ADVERSE EVENTS INVOLVING CERTAIN CHINESE HERBAL MEDICINES

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ADVERSE EVENTS INVOLVING 
CERTAIN CHINESE HERBAL 
MEDICINES AND THE 
RESPONSE OF THE PROFESSION 
Richard Blackwell 
JOURNAL OF CHINESE MEDICINE NUMBER 50 JANUARY 1996 
 
Introduction 
As Chinese herbal medicine becomes increasingly widely 
practised in the West, reports of occasional adverse effects 
are appearing in the literature and questions are being 
asked about safety. If we are to retain the confidence and 
support of the public we must address these issues in a 
spirit of openness and with a willingness to learn the 
relevant lessons. 
In this article I present a wide-ranging, though not exhaustive, 
review of reports in the English-language literature 
of adverse events involving Chinese herbs. In particular, 
I have devoted attention to a series of cases of liver 
damage, including two fatalities, which have occurred in 
the UK in patients taking Chinese herbs for skin disease. 
This is the first time all this information has been gathered 
together in one place. 
It is important to remember that these adverse events are 
extremely unusual. Chinese herbal medicine is generally 
both safe and effective, and there are many patients who 
have experienced dramatic benefits to their health from 
treatment. All medicines are assessed in terms of their riskbenefit 
ratio and it should not be surprising that Chinese 
herbal medicines may also occasion rare but significant 
adverse events. The aim of this article is to assist a process 
of debate and development within the profession as we 
work to minimise what risks there are. 
Kidney Damage from Slimming Treatment 
in Belgium 
One of the most serious recent occurrences of toxicity 
involving Chinese herbs came to light between 1991 and 
1992 in Belgium, where a series of young women were 
admitted to hospitals suffering from renal failure1. Investigations 
initially discovered nine cases and revealed that 
they had all been taking medication for slimming from the 
same clinic, which was run by doctors not herbalists. The 
clinic had been giving slimming treatments for fifteen years 
without such problems, but in 1990 the composition of the 
slimming capsules was changed and two Chinese herbs 
were included. 
The slimming clinic claimed that the new formula contained: 
Cascara powder 20-150 mg 
Acetazolamide 25-45 mg 
Belladonna extract 1-2 mg 
Hou Po (Cortex Magnolia officinalis) 100-200 mg 
Han Fang Ji (Radix Stephania tetrandra) 100-200 mg1 
However, as discussed below, it is now certain that the 
second Chinese herb was not in fact Han Fang Ji but rather 
was either Guang Fang Ji (Radix Aristolochia Fangchi) or an 
unknown adulterant. 
In addition to the above formulation, most patients at the 
clinic were also prescribed a capsule containing the amphetamines 
fenfluramine and diethylproprion and the tranquilliser 
meprobamate, and were given intradermal injections 
of artichoke extract and euphyllin1. Many will consider 
such a regimen to constitute extremely dubious practice, 
and indeed the Faculties and Medical Board in Belgium 
have warned doctors not to prescribe slimming products 
composed of appetite inhibitors and diuretics2. Also, it will 
be immediately apparent to practitioners of Chinese herbal 
medicine that neither Hou Po nor Han Fang Ji are traditionally 
indicated for weight loss, and it is also obvious that they 
were not being prescribed on an individualised basis following 
a diagnosis according to the principles of Chinese 
medicine. 
It is worth noting that these patients were also put on a 
low calorie diet, which might have enhanced the effect of 
the medicines they were given. 
Since the first published report from Belgium, a total of 53 
cases of renal failure have now been reported2. The patients 
affected require kidney dialysis with a view to eventual 
transplantation. This is clearly an extremely serious situation 
and it is important to try to understand what went 
wrong. The cases of kidney damage did only occur once the 
Chinese herbs were added to the formula, so the toxic 
reaction must have involved them in some way. 
The first problem concerns the identity of the herbs 
involved. Chromatographic studies confirmed the presence 
of Hou Po in the capsules1. However, the same studies 
showed that the capsules did not contain tetrandrine, which 
is a major constituent of Han Fang Ji. These studies also 
isolated an unknown alkaloid which was not present in 
samples of Han Fang Ji. Finally, microscopic examination 
showed the presence of calcium oxalate in both the capsules 
and the importer’s sample of Han Fang Ji. Such crystals are 
not found in Han Fang Ji according to the Pharmacopoeia of 
the PRC3 but they are present in Guang Fang Ji (Radix 
Aristolochia Fangchi). The Chinese Medicinal Material 
Research Centre (CMMRC) in Hong Kong also studied 
samples of the herb supplied as Han Fang Ji by the exporter 
in Hong Kong and found aristolochic acid to be present4. 
The CMMRC later studied samples of the slimming capsules 
themselves and found them to contain aristolochic 
acids A and B5. 
One very definite possibility therefore is that the herb 
actually used in these capsules was not Han Fang Ji (Radix 
Stephania Tetrandra) but was in fact Guang Fang Ji (Radix 
Aristolochia Fangchi). This herb contains aristolochic acid, 
and this chemical in isolation can produce nephrotoxic 
reactions6. However, although the potential toxicity of Guang 
Fang Ji is known in Chinese medicine2 the whole herb is 
used in China without producing such toxicity. It has also 
been pointed out that 185 kg of the supposed Han Fang Ji 
was distributed to practitioners throughout Belgium, but 
only in this one slimming clinic did problems occur. We 
have already mentioned that at this clinic the herbs were not 
prescribed by properly trained practitioners of Chinese 
herbal medicine, nor in accordance with Chinese medical 
theories. Furthermore, instead of being combined with 
other herbs which may serve to minimise any potential for 
toxicity, in this case the herbs were instead combined with 
an extraordinary mixture of pharmaceutical drugs. 
It is certain then that the herb supposed to be Han Fang Ji 
was misidentified by the exporters in Hong Kong, by the 
importers in Belgium and by the doctors in the slimming 
clinic. It is very likely that the herb used was in fact Guang 
Fang Ji and that this herb’s potential for toxicity was massively 
amplified by its use in combination with other drugs, 
in patients for whom it was not indicated, and by practitioners 
untrained in its use. 
However, there is definitely some confusion here. The 
initial report of studies done in Belgium clearly states that 
the slimming capsules did not contain aristolochic acid1, 
and instead speaks of the presence of an unknown alkaloid. 
Only in the later report from the CMMRC is it claimed that 
the capsules did contain aristolochic acid2. There remains 
therefore a second distinct possibility, that the capsules 
contained neither Han Fang Ji nor Guang Fang Ji, but some 
unknown and severely nephrotoxic adulterant. 
There are several lessons to be drawn from this tragic 
series of cases of kidney damage: 
• Chinese herbs should only ever be prescribed by fully 
trained practitioners of Chinese herbal medicine, in accordance 
with a traditional individualised diagnosis. 
• When herbs with some potential for toxicity are mixed 
with modern drugs there may be previously unknown 
consequences, as a result of the potentiation of the toxicity 
of the herb by the metabolic and physiological effects of the 
drugs. This is clearly an important issue which requires 
further discussion and elaboration. Some important work 
has already been done on producing lists of herbs which are 
known to have some potential for toxicity7. 
• Proper identification and quality control of herbs by 
suppliers is a key ingredient in the safe practice of Chinese 
herbal medicine. 
Toxicity from Patent Medicines- 
Jin Bu Huan & Others 
Traditionally, patent medicines are based on traditional 
herbal formulas and are prescribed according to a traditional 
diagnosis. However, modern patents have moved 
away from the traditional formulations, and we have begun 
to see problems as a result. Reports from the USA in 1993 
and 1994 drew attention to toxicity problems with the 
patent medicine Jin Bu Huan Anodyne Tablets, made by 
Kwangsi Pai Se Pharmaceutical/Bose Drug Manufactory, 
Kwangsi, China8,9. Seven adults developed symptoms of 
hepatitis after taking Jin Bu Huan for between 7 and 52 
weeks. Symptoms and signs included fever, fatigue, nausea, 
pruritus, abdominal pain, jaundice and hepatomegaly. 
Liver function tests and liver biopsy results confirmed 
acute hepatitis and were consistent with a drug reaction. 
Two patients later recommenced the use of Jin Bu Huan and 
both experienced a rapid return of the symptoms of hepatitis. 
All seven patients made gradual but complete recoveries 
on ceasing the use of the patent medicine. 
The precise mechanism of the hepatitis is not entirely 
certain. The abrupt reappearance of symptoms in the patients 
who recommenced taking the tablets suggests a hypersensitivity 
reaction, and the liver biopsy showed eosinophilia 
in two cases, which also suggests an allergic mechanism. 
An immunoallergic mechanism therefore seems most 
likely9. However, there are also some suggestions of a direct 
hepatotoxic effect9. 
The package insert for these tablets recommended their 
use for pain relief or insomnia and claimed that the ingredients 
were 70% starch and 30% levo-alkaloid from Polygala 
chinensis (presumably this refers to Yuan Zhi - Radix 
Polygalae Tenuifoliae). However, analysis of the tablets 
showed that they contained 36% of levotetrahydropalmatine. 
This alkaloid is not found in plants of 
the genus Polygala, but it is found in the genera Stephania 
and Corydalis9. Almost certainly, the alkaloid in these 
tablets was actually extracted from Yan Hu Suo (Rhizoma 
Corydalis Yanhusuo). This herb is traditionally known to 
alleviate pain and we know there have been studies on the 
hypnotic and sedative effects of tetrahydropalmatine extracted 
from it22 . This herb is also known as Yuan Hu, hence 
presumably the confusion with Yuan Zhi (although the 
Chinese characters are different). 
Several points are evident here: 
• The labelling of this product in English was inaccurate. In 
addition, the incorrect weight of the active ingredient suggests 
poor quality control by the manufacturers. 
• Traditionally, Chinese herbs are always used in combination 
with other herbs and prescribed in order to treat the 
underlying disharmony causing the symptoms. This tablet 
was based on only a single herb and indicated purely for 
symptomatic relief. 
• What is more, these tablets did not even contain the whole 
single herb, but a single chemical extracted from a herb. 
This is not the practice of traditional medicine, rather it 
represents a modern pharmaceutical approach. It is debatable 
whether this product could really be described as 
“herbal” at all - it is more akin to a novel and unlicensed 
drug! The chemistry of whole herbs involves complex 
interactions among their constituents which are poorly 
understood10, and there is evidence that whole herbs are 
significantly less toxic than single “active ingredients” isolated 
from them11,12. Certainly, there are no reports in the 
literature of any problems with the whole herb Yan Hu Suo. 
Also in the USA, in three separate incidents, children 
aged two and a half years and 13- and 23- months took 
unintentional overdoses of Jin Bu Huan, amounting to 17, 60 
and 7 tablets respectively. Each of these children became 
seriously ill, with rapid onset of life-threatening bradycardia 
and central nervous system and respiratory depression13. 
Fortunately each child made a full recovery. These 
cases underline the additional dangers from concentrated 
single chemical extracts from herbs. 
There have also been reports from Hong Kong and the 
USA of patent medicines containing paracetamol, aspirin, 
antihistamines, theophylline, bromhexine and synthetic 
corticosteroids, and from Hong Kong, the USA and Australia 
of other patent medicines containing cadmium, lead 
and arsenic1. In Malaysia, a woman developed kidney 
damage after taking a patent medicine which was found to 
contain phenylbutazone14. In the UK, skin creams for eczema 
have been found to contain corticosteroids and a 
potent antibiotic15,16,17. 
What is evident in these cases is that most of these 
problems are not being caused by traditional patent medicines 
but by modern formulations containing a single chemical 
only or combining Chinese herbs with Western drugs. 
The advice given to its members by the Register of Chinese 
Herbal Medicine (RCHM) in the UK is relevant here: 
Never prescribe a patent medicine unless you know all its 
ingredients. Avoid all patents containing Western 
medicines (it is in any case illegal to prescribe many of 
these unless you are a registered medical practitioner). 
Patents with added Western drugs can often be identified 
by the words Fu Fang or Qiang Li before the name. Avoid 
all patents containing heavy metals (they are toxic and 
illegal). Use reputable suppliers. Suppliers must be 
encouraged to adopt careful quality control measures15. 
Toxic Effects from Adulterants or 
Erroneous Substitutes 
In 1991 a case was reported from Hong Kong of encephalopathy 
and neuropathy following ingestion of a decoction 
supposedly prepared from Long Dan Cao (Radix Gentiana 
longdancao). Investigation showed that the toxicity was in 
fact due to adulteration of the herb by the supplier in 
mainland China with the roots of Podophyllum emodi, 
which contained podophyllotoxin18. Similarly, the Chinese 
Medicinal Material Research Centre (CMMRC) in Hong 
Kong investigated a case of serious vomiting and abdominal 
pain in Kuala Lumpur and a case of serious vomiting 
and headache from Taipei. Both people had taken decoctions 
supposedly containing Wei Ling Xian (Radix Clematis). 
Investigation revealed that the importers in Kuala Lumpur 
and Taipei had been persuaded to accept a new source of 
Wei Ling Xian and had not realised that the herb supplied 
was actually a toxic adulterant, which again proved to be 
Podophyllum emodi5. 
The CMMRC also investigated four cases of drowsiness 
and confusion affecting four women in Hong Kong, all of 
whom had obtained their prescriptions from the same herb 
shop. In each case the prescription included Ling Xiao Hua 
(Flos Campis grandiflora or C. radicans). In Hong Kong and 
southern China this herb is commonly replaced with Pao 
Tung Hua (Flos Paulownia fortunei or P. tomentosa). However, 
in these cases the retailer at the herb shop had mistakenly 
used Yang Jin Hua (Datura metel), which contains 
atropine and scopolamine and is known to cause symptoms 
such as confusion at the doses used5. 
In the USA, a man took a traditional herbal prescription 
containing 36 ingredients. He become ill with abdominal 
colic, muscle pain and fatigue, was hospitalised for 3 weeks, 
and was eventually diagnosed as suffering from acute 
intermittent porphyria. The cause was traced to lead poisoning 
due to contamination of the Hai Ge Fen (Concha 
Cyclinae Sinensis, clam shell) in his prescription19. 
Expensive herbs such as Ren Shen (Panax ginseng) may 
particularly tempt fraudulent substitution. In the 1970s, 
Ginseng preparations bought in the USA were found to 
contain Mandragora officinarum (toxic component scopolamine), 
Rauwolfia serpentia (toxic component reserpine) 
and Cola species41. There have also been other reports of 
substitution of Ren Shen20, including a famous case involving 
Linford Christie at the Seoul Olympics where what was 
supposed to be Ren Shen was found to contain ephedrine. 
All these cases again point to the crucial need for good 
identification checks and quality control by suppliers. A 
minimum requirement would probably be the examination 
by microscopy and chromatography of each batch of herbs 
by trained pharmacognocists. 
Problems with Herbs of Known Toxicity 
A handful of the hundreds of herbs commonly used in 
Chinese herbal medicine have always been known to be 
potentially toxic, but they have continued to be used with 
care because of their therapeutic value. The most important 
examples are the aconites. 
A review of reports of toxicity in Hong Kong21 showed 
that most of the cases of serious poisoning were due to the 
use of Cao Wu (Radix Aconitum kusnezoffi) and Chuan Wu 
(Radix Aconitum carmichaeli - the main root). These herbs 
contain highly toxic alkaloids, including aconitine, which 
activate sodium channels and over-stimulate cell membranes. 
Side effects are neurological, cardiovascular and/ 
or gastro-intestinal and death can occur due to cardiovascular 
collapse or ventricular arrhythmia. 
Both of these herbs are traditionally known to be very 
toxic, and Chinese herbal pharmacopoeias warn of this. 
Nonetheless, in some of the Hong Kong cases quite high 
doses of 7-11g had been prescribed. This suggests a lack of 
appropriate caution to say the least and raises concerns over 
the training and competence of practitioners, particularly 
since herbal medicine is unregulated in Hong Kong. Even 
when the indications and dosage are correct, problems can 
arise. The roots may contain variable amounts of toxic 
components and patients’ sensitivity may also vary22. Furthermore, 
patients are relied upon to boil these herbs for a 
long time to reduce their toxicity, and these instructions 
may not always be followed correctly. More complex is the 
situation relating to Fu Zi (Radix Lateralis Aconiti 
Carmichaeli Praeparata - the processed accessory roots). 
This herb is less toxic than the main root and is preprocessed 
to further reduce its toxicity (the unprocessed 
form is called Sheng Fu Zi and is rarely used). Herbalists find 
this herb extremely useful - it is warming and drying and it 
tonifies yang. However, there have been some reports of 
problems with Fu Zi in Hong Kong23. 
In the UK, although the legal situation is somewhat 
ambiguous, it appears that all forms of aconite are effectively 
banned for internal use. It can certainly be argued that 
herbs with such clear and established toxicity as Cao Wu and 
Chuan Wu should be restricted to use only when patients are 
under close medical supervision, probably as in-patients. 
This would permit the rapid detection of adverse reactions, 
which can then be successfully treated with atropine. In the 
case of Fu Zi, one could argue for its use being allowed at 
low doses by qualified and regulated practitioners, and 
with clear advice to patients about the need to pre-boil Fu Zi 
to reduce its toxicity even further. 
Toxic Effects from Rare Herbs - Hong Kong 
The herbs Yang Jin Hua (Datura metel) and Nao Yang Hua 
(Flos Rhododendri mollis) contain scopolamine, hyoscamine 
and atropine and they have been reported as the cause of 
cases of anticholinergic poisoning in Hong Kong2l. These 
herbs are rarely used by practitioners of Chinese herbal 
medicine in Europe, although the former can be obtained 
from some suppliers7. The related herb Datura stremonium 
is used by Western herbalists and in the UK this is allowed 
by the 1968 Medicines Act within a restricted dosage range. 
It would seem sensible for Yang Jin Hua (Datura metel) and 
Nao Yang Hua (Flos Rhododendri mollis) to also be restricted 
to use at low doses by qualified and regulated 
practitioners. 
Cases of Liver Damage in Skin 
Disease Patients 
In the UK there has been a great surge in the popularity of 
Chinese herbal treatment for skin conditions. This followed 
considerable media interest, stimulated by two clinical 
trials which showed the value of Chinese herbs in the 
treatment of eczema24,25. 
There have now been several cases in the UK where 
patients have become clinically ill with liver problems after 
taking Chinese herbs for the treatment of skin conditions, 
and a similar case has been reported from New Zealand. 
Two of these patients have died. 
The details of a number of these cases have now been 
published separately. It has often proved difficult to obtain 
much information about the herbs prescribed and details of 
the Chinese diagnosis have never been obtained, but there 
are a number of cases where details are now available of the 
prescriptions given. Unfortunately it is very difficult to 
identify the species, given a dried specimen of only one part 
of the plant, and to compound the difficulty the identification 
of the herbs in some of these cases was done by 
botanists, not by specialists in Chinese herbs. As a result 
some of these prescriptions may contain errors in identification. 
Nonetheless, there is enough information here to 
allow us to draw some clear conclusions. These are presented 
in the discussion section after the individual cases. 
Case 1 
This is the first fatality to have occurred in the UK which 
was linked to Chinese herbs. A letter from the National 
Poisons Unit reporting this case was published in the Lancet 
in 199226. 
The patient, a 28 year old woman, developed jaundice 
after taking Chinese herbs for several months and was 
admitted to hospital with hepatitis. The symptoms resolved 
satisfactorily. Six months later the patient began 
taking Chinese herbs again. Two or three weeks after this 
she was again admitted with jaundice, and tragically died 
of acute liver failure. A post-mortem revealed total necrosis 
of the liver. 
The hospital was able to exclude the more common 
infectious causes, e.g. hepatitis A and B. There was no 
history of exposure to hepatotoxic chemicals, and the only 
Western drugs being taken prior to the jaundice were 
antacids. There were no traces of hepatotoxic drugs in the 
urine, nor of heavy metals in the blood or urine. 
The Lancet letter also gave details of the herbal prescription 
which this patient supposedly was taking. However, 
after further investigations by Dr. David Atherton it has 
been discovered that the prescription given to the NPU was 
in fact for a different patient of the same name27! The NPU 
analysed their sample for aflatoxins (toxins from mould on 
the herbs) and for pyrrolizidine alkaloids, and found none, 
but clearly this particular result is meaningless since the 
wrong sample was tested. The possibility of contamination 
or adulteration of the herbs therefore remains in this case. 
Dr. Atherton has now provided us with details of the 
prescription which was actually taken by this woman 
throughout her treatment27: 
Pinyin Pharmaceutical Botanical Dosage 
name name name 
Bai Ji Li Fructus Tribuli Tribulus terrestris 3 chien (9g) 
Terrestris 
Jing Jie Herba seu Flos Schizonepeta 1 chien (3g) 
Schizonepetae tenuifolia 
Tenuifoliae 
Yin Chen Hao Herba Artemisia Artemisia scopariaa 3 chien (9g) 
Yinchenhao 
Sheng Di Radix Rehmanniae Rehmannia 3 chien (9g) 
Huang Glutinosae (not glutinosa 
pre-cooked) 
Mu Dan Pi Cortex Moutan Paeonia 3 chien (9g) 
Radicis suffructicosa 
Bai Xian Pi Cortex Dictamni Dictamnus 3 chien (9g) 
Dasycarpi Radicis dasycarpus 
Gan Cao Radix Glycyrrhizae Glycyrrhiza 1.5 chien 
Uralensis uralensis (4.5g) 
Dan Zhu Ye Herba Lophatheri Lophatherum 2 chien (6g) 
Gracilis gracile 
Mu Tong Caulis Akebiaeb Clematis armandiib 2 chien (6g) 
a This is the species I was given for this herb. However, both Artemisia 
scoparia and Artemisia capillaris are used and it is not entirely clear 
which was present here. 
b The pharmaceutical name now used is Caulis Mutong. Old 
pharmacopoeias most often list Akebia trifoliata and Akebia quinata as 
this herb. However, in modern China either Clematis armandi, Clematis 
montana, or Aristolochia manshuriensis may be used22. 
The above is based on the practitioner’s written prescription, 
which gave the herb names in Chinese. 
In response to this fatality, and a number of other early 
reports of high blood levels of liver enzymes in patients 
taking herbs for eczema and psoriasis28,29, the RCHM made 
the following recommendations to its members in 1992 and 
1993l5,16: 
• that all patients with a history of liver or kidney disease in 
the last five years should not be treated without regular 
blood-testing to monitor liver and kidney function. 
• that practitioners should carefully monitor their patients 
and be vigilant for any early indications of liver damage. 
• that practitioners should take care with dosage in patients 
with skin diseases. A total prescription weight of 35 g/day 
(or 0.5 g/kg of body weight) was recommended. 
• that practitioners should consider regular blood-testing 
of all patients with skin diseases. This last recommendation 
was only taken up by a handful of practitioners. Many 
practitioners were reluctant to import such a non-traditional 
measure into the practice of Chinese medicine, and 
there were also obstacles of cost and practicality. 
Case 2 
This case came to the attention of the RCHM Council in May 
1994, when we were approached by a woman whose sister 
had been admitted to hospital with jaundice whilst taking 
a course of Chinese herbs. The hospital had investigated 
other possible causes for the jaundice and concluded that 
the herbs were probably responsible. The woman approached 
the RCHM because the practitioner claimed to be 
“a registered practitioner”. However, the practitioner turned 
out not to be a member of the RCHM. The practitioner was 
initially reluctant to give any details of the prescription, but 
after the patient’s sister threatened legal action she divulged 
the following details. The dosages are not known. 
Pinyin Pharmaceutical Botanical 
name name name 
Jing Jie Herba seu Flos Schizonepeta tenuifolia 
Schizonepetae 
Tenuifoliae 
Fang Feng Radix Ledebouriellae Ledebouriella divaricataa 
Divaricatae 
Huang Qin Radix Scutellariae Scutellaria baicalensis 
Baicalensis 
Ban Lan Gen Radix Isatidis seu Baphicacanthus cusia, lsatidis 
Baphicacanthi tinctoria or I. indigotica 
Mu Dan Pi Cortex Moutan Radicis Paeonia suffructicosa 
Zi Su Ye Folium Perillae Perilla frutescens 
Frutescentis 
Mai Men Tuber Ophiopogonis Ophiopogon japonicus 
Dong Japonici 
Gou Qi Zi Fructus Lycii Lycium barbarum or 
L. chinense 
Bai Shao Radix Paeoniae Paeonia lactiflora 
Lactiflorae 
Shan Yao Radix Dioscoreae Dioscorea opposita 
Oppositae 
Mu Tong Caulis Mutong Aristolochia manshuriensis, 
Clematis armandi, or 
C. montanab 
Fu Ling Sclerotium Poriae Poria cocos 
Cocos 
Chen Pi Pericarpium Citri Citrus reticulata 
Reticulatae 
Bai Xian Pi Cortex Dictamni Dictamnus dasycarpus 
Dasycarpi Radicis 
Gan Cao Radix Glycyrrhizae Glycyrrhiza uralensis 
Uralensis 
Bai Jiang Can Bombyx Batryticatus Bombyx mori infected with 
Beauveria bassiana 
a Also known as Ledebouriella seseloides or Saposhnikovia divaricata. 
b Old pharmacopoeias most often list Akebia trifoliata and Akebia 
quinata as this herb. However, in modern China either Clematis 
armandi, Clematis montana, or Aristolochia manshuriensis may be 
used22. 
The above is based on the practitioner’s written prescription, 
which gave the herb names in Chinese. 
The information available on this case is rather limited, 
but it is included here to make the information available to 
practitioners, who may particularly wish to study all the 
prescriptions which may have been involved in adverse 
events. 
Case 3 
This case, reported by Kane et al.30, was of a 31 year old 
white woman who presented to her general practitioner in 
September 1991 complaining of loss of appetite, nausea and 
fatigue. She had had dark urine and yellow sclerae for the 
previous 24 hours. Examination revealed jaundice and an 
enlarged liver. Blood tests revealed raised levels of alanine 
transaminase, alkaline phosphatase and bilirubin, confirming 
liver damage. 
The patient was not taking regular prescribed drugs, 
drank hardly any alcohol, and had had no recent injections 
or blood transfusions. The provisional diagnosis was viral 
hepatitis, but blood tests for hepatitis A were negative. 
Three months later she was tested for hepatitis B and C and 
for auto-antibodies and these tests were also negative. 
The patient’ s liver function returned to normal over the 
next eight weeks, but after another six weeks she again 
complained of malaise, itching and dark urine. She had 
mild jaundice, and blood levels of alanine transaminase 
and alkaline phosphatase were again raised. 
This time the patient was carefully questioned and she 
revealed that before the first episode she had taken Chinese 
herbs for her psoriasis. The herbs were taken daily for two 
months as a decoction. She had begun taking the herbs 
again just three days before the second episode of jaundice. 
She stopped the herbs again and her liver function returned 
to normal after eight weeks. She remained well during 18 
months follow up. 
In this case, the recurrence of both symptoms and biochemical 
evidence of liver damage shortly after resuming 
the herbs strongly incriminates the herbs as the cause of the 
liver damage. 
The herbs showed no evidence of contamination by 
heavy metals or fungi. The prescription was examined and 
analysed at the Dept. of Pharmacognosy in the School of 
Pharmacy of the University of London. They identified the 
herbs by their Latin botanical names as: 
Pinyin Pharmaceutical Botanical 
name name name 
Bai Xian Pi Cortex Dictamni Dictamnus dasycarpus 
Dasycarpi Radicis 
Mu Dan Pi Cortex Moutan Radicis Paeonia suffructicosa 
Sheng Di Radix Rehmanniae Rehmannia glutinosa 
Huang Glutinosae 
(not pre-cooked) 
Bai Hua She Herba Hedyotidis Hedyotis diffusaa 
She Cao Diffusae 
Shan Dou Gen Radix Sophorae Sophora subprostatab 
Subprostatae 
Long Dan Cao Radix Gentianae Gentiana scabra 
Longdancao 
Tu Fu Ling Rhizoma Smilacis Smilax glabra 
Glabrae 
Zao Xiuc Paris polyphylla Paris polyphylla 
a Also known as Oldenlandia diffusa. 
b There are two types of this herb: the southern type is known as Guang 
Dou Gen (Sophora subprostata, also known as S. tonkinensis) and is 
considered to be toxic, the northern type is known as Bei Dou Gen 
(Menispermum dahuricum) and is mostly recommended for use since 
it is without adverse effects31. 
c Also known as Qi Ye Yi Zhi Hua .This herb is traditionally considered 
to be slightly toxic31. 
In this case it is clear that two herbs in the prescription had 
some known potential for toxicity. 
Case 4 
This case was also reported by Kane et al.30 A 61 year old 
Chinese woman living in the UK presented with nausea, 
malaise, weight loss, dark urine and jaundice. Blood tests 
showed raised levels of aspartate transaminase, alkaline 
phosphatase and bilirubin, confirming liver damage. She 
had no known history of exposure to hepatitis viruses or 
other toxins, she drank very little alcohol, and her only 
prescribed drugs had been a short course of terfenadine. 
Blood tests for hepatitis A, B and C were negative. She had 
been taking Chinese herbs for her eczema for 11 months. 
This patient was advised to stop the herbal treatment and 
her symptoms disappeared within days. Her liver function 
returned to normal within three months. 
The herbs were identified by the Dept. of Pharmacognosy 
in the School of Pharmacy 
Pinyin Pharmaceutical Botanical 
name name name 
Bai Xian Pi Cortex Dictamni Dictamnus dasycarpus 
Dasycarpi Radicis 
Mu Dan Pi Cortex Moutan Radicis Paeonia suffructicosa 
Wu Wei Zi Fructus Schisandrae Schisandra chinensis 
Chinensis 
Dang Gui Radix Angelicae Sinensis Angelica sinensis 
Chai Hu Radix Bupleuri Bupleurum chinense 
Huang Bai Cortex Phellodendri Phellodendron chinense 
Bai Ji Li Fructus Tribuli Terrestris Tribulus terrestris 
Jing Jie Herba seu Flos Schizonepeta tenuifolia 
Schizonepetae Tenuifoliae 
Chan Tui Periostracum Cicadae Cryptotympana 
pustulataa 
Fang Feng Radix Ledebouriellae Saposhnikovia 
Divaricatae divaricatab 
a Also known as Cryptotympana atrata. 
b Also known as Ledebouriella divaricata or L. seseloides. 
In this case it seems extraordinary that this woman had 
been taking Chinese herbs for 11 months without any 
apparent problems for most of this time. This raises several 
important questions: 
• was the prescription changed in the last few weeks? We 
only have information about the prescription she was taking 
when she became ill. If we knew that a herb had recently 
been added, then that herb would be strongly suspect. 
• had there recently been a delivery of a new batch of one 
of the herbs? If so, there may have been problems with the 
correct identification and preparation of the herbs in the 
new batch. This would support the suggestion that good 
quality control is a key issue. 
• had some other factor intervened? We do not know 
whether there had been changes in the patient’s diet, or 
whether she had been stressed or over-tired etc. 
Case 5 
Another case of severe hepatitis was reported in 1994 in the 
New Zealand Medical Journal32. A 37 year old woman 
presented to her doctor with general malaise. Blood tests 
showed raised levels of alkaline phosphatase, GGT, ALT 
and AST, all consistent with liver damage. Over the next 
two weeks her liver function deteriorated and she was 
admitted to hospital. The blood levels of liver enzymes rose 
to very high levels before beginning to gradually decline. 
Her liver function finally returned to normal seven weeks 
after the initial presentation. Tests for hepatitis A, B and C 
were all negative. She had antibodies to Epstein-Barr virus 
showing that she had been exposed to the virus in the past 
and was now immune. Tests for other infective agents were 
negative. Liver biopsy revealed features most consistent 
with toxic or drug induced liver damage. 
Thirteen days before presenting to her doctor, this patient 
had begun treatment with Chinese herbs for her psoriasis. 
She drank alcohol rarely and had no history of intravenous 
injection, blood transfusion or recent overseas travel. Interestingly, 
she had had a routine blood test three months 
previously and at this time the liver function tests were 
normal. 
The herbs which were prescribed by the herbal practitioner 
were as follows. With the exception of Jianqu they are 
given by their Latin pharmaceutical or botanical names in 
the published report. 
Pinyin Pharmaceutical Botanical 
name name name 
Qing Dai Indigo Pulverata Levisa Processed from: Isatis 
tinctoria, I. indigota, 
Baphicacanthus cusia, 
Polygonum tinctorium or 
Clerodendon 
cyrtophylluma 
Dan Shen Radix Salviae Salvia miltiorrhiza 
Miltiorrhizae 
Wu Wei Zi Fructus Schisandrae Schisandra chinensis 
Chinensis 
Bai Zhi Radix Angelicae Angelica dahurica 
Dahuricae 
Pu Gong Herba Taraxaci Mongolici Taraxacum mongolicum 
Ying cum Radice 
Tu Fu Ling Rhizoma Smilacis Glabrae Smilax glabra 
Bai Xian Pi Cortex Dictamni Dictamnus dasycarpus 
Dasycarpi Radicis 
Wu Mei Fructus Pruni Mume Prunus mume 
Jian Qub Massa Fermentata b 
a The published report names this herb as Indigo naturalis. It is not 
entirely clear whether this was Da Qing Ye (Folium Daqingye), i.e. the 
unprocessed leaf, or Qing Dai, which is woad - a powder made from the 
leaf. 
b More commonly known as Shen Qu, this is a non-standardised 
fermented leaven including various herbs such as Qing Hao (Herba 
Atermisiae Annuae), Xing Ren (Semen Pruni Armeniacae), Cang Er Zi 
(Fructus Xanthii Sibirici) and Chi Xiao Dao (Semen Phaseoli Calcarati)22,23. 
Case 6 
This case is the second fatality to have occurred in the UK. 
It was reported in a letter to the British Medical Journal in 
199533. A 32 year old man was admitted to hospital with 
fulminant liver failure, otherwise known as massive hepatic 
necrosis. Within a week of presentation he was deeply 
jaundiced and went into coma. Liver transplantation was 
attempted but did not succeed in saving the patient’s life. 
Tests were unable to identify any viral, immunological or 
metabolic cause of liver failure. Four weeks before presentation 
the patient had begun treatment with Chinese herbs 
for lipomas. 
The practitioner’s notes reveal that the patient was born 
in India and had a history of jaundice as a child. Apparently 
he had also had jaundice in his early twenties. He had been 
prescribed ten packets of herbs and he had taken one packet 
of herbs a day as instructed. Throughout these ten days he 
had felt ill and had diarrhoea but he had persisted with 
taking the herbs. After three weeks he was still unwell and 
began to become jaundiced. At this point he went to his 
doctor and was hospitalised. 
One of the tragic features of this case is that had this 
patient stopped the herbs as soon as the diarrhoea began, he 
would probably still be alive. His death could almost certainly 
have been prevented if he had been given written and 
verbal instructions to stop taking the herbs and contact the 
practitioner if he should develop any symptoms like those 
of a cold or flu, or any digestive disturbance such as nausea 
or diarrhoea. 
The following is the herbal prescription as taken from the 
practitioner's notes, with the herbs given by their Chinese 
names. However, it should be said that the notes are scanty 
and not completely clear so we can not be entirely sure of the 
prescription given. 
Pinyin Pharmaceutical Botanical Dosage 
name name name 
Bai Xian Pi Cortex Dictamni Dictamnus dasycarpus 9g 
Dasycarpi Radicis 
Shan Zha Fructus Crataegi Crataegus pinnatifida 9g 
or C. cuneata 
Zhi Ke Fructus Citri Citrus aurantium 4.5g 
Aurantii 
Tian Hua Fen Radix Tricho- Trichosanthes kirilowii 9g 
santhis Kirilowii 
Chen Pi Pericarpium Citri Citrus reticulata 3g 
Reticulatae 
Chi Shao Yao Radix Paeoniae Paeonia veitchii or P. 6g 
Rubrae lactiflora 
Dang Gui Wei Radix Angelicae Angelica sinensis 9g 
Sinensis 
Fang Feng Radix Ledebouriella 9g 
Ledebouriellae divaricataa 
Divaricatae 
Bai Zhi Radix Angelicae Angelica dahurica 6g 
Dahuricae 
Fu Ling Sclerotium Poriae Poria cocos 12g 
Cocos 
Bai Zhu Rhizoma Atractylodes 9g 
Atractylodis macrocephala 
Macrocephalae 
Gan Cao Radix Glycyrrhizae Glycyrrhiza uralensis 6g 
Uralensis 
a Also known as Ledebouriella seseloides or Saposhnikovia divaricata. 
The School of Pharmacy in the University of London is 
reported to have consulted a Chinese expert in pharmacognosy 
about the herbs in this prescription and they concluded 
that none of the herbs appears to be directly hepatotoxic, 
which probably points to an immunoallergic mechanism. 
Further clarification of this report is required. 
Discussion of cases 
In many of these cases all the other obvious possible causes 
of liver damage can be confidently excluded, and it is clear 
that something about the herbal treatment is the cause of the 
adverse reactions. Adulteration or misidentification of herbs 
seems an unlikely explanation since the cases are spread 
over several years and involved different practitioners, and 
the herbs have been examined and identified in several 
cases. The fact that the majority of these cases occurred in 
the UK may be due to the large number of patients with skin 
diseases being treated in this country. If we conclude then 
that something about the herbal treatment is the cause of the 
adverse reactions, this raises two important questions: 
1. are these adverse reactions being caused by a single herb 
or by several? 
2. is the herb or herbs directly toxic to liver cells, or is this an 
immunoallergic or idiosyncratic reaction? 
A careful examination of these prescriptions shows that 
one herb is common to them all, namely Bai Xian Pi (Cortex 
Dictamni Dasycarpi Radicis), and it has been suggested that 
this herb may be the cause of the hepatitis33. Since this herb 
is mostly used to treat skin disease, this would explain why 
these cases of liver damage have been confined to patients 
being treated for skin disease. 
However, there are no reports in the literature of Bai Xian 
Pi being directly hepatotoxic, and this includes a recently 
published Chinese language pharmacopoeia which gives 
details of animal research and clinical studies on this herb34. 
So if Bai Xian Pi is involved, the mechanism would appear 
most likely to be a rare allergic hypersensitivity and not 
direct toxicity. 
We should note that in two of the above cases (Cases 1 and 
3), patients experienced a much more rapid adverse reaction 
when they re-started the herbs a second time. This is 
also strongly suggestive of an allergic mechanism. 
In two controlled clinical trials examining the benefits of 
Chinese herbs in the treatment of eczema24 25, all participants 
were given liver function tests and there were no 
reports of problems. Bai Xian Pi is one of the ten herbs 
contained in the standardised herbal remedy Zemaphyte 
which was used in these studies. However, the relatively 
small numbers involved in these trials make it difficult to 
draw firm conclusions, and further clinical research is 
clearly needed. 
It has been pointed out by practitioners that probably as 
many as 70-80% of prescriptions for skin disease contain Bai 
Xian Pi. It is possible that this is the reason why this herb 
occurs in each of the above prescriptions, and that the 
causes of the hypersensitivity reaction are more complex. 
Certainly, it has been suggested that several herbs can be 
involved in immunoallergic reactions35, and patients with 
atopic conditions such as eczema or with a history of liver 
disease might be particularly vulnerable to such reactions. 
In case 3 in particular, it is clear that other herbs in the 
prescription could have been involved in the toxic effect. 
We should therefore be cautious about attributing all these 
cases of hepatitis to a single herb when there are so many 
other variables. 
In conclusion, it appears almost certain that the hepatotoxic 
effect which occurred in these cases was of an 
immunoallergic type and was not due to a herb which is 
directly hepatotoxic. This has two major implications: firstly, 
that the toxic effect is probably not dose-related, and secondly 
that these sorts of herbal prescriptions are only 
potentially toxic to certain individuals who have an allergylike 
sensitivity to them, and do not do any harm at all to the 
vast majority of people. The problem is to devise strategies 
to protect those individuals who do have this immunological 
sensitivity. 
Chinese herbs are widely used in the UK for the treatment 
of eczema and psoriasis, so it is clear that the incidence of 
adverse events is quite low, probably affecting one person 
in tens of thousands. Most individuals definitely appear to 
tolerate the herbs without apparent harm, and the clinical 
trial results support this conclusion. The problem is that 
when the adverse reaction does occur it can clearly be lifethreatening. 
No-one fully understands the mechanisms of 
such idiosyncratic reactions, which are also known to occur 
with some drugs. It is generally suspected that there can be 
a genetic susceptibility which makes some individuals 
vulnerable. 
It is noteworthy that both of the fatalities involved people 
of Indian origin. This may indicate a genetic susceptibility, 
or it may be that both these individuals already had compromised 
liver function, perhaps as a result of infectious 
hepatitis earlier in life. In any case, it is clear that people 
with poor liver function will be particularly at risk. 
However, great caution is undoubtedly needed with all 
patients. In Case 5 above the woman is known to have had 
perfectly fine liver function three months previously, but 
she nonetheless developed severe hepatitis and was hospitalised 
after taking the herbs for only 13 days. 
In the light of the above, the RCHM has taken the view 
that whatever the precise mechanisms and whether or not 
a single herb is the cause, the first priority is to protect future 
patients. The second fatality in particular (Case 6) could 
almost certainly have been prevented by good practice, and 
the RCHM has emphasised this by issuing the following 
updated guidelines36: 
• A detailed case history is essential to determine whether 
there is any history of jaundice or hepatitis. Where there is 
such a history, patients must be closely monitored and this 
must include liver function tests. 
• Although hypersensitivity reactions are not directly dosedependent, 
continuing caution with dosage is advised for 
the time being. 
• Patients should be carefully monitored, and in particular 
practitioners should be alert to any early signs of liver 
damage37. 
• All patients should be given written guidelines warning 
them to stop taking their herbal medicine and immediately 
contact their practitioner if they experience symptoms such 
as nausea, vomiting, diarrhoea, flu-like symptoms, and 
hypochondriac tenderness. 
The practitioners involved in the six cases reported above 
appear to have been fully trained, but five of the six were not 
members of the RCHM. In the one case where the practitioner 
was a member of the RCHM, the Register’s guidelines 
had not been followed. Although the numbers are too 
small to allow firm conclusions, this may reflect the fact that 
a good level of training is not in itself enough to ensure safe 
practice, but must be complemented with membership of a 
professional body with Codes of Ethics and Practice, complaints 
procedures, and channels of regular communication 
to keep members informed. 
A possible addition to the RCHM’ s guidelines would be 
for practitioners to take care to closely monitor patients who 
consume a lot of alcohol, and this should probably include 
liver function tests. Practitioners should also be aware that 
immunoallergic effects are often much worse on re-exposure 
to the medicine. A patient who has experienced suspicious 
symptoms and stopped taking their herbs may experience 
a much more rapid and more severe reaction if they 
begin to take the herbs again at a later date. Cases 1 and 3 are 
good examples of this. 
It is important to stress to practitioners, most of whom 
have not experienced any problems with their own patients 
being adversely affected, that this does not mean that there 
is not a problem. Since it is probable that only one person in 
every few thousand is vulnerable to liver damage from the 
herbs, this would mean that one would have to treat five or 
ten thousand people before one would expect (statistically) 
to have one patient become ill with liver damage. 
It has been suggested by some agencies that all patients 
being treated with Chinese herbs should receive routine 
blood tests for liver damage38. However, most practitioners 
are resistant to this idea, on grounds of cost and inconvenience 
to patients and because many patients dislike giving 
blood samples. It is also true that several prescription drugs 
carry small risks of liver damage but continue to be used 
without resort by doctors to liver function testing of all their 
patients. This illustrates the point that adequate training 
and good practice are the keys to patient safety. 
It is unfortunate that we do not have enough details on 
these cases to enable us to analyse them in terms of a 
Chinese medicine approach to the individual’s patterns of 
disharmony. It is possible that factors in patients’ diet or 
lifestyle or constitution may make them more vulnerable to 
hypersensitivity reactions to some herbs. 
It has also been suggested that the overall balance of the 
prescriptions may be inappropriate in some way, and in 
particular that they may be focused too much on clearing 
pathogenic factors and may not do enough to support the 
Spleen or the Liver. However, many experts on herbal 
dermatology in China feel that focusing on the pathogenic 
factors is the correct strategy. Certainly it is true that some 
of the prescriptions given in these six cases are quite strongly 
draining, but the prescription used in Case 6 contained a 
number of herbs to support the Spleen, and the prescription 
used in Case 2 contained a number of herbs to support 
blood and yin. Another possible factor is that a high overall 
dosage of herbs may put additional stress on the Spleen in 
particular. In addition, it has been suggested that herbs 
which modern research has shown to have hepato-protective 
effects should be added to our prescriptions for skin 
diseases. There is a need for further discussion and debate 
of all these questions within the profession. 
Another question arising from these cases is the absence 
of reports of liver damage in patients receiving treatment 
for skin diseases in modern China. It is striking that Case 4 
above is of a Chinese woman, so there does not appear to be 
anything in the way of genetics or diet protecting Chinese 
patients. The most likely explanation is that hepatitis A and 
B are endemic in China anyway. It is entirely possible that 
if there are occasional cases of herb-induced hepatitis in 
China these are assumed to be infectious in origin and the 
true cause is missed. 
A clear lesson from these tragedies is that the profession 
must urgently organise national and international reporting 
mechanisms in order to detect adverse effects from 
Chinese herbs quickly and effectively. Accurate information 
is most important. In the UK we are now seeing good 
levels of co-operation between the profession and bodies 
such as the National Poisons Unit and Schools of Pharmacy, 
which will help to improve the flow of information in both 
directions. 
The second lesson is that good patient management is 
essential. In particular we can identify the following: 
• good communication with patients. Patients must be 
warned both verbally and in writing of potential adverse 
effects and of the importance of stopping the herbs and 
contacting their practitioner should these occur. 
• regular monitoring of patients. Patients should be seen 
every week or two at first and generally never less than 
every four weeks. Appointments should last for at least 15 
minutes to allow time to fully review each case. 
Finally, it is important to remember that Chinese herbal 
treatment has been shown to be remarkably effective for 
stubborn and unpleasant skin diseases such as eczema, 
which cause a great deal of suffering and distress24,25. Our 
aim must be to continue to offer this beneficial treatment 
while protecting potentially vulnerable individuals from 
unnecessary and avoidable harm. 
Conclusion 
In conclusion, we can see that the vast majority of adverse 
events involving Chinese herbs which have been reported 
in the literature can be avoided by the following measures: 
• Chinese herbs should only ever be prescribed by fully 
trained practitioners of Chinese herbal medicine, in accordance 
with a traditional individualised diagnosis. Training 
of practitioners should include the ability to monitor for 
and recognise adverse effects. The RCHM has begun the 
task of establishing agreed educational standards in the UK 
and this is clearly a matter of some urgency. Professional 
bodies will increasingly need to be able to guarantee minimum 
standards of practice and to enforce codes of ethics 
and practice, and legal protection of title and self-regulation 
will be necessary to achieve this. 
• Chinese herbs should be prescribed in the traditional 
manner, according to an individualised diagnosis based on 
the theory and practice of Oriental medicine. The herbs 
should be used according to their traditional indications 
and in established combinations. 
• There should be compulsory Codes of Practice for practitioners 
which include many of the recommendations made 
in this paper, including requirements to monitor patients 
regularly, to arrange regular blood tests before treating 
patients with a history of liver diseases, to fully inform 
patients, etc. In the case of the RCHM such a Code already 
exists, but membership is entirely voluntary and as a result 
disciplinary procedures are weakened and some practitioners 
do not join at all. 
• Whenever it is proposed to use herbs in novel ways, for 
example in the form of chemical extracts, or for symptomatic 
treatment, then careful and thorough clinical research 
and monitoring must be undertaken. A similar caution 
should be applied to the prescribing of obscure or 
unusual herbs. 
• A handful of herbs traditionally known to be seriously 
toxic, such as Cao Wu and Wu Tao, should probably be 
restricted to use in hospital settings only. 
• A number of herbs with some potential for toxicity, such 
as Fu Zi, should probably be restricted to use at specified 
doses by fully trained practitioners only. Herbs with some 
potential for toxicity should not be prescribed for patients 
who are also taking modern drugs. 
• Proper identification and quality control of herbs by 
manufacturers and suppliers is a key ingredient in enabling 
the safe practice of Chinese herbal medicine. A minimum 
requirement would probably be the examination by 
microscopy and chromatography of each batch of herbs by 
trained pharmacognocists. 
• Suppliers should not make available patent medicines 
whose ingredients are not certain, and practitioners should 
not prescribe them. 
It is interesting to note that these suggestions are similar 
to the recommendations of the Report of the Working Party 
on Chinese Medicine appointed by the Secretary for Health 
and Welfare in the Hong Kong administration. The recommendations 
include: the registration of herbal practitioners; 
the creation of a list of “potent herbs” which should 
only be available with a prescription from a herbal practitioner; 
licensing of the processing, manufacture, import 
and distribution of raw herbs and patent medicines; and 
improvements to the training of both practitioners and 
dispensers39. 
We should remember that adverse effects from Chinese 
herbs are rare. In Hong Kong, where the use of Chinese 
herbs is both widespread and unregulated, it has been 
shown that only 0.2% of the general medical admissions to 
the Prince of Wales Hospital were due to adverse reactions 
to Chinese medicine, as compared to 4.4% of admissions 
caused by Western pharmaceuticals40. As we have seen, 
improvements in quality control and in the training and 
regulation of practitioners would substantially reduce the 
already low incidence of problems involving Chinese medicine. 
These improvements will assist greatly in establishing 
Chinese herbal medicine in the West as a safe and effective 
form of treatment. 
Acknowledgements 
Many thanks to the following for their valuable assistance 
and guidance: Mazin Al-Khafaji, Dr. David Atherton, 
Charles Buck, Peter Deadman, Dr. Han Liping, Ken Lloyd, 
Michael McIntyre, Dr. Zhong Shouming. The views and 
opinions expressed in this article are, however, entirely my 
own. 
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Biography 
Richard Blackwell graduated in Medical Science from the 
University of Nottingham Medical School. He is Deputy Principal 
of the Northern College of Acupuncture in York, and has 
taught Chinese medicine and acupuncture since 1988. He was 
a member of the Register of Chinese Herbal Medicine from 
1986 to 1991 and its President from 1991 to 1994.

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ADVERSE EVENTS INVOLVING CERTAIN CHINESE HERBAL MEDICINES