High Fever, Chills, Body Aches, and Not a Drop of Sweat? What Ma Huang Tang (Ephedra Decoction) — the First Sweating Formula of the Shang Han Lun — Is Really For

Patient search terms: cold with high fever and chills / whole-body bone pain / fever with no sweating / so cold that even a thick quilt doesn’t help / how to induce sweating during a cold / Ma Huang Tang

Corresponding medical names: tai yang cold damage, exterior excess pattern · externally contracted wind-cold · Ma Huang Tang pattern · wind-cold binding the exterior

Opening: why Doctor Luo is teaching the Shang Han Lun during the pandemic

In this episode, Doctor Luo begins telling the stories of Doctor Xu Shuwei and the Shang Han Lun — from the book Shang Han Jiu Shi Lun (Ninety Treatises on Cold Damage).

💬 Note from Doctor Luo: Why talk about this now? Because these days, everyone should learn a little about how to treat externally contracted illness. As we all know, the epidemic situation has grown complicated, and each of us needs to know how to protect ourselves. Learning some experience in treating external-contraction diseases and infectious diseases with Chinese medicine is especially valuable right now. So I decided to lecture on the Shang Han Lun — I cannot cover it comprehensively, but through Doctor Xu Shuwei’s case records, I can show you how the ancients practiced medicine.

Today’s case is the fourth Ma Huang Tang pattern in the book.

The patient: Doctor Xu Shuwei’s fellow townsman, staying at Jianfu Temple

The patient was Doctor Xu Shuwei’s fellow townsman, named Qiu Zhongchen, who was staying at Jianfu Temple in Piling — Piling is today’s Changzhou. He had contracted cold damage, that is, an externally contracted illness, and summoned Doctor Xu to treat him.

First, a word about Doctor Xu Shuwei himself. Later in life he held office — people called him Scholar Xu (Xu Xueshi); it is said he rose to the rank of grand academician and entered the imperial court, counting Han Shizhong and others among his friends. He eventually resigned his post and returned home to treat the common people. But in his early years he was already elderly and still had no official position — he kept taking the civil-service examinations, year after year. So at this time he was simply a physician treating ordinary folk, and people did not treat him with particular deference — they called him in the way they would call any local doctor. Today’s case has something of that flavor.

First visit: fever, headache, thirst — and a pulse that disappears below the chi position

Doctor Xu examined him: fever, headache, and thirst — burning up, head aching, and thirsty. Then he felt the pulse: floating and rapid, but without strength — the pulse floated, beat fast, yet had no force; moreover, below the chi position it could not be pressed at all — the lower pulses could not be felt.

💬 Note from Doctor Luo: When the chi pulse cannot be felt, what does that mean? It means this person has a deficiency. Look at the three pulse positions — cun, guan, and chi: the chi position corresponds to the kidneys. A floating, rapid pulse without strength is the pulse image of external pathogen present while the interior is already deficient.

Doctor Xu told him: your illness is the Ma Huang Tang pattern.

Ma Huang Tang and Gui Zhi Tang: the two brothers of the exterior patterns

At this point, Ma Huang Tang deserves a proper introduction — it stands alongside Gui Zhi Tang (Cinnamon Twig Decoction) as one of the two great classical formulas.

💬 Note from Doctor Luo: What does Gui Zhi Tang treat? It treats exterior deficiency with cold — weakness at the body surface. What does Ma Huang Tang treat? It treats exterior excess — the pattern of excess at the exterior, where cold pathogen is locked onto the body surface and the battle between upright and pathogenic forces at the surface is extremely fierce. Everyone should remember: Gui Zhi Tang you may use yourself, but Ma Huang Tang you should not casually use on your own — this decoction is fierce. Very fierce.

The composition of Ma Huang Tang, as Zhang Zhongjing wrote it clearly:

Ma huang (ephedra), nodes removed, three liang — in Han-dynasty measure about 45 grams; we usually write 9 grams today, a smaller amount;
Gui zhi (cinnamon twig), bark removed, two liang — 6 grams by today’s reckoning, though the ancient two liang was about 30 grams;
Zhi gan cao (honey-fried licorice), one liang — 3 grams;
Xing ren (apricot kernels), skins and tips removed, seventy pieces — about 10 grams today.

💬 Note from Doctor Luo: Do you see? The distinctive feature of this formula is that ma huang is the largest dose — bigger than gui zhi, bigger than gan cao. Why? Because ma huang is the herb that induces sweating. In Zhang Zhongjing’s Han dynasty (Eastern Han), formula doses were all very large.

The eight signs of Ma Huang Tang: high fever, chills, bone pain, and not a drop of sweat

Ma Huang Tang treats tai yang disease presenting with eight symptoms, which together constitute the Ma Huang Tang pattern. What are the eight?

💬 Note from Doctor Luo: The first is headache, the second is fever — after being attacked by cold, the head aches and the temperature rises. The third is body ache, the fourth is lower-back ache, and also joint pain — everyone who has had a high fever knows this feeling: every joint in the body hurts, so badly you almost want to hit yourself with the sole of your shoe to feel better. Then there is fear of wind, and no sweating — blazing fever with not a drop of sweat, burning very hot yet completely dry. And the last is panting — the rapid, urgent breathing.

Among these eight, the clearest difference between Ma Huang Tang and Gui Zhi Tang lies in the fear of wind and the sweating:

💬 Note from Doctor Luo: In the Gui Zhi Tang pattern the patient fears wind — putting on an extra layer of clothing helps. Oh, the wind blows, put on a jacket and it’s fine. Not so with Ma Huang Tang: fever, headache, burning up — how afraid of cold? So afraid that even under a thick quilt he still feels cold! You touch his forehead and his temperature is already 40 degrees, but he himself does not feel hot — only cold, with goosebumps, wanting to bury himself under the quilt. That is the Ma Huang Tang pattern. In the Gui Zhi Tang pattern, it’s merely a slight aversion to wind when the breeze blows. Also, Gui Zhi Tang involves sweating — that’s the deficient kind; Ma Huang Tang is without sweating.

As for the “panting,” Doctor Luo added a special explanation — is this asthma?

💬 Note from Doctor Luo: I don’t think this is asthma. Contracting an external illness does not necessarily trigger asthma. The panting here is a sign of the body mobilizing its own energy — breathing becomes rapid because the body is preparing to fight, to resist the pathogen, so it looks like asthma. Put the symptoms together and you have the eight signs of Ma Huang Tang. Everyone who has been through it knows the experience: high fever, chills, so cold that even a thick quilt is not enough, aching joints, aching bones, aching head — that is the Ma Huang Tang pattern.

The mechanism of the Ma Huang Tang pattern was summarized by the ancients in four characters:

💬 Note from Doctor Luo: Wind-cold arrives and binds the body surface, struggling against the cold pathogen — wei yang is suppressed (wei yang bei e): the defensive yang is stifled; ying yin congeals and stagnates (ying yin ning zhi): the nutritive yin cannot circulate, and the channels through which the defensive forces travel are blocked. The body surface is bound by cold pathogen, locked in fierce combat. In short: wei bi ying ning — the defensive is closed and the nutritive congealed. This is when Ma Huang Tang is used.

Formula breakdown: one opening, one descending — restoring the lung’s dispersing and descending

Why is Ma Huang Tang put together this way? Each of the four herbs has its own role:

💬 Note from Doctor Luo: Ma huang is the sovereign herb for inducing sweating — extremely powerful, it disperses the cold pathogen that has suppressed the yang qi and the defensive qi at the body surface. Gui zhi, as we discussed in the Gui Zhi Tang episode, frees the blood vessels and opens up the ying qi. It is not enough simply to disperse the cold if your own defensive forces cannot reach their posts; only when the blood vessels flow freely and ying and wei are harmonized can upright qi and essence-qi travel to the body surface to defend against pathogens. Ma huang paired with gui zhi means the pathogenic qi in both ying and wei is vented and expelled, ying and wei circulate without obstruction, and the cold pathogen is scattered. Xing ren descends lung qi and regulates it — ma huang disperses outward, xing ren descends downward; this one-opening, one-descending combination is xuan fei ping chuan, opening the lung to calm panting, restoring the lung’s dispersing and descending functions. So this formula goes outward, inward, upward, and downward — the coordination is superb. Honey-fried licorice guards the center. This formula needs no ginger or jujube, and after drinking it you don’t need to eat congee — because at this stage the body is still comparatively sturdy, not as deficient as in the exterior-deficiency pattern; the body still has energy to mobilize, so congee is unnecessary.

Doctor Luo also shared a good deal of practical knowledge about ma huang itself:

💬 Note from Doctor Luo: Ma huang is not used much today — there were problems historically, so people became afraid of it. Ma huang induces sweating, and if the dose is even slightly off, the sweating cannot be stopped and the person can get into trouble — rivers of sweat pouring out. Zhang Zhongjing was extremely particular about removing the nodes — the nodes of the ephedra stem contain a particularly high amount of certain constituents that easily cause side effects. The decoction method also matters: boil the ma huang first — originally with nine sheng of water, boiled down by two sheng, and the foam on the surface must be skimmed off — this foam also contains constituents that cause side effects, mainly a racing heart, flushed face, extreme excitement, and profuse sweating from the head. Remove the foam, then add the other herbs and continue boiling. Also, some drugs and stimulants today are extracted from ma huang, which is why medicines containing ma huang are banned in some countries; during athletic competitions, anything containing ma huang cannot be sold. Some people who take ma huang-containing medicines feel palpitations and excitement, cannot sleep all night, or even find the sweating won’t stop — all because the rule of boiling it first and skimming the foam was not followed.

Doctor Luo also recalled his own early training with the old physician Master Zhang Daokuan:

💬 Note from Doctor Luo: The old master often told me he loved using ma huang: when a patient came in and he saw listlessness and insufficient upright qi, he liked to add a little ma huang to the formula — just two or three grams — to do what? Revive the yang qi, to rouse the body’s vitality. He generally combined ma huang with fu zi (aconite) and similar herbs, to revive the body’s energy and lift the upright yang. That was his experience; the old master taught me many ways of using ma huang, and I learned a great deal.

There are also raw ma huang and honey-fried ma huang: generally the raw form is used; honey-fried ma huang is far more gentle — in Zhang Zhongjing’s Ma Huang Tang, the raw form is used.

But Doctor Xu Shuwei said: the chi pulse is weak — we cannot induce sweating

Back to Qiu Zhongchen’s case. Doctor Xu said it was the Ma Huang Tang pattern — but there was a problem: the chi pulse was weak, both slow and weak, indicating something wrong within the body.

💬 Note from Doctor Luo: Zhang Zhongjing said: “When the chi pulse is slow, ying qi is insufficient, blood and qi are scanty — sweating must not be induced.” A slow chi pulse — beating sluggishly — means ying qi is insufficient and blood and qi are scanty; at such a time sweating cannot be induced.

So what did he do? Doctor Xu prescribed Jian Zhong Tang (Center-Fortifying Decoction) with dang gui and huang qi added — what is Jian Zhong Tang? Gui Zhi Tang with the peony doubled and some malt sugar added is Jian Zhong Tang (specifically, Xiao Jian Zhong Tang, Minor Center-Fortifying Decoction); dang gui (Chinese angelica) nourishes the blood, huang qi (astragalus) supplements the qi — this is supporting the upright qi. He had the patient drink it slowly.

The family grows impatient: “Just make him sweat!” — and they say it rudely

The next day, the patient could no longer endure it. His family members — morning and evening — kept saying to Doctor Xu: give him some sweating medicine! If it’s time to sweat, then sweat! Their words were less than courteous — they even spoke rudely.

💬 Note from Doctor Luo: At this point, Doctor Xu was treated much the way Doctor Yu Jiayan was — treating patients for free, going to their homes, and the family still complained he was too slow. Doctor Xu’s response: “yi yu xiang ren yin ren zhi — he is my fellow townsman, so I will endure it.**” He thought: this is my fellow villager, I will bear it patiently; let me not get angry. If they want to find fault, let them find fault — I will keep treating him.

The turning point: six or seven days later the chi pulse regains its strength — only then Ma Huang Tang

By the sixth or seventh day, the chi pulse responded to the finger — after six days it felt strong again, and its speed had returned to normal. Only then did Doctor Xu prescribe Ma Huang Tang.

💬 Note from Doctor Luo: He drank the first dose, then the second — after the second dose, wild talk, restlessness, and a stifled feeling: speaking deliriously, agitated, and oppressed. This was the qi and blood beginning to circulate, the body beginning to readjust. After a while, the delirium settled — it calmed down; and then he began to sweat. After the sweat broke, with five more days of recovery, the illness was completely cured.

Some people will say: this Doctor Xu is terribly slow — why not just induce sweating at once and be done with it? Doctor Luo says: not necessarily —

💬 Note from Doctor Luo: Some say one cold shouldn’t take so many days to treat. But what was Doctor Xu actually treating? He was treating the person’s body. Think about it: the chi pulse had slowed, which meant the body had a problem. He gradually supported the upright qi, and once the body was regulated, he expelled the external pathogen — when the upright qi is sufficient, the external pathogen leaves on its own. Doctor Xu’s entire process was one of supporting the upright and dispelling the pathogenic (fu zheng qu xie).

Doctor Xu explains the mystery himself: skip the proper sequence and you damage the five organs

Doctor Xu himself spelled out the mystery. He wrote (in his treatise):

💬 Note from Doctor Luo: Zhongjing said that when it is a Ma Huang Tang pattern you should treat it promptly — but what must the physician keep in view? Keep in view the exterior and interior, the deficiency and excess, and allow time (gu qi biao li xu shi, dai yi shi ri). You must know the state of its exterior-interior and deficiency-excess. If you do not follow the proper sequence — though the patient may be temporarily relieved, the five organs are damaged and lifespan is shortened (sui zan de an, ran kui sun wu zang, yi cu shou ming), the constitution deteriorates. What is there to admire in that?

Doctor Xu also told a story — the parable of Fan Yun:

💬 Note from Doctor Luo: In former times, Fan Yun was a subordinate of Chen Baxian. Chen Baxian was the founding emperor of the Chen dynasty in the Northern and Southern Dynasties period — formerly a great general, he deposed the reigning monarch and proclaimed himself emperor. He planned an enthronement ceremony, and the task was entrusted to Fan Yun. The date was nearly upon them when Fan Yun caught wind-cold — contracted cold damage. He had to preside over the ceremony, so he summoned the famous physician Xu Wenbo. He asked: can you make me well immediately? My superior’s task is due at once. Xu Wenbo said: making you well quickly is easy, but your upright qi will be injured — I fear that in two years you will no longer be here (kong liang nian hou bu fu); your constitution was never strong, and in two years you may be in serious trouble. Fan Yun said: “If I can hear the Way in the morning, I can die in the evening — let alone in two years! “ As long as the task is done, it matters not whether I die this morning or tonight — let alone in two years! Cure me at once. So Xu Wenbo heated the ground with fire — heated the earth until it was hot, spread peach leaves and cypress leaves over it, laid a mat and bed on top, and had Fan Yun lie upon it — the ground was steaming hot, and the sweat burst out in an instant. After the sweating, a warm powder (wen fen) was dusted over his body — a medicinal herbal powder that restrains perspiration. The next day he was well. Fan Yun was delighted, but Xu Wenbo said: this is nothing to rejoice over — your upright qi has already been injured. And indeed, two years later, the man died. This parable was widely circulated in antiquity and is recorded in the books.

Doctor Xu cited this parable precisely to make the point: “Taking sweat prematurely still shortens the lifespan” (fu qu han xian qi, shang cu shou ming) — if your upright qi is already insufficient and the sweat cannot come out, forcing the sweat injures your own upright qi and, as a result, affects your lifespan. Even Fan Yun’s case shortened his life — how much worse, then, to disregard exterior and interior, deficiency and excess, refuse to allow time, and merely rush to cure the illness?

💬 Note from Doctor Luo: And so Doctor Xu sighed: “Every day I see patients’ families who cannot endure three or four days” (mei jian bing jia bu nai san si ri) — day and night they press: “make him sweat, make him sweat.” And the physician? He weighs his own concerns: if I induce the sweating I’ll collect a larger fee, and if I delay two more days the patient may switch to another doctor — so he hurriedly goes along with their wishes and induces the sweat — rarely does trouble not follow (xian bu zi bi). Doctor Xu said: this is what I hold most precious in my practice — this warning.

The Nine Prohibitions of Ma Huang Tang: these nine kinds of people must never be forced to sweat

In the Shang Han Lun, Zhang Zhongjing wrote nine separate passages forbidding the use of Ma Huang Tang to induce sweating — the whole is called the eight signs and nine prohibitions of Ma Huang Tang: eight symptoms, nine prohibitions. What are the nine? Doctor Luo goes through them one by one:

💬 Note from Doctor Luo: The first is slow chi pulse (chi zhong chi) — exactly the situation Doctor Xu encountered. Zhang Zhongjing says “ying qi is insufficient; the blood is scanty” — such a person cannot be made to sweat. Why? Ying qi insufficiency: ying yin is the body’s fluids, and like blood, they are liquids. Sweat and blood share the same source (xue han tong yuan) — the fluid the body can use is, in effect, a fixed quantity: when blood is deficient it is converted to blood, when fluids are deficient it is converted to fluids. If you induce profuse sweating in a person whose blood is already scanty and whose ying qi is insufficient, you damage the ying yin further and injure the interior. So those with scanty blood or insufficient fluids are strictly forbidden from sweating.

The second is faint chi pulse (chi zhong mai wei) — Zhang Zhongjing explains this as interior deficiency. The upright qi must be sufficient for the fluids to be adequate and the sweat to come out. If the interior is already very deficient and the fluids inadequate, inducing sweat actually injures the upright qi of the interior.

The third: those with dry throat must not be made to sweat. Why? Dry throat is often a sign of kidney yin deficiency — the kidney channel passes through the throat. With kidney yin deficient, the body’s fluids are insufficient and yin blood is scanty; if you then induce sweating, it is like draining all the body’s fluids out at once, leaving the interior yin even more deficient.

The fourth: the urinary-dribbling patient must not be made to sweat, or sweating will bring blood in the urine (lin jia bu ke fa han, fa han bi bian xue) — those with dribbling, painful urination have damp-heat in the interior and cannot be sweated. Using hot herbs to induce sweat only makes the lower-burner heat fiercer and the damp-heat worse, and may bring blood in the urine.

The fifth: the sore-ridden patient (chuang jia) — one covered with sores, though the body aches, must not be made to sweat. Why would convulsions and spasms follow sweating? Because those with sores usually have concentrated heat-toxin; with heat-toxin present, the fluids are often injured and the yin blood damaged. Sweating then depletes the yin blood and triggers cramping — sweating brings rigidity (han chu ze jing).

The sixth: the nosebleed-prone patient must not be made to sweat (nü jia bu ke fa han) — those who frequently bleed from the nose. The nosebleeds have already occurred, the blood is already depleted; such a person’s yin blood is surely deficient, and sweating makes it more deficient still.

The seventh: the blood-losing patient must not be made to sweat (wang xue jia bu ke fa han) — those with chronic bleeding conditions; their blood is depleted too, and they cannot be sweated.

The eighth: the habitual sweater (han jia) — a person who already pours sweat in daily life cannot be made to sweat further; more sweating means more fluid loss. Sweat is the fluid of the heart (han wei xin zhi ye); sweat and blood share the same source, so with yin blood already scanty, the body can bear even less.

The ninth: a patient with internal cold must not be made to sweat (bing ren you han bu ke fa han) — Zhang Zhongjing especially notes that those with cold spleen and stomach cannot be sweated. A cold person is congealed, qi and blood stagnant — this is not something simple sweating can resolve. You must warm the interior (wen li), warming it up so the channels gradually open and the sweat comes out on its own. If the interior’s qi and blood are congealed and you force the sweat, you often injure the upright qi while the cold remains unresolved — and, worse, damage the yang qi further.

There is one more passage Doctor Luo singled out — when Zhang Zhongjing discussed the faint chi pulse, he mentioned those with palpitations:

💬 Note from Doctor Luo: The palpitation patient (xin ji) — a racing, pounding heart, as we now call palpitations — is often a person of insufficient qi and blood, and such a person cannot be sweated. Sweat such a person and the heart is gravely injured — problems are even more likely.

At this point, Doctor Luo summarized the essence of the Nine Prohibitions:

💬 Note from Doctor Luo: Zhang Zhongjing created Ma Huang Tang, the sweating formula, and then wrote out many prohibitions around it — what do these prohibitions look at? They look at whether your fluids and yin blood are scanty, whether the upright qi is insufficient, and whether there is cold in the interior. If any of these is present, do not induce sweating directly. You must first protect the interior: replenish the yin fluids and fluids, scatter the cold and warm the interior for the cold-type patient, and supplement the interior deficiency for the deficient-upright-qi patient — then, when you do induce sweating, the illness can be cured. So do not think that just because you were attacked by cold at the body surface, “I feel cold, so let me sweat” — that is not how it works. Many people keep forcing themselves to sweat, and the result is a body that grows ever weaker, an exterior that grows ever more deficient — next time the wind blows, another cold; the wind blows again, another cold. This is connected to inappropriate sweating.

Going further: sweating is not the goal — free-flowing qi and blood are

So what is the correct approach? Doctor Luo shared his own practice:

💬 Note from Doctor Luo: This is why I have always urged everyone to drink huai shan yao water (Huai yam water). In the earliest days I said intravenous fluids were acceptable — but indeed, some people’s upright qi is insufficient; after fluids and sweating, they should take something that tonifies the middle qi, something that supports the upright qi, to replenish it. If they don’t replenish it, next time it’s intravenous fluids again, always trying to sweat — that won’t do. Later, what I came to recommend is huai shan yao powder: use shan yao slices or powder to support the upright qi, and then let the sweat come out slowly. Sweating only after the upright qi is sufficient — that is the correct treatment, the Way. For those with deficient yin blood, sweating demands care — it can injure the yin severely, so you should nourish yin and blood first, regulate the body, and then sweat; sometimes, once the yin blood is replenished, the body’s qi and blood circulate naturally, the sweat comes, and the external pathogen resolves on its own.

Ordinary people have traditionally known the sweating method — at the start of a cold, drink some ginger soup, take some scallion, boil scallion whites in water and drink it. Doctor Luo says this is also a good method, but you must understand the principle:

💬 Note from Doctor Luo: In the past I would put a little brown sugar in the granule medicines — why brown sugar? To nourish the blood! These were things the ancients and the common people took very seriously, and we have forgotten them now — we only think about sweating. Sweating is absolutely not the goal — sweating is a means to make the qi and blood flow freely, to get the body’s upright qi circulating, and to resolve the external pathogen. So never think that sweating is appropriate in every situation. Understand the spirit of Zhang Zhongjing’s prohibitions: when your upright qi is insufficient, your fluids depleted, and your blood scanty, do not lightly induce sweating — if you lack the energy and insist on going into battle, the interior will consume enormous amounts of energy.

Later physicians all studied Doctor Xu’s method:

💬 Note from Doctor Luo: The later masters, Doctor Zhu Danxi and others, all treated patients the way Doctor Xu Shuwei did — because Doctor Xu came first, in the Song dynasty, and Doctor Zhu Danxi and the rest learned from him: in treatment they did not hurry; day by day they supported the upright qi first, and finally, when the standard formula was applied, the illness was cured. When Doctor Zhu Danxi treated his own classmate, also for diarrhea, he supported the upright qi for a long time — the patient himself thought he was dying — and in the end Doctor Zhu cured him with a purging method. This is what it means for a physician to hold the art in his heart (xin li you shu) — Doctor Xu’s approach is a treatment method that considers the patient’s body over the long term. If you want the simple route, of course I can make you sweat — but I am treating your whole body; sweating is only a momentary matter. If I replenish your upright qi and then induce sweating, curing this external contraction is easy; but if you cure the external contraction while the body is still deficient, the body still has a problem.

Finally, Doctor Luo added a practical word of caution:

💬 Note from Doctor Luo: Ma Huang Tang is not something everyone dares to use, nor is it to be used casually — even enthusiasts may not gauge it precisely. But this idea we should grasp: the idea of knowing when not to lightly induce sweating. During the epidemic, the more we can share methods and ways of thinking about external-contraction illness, the better — I hope that while isolating at home, everyone can learn a little Chinese medicine. It will do you good.

Tomorrow, the stories of Doctor Xu Shuwei’s practice continue.

Compiled from Doctor Luo Dalun’s lecture series on Doctor Xu Shuwei’s case records.