Ma Dou Ling (Birthwort Fruit)

Chinese Herb Actions

Chinese Herb Dosage

• What is the dosage of Ma Dou Ling?

  No dosage is published on this page, and this is a deliberate departure from how the rest of this library is written. Ma Dou Ling contains aristolochic acid, a compound the peer-reviewed literature describes as a Group 1 — established human — carcinogen. It is out of the Chinese Pharmacopoeia as of the 2020 edition and is prohibited in medicinal products throughout the United Kingdom. Printing a figure would imply a safe quantity exists, and for a genotoxic carcinogen no threshold has been established.

  • There is no “small enough” amount to quote. The Belgian cohort study that established the harm found cumulative dose mattered — totals above 200 grams of Aristolochia carried higher risk — but it found aristolochic-acid DNA adducts in every tissue sample it examined, including in patients below that total.
  • Processing does not solve it. Animal work has reported that processed fruit is less acutely toxic than crude fruit and is absorbed less completely, but the aristolochic acids remain present, and the authors of that work stated plainly that safety concerns still apply. No preparation or processing method is described on this page.
  • What this means for study. Students meeting Ma Dou Ling in a classical formula should learn it as a historical ingredient and learn what replaced it — the same way Xi Jiao is now studied. Contemporary Chinese-language teaching sources published since 2020 no longer carry it as a current medicinal.

  Sources: PMID 10841870, DOI 10.1056/NEJM200006083422301 (cumulative dose above 200 g associated with higher risk; aristolochic-acid DNA adducts in all analysed samples); PMID 23926199, DOI 10.1126/scitranslmed.3006086 (aristolochic acid described as a Group 1 carcinogen); PMID 24369268, DOI 10.1248/bpb.b13-00736 and PMID 28187732, PMC 5303205, DOI 10.1186/s12906-017-1626-2 (processed versus crude fruit in rodents; aristolochic acids still present); The Medicines (Aristolochia and Mu Tong etc.) (Prohibition) Order 2001, SI 2001 No. 1841. Reference statement only — not a prescription and not a usage instruction.

Chinese Herb Contraindications & Cautions

• Is Ma Dou Ling banned, and what did regulators actually do?

  Two regulatory actions are documented and verified. China removed Ma Dou Ling from the Chinese Pharmacopoeia in the 2020 edition, and the United Kingdom has prohibited every species of the genus Aristolochia in medicinal products since 1 July 2001. Those are the two we can state at source. Claims that other jurisdictions “banned” the herb circulate widely, but we could not resolve them to a regulator’s own published words, so we do not repeat them here.

  • China. Three independent peer-reviewed papers record the same thing: the 2015 Chinese Pharmacopoeia set an aristolochic-acid content specification for Aristolochiae Fructus (Ma Dou Ling) and Aristolochiae Herba (Tian Xian Teng); the 2020 edition contains neither. Related Aristolochia herbs — Guan Mu Tong, Guang Fang Ji and Qing Mu Xiang — had already been prohibited in China from 2004.
  • United Kingdom. The Medicines (Aristolochia and Mu Tong etc.) (Prohibition) Order 2001, SI 2001 No. 1841, made 9 May 2001 and in force from 1 July 2001, prohibits the sale, supply and importation of medicinal products consisting of or containing any plant of the genus Aristolochia. The same Order also names several species commonly substituted for one another under the trade names “Mu Tong” and “Fangji.”
  • What we are not claiming. We make no statement about the current position of United States or European Union regulators. Secondary literature attributes actions to both, but the underlying regulatory documents could not be retrieved and read, and on a question this consequential we would rather say nothing than repeat something on trust.
  • Scale of historical exposure. A study of Taiwan’s national health-insurance records for 1997–2003 found that in a random 200,000-patient cohort, 78,644 patients had received products containing aristolochic-acid herbs across 526,867 prescriptions; roughly 7% had a cumulative exposure above 100 grams of Xi Xin, Mu Tong or Ma Dou Ling. This was not a rare herb.
  • The traditional cautions our record already carried — avoid in cough from deficiency or cold, avoid with loose stools from Spleen deficiency, and avoid prolonged or large-dose use — are retained here as part of the historical record. They are, in hindsight, an inadequate description of the risk.

  Sources: PMID 38706826, DOI 10.1016/j.chmed.2023.02.008; PMID 32742301, PMC 7388521, DOI 10.1186/s13020-020-00357-3; PMID 40421208, DOI 10.3389/fphar.2025.1551531 (all three on the 2015-to-2020 Chinese Pharmacopoeia change); PMID 18588699, PMC 2488332 (2004 prohibitions in China); The Medicines (Aristolochia and Mu Tong etc.) (Prohibition) Order 2001, SI 2001 No. 1841 (United Kingdom, read at source); PMID 18945373, PMC 2584031, DOI 10.1186/1749-8546-3-13 (Taiwan prescription-exposure analysis). Neutral reference facts.

Chinese Herb Toxicity & Overdose

• Is Ma Dou Ling toxic, and what does aristolochic acid actually do?

  Yes. The fruit contains aristolochic acids, and the harm they cause is among the best-characterised in the whole of herbal toxicology: a progressive, irreversible interstitial kidney fibrosis, and urothelial cancer of the upper urinary tract. The damage is genetic — aristolochic acid forms DNA adducts and leaves a distinctive mutational fingerprint that can be found in tumour tissue years later.

  • What is in the fruit. An analytical study quantified seven aristolochic-acid analogues — aristolochic acids I, II, IIIa, IVa and VIIa, plus aristolactams I and II — across 11 batches of A. contorta fruit, 15 batches of A. debilis fruit and 33 commercial Ma Dou Ling samples. A separate comparison across several aristolochic-acid-bearing herbs found Aristolochia debilis material to carry the highest total content of those tested.
  • No concentration figure is published here. The milligram-per-gram number that circulates online for “Ma Dou Ling” was in fact measured in the root of A. debilis — a different herb (Qing Mu Xiang) — not in the fruit. We checked, could not obtain a clean fruit-specific figure, and omit it rather than repeat a mismatched one.
  • The kidney injury. First reported in 1993 in nine young women in Brussels who developed rapidly progressive interstitial renal fibrosis after the same slimming regimen, in which Stephania tetrandra had been replaced with Aristolochia fangchi. Serum creatinine doubled in roughly three months. The cohort eventually exceeded 100 patients, and comparable cases have since been reported worldwide.
  • The cancer. Of 39 Belgian patients with end-stage disease who underwent preventive surgery, 18 — 46% — had urothelial carcinoma, and 19 of the remaining 21 had urothelial dysplasia. Aristolochic-acid-related DNA adducts were present in every tissue sample analysed.
  • Confirmed independently in populations. Taiwan has the highest reported incidence of upper-tract urothelial cancer in the world; adducts were found in the renal cortex of 83% of patients carrying the characteristic mutation. A population case-control study of 4,594 urinary-tract-cancer cases against 174,701 controls found a dose-response relationship independent of arsenic exposure. Balkan endemic nephropathy, long unexplained, is now attributed to dietary contamination by a related Aristolochia species.
  • The mutational load is extraordinary. Genome sequencing of aristolochic-acid-associated urothelial cancers found roughly 150 mutations per megabase — higher than smoking-associated lung cancer or ultraviolet-associated melanoma.

  One contested extension. Some studies report the same mutational signature in liver cancers, including in a large majority of one Taiwanese series. That extension has been challenged on the grounds that the signature is not unique to aristolochic acid — several industrial and chemotherapeutic agents produce a similar pattern. We record the urothelial evidence as established and the liver-cancer attribution as disputed.

  Sources: PMID 22484602, DOI 10.1007/s11418-012-0664-9; PMID 37804820, DOI 10.1016/j.phymed.2023.155092; PMID 8094166, DOI 10.1016/0140-6736(93)92984-2; PMID 10841870, DOI 10.1056/NEJM200006083422301; PMID 18418355, DOI 10.1038/ki.2008.129; PMID 22493262, PMC 3361449, DOI 10.1073/pnas.1119920109; PMID 20026811, PMC 2815723, DOI 10.1093/jnci/djp467; PMID 17942951, DOI 10.1681/ASN.2007050537; PMID 23926199, DOI 10.1126/scitranslmed.3006086; PMID 29209916, DOI 10.1007/s11684-017-0611-y (the challenge to signature specificity). Neutral reference facts, not medical advice.

• This herb is considered toxic.
  (while some Chinese herbs are toxic, it must be noted that many come prepared, or are combined, to mitigate their toxicity)

Herb-Drug Interactions

• Does Ma Dou Ling interact with medications?

  The relevant hazard is not a conventional drug interaction — it is the aristolochic acid itself — but one laboratory finding is worth recording: fruit extract inhibited several drug-metabolising cytochrome P450 enzymes in rat liver microsomes and in living rats. Activity of CYP1A2, CYP3A1 and CYP2E1 was reduced, with no significant effect on CYP2C6; the authors concluded the material was a candidate for clinically significant interactions with co-administered drugs.

  • Why this matters even in a historical entry. Enzyme inhibition of this kind raises the blood levels of many prescription medicines. If aristolochic-acid-containing material is still in circulation informally — and the nephrology literature notes such products have continued to be sold online — that is a second, separate route to harm on top of the carcinogenicity.
  • Kidney impairment compounds everything. Excretion of aristolochic acid is itself impaired once renal function falls, which is one reason reviewers have been reluctant to accept “reduced-content” preparations as safe.

  Sources: PMID 26004704 (inhibition of CYP1A2, CYP3A1 and CYP2E1 by Aristolochia debilis fruit in rat microsomes and in vivo); PMID 18418355, DOI 10.1038/ki.2008.129 (continued informal sale of aristolochic-acid products); PMID 33815744, PMC 7989132, DOI 10.1177/2042098621997727 (impaired excretion in renal impairment; attenuated-toxicity preparations not established as safe). Reference information, not medical advice.

Western / Biomedical Research

Chinese Herb Clinical Studies & Research

Provided as research context — a summary of published biomedical study, not a therapeutic or medical claim.

• Is there modern research on Ma Dou Ling (Aristolochiae Fructus)?

  Yes, and almost all of it is toxicology, analytical chemistry or epidemiology rather than therapeutics. There is no active clinical research programme investigating the fruit as a treatment, and given a Group 1 carcinogen in the material there could not legitimately be one. The research value of this herb now lies in what it taught the field about herb identity, substitution and regulation.

  • Analytical identification. Method work can distinguish the two source species by their aristolochic-acid profiles: aristolochic acid IVa exceeds VIIa in A. contorta fruit and the reverse holds in A. debilis. In one survey all 33 commercial Ma Dou Ling samples examined proved to be A. contorta — a reminder that what is in the jar is an empirical question.
  • Comparative content. A 2023 study measuring total aristolochic acid I, II and aristolactam I across herbs and finished products ranked Aristolochia debilis material highest of those compared, above Fibraurea recisa, Asarum and three proprietary granule products.
  • Toxicology. Rodent studies have compared crude and processed fruit by acute and subacute toxicity and by pharmacokinetics, finding lower peak concentrations and lower exposure to aristolochic acids I and II from the processed material — while stating that the aristolochic acids remain and the safety concern is not removed.
  • The nomenclature lesson. A 2007 analysis used the Aristolochiaceae as the worked example of why pharmaceutical Latin binomials, not romanised trade names, must govern botanical identity. That paper is arguably the most useful thing ever written about this herb, and it is about naming rather than pharmacology.
  • Epidemiology. The kidney and urothelial-cancer literature summarised in the toxicity section above constitutes the largest body of research connected to this material: the Belgian cohort, the Taiwanese case-control and adduct studies, Balkan endemic nephropathy and the genome-wide mutational-signature work.

  Sources: PMID 22484602, DOI 10.1007/s11418-012-0664-9; PMID 37804820, DOI 10.1016/j.phymed.2023.155092; PMID 24369268, DOI 10.1248/bpb.b13-00736; PMID 28187732, PMC 5303205, DOI 10.1186/s12906-017-1626-2; PMID 16863692, DOI 10.1016/j.phymed.2006.05.009; PMID 10841870; PMID 22493262, PMC 3361449; PMID 20026811, PMC 2815723; PMID 23926199. Research context, not a therapeutic claim.

Chinese Herb Notes

• How does Ma Dou Ling relate to Qing Mu Xiang, Tian Xian Teng and Guang Fang Ji — and which formula on this site contains it?

  Ma Dou Ling, Qing Mu Xiang and Tian Xian Teng are three different herb names for three different parts of one plant, Aristolochia debilis — the fruit, the root and the stem respectively. This is a documented example of what one analysis of Chinese herbal nomenclature calls a “multiple-to-one” naming pattern, where several herb names derive from a single species. All three parts belong to a genus that contains aristolochic acid, so the safety question travels with the plant, not with the part name.

  • Qing Mu Xiang (the root) — prohibited in China since 2004, along with Guan Mu Tong (A. manshuriensis) and Guang Fang Ji (A. fangchi). The Sacred Lotus does not hold a separate entry for Qing Mu Xiang.
  • Tian Xian Teng (the stem) — carried in the 2015 Chinese Pharmacopoeia and removed, alongside Ma Dou Ling, from the 2020 edition. We do not hold a separate entry for it either.
  • Guang Fang Ji — a different species of the same genus, and the herb actually implicated in the Belgian cases described in the cautions section below. We do hold an entry for it, and it is the one to read alongside this page.
  • A name worth not confusing — Mu Xiang (Aucklandia) and Fang Ji as supplied from Stephania tetrandra are unrelated to the Aristolochia genus. The historical harm arose precisely because similar-sounding names were substituted for one another in commerce.

  The one formula on this site that contains it. Ma Dou Ling appears in a single formula in our records: Bu Fei e Jiao Tang (Tonify the Lungs Decoction with Ass-Hide Gelatin), recorded here at 15 grams alongside E Jiao 45 g, Geng Mi 30 g, Niu Bang Zi 7.5 g, Zhi Gan Cao 7.5 g and Xing Ren 6 g. That is the formula’s traditional composition as transmitted, and we state it plainly rather than quietly editing it.

  Open composition question for the site editor. Because the fruit is out of the Chinese Pharmacopoeia and prohibited in the United Kingdom, the composition recorded for Bu Fei e Jiao Tang is a historical composition, not a description of anything a reader should compound. Whether that formula record should carry a substitution note, or be presented as historical in the same way this page is, is an editorial decision that has been raised and not taken unilaterally. We have changed no formula data.

  Sources: PMID 16863692, DOI 10.1016/j.phymed.2006.05.009 (madouling, qingmuxiang and tianxianteng derive from the fruit, root and stem of Aristolochia debilis; fangji names cover three unrelated species); PMID 18588699, PMC 2488332, DOI 10.1186/1749-8546-3-7 (Guan Mu Tong, Guang Fang Ji and Qing Mu Xiang prohibited in China since 2004); PMID 38706826 (Aristolochiae Fructus and Aristolochiae Herba in the 2015 Chinese Pharmacopoeia, absent from the 2020 edition); Sacred Lotus formula and herb records. Reference information only.

This herb is banned or illegal in the United States