The General and the Justice
On Lóng Dǎn Xiè Gān Tāng
It’s been a busy stretch here at Mulch HQ and I haven’t gotten around to writing a post in a while. I’m working on some courses at the moment, which involves some graphic design, so I thought I’d bump an infographic with some commentary just to say hey.
Lóng Dǎn Xiè Gān Tāng 龍膽瀉肝湯
Here is a graphic I made about Lóng Dǎn Xiè Gān Tāng (Gentiana Liver-Draining Decoction, LDXGT for short). There are a few different formulas that go by this name, but the one pictured here seems the most widely used today. Scheid et al (2009) credit this prescription to a text called Yīfāng Jíjiě (醫方集解, Medical Formulas Collected and Analyzed) by Wāng Áng (汪昂), from 1682.
Here is a relevant passage from the source text (translation mine):
治肝膽經實火濕熱，脅痛耳聾，膽溢口苦，筋痿陰汗，陰腫陰痛，白濁溲血（脅者，肝膽之部也，火盛故作痛；膽脈絡於耳，故聾；肝者，將軍之官也，謀慮出焉。膽者，中正之官也，決斷出焉。膽虛故謀慮而不能決；膽氣上溢，故口為之苦；肝主筋，濕熱勝故筋痿；肝脈絡於陰器，故或汗、或腫、或痛；白濁、溲血，皆肝火也）。
Treats liver and gallbladder channel repletion fire and damp-heat; rib-side pain; deafness; gallbladder spillage; bitterness of the mouth; sinew wilting; yīn [genital] sweating, swelling and pain; white turbidity; and bloody urine.
(The rib-side is part of the liver and gallbladder, and exuberant fire gives rise to pain; the gallbladder vessel networks with the ears, causing deafness; the liver holds the office of general, and is responsible for planning and strategy. The gallbladder holds the office of justice, from which decision emanates. In gallbladder deficiency, therefore, one is unable to decide in planning; gallbladder qì ascends and spills over, therefore the mouth becomes bitter; liver governs sinews, damp-heat prevails therefore there is sinew wilting; the liver vessel networks with the genitals, therefore there may be sweat, swelling, or pain; white turbidity and bloody urine are both [due to] liver fire.)
龍膽草（酒炒） 黃芩（炒） 梔子（酒炒） 澤瀉 木通 車前子 當歸（酒洗） 生地黃（酒炒） 柴胡 甘草（生用）。
Lóng Dǎn Cǎo (Rx Gentianae, wine fried), Huáng Qín (Rx Scutellariae, fried), Zhī Zĭ (Fr Gardeniae, wine fried), Zé Xiè (Rz Alismatis), Mù Tōng (Caulis Akebiae), Chē Qián Zǐ (Sm Plantaginis), Dāng Guī (Rx Angelicae Sinensis, washed in wine), Shēng Dì Huáng (Rx Rehmanniae, wine fried), Chái Hú (Rx Bupleuri), Gān Cǎo (Rx Glycyrrhizae, use raw).
此足厥陰、少陽藥也。龍膽瀉厥陰之熱（肝），柴胡平少陽之熱（膽），黃芩、梔子清肺與三焦之熱以佐之；澤瀉瀉腎經之濕，木通、車前瀉小腸、膀胱之濕以佐之；然皆苦寒下瀉之藥，故用歸地以養血而補肝，用甘草以緩中而不使傷胃，為臣使也。
These are medicinals for foot juéyīn and shǎoyáng. Lóng Dǎn Cǎo drains juéyīn heat (liver); Chái Hú calms shǎoyáng heat (gallbladder); Huáng Qín and Zhī Zĭ assist by clearing lung and triple burner heat; Zé Xiè drains dampness from the kidney channel; Mù Tōng and Chē Qián Zǐ assist by draining dampness from the small intestine and bladder; however, all are bitter cold downward draining medicinals, so use Dāng Guī and Shēng Dì Huáng to nourish blood and supplement the liver, and use Gān Cǎo to relax the center and prevent injury to the stomach, serving as ministers.
Formula analysis
Scheid et al. (2009) has a slightly different analysis of the formula: Chái Hú, Huáng Qín and Zhī Zĭ are given as deputies (a.k.a. ministers, 臣chén) rather than the blood tonics in the source text. I had originally listed the formula ranks in the graphic, but pulled them after reading the Wāng Áng passage above.
I also summarized the combined action of Huáng Qín and Zhī Zĭ as clearing heat from the triple burner; since Huáng Qín enters channels in and treats problems of all three burners and Zhī Zĭ straight up treats the triple burner, I thought it more succint than just repeating the actions of Lóng Dǎn Cǎo that they amplify. It also highlights the tropism of the two medicinals for the shǎoyáng. I drew in a connection between the two and Chái Hú; the two are paired with Chái Hú in some important formulas, demonstrating different aspects more or less the same pathomechanism. In Xiǎo Chái Hú Tāng (Minor Bupleurum Decoction), Chái Hú pairs with Huáng Qín to clear heat from the shǎoyáng, where in Dān Zhī Xiāo Yáo Sǎn (Moutan and Gardenia Free Wanderer Powder), Zhī Zĭ is used with Chái Hú to clear depressive liver heat. Both are cases in which a pathogenic influence -- from without or within, from cold damage or affect damage -- blocks the qi mechanism of the shǎoyáng. In LDXGT, the pathodynamic can be seen to extend to the entirety of the triple burner; the clinical manifestations follow logically from the two formulas mentioned above, with the addition of disrupted distribution and elimination of fluids.
Thus it is not enough in this scenario to disperse constrained heat – it must be drained through the lower burner as well. Thus the triumvirate of Zé Xiè, Mù Tōng (these days often substituted with Tōng Cǎo / Medulla Tetrapanacis), and Chē Qián Zǐ. Chē Qián Zǐ provides additional liver clearing, where Zé Xiè dredges the lower burner and enters the kidney and bladder channels. Both are cold and sweet. Cold, bitter Mù Tōng drains fire from the heart and small intestine, thus draining the liver according to the mother-child principle in chapter 69 of Nán Jīng (Classic of Difficulties).
On the other side of the graphic are the supplementing agents. I included an upward arrow to indicate the action of supplementing yīn-blood to support the orderly reaching of the liver. As I have written before, I consider this a crucial concept in understanding liver pathology. I often see (and have taught, in the past) that this pair is included as damage control against the cold, bitter, drying ingredients of the rest of the formula. While this is true, I think their role goes beyond that and perhaps Wāng Áng was on to something when he named these two herbs as ministers rather than assistants or envoys.
Formula combining
LDXGT is a mainstay in my clinic. I always make sure I have some in stock. It is not a formula I modify often, to be honest. I usually prescribe it in pills or as a straight granule formula. It was with interest, then, that I read of some of its uses as a whole formula ingredient in Brand (2010). Brand writes of the Taiwanese practice of combining entire formulas as if it were a single ingredient in a larger prescription. Among some of the uses he describes are LDXGT combined with Cāng Ěr Zǐ Sǎn (Xanthium Decoction) to treat nasal abyss due to gallbladder-brain heat, and LDXGT combined with Shū Jīng Huó Xuè Tāng (Channel-Relaxing Blood-Invigorating Decoction) and Gān Lù Yǐn (Sweet Dew Beverage) to treat a case of Sjögren's syndrome with rheumatoid arthritis.
A Formula to Have Up One’s Sleeve
I often give LDXGT to patients who suffer from shingles or herpes outbreaks as an acute formula to have around in case of a flare. Good results have been reported in taking the herbs as soon as possible after symptoms begin to appear. Of course, it is also an acute formula for episodes of liver constraint erupting into fire, often triggered by bouts of frustration and anger. One of my patients simply calls it “my pissed-off herbs”, and will refer to it as such when asking for refills. For those with constitutionally heated livers, it can be a versatile formula to address a wide array of complaints: inflammatory, urogenital, dermatological, emotional, neurological, etc. etc.
Thanks, as always, for reading. Back to the slide deck I go…
Note: this newsletter is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have.
References
Brand, E. (2010). A clinician's guide to using granule extracts. Blue Poppy Press.
Scheid, V., Bensky, D., Ellis, A., & Barolet, R. (2009). Chinese herbal medicine: Formulas & strategies (2nd ed.). Eastland Press.
Wang, A. (1682). Yifang jijie. https://jicheng.tw/tcm/book/%E9%86%AB%E6%96%B9%E9%9B%86%E8%A7%A3/index.html