Thunder and the Household of the Gallbladder
On Wēn Dǎn Tāng
This week I got around to a post that I knew I would write eventually, but kept putting off for one reason or another: some readings and ruminations on Wēn Dǎn Tāng, Warm Gallbladder Decoction. Those colleagues who know me are doubtless aware of my fondness for this formula. So, here goes.
Background
Scheid et al. (2009) discuss several formulas with the same name as far back as the 6th century. The formula as we know it was originally from Sān yīn jí yī bìng zhèng fāng lùn (Discussion of Illnesses, Patterns, and Formulas Related to the Unification of the Three Etiologies) by Chén Yán (1174).
The source text does mention cold as an indication for this formula; interestingly in the text there is variant formula for gallbladder vacuity cold which has the same name but different ingredients. Over the years, the formula has been more closely identified with treating disorders characterized by phlegm-heat signs.
The formula as given in Scheid et al. (2009)
· Zhú Rú (Caulis Bambusae In Taeniam), 6g
· Bàn Xià (Rz Pinelliae), 6g
· Zhǐ Shí (Fr Aurantii Immaturus), 6g
· Chén Pí (Pc Citri Reticulatae), 9g
· Fú Líng (Poria), 4.5g
· Zhì Gān Cǎo (Rx Glycyrrhizae Praeparata), 3g
· Grind into powder, decoct 12g in a cup of water with 5 slices Shēng Jiāng (Rz Zingiberis Recens) and 1 piece Dà Zǎo (Fr Jujubae).
There is a lot of discussion on the prescription in Formulas & Strategies, which I won’t rehash here. I thought I would add a couple of passages from my readings, followed by a few thoughts of my own.
Take 1: Wáng Mèngyīng
The first entry is from Wēn Rè Jīng Wěi (Warm Disease Warp and Weft) by Wáng Shìxióng (a.k.a. Wáng Mèngyīng, 1808-1868), published in 1852. The text includes a quote by Luō Měi which was also included in the discussion by Scheid et al (the translation here is mine).
溫膽湯
竹茹 枳實 半夏（各一兩） 橘紅（一兩五錢） 茯苓（七錢） 甘草（炙 ，四錢）每服四五錢 ，生薑一片 ，紅棗一枚 ，水一鍾五分 ，煎七分服 。
羅東逸曰 ：膽為中正之官 ，清靜之府 。喜寧謐 ，惡煩擾 。喜柔和 ，不喜壅鬱 。蓋東方木德 ，少陽溫和之氣也 。是以虛煩驚悸者 ，中正之官 ，以熇熱而不寧也 。熱嘔 、吐苦者 ，清靜之府 ，以郁久而不謐也 。痰氣上逆者 ，土家濕熱反乘 ，而木不得遂其條達也 。如是者 ，首當清熱 ，及解利三焦 。方中以竹茹清胃脘之陽 。而臣以甘草 、橘 、半 ，通胃以調其氣 。佐以枳實 ，除三焦之痰壅 。使以茯苓平滲 ，致中焦之清氣 。且以驅邪 ，且以養正 ，三焦平而少陽平 ，三焦正而少陽正 ，膽家有不清寧而和者乎 ！和 ，即溫也 。溫之者 ，實涼之也 。晉三亦云 ：膽氣退熱為溫 ，非謂膽寒而溫之也 。
雄按 ：此方去薑 、棗 ，加黃連 ，治濕熱痰而化瘧者 ，甚妙 。古人所未知也 。
Luó Dōngyì [a.k.a. Luō Měi] said: The gallbladder acts as the official of justice, the palace of tranquility. It is fond of peace and quiet, and loathes vexation and annoyance; rejoices in softness and gentleness, and finds no joy in congestion and constraint. Topping the virtues of the East and of Wood, shǎoyáng’s qì is gentle and mild. Therefore, if there is vacuity vexation and fright palpitations in the official of justice it is due to parching heat and agitation. If there is heat retching and bitter vomiting in the palace of tranquility it is because of chronic depression (stagnation) and disturbance. Phlegm and qì ascend counterflow, damp heat rebels and gains the upper hand against the household of Earth, and Wood cannot succeed in its orderly reaching. This being the case, one must chiefly clear heat as well as resolve and disinhibit the triple burner. In the formula there is Zhú Rú which clears the yang of the stomach duct. The deputies, Gān Cǎo, Jú Pí, Bàn Xià, unblock the stomach and regulate its qì. The assistant, Zhǐ Shí, eliminates phlegm congestion in the triple burner. The envoy, Fú Líng, is neutral and seeps (dampness) to convey the clear qì of the middle burner. (When one) both expels evils and nourishes the upright, calms the triple burner and calms shǎoyáng, rectifies the triple burner and rectifies shǎoyáng, how then can the household of the gallbladder not be clear, peaceful and harmonious! Harmonious means warm. To warm is in reality to cool. Jìnsān also said when gallbladder qì abates heat, it becomes warm, it is wrong to say that the gallbladder is cold so warm it.
Comment: This prescription removes Shēng Jiāng and Dà Zǎo, and adds Huáng Lián (Rz Coptidis), which excels at treating damp-heat and phlegm and transforming malaria. It was not known to the people of antiquity.
A few notes:
· Jìnsān refers to Wáng Jìnsān (1698 - 1761）a.k.a. Wáng Zǐjiē, one of the teachers of the great physician Yè Tiānshì.
· Note that the roles of the formula hierarchy (chief, deputy etc) are slightly different than in Scheid et al.
· The character Wēn [溫] means both “warm” and, in another sense “mild, gentle”. So there is a bit of play on words here: clearing heat allows the gallbladder to return to its mild and gentle nature, therefore to cool the gallbladder is to make it warm.
Take 2: Wáng Xùgāo
The second passage is from Wáng Xùgāo, whose work is frequently mulched in our posts. This is from Yī Fāng Zhèng Zhì Huì Biān Gē Jué (Compilation of Medical Formulas, Patterns and Treatments), 1897:
溫膽湯方即二陳（茯苓、甘草、半夏、陳皮。）竹茹枳實棗（大棗）姜（生薑）循。少陽膽熱移於胃，胃熱蒸痰是病因。嘔苦痰涎不得寐，滌痰泄熱以寧神。（二陳和胃滌痰，竹茹清上焦之熱，枳實泄下焦之熱。治三焦而不及於膽者，以膽為生氣所從出，不得以苦寒直傷之也。命之曰「溫」無過泄之戒辭，非以膽寒而溫之也。）
傷寒病後多斯證，（虛煩嘔惡，口苦不眠，傷寒病後最多此證。）雜病煩驚悸亦遵。（皆痰熱擾亂心神）或益黃連或參（人參）棗（酸棗仁），心虛煩熱可加勻。（心虛神怯加人參、棗仁，名人參溫膽湯。煩熱甚者加黃連，名黃連溫膽湯。）心為君主出乎震，膽氣清寧神自馴。（旭高按：心為君主而出乎震，震位東方，在人屬膽，膽為甲木，生心丁火，是以膽氣怯者，心神必虛，膽氣壯者，心神多旺。然則心者，雖為君主之官，而實聽命於膽，故《素問·五臟生成論》曰：「凡十一臟，皆取決於膽也。」）
The formula Wēn Dǎn Tāng is Èr Chén (Fú Líng, Gān Cǎo, Bàn Xià, Chén Pí) followed by Zhú Rú, Zhǐ Shí, Dà Zǎo, and Shēng Jiāng. The etiology is shǎoyáng gallbladder heat moving to the stomach, and stomach heat steaming phlegm. [Treats] bitter vomiting, phlegm-drool, inability to sleep; it sweeps phlegm and discharges heat to calm the spirit. (Èr Chén harmonizes the stomach and sweeps phlegm, Zhú Rú clears upper burner heat, Zhǐ Shí discharges lower burner heat downward. Treatment of the triple burner must not reach the gallbladder, because the gallbladder acts as the place from where vital qì issues, and one must not allow bitter and cold to directly injure it. It is given the name "warm" as a caution against excessively discharging; it is wrong to think that the gallbladder is cold so one must warm it.)
Many patterns developing after cold damage illness (vacuity vexation, nausea and retching, bitter taste in the mouth, sleeplessness, most common presentations after cold damage illness.) Miscellaneous diseases, vexation, fright palpitations also can be observed. Each of these is phlegm heat harassing the heart spirit. Possibly augment the formula with Huáng Lián or Rén Shēn (Rx Ginseng) and Suān Zǎo Rén (Sm Zizyphi Spinosae); for heart vacuity vexation heat one can add each in equal amounts. For heart vacuity spirit timidity add Rén Shēn and Suān Zǎo Rén, this is called Rén Shēn Wēn Dǎn Tāng, for severe vexation heat add Huáng Lián, this is called Huáng Lián Wēn Dǎn Tāng.
The heart’s role as sovereign stems from Thunder [trigram 4], the gallbladder qì clears and pacifies the spirit so it is naturally obedient (Xùgāo comments: the heart’s role as sovereign stems from Thunder, Thunder’s place is the direction of the East, which in humans pertains to the gallbladder, the gallbladder is Jiǎ [stem 1] Wood, which engenders the heart, Dīng [stem 4] Fire. Thus if the gallbladder qì is timid, the heart spirit must certainly be empty, and if the gallbladder qì is strengthened, the heart spirit will flourish abundantly. So it is, regarding the heart, that even though it holds the office of sovereign, in reality it takes orders from the gallbladder, for this reason. Sù Wèn “Wǔ Zàng Shēng Chéng Lùn” says “all the eleven viscera, each depends on the gallbladder.”)
Notes:
· Thunder/trigram 4 refers to the Yì Jīng, or Book of Changes.
· Stem 1 and stem 4 refer to the Ten Celestial Stems
Mulch thoughts
I often remark to students that Wēn Dǎn Tāng is my favorite formula. There are many that I use frequently but it seems that year after year, when I look over my prescriptions, Wēn Dǎn Tāng is always at or near the top of the list.
The very first time I used it was to treat a patient who had suffered a kind of psychic injury from kundalini practice. She was on multiple psychiatric medications and had to take a leave of absence from her work due to her condition. I observed several diagnostic markers which I have used ever since in considering this formula: a thick discolored tongue coating; a sticky feeling on the surface of the skin, both on the abdomen and the channels; substernal and/or subcostal tension or “stuckness”; a glossy, rosy look to the face from the heat forcing the phlegm upwards; evidence of mental clouding, repetition of words or phrases, soliloquies, unclear speech or blocked expression. The transformation by using Wēn Dǎn Tāng can be remarkable, as it was in this first case of mine: she was able to reduce and eventually discontinue medication and return to her occupation.
As might be deduced from the centuries-old controversy over the name, the formula is considered cooling but I don’t find it terribly cold; it is drying but I don’t find it overly parching. I have used it in post-febrile, chemo support and even in cases where the patient has insufficient yīn but they nevertheless have phlegm clogging the triple burner. In my opinion Wēn Dǎn Tāng can be considered in any case of depressive heat from a dysfunctional middle burner qì dynamic. Its use is more suited to qì-aspect disorders, as opposed to formulas which involve the blood-aspect as well such as Xiāo Yáo Sǎn, Free Wanderer Powder; however it can be modified with blood invigorating, depression-relieving ingredients like Yù Jīn (Rx Curcumae) and Dān Shēn (Rx Salviae Militiorrhizae) to treat complex problems of phlegm and blood stasis. Its ability to clear the mind and open the portals can be enhanced by adding herbs such as Shí Chāng Pú (Rhizoma Acori Graminei) and Yuǎn Zhì (Rx Polygalae).
Conclusion
There is a lot more I could say about Wēn Dǎn Tāng, but perhaps it is better left to another time. I have certainly found it useful for many clinical situations. Its ability to treat the spirit through restoring the qì dynamic, clearing heat and sweeping phlegm is invaluable in many cases that we encounter every day in this ever-warming, post-just-about-everything world.
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
Scheid, V., Bensky, D., Ellis, A., & Barolet, R. (2009). Chinese herbal medicine: Formulas & strategies (2nd ed.). Eastland Press.
Wáng, S. (1852). Wēn rè jīng wěi. https://jicheng.tw/tcm/book/%E6%BA%AB%E7%86%B1%E7%B6%93%E7%B7%AF/index.html
Wáng, X. (1897). Yī fāng zhèng zhì huì biān gē jué. https://jicheng.tw/tcm/book/%E9%86%AB%E6%96%B9%E8%AD%89%E6%B2%BB%E5%BD%99%E7%B7%A8%E6%AD%8C%E8%A8%A3/index.html
Wiktionary. (n.d.). 溫. Retrieved August 16, 2023, from https://en.wiktionary.org/wiki/%E6%BA%AB
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