By Professor Huang Huang, Nanjing University of CM
The indications of herbal medicine specify the appropriate and correct use of herbs in clinical practice. These are also known as the herbal indications. For example, the indications of 麻黄(ma huang, Herba Ephedrae) create the ma huang (Herba Ephedrae) pattern, while the indications of 桂枝(gui zhi, Ramulus Cinnamomi) construct the gui zhi (Ramulus Cinnamomi) pattern. Through thousands of years of study, the medical principle of traditional Chinese medicine applies the use of herbs to such patterns.
Herbal medicine indications do not stem from the theory of animal laboratory test results, but instead from our ancestors' years of direct experience in treating diseases. Legend says that our ancestors had contact with herbs where the Divine Husbandman tasted hundreds of herbs". These principles come from direct experience rather than theory.
Herbal indications take into account the human person. It could be said that western medicine treats "human diseases," and traditional Chinese medicine treats "humans with diseases". Treating the human being is the premise of using herbal indications. Therefore, in On Cold Damage and Miscellaneous Diseases (伤寒杂病论), there are many idioms such as "patient," "thin people," "person who suffers from center cold," "person who suffers from dampness," "the rich," "strong person," "weak person," "patient suffering from heavy sensation of the head with dizziness," and "person who suffers from seminal loss". Chinese medicine considers the persons' constitutions, symptoms, signs, mental and psychological states, behaviors, and lifestyles to be important aspects. Other factors are considered such as whether the patient is fat or thin, strong or weak, has a yellow face or a white face; feels aversion to cold or heat, with or without fever, sweats, appetite, vomiting; suffers from diarrhea or constipation, has bleeding or no bleeding, feels fullness and pain below the heart of stuffiness below the heart, suffers from cough and counterflow with qi ascending or shortness of breath, fullness in the chest or in the abdomen, fullness or hard fullness, feels thirsty or not, with uninhibited or inhibited urination, feels vexation or not, dizzy or not, sleepy or sleepless, keeps silent with no desire to talk or acts as if crazed, with qi surging up or shortness of breath, suffers from an hoarse of blocked throat or a sore throat, with a floating or sunken pulse, with a moderate or skipping pulse, etc. are all major concerns when doctors decide what herbs to prescribe.
The criteria that determine therapeutic effect are the basic vital signs such as whether the patient is sweating or not, whether the pulse can be felt or not, whether the patient feels thirsty or not, whether bleeding stops or not, etc. The purpose of using herbs according to the pattern is to relieve the patient's pain. The pain here refers entirely to the patient's subjective experience. It is associated with physical and mental suffering and the decrease in the quality of life. It ca be said that traditional Chinese medicine's greatest objective and ultimate goal lies in relieving the patients' suffering and improving their quality of life.
Herbal indications are objective. This comes from thousands of years of clinical practices with solid proof. It is neither a philosophical concept nor a religious perception, but it is a known fact. When Zhang Zhong-jing made reference to "observing the pulse and signs," it means that the pulse and signs are objective. Herbal indications can be refuted and can be validated by its efficacy. In clinic, appropriate herbs must be used when the corresponding indications exist, and the therapeutic effect should follow. On the contrary, if herbs are not used based on appropriate indications, or if the herbs are used without the presence of certain indications, the results will certainly be inadequate. Wrong diagnosis or the slightest deviation will bring unsuccessful outcomes. Therefore, herbal indications are objective, which means its results can be observed and verified.
Herbal indications are specific and simple. There are no abstract theories such as the yin and yang, five phases, original qi mingmen (life-gate), liver yang and heart fire, spleen deficiency or kidney deficiency. Instead, the foundation for using the herbs is based on observing the patients themselves. Factors to consider are whether the patient's body type is tall, short, fat, or thin; whether the skin is black, white, moistened or dry. Important aspects to observe are the pathological appearances of mouth, eyes, nose, tongue, lip, throat, pulse, abdomen, blood, secretions, and excretions because they constitute the herbal indications. The indications are the most basic and important factors that constitute concepts in traditional Chinese medicine. Indications are essential for various pattern identifications such as: Eight principles pattern identification, six channels pattern identification, disease case pattern identification, organ pattern identification, qi, blood and fluid pattern identification, wei qi and ying blood pattern identification, triple jiao pattern identification. It is impossible to understand traditional Chinese medicine without becoming very familiar with the indications.
Herbal indications are integrative. The indications of single herbs and formulas are quite different from the "patterns" in modern traditional Chinese medicine or "diseases" in western medicine. Herbal indications developed through the practical and clinical use of the herbs. However, it will be difficult to discuss the indications without reference to specific herbs because the indications refer to specific modern diseases, syndromes, symptoms, or constitutional types.
Herbal indications are stable. The diseases continue to change throughout time. Some diseases are managed and controlled but new diseases arise. AIDS, Ebola virus, 0-157 coliform bacilli, and SARS did not exist before, but they are the current diseases in our society today. Diseases will continue to evolve and change. However, the human body's response to disease does not change at all. Our current experiences of disease with symptoms such as fever, cough, coma, and bleeding do not differ from what our ancestors experienced in their times of illness. Herbal indications are diagnostic and reflect the pathological responses of the "human being" regardless of the type of pathogen. The herbal indications are stable with nearly no change in thousands of years, and they will not change even with new or changing diseases. Regardless of the era or type of disease, we can use 柴胡 (chai hu, Radix Bupleuri), and 桂枝(gui zhi, Ramulus Cinnamomi) as long as we see 柴胡 (chai hu, Radi Bupleuri) indications and 桂枝 (gui zhi, Ramuls Cinnamomi) indications. This fact is true whether we are living in Zhang Zhong-jing's times or in our modern times today. Therefore, herbal indications can withstand the test of time. Doctor Xu Ling-tai of the Qing Dynasty stated: "A prescription's ability to treat disease is fixed, but the diseases are always changing. If we treat disease based on this understanding of prescriptions, the therapeutic outcome will always be achieved regardless of how diseases change" (Foreword for Categorization of Formulas from the Discussion on Cold Damage, 伤寒论类方).
Herbal indications are strict. Herbs can only be used when the appropriate indications exist. If there are no such indications, the corresponding herbs should not be used. The modification of herbs should change according to the changing clinical indications, but not randomly. Take 桂枝汤 (Gui Zhi Tang, Cinnamon Twig Decoction) as an example. It can be used when the indications are aversion to wind, sweating, and a floating pulse. If there is excessive sweating, with aversion to cold and pain in the joints, 附子 (fu zi, Radix Aconiti Lateralis Praeparata) must be added. if the patient suffers from body pain and has a sunken and slow pulse after sweating, then 人参 (ren shen, Radix et Rhizoma Ginseng must be added. if qi surges up into the heart from the lower abdomen, then add 2 liang of 桂枝 (gui zhi, Ramulus Cinnamomi). If there is pain in the abdomen, 芍药 (shao yao, Paeonia Lactiflora Pall) should be added. If there is no sweating but thee is stranguria, then remove 桂枝 (gui zhi, Ramulus Cinnamomi) and add 白术 (bai zhu, Rhizoma Atractylodis Macrocephalae) and 茯苓 (fu ling, Poria). There should be a specific reason for every modification. As Yu Jia-yan stated: "Use the herbs according to its corresponding diseases. Herbs should vary with the variation of disease". Applying this principle is the key for modifying herbs, regardless of how the disease changes. The strict guidelines for prescribing formulas account for the variations in these clinical classical prescriptions.
Herbal indications are scientific. Science is an objective observational study of the world. As Darwin said: "Science is intended to manage all the facts, in order to obtain consistent rules or conclusions". These conclusions are the relationship between objective facts. Herbal indications come from large amounts of data gained from clinical practice. Doctors have put the herbs to test through numerous practical applications thereby establishing the relationship between the herbs and their corresponding diseases. The most fascinating part of traditional Chinese herbal medicine is that it has a scientific basis with strong replicability.
Herbal indications are integrated. Just as every radish has one delve, every Chinese herb has one indication. There is strong specificity and relevance between the indications and herbs. Every single classical herb should have its corresponding indication. The herb can only be used when its corresponding indication exists. Moreover, the herb must be removed when its corresponding indication no longer exists. Every herb has two characteristics: Strict indications and repetitive therapeutic effect. The mutual correspondence between herbs and signs is referred to as "prescribing herbs according to indications".
Zhang Zhong-jing categorized these herbal indications. There are phrases such as "gui zhi indications," and "chai hu indications" in the Discussion on Cold Damage (伤寒论). The "lily disease" in the Essentials from the Golden Cabinet (金匮要略). These descriptions refer to the herb's specific indications. The beginner's mind understands the selection of Chinese herbs through applying the following technique: Theory-method-decoction-herb. In actuality, the opposite is true. When experienced clinicians approach a patient, they first consider the pertinent "single herbal indication," then the "formula indications," then the "treatment method," and then finally the "theory" is derived. Every single herb has strict indications. Every single formula prescription has a combination of specific herbs which requires specific existing indications. This method is the basis for prescribing and using herbs. As Zou Shu said: "If one does not know that each disease has its appropriate prescription, that each prescription has its single herbs, and that each single herb has its effect, then one cannot determine which herbs to use. Then how can a doctor prescribe? How can a doctor treat disease if they fail to make a prescription?" (Commentary on the Classic of Materia Medica, 本经疏证)
The single herbal indication is the foundation that constitutes formula indications. The formula indications are the enlarged indications of single herbs. Therefore, Zhu Gong considered the single herbal indication and the formula indications as a whole. He said: "Before the prescription is prescribed, the herbal indication should be identified as a certain prescription governs a a certain disease" (Book to Safeguard Life Arranged According to Pattern, 类证活人书). However, the single herbal indication is different from the formula indications. Formula indications are not the simple addition of the indications of single herbs. Instead, they are a completely different and complex combination. Formula indications should be understood as a single indication.
Correspondence of herbal indications is how this medicine gains its therapeutic effect. To achieve clinical results, the indications should correspond to the herbs. "Take the prescription only when the disease corresponds to it completely" (CD 317). This method is known as "prescribing herbs according to the indications". If gui zhi (Ramulus Cinnamomi) was an arrow, and the gui zhi indications were the target, we need only to aim right at the target and shoot straight. Therapeutic results can be achieved and guaranteed when the herb or decoction correspond to the indication. However, if they do not match, the herbs will be ineffective. This is the key for the therapeutic outcome in traditional Chinese medicine.
"Our ancestors made every single decoction to correspond with every single indication. If it was a harsh winter season and 白虎汤 (the Bai Hu Tang, White Tiger Decoction) indications were observed, how could one decline using 石膏 (shi gao, Gypsum Fibrosum)? If it is midsummer and 真武汤 (Zhen Wu Tang, True Warrior Decoction) indications are present, how could one refuse to use 附子 (fu zi, Radix Aconit Lateralis Praeparata)? If an old patient can tolerate purging, why not use 芒硝 (mang xiao, Natrii Sulfas) and 大黄 (da huang, Radix et Rhizoma Rhei)? If a strong patient can endure warming, why not use 干姜 (gan jiang, Rhizoma Zingiberis) and 附子 (fu zi Radix Aconiti Lateralis Praeparata)? These recommendations are for the patients who need these herbs" (Discussion on Prescriptions in the Golden Mirror, 金镜内台方义).
The correspondence of herbal indications is the principle for using natural herbs clinically. The ingredients of natural herbs are extremely complicated. The question can be asked, what will be the effect after the herbs are administered? Its secret is truly difficult to know. With data from animal laboratory testing and modern medicine's insight into the human physiology and pathology, we can now guide traditional and natural herbs into the body via brewed decoctions, pills, and powder preparations. The patient is asked to take the decoction of natural herbs and it is hoped that good results will occur but this may not be the case. The scientific community may show respectable interest in the effective clinical applications and principles obtained by our ancestors' years of clinical practice. The principle of applying herbal indications should not be dismissed.
The correspondence of herbal indications relates to medical diagnosis and treatment. It is not uncommon that modern medicine can diagnose but does not have the knowledge for treatment. However, in traditional Chinese medicine, the herbal indications can be identified even if the specific diseases cannot be determined by modern medicine. Treatment ca be applied whenever the indications are apparent. The principles of using herbal indications do not require the identification of a specific disease pathogen, but is only concerned about the human body in the progression of a disease. The human body's reaction to the pathology and disease is most relevant for treatment. Therefore, the proof of the herbs lies in the application and outcomes on the human body and the pathology. using scientific methods to study herbal medicines will definitely reveal new discoveries in the progression of human pathology.
Identifying herbal indications is the hallmark of a clinician's efficacy and success. The ability of a famous doctor is associated with "meticulous care" or his ability to "identify the pattern accurately". However, knowing the corresponding indications to certain herbs is the best and absolute course towards a correct diagnosis and herbal treatment since clinical results can often vary depending on the doctor's clinical experience, way of thinking, and mental state. Understanding the correspondence of indications for herbs is an excellent goal for every TCM clinician to achieve.
The Discussion on Cold Damage and the Essential Formulas from the Golden Cabinet contain a large amount of ancient empirical formulas and the explanations of their use. These empirical formulas have a long history, and are the accumulation of experience gained by the thorough application of natural herbs, and are called "classical formulas" by later generations. There are many clinicians who excel at making use of the ancient formulas in the Discussion on Cold Damage and the Essential Formulas from the Golden Cabinet, and the study of their use forms a unique school of medical thought, the classical formula school. The explanations for using each formula made by Zhang Zhong-jing, show the unique scientific perspective of Doctor Zhang Zhong-jing. Indications for many formulas are descriptions of a certain type of disease, or a certain constitution. In reality, such descriptions can be typical, non-typical, comprehensive, limited, superficial, or detailed, but it is believed that the descriptions are very objective. His way of thinking and method of studying the human body and its diseases has become the foundation for the development of Chinese medicine.
In the Discussion on Cold Damage, of the 114 prescriptions, there are 113 prescriptions with specific formula names with a total of 91 herbs. Thirty-six formulas are used once and fifty-five prescriptions are used more than twice. In the Essentials from the Golden Cabinet, of the 205 prescriptions, there are 199 prescriptions with specific formula names with a total of 156 single herbs. In these prescriptions, sixty-two herbs are used more than once and fifty-five herbs are used more than twice. This book selects the fifty most frequently used herbs and explains their indications as described by Zhang Zhong-jing's formulas, reducing herb patterns, and frequently used formulas. Be assured that any doctor can create numerous new formula prescriptions from these fifty herbs as long as they can truly understand every herb's indications and the herb combinations.
"Classic books should be read over and over again. After reading the books and contemplating on them, you will realize that the truth lies in the books." (Su Shi, Song Dynasty). The Discussion on Cold Damage and the Essentials from the Golden Cabinet are actual records of clinical practice. Doctors of all dynasties recommend reading Zhang Zhong-jing's book over and over again with a special focus on the clinical work which can provide significant insights.
I hope my work can inspire more people to learn about ancient traditional Chinese medicine. Only by learning from our ancestors can we make progress. Only when the root is embedded deeply into earth can branches and leaves thrive. The development of traditional Chinese medicine cannot be separated from its outstanding ancient lineage because it is truly the root of traditional Chinese medicine.
(Note: Ingredients, preparation, direction, and the origin are described under each prescriptions of this list.)
Professor Huang Huang was born in Jiangyin, Jiangsu province in 1954. He is currently the dean emeritus of the School of Basic Medical Science, professor, and supervisor to doctoral students in Nanjing University of CM.
He focused on investigating and summarizing the experiences of famous TCM clinicians and examined the different schools of classical formulas with a particular emphasis on studying the herb and formula indications after the 1990's. He developed the first questionnaire on the clinical experiences of famous TCM clinicians in China and has directed research on the academic experiences of 330 famous TCM clinicians in China, which was consigned by the State Administration of Traditional Chinese Medicine. He has also written collections on the clinical experiences of contemporary famous TCM clinicians, such as the Discussion on Formulas and Medicinals by Famous TCM Clinicians (名中医论方药), Insights about Formulas and Medicinals (方药心悟), and the Truth of Formulas and Medicinals (方药传真). He focuses on and advocates the study and application of TCM classical formulas, modern literature on single herb and formula indications, and the application for classical formula patterns on constitutional types.
Zhang Zhong-jing's Clinical Application of 50 Medicinals
By Huang Huang Ph. D. TCM
Published by People's Medical Publishing House; English edition (2008)
Format: 180 mm x 255 mm (7.50 x 10.50 inches), 592 pages, hardcover, library binding