I’m excited to explore the extremely clinically relevant formula Gualou guizhi tang in some detail. What a great first formula in this JGYL formulas project.
I just love all the derivatives of Guizhi tang. How incredible is Gui zhi tang? It forms the foundation of a large proportion of Zhang zhongjing’s (ZZJ) formulas and yet is the simplest, most unassuming formula we have in the materia medica. Here, we make the slightest addition to that pure formula and end up with a quite different energy and effect. This is the minimalist power of classical Chinese herbal formulas!
In this article, I’ll go over the basics and some clinical notes from my own practice.
Gualou guizhi tang 栝楼桂枝湯 in the JGYL
This formula is the first in the second chapter of the Jin gui yao lue, thus the first in the text.
“In greater yang disease, if all signs are present and [in addition] the body is rigid and stretched but the pulse is sunken and slow, this is tetany. Gua lou gui zhi tang governs.1
This is the only appearance of this formula in ZZJ’s works, though the majority of this formula is contained inside of Chaihu guizhi ganjiang tang. A conversation for a different day!
Ingredients and proportions
Note : In this work, I chiefly rely on the Shennong bencao jing 2, Shanghan lun, Jingui yaolue and a few related secondary texts. If I say an herb is the X herb of the X class, this refers to its classification in the Tangye jing. In some cases, this information (seems to) conflict with what you see in the standard textbooks, a fruitful space for discussion!
Guizhi – 3 liang
Cinnamon twig is one of the most commonly used herbs in ZZJ’s formulas. It works to warm and release the muscle layer and thus the Taiyang surface. It is pungent and warm, as well as being the wood herb of the wood class. That intensified wood energy feeds the fire via the generation cycle, filling the yang of the Heart and encouraging outward movement and warmth to the surface. In decoction of this formula, Guizhi DOMINATES.
Shaoyao – 3 liang
Peony root, common companion to Guizhi, comes in white (Baishao) and red (Chishao) versions. It’s a bitter and neutral herb and the earth herb of the metal class. Here we use 3 liang – so in a 1:1 relationship with Guizhi. The pungent woody warmth of Guizhi is combined with the condensing moistening Shaoyao, they together help to restore normal regulation to the surface – stopping any tendency towards sweating. Also, this simple combination establishes normal qi and blood circulation in the surface which may, in itself, gently release the tight musculature typical of the Gualou guizhi tang pattern.
Gancao – 2 liang
Licorice root, one of the most recognizable Chinese herbs is used in this formulas – like so many others. Here, it appears we want the licorice fried version, so Zhi Gancao. Gancao is sweet and neutral and is the wood herb of the earth class. 3:2 ratio with the other herbs so far, a typical dosage for Gancao in ZZJ’s formulas. We know that Gancao detoxifies and “harmonizes” formulas, but in thinking about it as the wood herb of the earth class, we can also consider that it builds the center while simultaneously encouraging appropriate movement.
Shengjiang – 3 liang
Fresh ginger root – one of my favorite things on Earth! It is pungent and warm and the earth herb of the wood class. It is in that way the inverse of Gancao. Both work on the relationship of wood and earth, essential for the proper functioning of the center – around which everything else in the body turns. But here, our focus is on the generative and moving qualities of wood, and doing so in such a way that benefits earth.
Dazao – 12 pieces
Chinese date, or Jujube, is a common pairing with Gancao, where they work together to protect the center and harmonize the formula. This completes the formula Guizhi tang within Gualou guizhi tang. Dazao is sweet and neutral in the SNBCJ, and in the TYJ is the fire herb of the earth class. What is a piece of Dazao in granule gram weight? My teachers have used anywhere from 9-12 grams, and I’ve seen as many as 15 grams used as a “piece.”
Gualou / Tianhuafen – 2 liang
Trichosanthes is used as a root, whole fruit, peel or seed, and is commonly known as Chinese snake gourd (though the species is slightly different from the common grocery store snake gourd!). This is the most interesting herb in the formula in that it is relatively unique in ZZJ’s works. I know a lot about Guizhi tang, which forms the bulk of this formula, but comparatively less about Trichosanthes.
Because of this, I’m going to follow up this article with one looking specifically at Gualou / Tianhuafen in more detail. What I can say is that Gualou is not in the Tangye jing’s 25 herbs, but in the Shennong bencao jing, Tianhuafen is listed as bitter and cold. That’s true of the fruit as well. This bitter coolness will, in part, help to drain heat and restore moisture to the dry and damaged tissues.
- Guizhi 3 liang
- Shaoyao 3 liang
- Shengjiang 3 liang
- Gancao 2 liang, mix fried
- Dazao 12 pieces
- Gualou 2 liang
More about the relationship with Guizhi tang
In the formula preparation instructions, the formula reflects Guizhi tang in that you are meant to take the decoction in three doses and stay bundled so as to induce slight sweating. If the sweating doesn’t happen, you feed hot gruel to assist in the sweating process by both supplying the types of substances necessary to make sweat AND warming the person internally.
A key point in the text is where it says that the pulse is sunken and slow, confounding expectations. The implicit understanding is that, like in other Taiyang disease, the pulse should be superficial or floating (as we learn first in the first line of the Shanghan lun) and – while not necessarily rapid – certainly not slow. In this situation, the body is not working at the surface, but at the interior – it is no longer a simplex yang conformation illness. It’s a more complex situation – thus its presence in the Jingui, which deals in complex diseases.
Given that this formula is based on Guizhi tang, we can surmise a thing or two about how the pathology developed. Obviously, this is Taiyang disease, and thus requires the regulation of the surface (Guizhi, Baishao, to some extent Shengjiang) while simultaneously bolstering the Taiyin center (Shengjiang, Gancao, Dazao). So, there is surface dysregulation, with the attendant sensitivity to wind & claminess.
If the surface is open too long, or if the patient is already deficient of fluids to begin with, Yangming type dryness could definitely be the result. The “Stomach domain” gets dry, impacting the fluids, tissues and areas associated with that domain. I’ll return to this point at the end of this article, and it will dominate the deeper discussion of Gualou in the next article.
Tetany – what is it and how does it show up today?
As mentioned above, the JGYL indicates that this formula treats tetany. What, exactly, is tetany – and how might it show up in your clinic?
Tetany is written as either jìng 痙 or as cì 痓. It is described as being an intense tightness, rigidity and spasming of muscle tissues, usually with attendant loss of easy movement and significant pain. Tetany can occur anywhere in the body and can be accompanied by a wide range of symptoms. In clinic, it can be challenging to decide whether a given tight, painful back is truly tetany in this sense, or whether it is something else.
As always, paying close attention to the accompanying signs and symptoms is key to differentiating similar presentations.
There are two forms of tetany described in the JGYL. The soft/yin form, as would be treated by Gualou guizhi tang, involves an open surface, and thus, sweating. The hard/yang form, then, has no sweating, and is associated with formulas like Gegen tang. I think we can safely assume that the hard form would be more acute, tight and painful than the soft form. 3.
In my clinical practice, I have used this formula to treat very mild and very severe cases of tight, painful muscles – especially in the back and shoulders.
One classic type of person I see with this presentation is the typical office worker. In an office environment with forced air HVAC and lots of intellectually oriented work, dehydration is a common problem. Add to that 8+ hours hunched over a computer, particularly if no efforts are made to improve ergonomics? Well, I’m not going to say that these conditions by themselves will cause a Gualou guizhi tang pattern, but it sure isn’t helping.
I have also used the formula with some success to treat more severe forms of tetany including rigidity in the neck due to spinal fusions as well as acute myoclonus secondary to severe viral infections.
I almost always use GLGZT as an addition to another Guizhi tang based formula, or one that works well with it. For instance Chaihu guizhi tang + Gualou guizhi tang for seasonal allergies with coughing and sneezing that results in a lot of neck and upper back tension.
What is the Gualou doing in Gualou guizhi tang?
Most of this article has been about Guizhi tang, which makes sense given the composition of the formula. But, to me at least, it is initially confusing how Gua lou gui zhi tang has such different symptoms and signs than does straight Guizhi tang. So, in the next article, I’m going to get more familiar with Gualou, comparing it with a formula that should have similar signs and symptoms, Guizhi jia gegen tang.
I’ll share my sensory experiences from drinking several different decoctions, and suggest formula dynamics as well as additional information about what this formula might treat. I’ll link that article here when it is finished.