辛×，男，53岁，干部。因眩晕耳鸣曾就诊于中医私人门诊，予开中药汤剂内服，同时，配以商陆15克，嘱其碾碎外敷于耳穴治疗。1995年11月7日，由他人取药，未加细问，遂将商陆与其他中药同煮。患者服药半小时后即出现头昏行立不支，神志时清时寐，言语渐见混乱，间有幻觉躁动， Xin ×, male, 53 years old, cadres. Due to dizziness and tinnitus, he had been treated in a private clinic of Chinese medicine and administered with Chinese herbal decoction orally. At the same time, 15 grams of pokeweed were added to the auricular point for treatment. On November 7, 1995, the medicine was taken by another person and, without careful questioning, the pokeweed was cooked with other Chinese medicines. Half an hour after the patient took the drug, dizziness could not be achieved, and when the mind was clear, the speech became confused and there was hallucination.