THE NEW YORK HOSPITAL-CORNELL MEDICAL CENTER MEMORIAL SLOAN-KETTERING CANCER CENTER CURRENT CONCEPTS AND PERSPECTIVES IN NUTRITION A Nutrition Information Service for the Medical Profession Vol. 6 No. 2 July 1987 HERBS: USE AND ABUSE Jacqueline Gibson Gazella, M.S. in Clinical Nutrition, R.N. and John Thomas Pinto, Ph.D. Assistant Professor of Nutrition in Medicine, Cornell University Medical College Associate Laboratory Member, Memorial Sloan-Kettering Cancer Center Although herbs have been used by man for 5,000 years, many of their pharmacologic effects remain poorly understood (1). Of the estimated 800,000 plant species on Earth (1,2) about 250,000 have been categorized and only a small percent of these have been examined for pharmacologic efficacy. Dried and pressed plant specimens are stored in the world's estimated 1,800 public herbaria, but information about these plants remains largely unexplored (1). Consequently, most of the world's plant species are poorly classified, largely untested, and therefore remain obscure for practical use (1). An herb is defined as a plant or plant part used for its savory, aromatic, cosmetic or medicinal properties. Zaika et al. (3) as well as a number of other investigators (4,5) have reported that while certain spices have long been known to have food preservative capabilities, herbs such as oregano, thyme, sage, rosemary, and garlic are currently being studied for their antibacterial, antifungal and variety of medicinal properties. Although approximately half of the drugs prescribed by U.S. physicians contain plant derivatives (1), the search continues for more medications to help treat the many diseases which still plague society. EVALUATION OF HERBAL PREPARATIONS AND PREVALENCE OF USE Clinical trials that have been designed to test currently used herbal preparations are laborious, time consuming, and costly, and it is understandable why many herbal preparations remain largely untested. Griffin (6) has suggested that for thorough evaluation of herbal preparations the following procedures should be performed: 1. evaluate the single herb; 2. test the entire plant preparation from which the herb was isolated; 3. compare the interaction of the herbal preparation and the synthetic pharmaceutical product. Despite the paucity of knowledge of pharmacologic efficacies of herbals, sales of tested, partially tested, and untested preparations in the United States are on the rise. Many people have turned away from conventional medicines, with the belief that "natural" substances like herbs are safer than synthetic substances (7-11). Total herb sales from U.S. health food stores grossed $167 million in 1980 and are predicted to reach $360 million in 1987. This number includes revenue from food seasonings, teas, capsules and tablets, medications, deodorants, cosmetics, toiletries, shampoos and conditioners. These figures do not reflect sales of herbal preparations from outlets other than health food stores, such as supermarkets and some pharmacies (12). INCONSISTENCIES AMONG HERBAL PREPARATIONS Batch-to-batch variability is a serious problem with herbal preparations. Companies producing these preparations do not employ rigid quality-control personnel or standards and do not evaluate their products for purity and reliability. Plants may exhibit circadian rhythms, during which periods different amounts of active compounds may be produced, or plants may be harvested at different times of the day or in different seasons of the year (13). Some herbs are edible when immature but poisonous at maturity (14). Contradictory pharmacologic effects have been reported as a result of herbal preparations containing different subspecies of plants or alterations of chemical composition of active ingredients (15). Recently, an analysis of 24 herbal preparations of ginseng revealed absence of ginsenosides, the active pharmacologic constituent of ginseng. Further analysis of ginseng preparations indicated inclusion of incorrect species, altered mixtures of species, underweight products, and improper product labelling (16). Some herbs have produced responses in animals but have never been evaluated clinically in human subjects. Many times crude plant extracts have been tested and found to produce particular biologic effects, but the active principles remain unknown. Although medicinal properties of certain herbs may be known, the efficacy of individual preparations and products may not have been determined (15). In addition, the interactions of synthetic drugs with the variety of herbal preparations remain largely unknown (16). Because herbal preparations are usually not evaluated for purity and consistency of active components, they often contain accidental contaminants. Some preparations were identified to contain allergens, pollen, insert parts, mold and mold spores (14). Chan and others reported cases of lead poisoning in China due to ingestion of certain Chinese herbal preparations, but it was unclear whether the lead was an ingredient or a contaminant of these preparations (17). Parsons reported a case of arsenic poisoning due to contamination of yellow root herbal tea in the southern U.S., probably caused by soil and stream contamination in the plant's natural habitat (18). Small amounts of cocaine have been found in two herbal teas sold in the U.S.- Mate de Coca and Health Inca Tea. The levels of cocaine are small and are not thought to result in abuse or addiction; nonetheless, individuals consuming these teas have demonstrated positive urine tests for this drug (19). This may have legal ramifications with regard to recent interests of pharmaceutical and other companies to have their employees screened for use of drugs of abuse. HERBAL TOXICITIES AND TREATMENTS Herbs can be hazardous in many ways. They may be directly toxic or toxic when taken in combination with other preparations. Hogan (20) found menometrorrhagia in an Indiana woman taking a homemade herbal tea remedy, prepared from tonka beans, melilot, and woodruff, all natural sources of coumarin. Similarly, Kunkel and Spoerke (21) reported a bleeding diathesis after consumption of pennyroyal oil which contains a potent abortifacient that has also caused both liver and renal damage and death (22). Dobb and Edis (23) reported neuropathy and coma in an Australian patient who had overdosed on an herbal laxative taken as a form of weight control; the medication contained podophyllin, an antimitotic agent known to cause severe neurological symptoms; podophyllin poisoning has been associated with a number of fatal incidents involving herbal preparations. Herbs applied topically can also cause problems. Aloe, used externally or taken internally by herbalists, can produce skin irritation (11). Nwaefuna reported a case of allergic angioneurotic edema resulting from the use of an herbal hair dye (24). Other localized responses to herbs resulting in problems have been caused by ingestion of whole bay leaves. Three cases of bay leaf ingestion requiring endoscopic removal have been reported (25,26). The problem occurred when whole bay leaves were left in foods. The wavy edges of the leaves appear to make them prime candidates for adherence to the mucosa of the pharynx. Bay leaves should be removed before food is served. Herbs have caused localized allergic reactions in sensitized individuals. Farkas (27) reported cases of perioral dermatitis from ingestion of marjoram, bay leaf, and cinnamon. Stransky and Tsankov (28) reported a case of contact dermatitis from parsley. If herbal toxicity is suspected by a clinician, blood levels of active components are often unobtainable from most laboratories. Even in cases where blood levels of the herb ingredients are established, normal therapeutic levels are unavailable and interpretation is difficult. Antidotes for herbal intoxications are also mostly unavailable (21). Cases of herbal poisoning usually are treated supportively. Contact dermatitis resulting from direct exposure to plants such as poison ivy should be treated by cleaning the area and offering symptomatic treatment, which may or may not include antihistamines; astringent soaks are contraindicated for the face and genitals. If a caustic plant such as "dumb cane" (dieffenbachia) or jack-in-the-pulpit comes into contact with the oral mucosa, milk may be given and the patient observed to make sure airway closure does not occur (21). Gastrointestinal distress is a common symptom of plant poisoning and may require aggressive fluid replacement. Renal toxicity and primary renal failure from plants like rhubarb leaves and autumn crocus may require urinary alkalinization to treat hemolysis and correction of calcium balance to treat oxalate ingestion; rhubarb leaves are a good source of soluble oxalate salts (21). Herbal teas prepared from oleander, foxglove, or lily-of-the-valley may cause hyperkalemia and heart block. Treatment may include use of muscarinic cholinergic blockers such as atropine, phenytoin, cardiac pacing, and potassium-removal techniques. Fragment antibodies (Fab) which complex with digitalis glycosides derived from foxglove may be used in treatment, but it is uncertain whether these antibodies would be useful for treatment of poisoning with oleander whose digitalis-like glycoside may not cross react (21). Ingestion of ergot alkaloids may cause arterial vasospasm; therapy may include close medical observation, nitroprusside, or adrenergic blocking agents (21). Atropine-like symptoms produced by plants such as jimsonweed may require simple observation or judicious use of physostigmine (21). Nicotine found in both domestic and wild tobaccos may produce sequential peripheral ganglionic stimulation, then blockade, and may result in seizures, paralysis and death. Treatment includes control of seizures and provision of ventilatory support (21). Ingestion of volatile oils such as pennyroyal or eucalyptus, which are irritants and CNS depressants, may cause seizures and aspiration. Medical personnel should provide close observation of the patient, and be ready to treat aspiration; the risk of aspiration may contraindicate induction of emesis. Non-oily cathartics may be used, since oily cathartics may increase absorption of the toxins (21). Plant resins, such as those found in American ipecac, flowering spurge and common spurge, may cause severe vomiting and catharsis, CNS effects and muscle weakness. There are no known antidotes; treatment includes reduction of gastrointestinal effects and maintenance of hydration (21). Plant alkaloids, such as those found in monkshood and Senecio, may produce hepatomegaly, jaundice and ascites, and may mimic alcoholism, hepatitis or Reye syndrome. Treatment is supportive and will depend upon the degree of hepatic failure. Plants such as pokeberries or poke weed which contain certain mitogens may cause severe gastroenteritis, respiratory distress, or plasmacytosis. Treatment is symptomatic (21). Even when the active pharmacologic principles of plants have been isolated and classified, health professionals are not in agreement about how the herb should be handled. The United States FDA has banned sassafras root as a result of the Delaney Clause. (The Delaney Clause is part of the 1958 Food Additives Amendment of the Federal Food, Drug and Cosmetics Act, and prohibits the FDA from approving a food additive that has been found to induce cancer when ingested by man or animal. However, the Delaney Clause has no impact on carcinogens that occur naturally in foods). Sassafras has been shown to be both a hepatotoxin and hepatocarcinogen in laboratory animals (9). By contrast, sassafras root is currently recommended as a treatment for rheumatism in the British Herbal Pharmacopoeia (15). The use of common names instead of botanical names can also create problems. For example, Artemisia absinthium L., which contains an active narcotic derivative, can cause central nervous system disorders and generalized mental deterioration. This herb is used in folklore medicine as a relaxant (8,11), and is used to flavor absinthe, an alcoholic liqueur illegal in this country (9). The herb has at least eleven different common names (wormwood, absinthium, absinth, absinthe, madderwort, wermuth, mugwort, mingwort, warmot, magenkraut and harba absinthii), seven of which bear no resemblance to its botanical name (9). Because only common names are used, Heliotropium europaeum (heliotrope), containing pyrrolizidine alkaloids, potent hepatoxins (11,29), is often confused with Valeriana officinalis (garden heliotrope), containing valepotriates, which act as a sedative and muscle relaxant in laboratory animals (10,11,30). In order to avoid confusion and eventual toxicity, it has been proposed that herbs should be sold under both their common and botanical names (30). This practice would help protect not only the public health but public dollars. In Great Britain and the U.S.A., health food stores confuse the lay public by using elaborate or "catchy" scientific nomenclature to sell common substances. For example, sodium chloride tablets are disguised under the ancient name Natrium muriate; purified sand can be purchased as silicon oxide; and plaster of Paris, which could be purchased inexpensively in hardware stores, is sold as calcium sulfate (31). Moreover, there appears to be a lack of communication and uniformity of herbal preparations among herbalists. Oriental herbalists often complicate preparations by mixing complex recipes that contain herbs possessing identical pharmacologic effects (32). MODES OF HERBAL TOXICITY Toxic herbs have accidentally contaminated grain fields, which has resulted in their involuntary consumption. Heliotropium and crotolaria, which contain known hepatotoxins, have contaminated wheat fields in Afghanistan and India and have caused epidemic poisoning. In addition to crotalaria and heliotropium, senecio has contaminated grain fields in South Africa. Senecio, which more commonly causes hepatic vein thrombosis, has been implicated in the cause of primary liver carcinoma (33). This type of contamination is no longer a problem in advanced industrialized nations, where unwanted plants in grain fields are controlled by herbicides (33). Although ergot rarely contaminates grain, the potential for mass outbreaks in the U.S.A. still exists (21). Herbal toxicity as an occupational hazard has occurred. Chronic cough and chronic bronchitis in workers exposed to herbal dust in a tea processing and packing plant have been reported (34). Zuskin and Skuric (35) found a correlation between the occurrence rate of respiratory disease and tea processing in Yugoslavia. The workers packed conventional as well as herbal teas. Herbal poisoning has occurred in self-styled and weekend botanists who unwittingly picked the wrong herb. Foxglove (the source of digitalis) poisoning is common and sometimes fatal. The leaves from this plant are often mistaken for comfrey leaves (36,37). A California woman died after drinking oleander herbal tea; she had picked the leaves from a tree she thought was eucalyptus (38). Senecio longilobus (groundsel), which contains a potent and often fatal hepatotoxin (pyrrolizidine alkaloid, e.g., retrorsine), closely resembles Gnaphalium (gordolobo), a harmless plant used in folklore to treat gastrointestinal complaints or as a cough medicine and gargle (39). These two plants have been unwittingly exchanged (40). Natives of the West Indies and of South Africa have suffered from hepatic veno-occlusive disease from either drinking teas prepared from Senecio or using it in food (41). Similar mistaken identities have occurred among parsnips, jerusalem artichoke and horseradish, all edible plants, and poke root, a poisonous herb (42). Herbs used commonly as food flavorings and apparently innocuous in small amounts can be toxic in large amounts. Licorice root, widely used to flavor confections, has caused sodium and water retention, severe hypokalemia, hypertension, heart failure, and cardiac arrest (29,43). Licorice is present in clinically significant amounts in Lydia Pinkham's Compound, an over-the-counter preparation used to treat "women's problems", and at least one case of hypokalemic myopathy related to long-term ingestion of this compound has been reported (44). Glycyrrhetic acid, a metabolite of glycyrrhizin produced by human microbial flora (45), has a chemical structure closely resembling that of aldosterone. Patients have presented with symptoms of hyperaldosteronism after regularly consuming licorice in the form of candy (46-48). Karela (Momordica charantia), a powder found in Indian curries, has a known hypoglycemic effect and may upset the control of diabetes mellitus (29,49,50). Diabetic patients who regularly ingest curries may require a reduction in their dosage of oral hypoglycemic agents (50). Sage can act as an abortifacient (51). Small quantities of safrole, which has been shown to be both a hepatotoxin and hepatocarcinogen in laboratory animals, have been found in nutmeg, anise, mace and cinnamon (29). Nutmeg tea can cause a variety of untoward effects, ranging from nausea and vomiting to liver damage and death (11,43). The active principle in nutmeg is its essential oil, which ranges from 5 to 15% of the whole nut, depending upon the geographic region in which it is grown (11). When consumers express interest in obtaining certain herbal products, pathways become available for consumer exploitation even on a worldwide basis. "Vanilla extract" sold at roadside stands in Mexico for as little as $1.50 per quart may actually be tonka bean extract which contains large amounts of coumarin. This extract smells and tastes like vanilla extract (52). In addition to its effect on blood clotting, coumarin at a level of 0.5% or more of the diet of laboratory rats has been correlated with an increased occurrence of bile duct carcinomas. Coumarin is widely distributed in nature and is present in low concentrations in many naturally occurring flavoring agents (53). Of four Chinese women who had taken an herbal tea as a cure for pisoriasis, all had developed liver disease and one died. There is conflicting information as whether the tea originated in India or in Pakistan (54). Thus, when herbs are grown or is sold in one country and consumed in another, local health authorities may have less control over the quality and safety of the products. Reports of toxic effects of Chinese herbal preparations are widespread and the effects can be serious (55-59). The United States FDA has analyzed several Chinese herbal preparations that entered the U.S. illegally and that listed only herbal ingredients on the labels. These products were found to contain the following compounds: phenyIbutazone, aminopyrine, methyltestosterone, prednisolone, diazepam, chlorzoxazone, and acetaminophen. These illegal preparations are sold in Chinese pharmacies and gift shops. In Great Britain, Chinese herbal preparations have been found to contain the following substances: aminopyrine, phenyIbutazone, dexamethasone, indomethacin, arsenic, mercury, tin, zinc and lead. Again, only the herbal ingredients were listed on the packages (29). Dutch authorities have declared an embargo on Chinese herbal preparations, but Offerhaus and Dukes (60) suggest this would be impossible to enforce. The Medicines Commission of Germany has received reports of Chinese herbal preparations containing dexamethasone and prednisolone (61). Both phenyIbutazone and aminopyrine are known to cause agranulocytosis (55). Martin (62) reported an episode of agranulocytosis in a rheumatoid arthritic patient in Australia who was taking a Chinese herbal preparation obtained in Hong Kong. Questions have been raised as to why Chinese people, in general, do not demonstrate a higher incidence of agranulocytosis caused by their own herbal preparations. Martin (62) has suggested that as a result of possible genetic differences the Chinese population may be less susceptible to agranulocytosis than are other populations. Government controls and regulations are lacking with regard to the distribution of herbal remedies in China. However, legislation will require that all ingredients are to be listed on product labels (63). American health care providers should be aware that different ethnic groups often have strong beliefs about the use of herbs and other folklore remedies. "Bush teas" brought from Jamaica may cause liver disease due to contamination with Crotalaria fulva, which contains fulvine, a pyrrolizidine alkaloid (33,64). Veno-occlusive disease in infants and children in Jamaica has reached almost epidemic proportions due to drinking this tea (33). Mexican-American folklore practices apparently have originated from a combination of humoral medicine (which includes a hot-cold theory of disease) and practices handed down from generation to generation by the Aztecs (65). Mexican parents sometimes give their children azarcon, a bright orange powder, to treat chronic indigestion. This product contains significant amounts of lead (66). Southeast Asian refugees in St. Paul, Minnesota were found to have lead-containing folk remedies, which they give to their children to treat fever (66). Mercury and arsenic have been found in traditional herbal preparations brought from mainland to the United States by refugees (67). Delgado (68), Hernandez and others (69), Lieberman (70), and Koss (71) have reported in detail on an intricate network of foIkloric herbal practices within the Puerto Rican community. Delgado estimates that over half the herbs recommended by Spanish herbalists 500 years ago are still in use today. SUMMARY AND CONCLUSIONS Because of the widespread use and potentially toxic effects of some foIklore herbal remedies and the lack of public and scientific knowledge about their side effects, patients should be asked specifically whether they use herbal preparations. This inquiry should be adjunctive to questions regarding other self-imposed medical practices such as consumption of mega-vitamin preparations and over-the-counter pharmaceuticals. Health professionals should discourage the use of herbal products by patients when the source, active ingredients, and composition are uncertain. Also, consumption of herbs and herbal preparations by patients on certain medications should be controlled, monitored, or best avoided when the active ingredient is known to act either antagonistically or synergistically with the prescribed medication. Scientific inquiry into certain effects of herbs is under way and should be encouraged. Vietmeyer has reported on lesser known herbs such as amaranth and quinoa, currently under scrutiny because of their high protein oontent and favorable amino acid balance which would be desirable for human consumption (72). The World Health Organization, among others, hopes that an herb might provide an answer to the search for an inexpensive contraceptive that provides reliable fertility regulation with relatively few side effects (2). Lastly, consumers enjoy herbal teas as replacements for caffeine-and/or calorie-laden beverages; reliable information about herbal beverages would help health care professionals to assess accurately the safety and health risk of the preparations. TOXICITIES AND POTENTIAL USE OF COMMON HERBAL PREPARATIONS COMMON NAME(S)/ BOTANICAL NAME(S) COMMENTS ----------------- -------- Alfalfa leaves/ Contains vitamins A,D,E,C; minerals; saponins. Medicago sativa Folklore remedies include use as an analgesic and an antiarthritic. Toxicity includes flatulence and diarrhea (73). Contains canavanine, a toxic analogue of arginine. May produce severe lupus erythematosus-like syndrome (74). aloe/ Contains aloe-emodins and resinol-tannol (11). Aloe vera Clears lower bowel and stimulates peristalsis. A. barbadensis Works in concert with the bile in the gut (11). A officinalis Strong irritant laxative widely used in veterinary medicine for constipated large animals (43). Folklore remedies include treatment of burns and laxative (11,75). Toxicity includes skin irritation nausea, vomiting, diarrhea, red urine (11). In large doses, may cause nephritis (76). This plant is used in India by physicians to help control hyperlipidemia and hyperglycemia (77). anise seed tea Contains small amounts of safrole, a known hepatotoxin and hepatocarcinogen in rats and mice (29). apiol Abortifacient (51). apple (seed or Contains cyanogenetic glycoside, e.g., amygdalin, pits, bark and prunasin, dhurrin, linamarin, or lotaustralin leaves) (43,78). After food preparation, ingestion, or even when the plant tissue is bruised, hydrogen cyanide (HCN) or cyanide ion is produced, sometimes in sufficient quantity to cause cyanide poisoning. Has been fatal (43). apricot (seeds, See apple. pits, bark, leaves) aristolochic acid/ Folklore remedies include treatment of dermatitis, Aristolochia spp. rheumatism, gout (29). A carcinogen for a wide range of organs in the rat (29). autumn crocus/ May cause primary renal failure (21). Colchicum autumnale balm of gilead/ Contains salicin. Has anti-inflammatory and Poplar buds analgesic action similar to aspirin. Folklore remedies include minor treatment of aches and pains. Toxicity similar to the salicylates (15). bitter almond See apple. (seeds, bark, leaves) bloodroot tea/ Contains poisonous alkaloids, e.g., chelerythrine, Sanguinaria protopine, homochelidonine, and sanguinarine. canadensis Formerly prescribed by physicians as an expectorant and externally for treatment of chronic eczema and skin cancers (7,10). buchu/ Contains diosphenol (volatile oil); acts as a Barosma diuretic (betuline) (11). Folklore remedy includes use as a diuretic. Side effects include nausea and vomiting. buckthorn bark Is an irritant cathartic; has caused severe herbal tea diarrhea (43). burdock root tea/ Contains an atropine-like alkaloid (43). Toxicities Lappa herb include blurred vision, dilated pupils, dry mouth, inability to void, bizarre behavior, bizarre speech, and hallucinations (43,79). cassava beans/ Chronic use can result in cyanide intoxication Manioc goiter, tropical ataxic neuropathy, and amblyopia utilissima (43). May cause deafness (80). See apple. cassia/ "Cinnamon" as marketed in the U.S.A. today usually Ramulus cinnamomi is cassia (81) which contains small amounts of safrole (29). castor bean/ May cause renal impairment and hemolytic episode. Ricinus communis Contains the lectin, ricin (21). catnip/ Contains tannins (11) and anticholinergics (43). Nepeta cataria Folklore remedies include induction of euphoria and stimulation (10,43). Sometimes used in folklore to treat colic (21). Known hallucinogen (8,11,43). Continues to be used as snuff or smoked as a marijuana substitute (8,11). cayenne pepper Contains capsaican (11). Folklore treatments Capsicum include improvement of circulation, gastrointestinal frutescens irritant and counter irritant (11). Supposedly normalizes blood pressure (high and low) (82). Side effects include nausea, vomiting, and diarrhea (11). chamomile/ Folklore remedies include treatment of "female Manzanilla or complaints"; cramps; diarrhea; teething; and Anthemis nobilis sedation (33). May cause either allergic rhinitis or anaphylactic shock in persons known to be sensitive to ragweed, asters, and chrysanthemums (9,83,83). May cause contact dermatitis (43). Sometimes used as a milk replacement to treat diarrhea in infants. The prolonged use of this tea in the absence of other oral intake in infants can result in clinical water intoxication and subsequent hyponatremic seizure disorder because of inadequate sodium content (85). cherry seeds, See apple. pits, bark or leaves. cohosh, black/ Contains climifugin resin (11). Abortifacient Climifuga spp. (22,51). Folklore remedies include treatment of dyspepsia (11); induces menses (22). Side effects include nausea, vomiting, and catharsis (11). Should be especially avoided by pregnant women (15). cohosh, blue/ Contains lupin-type toxic alkaloids, and should Caulophyllum especially be avoided by pregnant women. Antirheumatic, spasmolytic, emmenagogue. Causes tonic contractions of uterus (15). comfrey/ Contains potent hepatotoxin (86,87) and carcinogen Symphytum spp. in animals (29). Rich in vitamin A precursors, vitamin C, calcium, potassium, phosphorus, and trace minerals (7). Has been used as a vegetable, beverage, or remedy. External use is apparently not hazardous (88). comfrey, Russian Hepatotoxin in rats (89). or Siberian/ Symphytum and uplandicum Nyman dandelion/ Folklore remedies include treatment of dyspepsia Taraxacum and sore throat accompanied by thirst and fever officinale (90); also diuresis (11). No toxicity reported (43). May stimulate gastric secretions (11). High in vitamin A precursors (7,11), vitamin C, niacin, protein, fat, and iron (11). devil's claw Abortifacient (43). Recommended in the British root tea/ Herbal Pharmacopoeia to treat rheumatism, arthritis, Harpagophytum gout, fibrositis and lumbago (15). dock root Contains a potent laxative (43). eucalyptus oil/ Folklore remedies include treatment of upper Eucalyptus respiratory infection, asthma, and cough. citriodora and Toxicities include gastroenteritis, seizures, other species cyanosis, kidney irritation, miosis, cardiovascular collapse, and coma (21). garlic/ Contains allyl disulfides (11). Enhances Allium sativum fibrinolysis (4). Purported antitumor properties; source of selenium. Improves glucose tolerance. Toxicities include hypotension, rashes, and leukocytosis (11). Recognized officially by the Japanese FDA as a treatment for hypertension (5). ginseng/ Contains saponin glycosides; decreases serum Panax glucose; increases cortisol levels (11). Folklore quinquefolium remedies include treatment of impotence, anemia, and depression, diabetes, edema, and hypertension (11). Panax Can cause gynecomastia due to content of estrogens ginseng (29,43). Can cause excitation, arousal, nervousness, tension, and hypertension (29,91). Mandrake root, which contains scopolamine, and snakeroot, which contains reserpine, may both be sold as ginseng (43). Only recognized use in U.S. is as a demulcent in skin ointments (92). There are three to six different species of genseng and many varieties grown on different continents; ginseng products sold in American health food stores may lack the active pharmacologic compound, ginsenosides (16). Ginseng, Different from Panax ginseng. Has undergone Russian or clinical trials in the USSR to treat stress, Siberian/ anemia, pneumonia, tuberculosis, and nausea Eleutherococcus secondary to cancer treatment. Given preventively, senticosis it has been reported to decrease the incidence of influenza and catarrh (16). goldenrod May cause allergic response in persons sensitive herbal tea to ragweed and its botanical family (43). golden seal Contains hydrastine (11). Folklore remedies include root/ treatment of dyspepsia and as an aid to stop post Hydrastis spp. partum bleeding (11). Toxicities include nausea and vomiting, paresthesia, CNS stimulation, respiratory failure and paralysis; has been fatal (11). groundsel/ Contains pyrrolizidine alkaloids which are Senecio recognized hepatotoxins, mutagens, carcinogens, longilobus and teratogens (29,93,94) and has been fatal (95). This herb has been misidentified as "gordolobo yerba" (Gnaphalium), a harmless herb, used by Mexican-Americans of the southwest; it can be purchased in herb stores in Arizona or picked wild (40). Toxicity caused by groundsel in children has resembled Reye syndrome (39). heliotrope/ Contains pyrrolizidine alkaloids, potent hepatotoxins Heliotropium (11,58,93,94). Sometimes contaminates grain fields, europaeum resulting in liver disease (87). Do not confuse with garden heliotrope (Valeriana officinalis) (10). horse chestnut/ Contains aesculin (coumarin glycoside) (11). Aesculus Folklore remedies include use as a sunscreen and hippacastanum antithrombin agent (11). Toxicities include nausea, vomiting, increased body temperature, hemolysis, and bleeding (11). Potentiates the anticoagulant action of coumarins (29). hydrangea/ Contains the glycoside, hydragin; saponin; cyanogene Hydrangea oils (11). Contains anticholinergics (43). Folklore paniculata remedies include use as a stimulant and carminative (11). Excessive amounts cause dizziness, chest pain, nausea, and vomiting (11). May have euphoric, stimulant or hallucinogenic effect (43) and is used as a marijuana substitute (8,11,96). Indian tobacco/ Contains lobeline piperidines, CNS stimulating Lobelia inflata alkaloids similar to nicotine, and anticholinergics (11,29). Folklore remedies include use as a stimulant and depressant (11), euphoriant (8), and emetic (97,98). Toxicities include sweating, vomiting, paralysis, hypothermia, coma, and death (43). Is smoked or used as tea (43). ink cap/Coprinus Contains disulfiram, used in aversion therapy atramentarius for alcoholics (29). jalap/Exagonium Contains the Jalapin resin, convolvulin, a potent purga, or cathartic (11). Side effects include watery Ipomoea jalapa or diarrhea and profuse fluid and electrolyte Ipomoea purga or imbalances secondary to hypercatharsis (11). Exagonium jalapa Can cause gastrointestinal symptoms if applied to an open wound. jimson weed/ Contains the alkaloid, atropine, hycoscyamine, and Datura scopolamine (10). Contains anticholinergics (43). stramonium Folklore remedies include treatment of asthma, dyspepsia; used as a hallucinogen (11), euphoriant, and stimulant (43). Toxicities include anticholinergic syndrome (11). Has been fatal (7,9). Is smoked or used as tea (11). juniper berries/ Herb has diuretic properties (43,75). Folklore Juniperis remedies include use as a diuretic, hallucinogen, communis euphoriant, and stimulant (43). Toxicity involves gastrointestinal irritability (43). karela/ Has a known hypoglycemic effect; may upset the Mamordica control of patients with diabetes mellitus (29,49). charantia Powdered karela is a component of Indian curries (29). laetrile Contains cyanogenetic glycoside found especially (vitamin B17)/ in the kernels of apricots, peaches and plums (29). Amygdalin Folklore remedies include treatment of cancer. Has been found ineffective in preventing or treating cancer and may produce cyanide poisoning (29). (See apple.) Licorice root/ Contains glycyrrhizin and glydyrrhizinic acid, which Glycyrrhiza are both metabolized to 18 beta-glycyrrhetic acid glabra by intestinal flora (45). Folklore remedies include treatment of dyspepsia and healing peptic ulcers (29). In large amounts, can cause sodium and water retention, severe hypokalemia, hypertension, heart failure, and cardiac arrest because of its aldosterone-like effects (29,43). lily of the Contains cardiac glycoside. May potentiate digitalis valley/ toxicity (29). Convallotoxin (acardiac glycoside) Convallaris is ten times more cardioactive than digitoxin (11). majalis Toxicities include nausea, vomiting, arrythmias, and dermatitis (11). mandrake/ A poisonous narcotic herb similar to nightshade, Mandragora which contains belladonna. Contains the alkaloids officinarum hyoscyamine, scopolamine, and mandragorine (10). Folklore uses include "suicide drug", hallucinogen, painkiller, sedative, and aphrodisiac (9,11). Toxicities include anticholinergic syndrome and death secondary to arrythmias (11). May be sold as ginseng. marigold Contains pyrethroids, which are used as insecticides herbal tea and have minimal toxicity in mammals. May cause allergic dermatitis and systematic allergic reactions in persons sensitive to ragweed and its botanical family. Large amounts may cause nausea, vomiting, and headache (43). mate tea or Folklore remedies include use as a stimulant and Paraguay tea/. diuretic (11). Mate has hallucinogenic, laxative, Ilex diuretic, and diaphoretic effects (11). Contains paraguariensis pyrrolizidine alkaloids and caffeine (11,29,43). Toxicities include caffeinism (insomnia, tachycardia, diarrhea, and anxiety), liver damage, and death (11,29,43,99). mistletoe Known hypertensive, diuretic and antispasmodic; may (leaves, stems, be cytotoxic (29). Folklore remedies include berries)/ treatment of infertility, asthma, epilepsy, cancer, Viscum album, and as an aphrodisiac (29,100). Contains biogenic Phoradendron amines and proteins that may cause gastroenteritis flavescens; (43). Certain species exhibit digitalis-like effects 1300 species of (21). Contains phytotoxins which produce effects this plant similar to those of cobra venom; contracture of exist (41). smooth muscle, depolarization of sketal muscle, resulting in vasoconstriction, shock and cardiac arrest (43). monkshood/ Contains aconitine alkaloids which first stimulate Aconitum then depress both central and peripheral$3Y·sory napellus nerves. Cardiac effects are similar to those of quinidine. Other toxic effects include tingling and burning sensations of lips and tongue, difficulty with swallowing and speech, blurred or double vision, restlessness, irritability, and confusion. One teaspoonful of the root may cause death by cardiac or respiratory failure within five minutes or as long as four days. This herb is widely recommended by herbalists to decrease blood pressure, to lower heart rate, and to treat fever and rheumatic pains (21). nutmeg tea/ Acts as a hallucinogen, abortifacient, and Myristica aphrodisiac. Folklore remedies include treatment fragrans of gastrointestinal disorders and rheumatism, and to promote menstruation (11). Small amounts can cause severe headache, cramps, nausea, and vomiting (43). Other effects include marginal decrease in basal body temperature, chest pain with a feeling of impending doom, headache, dizziness (11). Large amounts can cause liver damage and death (11). oleander/ Exhibits digitalis-like effects. May cause acute Oleander nerium glycoside poisoning with hyperkalemia and atrioventricular conduction defects leading to progressively higher grades of heart block. Immune crossover exists between oleander glycosides and those of digitalis (21). All parts of the plant are toxic; boiling or drying the plant does not inactive the toxins (38). Ingestions of a single leaf has been fatal (101). oleander, yellow Exhibits many of the effects as oleander (See Oleander). Thevetia peruviana peach or pear See apple. pannyroyal oil Known abortifacient (29,43,51). Folklore treatment (squawmint or of headaches and induction of diaphoresis, has a mosquito plant)/ calming effect, and can induce menses (9,22). Side Hedeoma effects include nausea, vomiting, hepatic and renal pulegioides or failure, coagulopathies; has been fatal (22). Marketed Mentha pulegium primarily as an insect repellent and herbal fragrance. peppermint tea/ Sometimes given to infants who have diarrhea as a Yerba buena temporary replacement for milk. The prolonged use of this tea in the absence of other oral intake can result in clinical water intoxication and subsequent hyponatremic seizures in infants because of inadequate sodium content (85). May cause menthol sensitivity (102). plum See apple. poke root/ Extracts contain phytomitogens and saponin glycosides. Phytolacca Folklore remedies include treatment of rheumatism; americana also used as an anti-parasitic and laxative. Berries are the least toxic part of the plant, but all parts are toxic. Boiling may or may not detoxify the plant (21). Ingestion may cause gastroenteritis. Absorption through skin abrasions may cause plasmacytosis (42,103). rhubarb leaves May cause renal toxicity possibly due to systemic absorption of soluble oxalate salts and their subsequent deposition in renal tissue (21). rosary pea Contains water-soluble toxins, which may cause (jequirity bean)/ intravascular hemolysis (21) Abrus precatorius rose hip tea High in vitamin C (7). Apparently safe in moderation (14). rue/ Known abortifacient (22,51). Can induce skin R. graveolens irritation (104). sage Known abortifacient (51). sarsaparilla/ Contains saponin glycosides. Recommended in the Smilax British Pharmaceutical Codex as a flavoring agent and to treat rheumatism, fevers, and skin conditions (15). Apparently safe in moderation (14). sassfras root/ Inhibits liver microsomal enzymes and therefore may Sassafras prolong the action of drugs (29). Folklore remedies officinale or include treatment of mumps, pneumonia, bronchitis, Sassafras head cold, "blood builder" (105); also used as a albidum carminative, antirheumatic, and flavoring agent (29). Contains a hepatotoxin and hepatocarcinogen in rats (43,106,107). Banned by the United States FDA under the Delany Clause (9). senna herbal Known anthraquinone cathartic (84). Folklore remedies tea (leaves, include laxative effect (7,43,75). Preparations have flowers, bark)/ caused severe diarrhea and have been fatal (43,84). Cassia acutifolia shave grass A diuretic tea. Contains nicotine and thiaminase. (horse tail or Has caused multiple undesirable effects in grazing bottle brush)/ animals, including thiamine deficiency with classical Equisetum arvense symptoms of beri-beri (43). snake root/ Contains reserpine and other alkaloids (43). Decreases Rauwolfia blood pressure. May cause edema, dizziness, coma, serpentina drowsiness, stupor, nasal congestion, diarrhea, pinpoint pupils, hypotension, decreased heart rate, and depression (11). Folklore remedies include use as a tranquilizer. Is ingested as a tea or smoked as a tobaco substitute (8). May be sold as ginseng. starch blockers/ Contains alpha-amylase inhibitor and hemagglutinins Extracted from (29). Lectins in the beans may bind and damage legumes as red intestinal microvilli (108). Side effects may include kidney bean nausea, vomiting, diarrhea, and abdominal pain. The (Phaseolus tablets have caused pancreatic enlargement in chickens vulgaris) (29). wild cherry Apparently safe in moderation (14). bark tea yarrow tea/ May produce allergic response in persons sensitive Millefolium to ragweed and its botanical family (43). Abortifacient in high doses (15). 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