Ma Huang in the Clinic - Andrew Nugent-Head

The Practical Herbalist #02: Ma Huang in the Clinic by Andrew Nugent-Head


INTRODUCTION: The Practical Herbalist is not a list of shortcuts nor a substitution for a classical understanding of prescribing herbs from the Flavor and Nature paradigm that defined our medicine. It expects the reader to have this as a foundation and assumes this knowledge. If the reader is new to the concept of prescribing from the Flavor Nature perspective that was established in the Nei Jing, or would like refreshing on its core principals, they are directed to the four excellent articles by JulieAnn Nugent-Head on classical herbalism published by the Journal of Chinese Medicine. If they wish more information, they can also watch her 3 hour introductory video The Nei Jing as Our Guide to Herbs or her complete online training program, The Classical Herbalist: an In Depth Training Course. Both are available on the Association for Traditional Studies’ online teaching platform: Simply search for them in the search box to find them among our many online courses.

 It may be strange to begin a series entitled The Practical Herbalist with an herb many western practitioners may never have taken, prescribed or even held in their hand before. But Ma Huang’s use traditionally by Chinese medicine and currently in pharmaceuticals make it important to understand as we adopt a practical approach to customizing formulas. The first thing to understand about Ma Huang is it does not induce sweating. Its important effect is to move water, and where that water is moved to and through depends on what Ma Huang is paired with. If Ma Huang is paired with warm and acrid Gui Zhi, water is pushed up and out the surface, breaking a sweat—this is what most practitioners think of due to the fame of Ma Huang Tang and the lack of attention paid to other Ma Huang formulas. In Ma Xing Yi Gan Tang, the water Ma Huang moves is guided out through the urine by bland and slightly cool Yi Yi Ren. In Ma Xing Shi Gan Tang, it is used to unblock congested lungs within a formula designed to cool the body with Shi Gao—the opposite of how most people view Ma Huang as a Tai Yang Wind Cold invasion only herb.

 But the truth is Ma Huang does not move water, it excites and stimulates the Yang. With greater Upright Yang movement, pathogenic Yin (fluids/damp in this discussion) is dislodged and moved out. Thus, the movement of water is not an action of Ma Huang, but a result of its action: stimulating Yang. As we are stimulating Yang, the flavor assigned to it is a Yang nature and flavor: warm and acrid. But Ma Huang is not a ‘warm’ or ‘hot’ herb, it is a Yang stimulating herb. Drinking a cup of Ma Huang as a tea does not produce warmth in the mouth or stomach the way drinking a cup of Gui Zhi, Gan Jiang, garlic or chilis does. Known as Mormon or Brigham Young Tea in Utah, a cup of Ma Huang may excite the heart but is not spicy or warming at all in a sensory way. To our detriment as practitioners, we frequently confuse the end result with the mechanism that created the end result, just as we assume a flavor or nature to be what the herb is instead of a short hand description of how it effects Yin and Yang.

 Why is this important? Because Ma Huang is a fantastic herb to push Yang into places which are blocked by cold and/or damp pathogens, thereby clearing the roads and allowing the Upright Qi to regain a foothold where it has been denied. Gui Zhi by itself will simply not be strong enough to expel deep cold with chattering teeth and a tight, wiry pulse. Gui Zhi’s flavor and nature is warm acrid, but in this case it is literally warming and thus moves Yang, as opposed to Ma Huang’s ability to move Yang and thus create warmth. When a head cold or severe sinus infection sets in with completely blocked passages and intense pain in the head, very few herbs are going to be strong enough to break the Pathogenic cold and damp in one of the hardest regions to reach—the head. Ma Huang can excite the Yang enough that we can force our way into the head, allowing other warming and drying herbs such as Gao Ben, Chuan Xiong, and/or Bai Zhi to actually reach the head and clear the sinuses. We can then add some light cold bitter herbs to hop on the train heading up into the head such as Bo He, Jin Yin Hua and/or Da Qing Ye to tackle the toxicity of green yellow phlegm along with the sinus infection.


It is also fantastic for pushing Upright Yang out to the extremities to dislodge the Damp Bi of arthritis in the hands or feet. While large doses of Gui Zhi paired with pathogenic exiting herbs like Yi Yi Ren and a list of other ‘damp draining’ herbs can be effective, it often fails or requires unrealistically large doses of Gui Zhi if the case is severe or there is already deformation of the joints. At that point, using Ma Huang to drive through the blockages is more effective. Variations of Ma Xing Yi Gan Tang based on the patient in front of us easily and quickly stops pain and swelling of arthritic joints. Cold, atrophied arthritic joints do well with Ma Huang as the driving force paired with Gui Zhi or more warming but less moving herbs like Gan Jiang, Jiang Huang, etc. Without the other herbs, Ma Huang will not solve the arthritis. But the ‘arthritis fixing herbs’ we might default to won’t get a chance to work if they can’t get there without strongly moving Yang to bring new Qi and blood to the fingers and wash away the stagnation and stasis entrenched there.


What follows is an analogy, and it is not really how it works but can help understand what herb to use when needing to push Yang through the body. Think of Sheng Jiang as first gear in a car designed to warm. It is certainly warming, but how warming it is and how far we can go in first gear is limited by our being only in first gear. If we need second gear pushing of Yang, we then add or switch to Gui Zhi, and we get further and stronger than we were in first gear. Need a third gear push? That would be Ma Huang. Need to really get the car moving? We could switch into fourth gear and use Fu Zi. Our first two gears are truly warming and thus helping Yang; our second two gears are not warming at all if placed in the mouth but move Yang strongly and thus allow warmth to return. This is very important to understand, as when we realize Ma Huang is moving Yang, and it does so by increasing our heart rate and exciting the system, we can then start using other methods to do so in a day and age when obtaining Ma Huang is difficult or not permitted.


In my years in China, I personally loved using Ma Huang. It is stronger than Gui Zhi, but not the heavy hand that Fu Zi can be when the Yang simply needs moving and not rescuing. Learning to accentuate Ma Huang’s circulatory stimulation and extremity reaching properties with warm acrid herbs or tempering its effects by literally thickening the soup of the patient’s formula with not just Xing Ren (ground, it makes a patient’s formula milky and soothing), or Yi Yi Ren (the barley boils out into a thickish starch), but also Shan Yao (starchy yam) or anything else that would soften its stimulating abilities allowed me to reach the actual doses used in the Shang Han Lun of up to 45g per formula and apply that across a wide variety of conditions. Auto-immune pain from lupus, fibromyalgia, RA as well as other pain conditions quickly lessen and vanish with proper pushing of the Upright Yang to drive the pain away. Matching the stimulation of Yang in an herb that is not actually hot to the taste means Ma Huang can be paired with herbs to treat hot or cold auto-immune and other conditions.


Having had this discussion with so many fellow practitioners over the years, the question that inevitably arises is what can we do if we do not have Ma Huang? The reason we began as we did in Practical Herbalist #01 is to erase the idea that the specific herb is what defines the formula. It is the desire for a specific flavor and nature effect on the body which lead to the picking of an herb based on what was available to the practitioners of the time. This means what the practitioners chose was dictated by the seasonal availability of herbs at the time they penned the formula which would become classic, as well as whether they were southern practitioners with one set of flora available to them or northern or western or eastern practitioners with a different set of flora around them. The practitioner set about to affect the Upright Qi and the Pernicious Qi, chose the correct flavor and nature which would accomplish the stimulation they needed, then grabbed what was on hand at that time and place to do so. The next thing we know, people are believing that the herb used is magic and a formula without that herb’s name is not a classic formula—missing that it was classical thinking of flavor and nature combined with availability that skyrocketed the herb in question to fame.


Of course, some herbs are simply so good at it that it would not make sense to use another unless we did not have them available. Or, in the case of Ma Huang, for unfortunate reasons an herb was banned due to misuse in other industries (dieting teas and weight loss programs, sigh). So what do we do when Ma Huang is not available but we need to drive Yang up to the head? One clever doctor in the Song Dynasty thought to use a handful of acrid herbs powered by caffeine in the form of tea, inventing Chuan Xiong Cha Tiao San in the process. Once we have grasped that, we can start looking at a variety of caffeine delivery methods, including tea, coffee, energy drinks, No Doze pills, etc. Perhaps using a large enough dose of Wasabi with Gui Zhi or crushed scallions and fresh ginger might be enough to break the pernicious blockade and allow the Upright Yang to return. Or we could really be practical and use Ma Huang in its currently available forms along with a cup of our formula at the same time. Ephedrine, pseudo-ephedrine, and ephedrine mimicking products are available over the counter in the super market. While Sudafed is the most obvious, Claritin and many others will all increase the heart rate and dry the waters. Where and how effectively can be decided by the herbs we prescribe to take concurrently with these over the counter medicines.


How safe is Ma Huang as an herb or in its current over the counter delivery methods? I can get quite worked up about this, so if you have not heard the podcast in which I do, listen to: Everything is dangerous if misused, but as long as it is profitable to the pharma industry, it is given a pass. Extra Strength Tylenol can cause liver damage if taken more than 4 times in a 24 hour period. But my 9 year old can find it on aisle 7 of our local supermarket and buy it all by himself. Liver damage in less than a day, OTC product. There are currently over 600 OTC and prescription medications containing the same active ingredient, including NyQuil. Ma Huang is a very tame and safe little sibling compared to that danger. Classified as a middle herb in the Shen Nong Ben Cao, we know it can drive away deficiencies and help the physical body, but cannot be used for long periods. Misused as a daily diet tea along with caffeine or by body builders trying to drive off water weight, we certainly could see damage to the kidneys (diuretic action) or heart (circulatory stimulator). But it would take a very long time while ignoring a vast amount of warning signs in the former or a very large dose coupled with caffeine and extreme exercise in the latter.


Outside of blatant misuse or continued misuse, we do need to be cognizant of one concern which can happen to us as responsible practitioners. Ephedrine can potentially cause prostate swelling in at risk men—simply type ‘Ephedrine Prostate Swelling’ into google for not just an education on the risk but on what kind of forums it is being discussed. The top hit the last time I checked was bodybuilding. While in the past I used Ma Huang often for sinus infections or deep cold in men over 50 who concurrently had prostate enlargement without a negative side effect, there was one case in which there was. A gentleman I had seen for years in China came in with a sinus infection, and after not responding to gentler herbs I prescribed Ma Huang—what I did not know was he had been high dosing on allergy medicines and the Chinese equivalent of Claritin along with the Ma Huang made for a very uncomfortable 8 hours before he could urinate easily again. Alone, neither caused a problem. Together, the synergy and delivery lead to a swollen prostate. As you might expect, I was very cautious going forward, being sure of what OTC medications male patients with prostate issues were using before prescribing not just Ma Huang, but any diuretic herb. As a middle herb which gained its fame treating potentially life threatening influenza, its strength should be respected and prescribed with respect. But it should not be feared, and most importantly, it should be understood for its flavor-nature role in a formula so we can effectively substitute yet achieve the same desired results.


Andrew Nugent-Head

January 27, 2019