. purpurea became the focusof research (primarily in Germany) byaccident.

Rules of theHerbal Marketing Game

Regulation of the herbal market muststrike a delicate balance between themotives and needs of the growers, retail-ers, practitioners, government regulatoryauthorities, and the needs of the public.Yet, without rules herbal growers andmanufacturers can get away with any-thing. A clear regulatory environmentacceptable to all involved parties shouldbe developed sometime in the future,which will help ensure consumer safety.One final issue in safe use of botanical

medicines is whether the herb is self-pre-scribed, prescribed by a credentialedpractitioner, or prescribed by a personuntrained in the area, such as a healthfood store clerk, a medical professionalwithout expertise in botanicals, and soforth. These people have not sought outapprenticeship, specialty training, peerreview, or other methods to validate theirknowledge. Despite good intentions,these people may lack the clinical tools tomake safe and effective decisions for

many health care concerns. Tell all ofyour patients that advice given byuntrained personnel to take an herb forany reason is usually not safe to follow.Clearly the public is responsible forchoosing professional botanical consul-tants or educating themselves in themany nutritional and tonic herbs whichare safe for self-care, but professionalsneed to make this known.

The "Safe, Not Sorry" StatisticsHerbs in general are simply safer than

synthetic drugs. Direct comparativestatistics are, unfortunately, not availableto back up this assertion yet. However,statistics from poison control centers doprovide some support. The number ofreported poisonings due to plants of allkinds (medicinal or otherwise) accountsfor only a small number of reported poi-sonings each year.U.S. News and World Report reported in

1988 that, of the 1.2 million reports ofexposure to poisons in the United States,7 percent (84,400) involved some kind ofplant.9 Of the 12 most reported plantsrelated to poisoning, only one, Phytolaccadecandra (pokeweed), is used as a medici-nal plant. Most of the reported plantswere common house plants such as philo-dendron, poinsettia, and holly. Anothercommonly reported toxic plant exposurewas to poison ivy.The American Association of Poison

Control Centers reported the followingdata for 1995.10 Out of a total of aroundtwo million reported poisonings (cover-ing most of the United States) for the

ALTERNATIVE & COMPLEMENTARY THERAPIES—FEBRUARY 1997 17

One longstanding problem with ephedrinehas been the facility with which it can be

transformed into amphetamines.

year, 5.2 percent (104,187) cases were dueto plant exposures of some kind. Onlythree of these cases led to the death of thepeople involved; two were infants, onewas an adult.Two surveys done in the United King-

dom found a total of 1070 reported casesof poisonings involving herbal prepara-tions as well as a number of unrelatedproducts, such as enzymes and glandularproducts.H Only 25 percent (270) of thesereports involved patients with symptoms,and only 34 of the cases were regarded as"probable" or "highly probable" thatherbal preparations were the cause of thespecific symptoms. This does not paint apicture of a silent epidemic of poisoningsby herbal medicines—quite the opposite.Though reports to poison control centersare voluntary and do not give the wholepicture, they are designed to detect large-scale and consistent reports of poisonings.There could be more cases of adverseeffects from medicinal plant use that gounreported, but it is unlikely that they arevery serious.

From Botanical to StreetDrug: The Ephedra ChronicleEphedra, Mormon tea, or ma huang

(Ephedra sínica or related species) is astrange-looking and very ancient plant.The most well-known species, E. sínica,has been used as a medicine in China for¡thousands of years. The herb is effectiveas a treatment for colds, asthma, coughs,obesity, and other problems.12 Use of thewhole herb has not been consistentlylinked to any serious adverse effects. The

Ephedra nevadensis

isolated active constituents in ephedra,however, alkaloids called ephedrine andpseudoephedrine, have raised numerousalarms.One longstanding problem with

ephedrine has been the facility withwhich it can be transformed intoamphetamines. Amphetamines areaddictive and can cause many seriousadverse effects; use without a prescrip-tion is illegal. Recently, however,ephedrine itself was used in variousproducts known by such names asHerbal Ecstacy [sic], Ultimate Xphoria,and Cloud 9. These products were mar-

Ephedra'sDeadly Attraction

What makes ephedra so attractive,despite its dangers? In today's atmosphereof increased restrictions against drug use,national publicity about its dangers, and astronger emphasis on natural foods andmedicine, consumers find the possibility of alegal and natural "high" appealing. Oneconsumer, a former user of the psychedelicMDMA, popularly known as Ecstacy, saidthat she enjoyed the energy and tingling allover her body produced by an ephedrapreparation. She claimed that she felt incontrol, that she did not lose track of time,and that her mind seemed to be clear. Shealso echoed a dangerous myth that isprobably all too common among laypeople:"It's herbal, so it's O.K."What is more, merchants of ephedra

preparations say that they appeal to usersof psychedelics while only providing acaffeine-like boost. Others, like SeanShayan, the chief executive officer of GlobalWorld Media Corporation, are attracted tothe idea of selling the "concept of ecstasy"to consumers seeking a safe, legal high. Mr.Shayan says that his company's chiefproduct, Herbal Ecstacy [sic], is safe, havingnever been linked to a death. Although, upto now, this seems to be the case,California health regulators are investigatingthe company. While insisting that HerbalEcstacy is safe if taken in recommendeddoses, Mr. Shayan is currently marketing areformulated Herbal Ecstacy [sic] 2, thatuses kava-kava root instead of ephedra.Source: Cowley, G., with Hager, M., Springen, K., King, P.,Miller, S., Stone, B. Herbal warning: Health-food storeshave built a new natural-drug culture. How safe are theirwares? Nçwsweek, May 6, ! 996, pp. 64, 66, and 67.

18 ALTERNATIVE & COMPLEMENTARY THERAPIES—FEBRUARY 1997

Recommended ReadingToxicology ofBotanical Medicine, 2nd EditionBy F. BrinkerPortland OR: Self-published

Adverse Effects ofHerbal Drugs, Volumes Iand IIBy P.A.G.M. De Smet, K. Keller, R.Hansel, R.F. Chandler, et al.Berlin: Springer-Verlag, 1992-1993

Handbook ofEdible WeedsBy J. DukeBoca Raton, FL: CRC Press, 1992

Essential Oil Safety: A Guide for Health CareProfessionalsBy R. Tisserand and T. BalacsEdinburgh: Churchill Livingstone, 1995

Tell Your Patients...Not only are individual herbal

formulations dangerous, but some herbalremedies that are safe when taken alonecan be dangerous when combined withother substances. For example:• Stimulant herbal laxatives, such as cascaraand senna, can increase potency ofdigoxin, causing stress on the heart.

• Diuretic herbs, such as birch leaf,dandelion leaf, or juniper, may increaseconcentrations of lithium in thebloodstream.

• Yohimbe, an herb used as an aphrodisiacor energy booster, can cause rasheswhen it is mixed with tyramine-rlchfoods, such as liver, cheese, or red wine;the herb can also cross-react with OTCproducts containingphenylpropanolamine (such as nasaldecongestants and diet aids).

Source: Cowley, G., with Hager, M., Springen, K., King,P., Miller, S., Stone, B. Herbal warning: Health-foodstores have built a new natural-drug culture. How safeare their wares? Newsweek, May 6, 1996, p. 68.

keted as causing a safe but pleasurablefeeling of stimulation. Many people sim-ply felt agitated after taking it. The prod-ucts were also rumored to beaphrodisiacs but this has never been sub-stantiated.Because of its advertised capacity to

make users feel good, the products wereabused and deaths related to taking theseproducts occurred. Many of the earlycases involved people with medical con-ditions, such as diabetes or high bloodpressure. Several cases went to court inwrongful death suits when people tookephedra supplements and died or suf-fered adverse effects.13 The Food andDrug Administration (FDA) is said tohave received notice of 15 people whodied after taking ephedra or ephedrine,and more than 395 complaints of badeffects from these products, since 1993.Many of these cases involved use ofexcessive doses.Interestingly, there are a number of

over-the-counter (OTC) drugs that con-tain ephedrine and pseudoephedrine.These include such brands as Primatene®(Whitehall Laboratories, New York City)and Sudafed® (Burroughs Wellcome,Research Triangle Park, North Carolina).In 1994 Ohio removed the OTC status ofthese drugs, limiting sales by licensedpharmacists to people over 18 years ofage. A host of other states began to regu-late the sale of ephedrine including a tem-porary move to status as a prescriptiondrug in Washington state.The recent wave of deaths related to

herbal products containing ephedra orephedrine promoted as stimulants has ledto banning of their sale in Florida andNew York.14'15 The FDA has yet to move

to ban their sale nationwide but this is apossibility.The Hazards of Regulating the

Potentially HazardousThis whole situation reveals a number

of problems with regulation of botanicalmedicines. First, the FDA has not provid-ed proof that ephedra (not ephedrine) isdangerous. Second, the dose at whichephedrine becomes dangerous has notbeen established. Third, it has not beenshown conclusively that ephedrine orephedra was solely responsible for anydeaths, even when taken in overdoses.The complete case records of the purport-ed poisonings have not been published toour knowledge. Fourth, the marketers ofthe "herbal ecstasy" products made manyoutrageous claims due to a lack of regula-tion or investigation. Many people mayhave been harmed as a result, and thereputation of legitimate herbal medicinewas, unfortunately, tarnished.Ephedra products containing less than

10 mg of ephedrine per daily dose areprobably safe. OTC drugs usually containmore than this level of ephedrine, thoughthis varies. People with high blood pres-sure, diabetes, stomach ulcers, heart dis-ease, thyroid problems, or enlargedprostates (benign prostatic hyperplasia)or who are pregnant or breast feedingshould not take ephedra. If a patient hasasthma or another condition that ephedramay help, the patient should first consultwith a knowledgeable medical practition-er to ensure safety.

Problematic PennyroyalPennyroyal is a fairly well known

abortion-inducing herb. However, it can

ALTERNATIVE & COMPLEMENTARY THERAPIES—FEBRUARY 1997 19

The FDA has not provided proof that ephedra (notephedrine) is dangerous. . . the dose at whichephedrine becomes dangerous has not been

established. . .and it has not been shown conclusivelythat ephedrine or ephedra was solely responsible for

any deaths, even when taken in overdoses.

have very severe side effects. The herbmay work by destroying the liver andother organs of the fetus and can do thesame to the mother. A fairly comprehen-sive review of the toxicity of pennyroyaloil has been published.16 The articlecites a total of seven cases of poisoningdue to pennyroyal reported in the medi-cal literature since 1905—hardly a majorhealth problem. Nevertheless, a womanshould not take this herb to induce abor-tion without close guidance and obser-vation.One of these cases is now somewhat

famous. A 24-year-old woman discoveredthat she was pregnant, and began takingpennyroyal along with Cimificuga race-mosa (black cohosh) to induce abortion.She was not aware that she had an ectopic(or tubal) pregnancy. She died. It isunclear if she died due to complicationsof the ectopic pregnancy alone or if theherbs, in any way, contributed to herdeath. It is fairly clear that the womanignored her symptoms for at least twodays, attributing abdominal pain to theherbs causing an abortion when, in fact,the ectopic pregnancy was worsening.The woman's parents are now suing thecompany that manufactured the penny-royal oil as well as the health food storewhere the woman bought the oil.17Inducing an abortion is a very serious

matter, and although this is obvious, itshould be emphasized that no untrainedperson should ever attempt one by anymeans. Pennyroyal oil is unsafe for use ofany kind without supervision by a highlytrained professional familiar with its use.Tell your patients that it is currently ille-gal for anyone to attempt to induce abor-tion using pennyroyal oil.

Unfortunately, scientific investigationof the effects of pennyroyal oil are virtual-ly nonexistent. It will never be known if itcan be safely used as an abortifacient ifstudy is not allowed or undertaken. Somepractitioners are supervising womenattempting to induce abortion with pen-nyroyal, demanding that they have a sur-gical abortion if the herbal abortion fails.These practitioners report no major prob-lems as long as they are able to monitorthe patient and as long as the patient iswilling to follow through. D

References1. Weston, C.F.M., Cooper, B.T., Davies, J.T.,Levine, D.F. Veno-occlusive disease of the liversecondary to ingestion of comfrey. Br Med J295:183,1987.2. Yeong, M.L., Winburn, B., Kennedy, M.,Nicholson, G. Hepatic veno-occlusive diseaseassociated with comfrey ingestion. / Gastroen-terol Hepatol 5:211-214,1990.3. Gordon, D.W., Rosenthal, G., Hart, J., Sirota,R., Baker, A.L. Chaparral ingestion: The broad-ening spectrum of liver injury caused by herbalmedications. JAMA 273(6):489-490,1995.4. Katz, M., Saibil, F. Herbal hepatitis: Subacutehepatic necrosis secondary to chaparral leaf. /Clin Gastroenterol 12:203-206,1990.5. Farnsworth, N.R. Relative safety of herbalmedicines. HerbalGram 29(suppl):36A-36H,1993.6. Harvey, J., Colin-Jones, DG. Mistletoe hep-atitis. Br Med / 282:186-187,1981.7. Roulet, M., Laurini, R., Rivier, L., Caíame, A.Hepatic veno-occlusive disease in newborninfant of a woman drinking herbal tea. / Pediatr112:433-434,1988.8. De Smet, P., Smeets, S.N.M. Potential risks ofhealth food products containing yohimbineextracts. BMJ 309:958,1994.9. U.S. News and World Report, May 16,1988, p. 79.

10. Litovitz, T.L., Felberg, L., White, S., Klein-Schwartz, W. 1995 Annual Report of the Amer-ican Association of Poison Control CentersToxic Exposure Surveillance System. Am HEmergMed 14(5):487-537,1996.11. Perharic, L., Shaw, D., Colbridge, M.,House, I., Leon, C, Murray V. Toxicologicalproblems resulting from exposure to tradition-al remedies and food supplements. Drug Safety11:284-294,1994.12. Robson, T. Ephedra sínica et spp. Austral JMed Herbalism 7:(Ar4&, 1995.13. Burros, M., Jay, S. Concern is growing overan herb that promises a legal high. New YorkTimes, April 10,1996, p. Bl.14. Anonymous. Florida bans lethal herb. NewYork Times, April 26,1996.15. Krauss, C. Pataki outlaws herbal stimulantused by youths. New York Times, May 24, 1996,p. Bl.16. Anderson, I.B., Mullen, W.H., Meeker, J.E.,Khojasteh-Bakht, S.C., Oishi, S., Nelson, S.D.,Blane, P.D. Pennyroyal toxicity: Measurementof toxic metabolite levels in two cases andreview of the literature. Ann Intern Med124:726-734,1996.17. Waxman, S. Lawsuits blame women'sdeaths on unregulated herbal products. Wash-ington Post, March 24,1996.

Eric Yarnell, N.D., has a private practice inDenver, Colorado. He is on the board of theBotanical Medicine Academy, a specialty boardfor using medicinal herbs. Lisa Meserole,M.S., R.D., N.D., is on the faculty of BastyrUniversity, Bothell, Washington. She also has aprivate clinical practice in Seattle.

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