Today, Beijing welcomed a late spring chill with a heavy snowfall. On the bus, I heard many people coughing.In daily life, we often encounter individuals troubled by chronic wheezing. Whether on the cold winter streets or in the quiet of the night, the sound of severe wheezing seems like a painful cry from the body.Chronic wheezing not only severely affects the quality of life of patients but can also pose a threat to their health. Many people seek medical help in various places, but often overlook a common herbal remedy called Ma Huang (Ephedra), which may bring new hope to those suffering from chronic wheezing.To better understand this herb, let’s study a passage from the Shang Han Lun (Treatise on Cold Damage).35. In Tai Yang disease, with headache, fever, body aches, lower back pain, joint pain, aversion to wind, no sweating, and wheezing, Ma Huang Tang (Ephedra Decoction) is the main treatment.The difference between Tai Yang disease with no sweating and the symptoms of Gui Zhi Tang (Cinnamon Twig Decoction) is the presence or absence of sweating. It (the Ma Huang Tang syndrome) also has fever, headache, and fever similar to Gui Zhi Tang. However, due to the absence of sweating, there is an excess of moisture on the surface of the body, leading to a heavier heat. This pressure on the body causes widespread pain, hence “body aches, lower back pain, joint pain” indicates pain everywhere.So, does Gui Zhi Tang cause pain? Yes, but it is milder. Gui Zhi Tang allows some sweating, which releases some moisture, reducing the pressure from external moisture and the toxins present, so it (the Gui Zhi Tang syndrome) is not as painful and does not affect the lungs, hence no wheezing. The Ma Huang Tang syndrome, on the other hand, has no sweating at all, so the pulse is tight; a tight pulse indicates that there is sufficient fluid in the blood vessels, which we call Jin Ye (body fluids). Not only does it cause pain everywhere, but it also inevitably affects the lungs, hence “aversion to wind, no sweating, and wheezing”.
Ma HuangBecause our body also excretes waste through the skin, in the case of Ma Huang Tang syndrome, there is no sweating at all, and the waste that should be excreted through the skin is all burdened onto the lungs. Therefore, the lungs are stimulated by the toxins from the waste, leading to wheezing. This is why ancient practitioners used Ma Huang Tang to treat wheezing, which makes a lot of sense. However, if there is no exterior syndrome, ancient practitioners would not use Ma Huang for wheezing. Unlike some Western doctors who love to use ephedrine at the first sign of wheezing, TCM emphasizes syndrome differentiation. If there is wheezing without sweating, and the symptoms of Tai Yang disease are present, then using Ma Huang Tang is appropriate. The formula for Ma Huang Tang is very simple. Ma Huang is combined with Gui Zhi (Cinnamon Twig), which induces sweating quite effectively. When Ma Huang is combined with Xing Ren (Apricot Kernel), it regulates wheezing.We all know that Xing Ren has the effect of descending Qi and regulating wheezing. Gan Cao (Licorice) also alleviates urgent wheezing; wheezing itself is an urgent condition, especially with pain, as the body is in pain everywhere, and Gan Cao also alleviates pain. This formula is: for Tai Yang disease, if there is also fever, headache, body aches, joint pain, and no sweating with wheezing, this type of Tai Yang disease must use Ma Huang Tang. This is completely different from the previous Gui Zhi Tang.Generally, we say that Gui Zhi Tang is a syndrome of exterior deficiency, which is Yang deficiency, specifically a deficiency syndrome of Yang. Ma Huang Tang, on the other hand, is an exterior excess syndrome. The preparation method for Ma Huang Tang is also to first decoct Ma Huang, remove the foam, boil for a couple of minutes, and then add the other herbs to cook. This (Ma Huang Tang) induces sweating quite powerfully, unlike Gui Zhi Tang.36. In cases of combined Tai Yang and Yang Ming disease, with wheezing and fullness in the chest, do not purge; it is advisable to use Ma Huang Tang.Look, this is also a case of combined Tai Yang and Yang Ming disease, which does not necessarily require purging. This combined disease refers to the symptoms of Tai Yang and “fullness”.The Yang Ming section refers to the stomach being full, which naturally leads to abdominal fullness. This is “chest fullness”, or there may be “dry stools”; these two diseases (the Tai Yang disease and fullness) occur simultaneously, hence it is also called a combined disease. However, it has another meaning. “Wheezing and chest fullness” indicates that the wheezing is the primary concern. The wheezing causes chest fullness, not the abdominal fullness causing wheezing. This (wheezing and chest fullness) is unrelated to Yang Ming disease, so do not purge; it is advisable to use Ma Huang Tang to resolve the exterior.Because “wheezing” is a disease common to both the exterior and interior, this is very important clinically. Wheezing caused by interior excess, if treated with Ma Huang Tang to induce sweating, will worsen; wheezing caused by unresolved exterior will worsen with purging. We have discussed this extensively; using purgatives for exterior syndromes not only fails to resolve the exterior but also draws the evil inward, leading to more severe illness. He (Zhong Jing) had this intention to make you pay attention to differentiation.Wheezing due to interior excess is primarily caused by fullness, which presses upward and then leads to wheezing.This section does not seem to have a problem of combined disease; it is simply that fullness and wheezing occur simultaneously. He specifically included “combined Tai Yang and Yang Ming disease” to remind you to differentiate whether it is wheezing due to Tai Yang disease or wheezing due to Yang Ming disease. Because wheezing due to Tai Yang disease can also have wheezing and fullness, but it is chest fullness. Wheezing due to Yang Ming disease can also have wheezing and fullness, but it is abdominal fullness. The main distinguishing point between these two diseases is which is primary: wheezing or fullness. If you cannot clarify this, it is easy to make mistakes, so he specifically included “combined Tai Yang and Yang Ming disease” (but in fact, this section is fundamentally a case of Tai Yang disease with Ma Huang Tang syndrome).37. In Tai Yang disease, if ten days have passed, and the pulse is floating and thin, and the patient is drowsy, the exterior has resolved. If there is chest fullness and pain in the hypochondrium, use Xiao Chai Hu Tang (Minor Bupleurum Decoction). If the pulse is only floating, use Ma Huang Tang.This is the most commonly seen in clinical practice. Catching a cold does not necessarily mean it has been ten days; according to the observations of the late Hu Xishu, this can happen in three to four days. The exterior is gone, but the pulse is still floating and thin.A thin pulse indicates a deficiency of fluids and blood; a floating and thin pulse indicates that the fluids on the surface are also deficient, and the blood is insufficient, indicating that it is still on the surface.At this time, the person also feels drowsy. Drowsiness is a special symptom that is half exterior and half interior, especially in Shaoyang disease. This symptom is not mentioned in the Shaoyang section, especially since it is a Chai Hu syndrome, which we can discuss slowly later.This (Chai Hu syndrome) is commonly seen in clinical practice. When the pulse is floating, giving sweating medicine is incorrect; this indicates that “the exterior has resolved”. Why? Because the pulse is floating and thin. The disease has entered the interior, and the person feels drowsy and weak.If at the same time there is “chest fullness and pain in the hypochondrium”, this indicates a Chai Hu syndrome, with fullness in the chest and pain in both hypochondria. The Xiao Chai Hu Tang states that “blood is weak and Qi is exhausted, and the pores are open”.
At the beginning of the illness, the pathogenic factor is at the outermost layer of the body, which is the “exterior”. At this time, the body’s immune system (the righteous Qi) detects the enemy (the pathogenic factor) and intends to drive it out through sweating. It is like ancient warfare, where the enemy is outside the city, and we plan to open the city gates to let the soldiers go to the city wall (the body surface) and drive the enemy back together. Both Gui Zhi Tang and Ma Huang Tang are methods the body’s righteous Qi uses to resolve exterior pathogenic factors through sweating.
However, after a fierce battle, the righteous Qi at the surface gradually becomes overwhelmed. It is like the soldiers on the city wall getting tired, and the forces are insufficient to continue holding the city wall (the body surface). However, the righteous Qi still does not want to give up the resistance; it plans to change the battlefield to continue fighting, thus moving the battlefield to the “half exterior and half interior” area.
The half exterior and half interior can be understood as the level where various organs in the body cooperate internally, involving the lungs, kidneys, and other organs, attempting to expel the pathogenic factors through the respiratory system (for example, coughing to expel phlegm) or the urinary system (urination may also carry away some pathogenic substances), or possibly trying to expel the pathogenic factors through the sweat glands.
When the righteous Qi retreats from the surface and strengthens the internal defenses, the fluids and blood at the surface decrease relatively. At this time, the pulse will change, from the floating pulse (indicating the pathogenic factor is at the surface) to a floating and thin pulse. “Thin” indicates insufficient Qi and blood, as the Qi and blood have been redirected to fight internally, leaving the surface “empty”.
At the same time, the person will feel very drowsy, wanting to lie down (drowsiness). It is like soldiers getting exhausted from fighting, all wanting to rest. At this time, if the exterior pathogenic factor has basically been resolved (the exterior has resolved), we should consider whether the patient has entered a Shaoyang disease state, which means checking if it meets the diagnosis of Xiao Chai Hu Tang syndrome.
In the Shaoyang disease stage, an important characteristic is the feeling of fullness and discomfort in the chest and hypochondrium. This is because the pathogenic Qi enters the half exterior and half interior, accumulating in the chest and hypochondrium, where the righteous Qi and the pathogenic Qi are battling, leading to such symptoms.
To determine whether it is a Chai Hu syndrome, one cannot only look at the symptom of “drowsiness”. If there is also fullness in the chest and pain in the hypochondrium, then it meets the criteria for Chai Hu syndrome, and at this time, Xiao Chai Hu Tang can be used for treatment.
The development of disease generally starts from the surface, gradually moving to half exterior and half interior, and then to the interior, or directly from the surface to the interior. In clinical practice, we often encounter situations where a person has a persistent high fever that does not subside; although the pulse appears floating (indicating the possibility of the pathogenic factor being at the surface, but it may also involve other conditions), it is also somewhat thin, and the person feels drowsy and weak.
In such cases, nausea, fullness in the chest and hypochondrium, and sometimes alternating chills and fever (feeling cold one moment and hot the next) often appear, which are typical manifestations of Chai Hu syndrome. At this time, using Xiao Chai Hu Tang as the main treatment is correct.
If the patient also exhibits symptoms such as dry mouth and tongue, and a white coating on the tongue, it is necessary to add Shi Gao (Gypsum) to the Xiao Chai Hu Tang. This situation is quite common in clinical practice.
In clinical practice, we often encounter patients with high fever lasting for many days, and this is often because the doctor did not consider using Xiao Chai Hu Tang, leading to the condition not improving. Situations like “ten days have passed, and the pulse is floating and thin, and the patient is drowsy” are the most common in clinical practice.
Xiao Chai Hu Tang uses Chai Hu as the main herb, with a larger dosage (historically half a jin, if one dose is divided into three parts, each part is about eight qian). Chai Hu and Huang Qin (Scutellaria) are both bitter and cold herbs, effective in clearing heat and relieving irritability. Chai Hu can treat fullness in the chest and hypochondrium; in the Shen Nong Ben Cao Jing (Shen Nong’s Classic of Materia Medica), it is recorded that it can “relieve Qi stagnation in the heart and abdomen”, which means it can eliminate the fullness and pain in the chest and hypochondrium caused by the accumulation of pathogenic Qi. Therefore, Chai Hu combined with Huang Qin can both reduce fever and alleviate discomfort in the chest and hypochondrium.
The formula also includes Ren Shen (Ginseng), Gan Cao, Da Zao (Jujube), and Sheng Jiang (Fresh Ginger), which are all herbs that strengthen the stomach, along with Ban Xia (Pinellia) to stop vomiting. This is because Chai Hu syndrome belongs to Shaoyang disease, which generally has vomiting symptoms.
The reason for using these stomach-strengthening herbs is that the pulse being floating and thin indicates that the body’s fluids and blood are insufficient, and the fluids are produced by the stomach. The reason the external pathogenic factor can invade the body is that the fluids at the surface are insufficient to resist the pathogenic factor, allowing it to develop inward.
In the stage of Xiao Chai Hu Tang syndrome, while the pathogenic factor has not completely entered the body, we should use stomach-strengthening herbs to generate fluids, replenish the body’s righteous Qi, and enhance the ability to resist the pathogenic factor. As Xu Ling Tai said, “the brilliance of Xiao Chai Hu Tang lies in Ren Shen“, emphasizing the importance of Ren Shen in this formula.
However, if the pathogenic factor has already entered the body, we should not use stomach-strengthening herbs, as it would be like closing the door to catch a thief, which is not conducive to recovery.
Xiao Chai Hu Tang is both a heat-clearing agent, helping the body to reduce fever; and a stomach-strengthening agent, which can strengthen the stomach and stop vomiting.
In clinical practice, most patients with Xiao Chai Hu Tang syndrome have poor stomach function, which is why vomiting symptoms occur. Generally speaking, if there are no vomiting symptoms, it is unlikely to be Shaoyang disease, and if there are no thirst symptoms, it is unlikely to be Yang Ming disease (which usually has thirst symptoms). Shaoyang disease often accompanies vomiting symptoms.
Through the passages of the Shang Han Lun, we learn not only about Ma Huang Tang but also about Xiao Chai Hu Tang.
Although Ma Huang has significant efficacy in treating chronic wheezing, caution is also needed when using it. Due to its strong sweating and lung-dispersing properties, patients with exterior deficiency sweating, Yin deficiency night sweating, and those with both lung and kidney deficiency cough and wheezing should use it with caution.
In summary, this ancient herb, Ma Huang, has unique advantages and potential in treating chronic wheezing. We should fully recognize and utilize the efficacy of Ma Huang.
However, during the process of use, it is essential to follow TCM principles, differentiate syndromes, and use medications rationally, allowing this magical herb to better serve us.
I am Dr. Chen from Beijing, and I welcome you to follow me!