Fever That Comes and Goes, a Cold That Just Won’t Leave? Doctor Xu Shuwei Treats Cold Damage with Gui Zhi Ma Huang Ge Ban Tang (Half Cinnamon Twig and Ephedra Decoction) — Resolve the Exterior Before Purging
Patient search words: fever coming and going / recurrent fever / a cold that never gets better / fever that will not break / cold with fever and no bowel movement / urticaria that keeps coming back
Corresponding medical terms: cold damage (shang han) · taiyang exterior pattern (tai yang biao zheng) · unresolved exterior pattern (biao zheng wei ba) · insufficient upright qi (zheng qi bu zu) · hidden rash / urticaria (yin zhen)
The opening: the medicine was already brewed — he reached out and stopped it
Today we continue the stories of Doctor Xu Shuwei, the great formula master, using the formulas of the Treatise on Cold Damage.
Doctor Xu Shuwei, courtesy name Zhike, was a celebrated physician of the transition between the Northern and Southern Song dynasties, known as “Scholar Xu” (Xu Xueshi). He was one of the founders of the classical formula school (jing fang pai). His Discussion of Ninety Cases of Cold Damage is the earliest surviving monograph of case records in Chinese medicine — one case, one discussion, explaining Zhang Zhongjing’s principles through and through; his other work, Effective Formulas from the Household Pharmacy, also collects many of his own verified cases. Today’s case is recorded in both books.
💬 Note from Doctor Luo: This case is especially interesting — the physician had already brewed the da huang and mang xiao (rhubarb and mirabilite), the purging decoction was about to be poured down the patient’s throat, when Doctor Xu Shuwei walked in, reached out his hand, and stopped it. The words he used, “gù shǎo dài,” mean simply: please wait a moment, let me have a look first. That single gesture saved a man’s life.
Who was the patient? In summer, an official fell ill
That summer, an official fell ill — and he happened to be one of Doctor Xu Shuwei’s relatives.
What illness? Cold damage (shang han) — an externally contracted disease. What symptoms? His body was hot — he had a fever; headache; no sweating at all; and his bowels had not moved for five days.
💬 Note from Doctor Luo: Look at this: fever, headache, no sweat — that is the classic picture of an external pathogen at the body surface; five days without a bowel movement suggests the heat was moving inward and the stool was drying and binding. The physician who had been called in took one look: isn’t this yang ming excess (yáng míng fǔ shí)? Da huang, mang xiao — the Cheng Qi Tang family of formulas — purge! The medicine was brewed and ready to pour.
What did Doctor Xu Shuwei think? The most crucial stroke of the whole case
Just then Doctor Xu Shuwei happened to be returning from the countryside into town, and came to visit this relative. The moment he saw the situation he stopped them: “Gù shǎo dài — please wait a moment. Now that I am here, I must take a look.”
He took the pulse: slow and floating (mài huǎn ér fú).
💬 Note from Doctor Luo: These two words carry an enormous amount of information. A slow pulse means the upright qi is insufficient — the pulse has no force when you press it; a floating pulse means the external pathogen is still at the body surface — it has not entered the interior. Then look at the patient: he was lying in a sealed room — doors and windows shut tight — and said he was especially afraid of wind, that a single draft was unbearable. That is called aversion to wind (wù fēng). Doctor Xu Shuwei now had his answer: the exterior pattern had not yet resolved — the external pathogen was still clinging to the surface of the body!
And what were the da huang and mang xiao that the other physician had prepared meant for? For yang ming excess with hard stool. What is yang ming excess? The body’s upright qi is strong, the fight against the pathogen is fierce, heat reaches its extreme, heat binds in the interior and the stool dries — only in that situation do you dare use a powerful formula like Da Cheng Qi Tang.
💬 Note from Doctor Luo: But this patient? The pulse was slow — the upright qi was insufficient; and although the bowels had not moved, the belly was not distended, and pressing it caused no pain — none of the “fullness and pain” signs of yang ming excess were present. Zhang Zhongjing laid down the rule: only when the exterior pattern has resolved may one purge (biǎo zhèng bà, fāng kě xià) — you must first release the exterior and drive the pathogen out through the surface; if you purge while the exterior pathogen is still there, the consequences are serious. Doctor Xu Shuwei’s own words were: the evil poison takes advantage of the deficiency and enters inside (xié dú chéng xū ér rù nèi) — your upright qi is already insufficient, purging injures it further, and the pathogen seizes the chance to bore inward: in mild cases the illness drags on without recovery; in severe cases it transforms into bound chest (jié xiōng) or heat diarrhea complicated by purging (xié rè lì) and worse. So when you should release the exterior, release the exterior — do not stare at the blocked bowels and purge recklessly.
The prescription: Gui Zhi Ma Huang Ge Ban Tang — once the sweat came out, the bowels moved too
What formula did Doctor Xu Shuwei give? Gui Zhi Ma Huang Ge Ban Tang — the Half Cinnamon Twig and Ephedra Decoction — to release the exterior and induce sweating first. After the sweat came out, he then used Xiao Chai Hu Tang (Minor Bupleurum Decoction) to draw the remaining pathogen outward. And the result?
The sweat came out, the bowels moved, and within a few days he was well.
💬 Note from Doctor Luo: Through this case Doctor Xu Shuwei taught a great principle: treating cold damage follows a fixed order — while the external pathogen is at the body surface, you must release the exterior first; only after the exterior is resolved, if true yang ming excess remains inside, do you purge. Why? The upright qi is the key — you must not injure the upright qi; only by protecting it do you keep the strength to fight the pathogen. Zhang Zhongjing repeats this order throughout the Treatise on Cold Damage, and in later case records there are very many patients whose illnesses were made lingering precisely because purging was used wrongly.
Breaking down the formulas: Gui Zhi Tang and Ma Huang Tang — a pair of “exterior-pattern brothers”
Before going further, we need to make clear two foundational formulas, both by Zhang Zhongjing.
Gui Zhi Tang (Cinnamon Twig Decoction) — the very first formula of the Treatise on Cold Damage. What does it treat? Exterior deficiency (biǎo xū) : an external pathogen reaches the surface, the body’s upright qi is insufficient, the resistance is weak, and the main signs are sweating, constant sweating, fear of wind and cold. Gui Zhi Tang’s action is called harmonizing the nutritive and defensive qi (tiáo hé yíng wèi) — which in plain words means regulating the spleen and stomach: when the spleen and stomach are well regulated and the upright qi is sufficient, there is strength to fight the pathogen.
💬 Note from Doctor Luo: Gui Zhi Tang is very simple: gui zhi (cinnamon twig) — moving the defensive qi, warming and unblocking; shao yao (peony root) — sour and astringent, protecting the yin qi; zhi gan cao (honey-fried licorice); together with sheng jiang (fresh ginger) and da zao (jujube dates) to harmonize the spleen and stomach. Just these five herbs manage a huge range of illnesses.
Ma Huang Tang (Ephedra Decoction) — treats exterior excess (biǎo shí) : the body’s upright qi is strong, the struggle against the pathogen is intense, and the signs are no sweating and strong body heat. At this point you only need to help the patient sweat and defeat the cold pathogen in one stroke. Its composition: ma huang (ephedra) — spreading the lung qi, releasing the exterior, warm in nature, stirring the body to sweat; gui zhi, gan cao, and xing ren (bitter apricot kernel).
💬 Note from Doctor Luo: One thing everyone should know: ephedra has a stimulating effect — some people take it and their heart races all night, unable to sleep; it really can excite a person. That is why people today, who are not as sturdy, generally can use su ye (perilla leaf), fang feng (saposhnikovia root), and jing jie (schizonepeta) in place of ma huang to induce sweating. In my early years I followed the senior physician Zhang Daokuan on his rounds in Liaoning, and he loved using ma huang — two or three grams in a formula, saying it was to stir the body’s yang qi. Used correctly, it works at once; and the decoction method has its rules — ma huang must be boiled first, boiled for a moment or two, the foam skimmed off the top, and only then the other herbs added — that is the procedure Zhang Zhongjing handed down.
What does “half and half” mean? And why do colds drag on in people with insufficient qi
Gui Zhi Ma Huang Ge Ban Tang is simply Gui Zhi Tang at half strength and Ma Huang Tang at half strength, the two formulas combined into one. There is a brother formula called Gui Zhi Er Ma Huang Yi Tang: two parts Gui Zhi Tang to one part Ma Huang Tang.
💬 Note from Doctor Luo: What do these two formulas treat? The state of people with insufficient upright qi — the elderly, children, the frail — after they encounter an external pathogen. Such a person wants to resist but lacks the strength, so the typical picture is fever that comes and goes, like malaria — one bout a day, two or three bouts a day; the pulse is slow; he is afraid of cold and wind; but he is not vomiting and not thirsty — no vomiting means the illness is not in the lesser yang (shao yang); the bowels are basically normal, so it is not in the yang ming. Where is it? Still in the taiyang — the external pathogen is still clinging to the surface and has not left. Gui Zhi Tang supplements the upright qi, Ma Huang Tang disperses the surface cold: supporting the upright and expelling the pathogen at the same time, and the pathogen is resolved.
To be honest, most people today have insufficient upright qi — who among us doesn’t know someone whose “cold just won’t get better”? A sturdy person’s cold clears up within a week for sure; but a frail person, an elderly person confined to bed — their colds are genuinely hard to treat, better for two days and then struck again, dragging on for a month or two. That is precisely the pathogen never being thoroughly driven out.
💬 Note from Doctor Luo: Zhang Zhongjing’s thinking here is extremely clever: more strength for supporting the upright qi with Gui Zhi Tang, less strength for sweating with Ma Huang Tang — that is the two-to-one version; and for someone whose upright qi is still fairly decent, half and half. He was adjusting the proportion between supporting the upright and expelling the pathogen. This idea applies extremely widely.
Bonus case one: Doctor Yu Changrong treats Mr. Li — one fever bout a day, for three days
A case from the late senior physician Doctor Yu Changrong. Mr. Li, 49 years old, came for treatment on April 10, 1963.
What symptoms? Aversion to cold with shivering — cold to the point of trembling; fever; sweating that cools the body — after a sweat, the body cooled down. But the next day it came again: once a day, for three consecutive days. In addition: headache, soreness and distending pain of the limbs, low back pain, cough with scant phlegm, poor appetite; urine and stool still normal. The pulse was floating and tight (fú jǐn), the tongue coating white, thick and slippery.
💬 Note from Doctor Luo: See this “once a day” — why? Insufficient upright qi! If the upright qi were sufficient, one good sweat would break the fever and that would be the end of it. The fact that he could only mount one battle against the pathogen per day means the upright qi could not push the pathogen through. Doctor Yu’s judgment: release the exterior with acrid-warm herbs, in a light dose — Gui Zhi Er Ma Huang Yi Tang: gui zhi 9 g, bai shao (white peony root) 9 g, xing ren 6 g, zhi gan cao 6 g, sheng jiang 6 g, ma huang 4.5 g.
After taking it, the chills and fever were resolved — the fear of cold and the fever were both gone. What remained? Palpitations, shortness of breath, slight wheezing, mild abdominal pain that felt better on pressure, the pulse turning wiry and slow — the exterior pathogen was gone, but the qi and blood were now insufficient: the nutritive blood deficient, the spleen weak, the qi stagnant. What to do? Xiao Jian Zhong Tang (Minor Strengthening the Middle Decoction) — to supplement the spleen and stomach and harmonize the nutritive and defensive qi. This formula carries the shadow of Gui Zhi Tang, with the peony doubled — one dose and he was at ease.
💬 Note from Doctor Luo: Notice this strategy of switching formulas: expel the pathogen first, then support the upright after the pathogen is gone — Gui Zhi Er Ma Huang Yi Tang released the exterior pathogen, Xiao Jian Zhong Tang built up the spleen and stomach and the nutritive and defensive qi. The way Chinese formulas transform into one another is fascinating: Gui Zhi Tang harmonizes the nutritive and defensive; Xiao Jian Zhong Tang regulates the spleen and stomach — and in fact the root of both the nutritive and the defensive qi lies in the spleen and stomach.
Bonus case two: Doctor Liu Duzhou treats a 12-year-old girl — too much sweating from a fever remedy, and the fever returned the next day
A case from the late Doctor Liu Duzhou — the great Treatise on Cold Damage master of our university, Beijing University of Chinese Medicine.
The patient, Miss Liu, was 12 years old. In early spring she caught wind-cold, with headache and fever. Her family bought her a patent fever powder, Ping Re San, and after taking it she sweated profusely and the fever broke — but the next day: fever with chills, striking like malaria: once in the morning, twice in the afternoon.
💬 Note from Doctor Luo: See — this is exactly like the previous case: recurrent attacks. Every one of us has had colds, and many people know this experience — a fever bout every day, feeling better, then burning again the next day. Once you study the Treatise on Cold Damage you understand: when the upright qi is insufficient, the resistance is weak, the pathogen cannot be driven out, and so it keeps recurring. Doctor Liu analyzed this girl: the pulse was floating and slightly rapid, the tongue coating thin-white and moist — the sweating had been excessive; too much sweat injured the nutritive qi, and the exterior pathogen was instead left stranded. No more heavy sweating — use Gui Zhi Er Ma Huang Yi Tang to induce a light sweat: gui zhi 5 g, bai shao 5 g, sheng jiang 5 g, da zao 3 pieces, ma huang 3 g, xing ren 3 g, zhi gan cao 3 g.
The result: one dose, a light sweat after taking it, and the illness was cured.
Bonus case three: Doctor Liu Jingqi treats urticaria — large welts erupting five or six times a day
Zhang Zhongjing has another original passage that concerns the skin: “When the face shows a reddish heat color, the exterior has not yet resolved; because no light sweat was obtained, the body is sure to itch” — when sweat cannot come out, the pathogen stagnates at the surface and the body itches. So some skin problems are also treated with the thinking of Gui Zhi Ma Huang Ge Ban Tang.
A case from Doctor Liu Jingqi: Miss Sun, 45 years old, came on July 20, 1982. Aversion to cold with fever, and large welts over the whole body, for more than twenty days — that is urticaria (hives), erupting five or six times a day: the body covered in welts, fading after a while, then rising again. Before the illness began she had sweated and then been caught in the rain.
💬 Note from Doctor Luo: When you sweat, the pores open; the rain and cold wind strike, the external pathogen blocks the surface, the sweat wants to come out but cannot, it stagnates in the skin, and it becomes welts. This woman had tried every Western medicine — injected calcium, oral chlorpheniramine (Piriton), vitamin C — nothing worked. Her face was pale, the dermographism test was positive, the tongue coating white, the pulse wiry. Doctor Liu’s judgment: wind-cold binding the exterior, unable to vent (fēng hán shù biǎo, bù dé xuān xiè) — release the exterior with acrid-warm herbs, disperse wind and stop the itching. With what? Gui Zhi Ma Huang Ge Gen Tang (Cinnamon Twig, Ephedra and Pueraria Decoction): gui zhi 5 g, bai shao 3 g, sheng jiang 3 g, zhi gan cao 3 g, ma huang 3 g, da zao 4 pieces, stir-fried xing ren 3 g — an extremely light dose.
The result: clinically cured in six doses, with no recurrence in a three-month follow-up.
💬 Note from Doctor Luo: For diseases of the body surface and the lung channel, a lighter dose is better — light herbs travel upward (qīng yào shàng xíng). Clinically this really happens: a heavy dose produces no response, you lighten the dose, and it works. One more warning about urticaria — everyone must be alert: when it breaks out over the whole body, the dangerous place is the throat — if the wind welts swell inside the larynx, breathing becomes difficult, the more it is stimulated the larger it grows, and it can genuinely suffocate a person. If someone at home breaks out all over, get them to drink Chinese medicine quickly; if no medicine is at hand, take an antihistamine (for example loratadine); if it is severe, go to the hospital emergency room, and epinephrine may be needed. Also, severe allergy to foreign proteins — foods you don’t normally eat, like fried locusts or fried soybeans — is quite dangerous too. People with insufficient upright qi who are prone to allergies should regularly drink some Gui Zhi Tang or Xiao Jian Zhong Tang, harmonize the nutritive and defensive qi, build up the spleen and stomach qi, and they will be far less likely to break out.
Closing: supporting the upright and expelling the pathogen can live in the same formula
So what have we learned today?
When your upright qi is insufficient, cold pathogen arrives at the body surface; your body wants to resist but cannot resist effectively, and the illness drags on without recovery — fever one moment, fine the next; the pathogen has stayed at the surface all along. What to do then? Zhang Zhongjing gave the approach: Gui Zhi Tang supports the upright, Ma Huang Tang releases the exterior — use them together.
💬 Note from Doctor Luo: The core idea in one sentence: supporting the upright and expelling the pathogen can be done at the same time — you only need to adjust the proportions. When the deficiency of upright qi is obvious, use Gui Zhi Er Ma Huang Yi Tang — mainly supporting the upright, expelling less; when the upright qi is still fairly decent, use the two formulas half and half. Zhang Zhongjing was combining the two approaches already in his own time, and so many later treatment strategies have their roots right here. This thinking is not only for colds — by analogy it applies to many diseases, because most people today have insufficient upright qi.
(Compiled from Doctor Luo Dalun’s lecture on Doctor Xu Shuwei’s case records; the case comes from Discussion of Ninety Cases of Cold Damage · The Sweat First, Purge Later Pattern.)