Tiny Formulas: Gan Cao Gan Jiang Tang

Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) is a most useful tiny formula to understand.  I hope readers take some time with this post so that this a real relationship with this little building block of so many formulas can sink in.  In another post, this formula is mentioned as part of the formula Cinnamon Twig, Poria, Schisandra, and Licorice Decoction, remove cinnamon, add Ginger, Asari, and Pinellia (guì líng wǔ wèi gān cǎo qu gui jia jiang xin xia tāng).  Although the proportions are different, the two herbs, Gan Cao and Gan Jiang are in many formulas such as Ban Xia Xie Xin Tang, Gan Cao Xie Xin Tang, Si Ni Tang, Li Zhong Wan and many more.  Below we see that Pao Jiang is sometimes used in place of Gan Jiang when there is bleeding.  This combination can be seen in the formula Sheng Hua Tang (click to read a post on this formula). Many formulas include Sheng Jiang and Gan Cao.  It is not uncommon in my practice to substitute Gan Jiang for Sheng Jiang in certain formulas such as Wen Jing Tang, thereby integrating the ideas of Gan Cao Gan Jiang Tang.

All this is to say that this formula is wonderful to understand and to give patients.  I consider it a formula to melt frozen earth and metal.  When earth and metal are frozen, fluids and blood cannot be absorbed and contained.  This explains why this formula can be used for thirst, incontinence, cough and bleeding.  When we see thirst, we often think of heat or dryness so we may forget to consider that the fluids may be unavailable because they are frozen.  When we see bleeding we often think of heat or deficiency.  We may not consider that the function of “wrapping” blood is impaired by frozen earth.  When we see incontinence we often think that there is lack of consolidation due to deficiency.  We may not consider that the absorption of fluids is impaired because the earth is frozen.  When we see cough, we should consider that the lung tissue may be frozen cold, thereby impairing the disseminating and descending function.

I think the cases and discussions below will be enlightening and helpful for your clinical practice!  The material below is all from a text put together by the famous classic formula doctor Liu Duzhou：Hand-Picked Shang Han Lun Case Studies of Illustrious Physicians    (伤寒名医验案精选).  It contains case studies and discussions about all of the formulas of the Shang Han Lun.  It is called Enjoy.

Formula: Licorice and Ginger Decoction (gān cǎo gān jiāng tāng)

Cooking method:  Decoct the above ingredients in 3 sheng of water down to 1 sheng.  Remove the foam.  Divide into two doses to be taken warm twice in one day.

Original text [Clause 29]: 

Shang Han the pulse is floating, there is spontaneous sweating, frequent urination, there will be heart vexation, a slight aversion to cold, and cramps in the feet, but Gui Zhi Tang is given to attack the exterior, this is a mistake.  Having given it, there is jue, the throat is dry, and if there is vexation and agitation with vomiting due to reversal, administer Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) to restore the Yang.  If the jue recovers, and the feet become warm, then after administering Peony and Licorice Decoction (sháo yào gān cǎo tāng) the feet will then stretch.  Where the stomach qi is disharmonious, if the speech is delirious, give a little Regulate the Stomach and Order the Qi Decoction (tiáo wèi chéng qì tāng).  Where heavy sweating was promoted, if then there is repeated hot needling, Frigid Extremities Decoction (sì nì tāng) governs.

Formula explanation:

Liu DuZhou

In the past, when the Yin and Yang were both depleted, often the ancient sages would first benefit the Yang and afterwards enrich the Yin.  This presentation uses Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) to restore the Yang as well.  When the Yang is generated the Yin grows.  When the Yang is consolidated the Yin is preserved. When all is said and done, the symptoms of restlessness and dry throat appear like Yin damage.  One must consider this when warming the Yang.  This formula uses Glycyrrhizae Radix (gān cǎo) in double the amount of Zingiberis Rhizoma (gān jiāng).   This is because warming the Yang of the middle this way does not damage the lower Jiao Yin.  Later generations also use this formula for spleen and lung deficiency cold patterns.  For example it is used for spleen Yang deficiency depletion in which the spleen is unable to wrap the blood which leads to bleeding.  In this case, Zingiberis Rhizoma (gān jiāng) should be changed to Zingiberis Rhizoma preparata (páo jiāng) to warm the spleen and increase the absorption of blood.  It can also be used for lung emaciation with deficiency cold in which the thin fluids are cold and the Qi becomes depressed.  In this case the up bearing does not control the down bearing causing vomiting of saliva, dizziness and bedwetting.  In this kind of case, this formula can be very effective!

Cases

Case example one: Nose bleed

Yue Mei-Zhong

Mr. Yan was 21 years old.  The patient suffered from an ordinary nose bleed and at the beginning he did not mind it.  At a certain point he to a long journey of and after 3 days returned home.  At 6:00 his not began to bleed and after 5 hours it had not stopped.  His family were alarmed and did not know what to do.  In the middle of the night they came knocking.  He leaned his head on a pillow and the blood was still flowing ceaselessly.  He kept a basin under the bed and it was half full of blood.  The patient’s face was as white as a sheet of paper.  Recently a cold Qi had entered and he could not get warm and did not speak.  His pulse was very faint.  Hi spirit was defeated.  I urgently gave him Licorice and Ginger Decoction (gān cǎo gān jiāng tāng)

The patient became warm in the limbs 1/2 an hour after taking the herbs.  His pulse gradually slowed and he was able to speak.  The bleeding also stopped.  The next day 12 gm of e jiao was added.  There was no reoccurrence.

DISCUSSION

This patient had an ordinary nose bleed and so the Yang networks were already damaged.  Because of recent unsatisfactory conditions, his liver qi rose greatly.  This caused the blood to gush.  The  Ling Shu: Cold and Heat says “When there is sudden disease with inner rebellion, the liver and lung being very closely linked can lead to blood overflowing from the nose and mouth”.  This is the mechanism of the above illness. In this case the bleeding  was profuse, and the Yin fluids were suddenly lost and the Yang was without anything to attach to.  Although it was the middle of the night, the Yin was spontaneously exuberant at the Yin time and the Yang was suddenly lost.  If someone had only used a method to nourish blood and stop bleeding, the Yin would have been supported but the Yang would have finally been difficult to recover.  In order to change the course in a moment the only hope was to rescue the Yang.  The Jue was healed as the feet became warm and the pulse continued to issue forth.  Afterward he became of sound mind.  This formula carries out the plan slowly and gently by following this meaning.  Although Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) is not a stop bleeding formula, it was able to stop the bleeding.  This is because “The nature of Yang is to protect the exterior by consolidating”.  Yang consolidates and so the Yin is spontaneously calmed and guarded in the interior.  This means that, when the dike is strong enough to hold back, there is no worry of flooding over.

Case two: vomiting blood

Zhao Shou-Zhen

This patient was named Wang and he often had an illness of vomiting blood.  He was given clearing cold and astringent herbs to stop bleeding.  The past summer the illness returned.   He took the previous herbs with no effect and later took herbs to warm and supplement along with herbs to scatter stasis.    This was also to no avail.  When I saw him, the bleeding was sporadic but unceasing.  the color was dark and the substance was watery.  He also had a frequent cough and vomited clear fluid.  His mouth was bland, he had a poor appetite and yellow urine.  Hi pulse was soft and moderate.  I did observation in order to determine the formula.   There was both cold and heat.  However, this was 1. not a heat presentation so Zhi (Zi) and Fu (Ling) are not used.  This is also not 2. damage and depletion to the original Yang with the protective qi being weak and so Gui (Zhi) and Fu (Zi) type formulas are not suitable.  In this case the pulse is soft and moderate but there is not 3. the presence of sticky stool spleen deficiency.  There is a cough with clear fluids but 4. the cold lung is not deficient.  When there is this presentation you could use Six-Gentleman Decoction (liù jūn zǐ tāng) with Platycladi Cacumen (cè bǎi yè) and jiao Schizonepetae Herba (jīng jiè) .  These methods were used but the bleeding did not stop.  It was thought about for a long time but they failed to grasp the meaning.  The chapter on vomiting blood in the 三字经 San Zi Jing by Xuan Yi and Chen Xiu-Yuan says “use the warming absorptive method of Cao and Jiang”.   The four gentlemen with (Ren) Shen and (Bai) Zhu is too supplementing and is inferior to the use of Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) to warm the lung and supplement the spleen.  This is why it is said that this formula supplements without consolidating and it warms without drying.

FORMULA:

I gave the patient 4 packages and the vomiting decreased in frequency.  After 3 more packages it completely stopped.  After that I used food and drink to regulate and nourish and did not use other herbs.

DISCUSSION:

The Qing dynasty writer Qin Bo-Wei in his 秦氏同门集 Qing Dai Tong Men Ji, points out “In chronic vomiting illness the root is deficiency and the qi is often cold and the power is moderate.  Therefore, in terms of treatment, the main principle will be to supplement and warm”.  Blood flows along the channels.  When it meets warmth it moves and when it meets cold it congeals.  If you use cold and cool herbs in a knee-jerk fashion, it may stop the bleeding for a time but then suddenly the blood will flow out of the vessels and the cold will cause stasis and a lack of movement of the blood.  Over time there will be vomiting of blood that does not cease and cannot be cured.  In this case of vomiting blood there is evidence of spleen and lung deficiency cold.  We followed the words of Yi and Chen to “use the warming and absorbing method of Jiang and Cao regulation”.  Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) warms the Yang Qi of the Tai Yin.  It consolidated and absorbed the blood to move appropriately.

Case Three: Taxation Lin

Zhao Shou-Zhen

The patient worked very hard on a summer day in the fields.  It was muggy and hot in a stifling way.  He rested, wanting to sit down frequently.  Unavoidably, damp heat made a sneak attack.   Thereupon he developed lin illness.  His urination was rough and painful.  It dripped and did not come out easily.  There was also blood seeping out.  He could barely stand the pain.  I felt his pulse and it was rapid and without strength.  He did not have thirst.  His tongue moss was with and sticky as well as slippery.  There was chest and epigastric oppression and a slight cough with abundant clear fluids.  The bowel moved easily.  From the interrogation I knew that the cause was extreme over work that caused the warm heat to be damaged.  This in turn damaged the blood.  However, he was given lots of cold herbs to clear heat.  Heat was clear but damp stayed.  For treatment it was suitable to disinhibit urination, enrich Yin, course the channels and harmonize the blood.  I gave Polyporus Decoction (zhū líng tāng) with Achyranthis bidentatae Radix (niú xī) and Trichosanthis Fructus (guā lóu) .  I gave him 10 packages and although the bleeding and pain decreased, the lin remained the same and the chest fullness and cough with phlegm got worse.  The explanation is that the water damp has floated upward and the cold was generated in the lungs so that the upper orifices were not open through and the lower orifices found it difficult to be open.  This is why there was a cough with phlegm.  This was cold and not heat.  The lower Lin was not heat but rather fell into the category of damp.  The focus was not the lower jiao but was rather the upper two jiao.  For treatment it was appropriate to warm the lung and fortify the spleen.  However, the two Zhu (Atractylodis macrocephalae Rhizoma (bái zhú) and Atractylodis Rhizoma (cāng zhú) are warm and dry and damage the fluid.  Ma Xin San damage the lung Qi.  All of these are not what should be used.  Instead one should use Licorice and Ginger Decoction (gān cǎo gān jiāng tāng).

I gave him 5 packages and the urination became longer and the bleeding stopped.  The chest also became comfortable and the watery fluids decreased.  Because the formula was being effective, I gave him 5 more packages and the illness was cured.  Afterward I gave him herbs to boost the qi and fortify the stomach to regulate and recuperate.

DISCUSSION:

This case is an example in which there was one mistake after another.  It was only by grasping the principle pattern that one can know how to treat this lin.  One cannot be constrained to the concept of warm heat.  The tip of Glycyrrhizae Radix (gān cǎo) is a lead herb for disinhibiting water and moving downward.

Case four: bed wetting

Zhao Shou-Zhen

Mr. Liu was 30 years old.  He had been wetting the bed for a long time.  During the day there is a break between his urination but at night it is continuous.  The doctors agreed that his kidney qi was deficient and depleted.  In order to warm the kidney and enrich water, Kidney Qi Pill (shèn qì wán) was used.  Methods were also used to supplement the kidney and warm and astrict by using Stabilize the Yin Decoction (gù yīn jiān).  Astragalus Decoction to Construct the Middle (huáng qí jiàn zhōng tāng) and Tonify the Middle to Augment the Qi Decoction (bǔ zhōng yì qì tāng)  was also used to treat spleen and stomach deficiency cold.  He also tried herbs such as Cervi Cornu pantotrichum (lù róng), Hominis Placenta (zǐ hé chē) and Tian Sheng Huang 天生磺.  He tried many things and there was some effect sometimes and sometimes there was no effect.  Over all though he still was left with the problem without an effective treatment method.  I could see that the previous formulas were not conforming to the presentation and that all his efforts were in vain.  I carefully examined his pulse and his right side cun and guan pulses were weak.  His tongue was white and glossy without moss.  His mouth was bland.  He coughed with some thin fluids and his appetite was slightly diminished.  His urine was long and clear and extremely frequent at night.  His bowels were sticky.  In this case the 3 zang, lung, spleen and kidney were all ill.  However, herbs to supplement the kidney and warm the spleen had been given repeatedly so I couldn’t just tonify the lung now.  Instead I considered the dispersion thirst pattern.  The lungs are the upper source of water and in this case water was not transforming there.  This poured down the the Kidney with the result that the spleen and kidney were not able to keep the water within the banks.  What should have been closed was open wide.  The lungs had to be treated as the priority.  Why couldn’t this be the root presentation?  As Jing Yue says “Although a small amount of water is beneficial to the kidneys, the kidneys also connect to the lungs.  If the lung qi has no strength the kidney will not be able to absorb water.  Therefore, to treat the water one must treat the qi.  To treat the kidneys, one must first treat the lungs”.  The presentation in this case is related to the kidneys.  The treatment method is to warm the lungs and transform fluids.  In addition, Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) was originally  for enuresis which is even more of a reason to use it in this case.

daily 2 doses

After 3 days the enuresis had significantly decreased.  The excess saliva also became scanty.  I gave him 5 more packages and the pattern was no longer present.  Altogether he took 16 doses over 8 days.  This difficult to treat presentation was unexpectedly cured.  Honestly this exceeded my expectations.

Case five: diarrhea

Zhao Shou-Zhen

The patient, Mr. Dai had gone to the Dragon Boat Festival and had used indiscretion in eating and drinking.  That night he received a wind cold and the next day he had developed a fever and aversion to cold.  He also had abdominal pain and diarrhea.  He took some medicine to resolve the exterior and treat indigestion and the exterior resolved but the diarrhea did not stop.  Erroneously this was considered a deficiency pattern so he was given warming and supplementing herbs.  The diarrhea stopped but he had abdominal distention and pain.  He took laxative herbs but thereupon the diarrhea did not stop.  Then he came to see me.  He had intestinal sounds and each day he had diarrhea 5-6 times.  There was no distention and no pain.  His mouth was bland with a tasteless flavor.  His tongue moss was thin and white.  It was not dry.  His pulses were weak and without strength.  I drew my conclusion about the disease condition determining it to be stomach cold without much spleen qi deficiency.  Because of the lack of spleen Qi deficiency, it was not appropriate to use Ginseng Radix (rén shēn) or Atractylodis macrocephalae Rhizoma (bái zhú) to supplement.  It was also not an intestinal heat with stomach cold pattern so it was not appropriate to use the three Drain the Epigastrium Decoction (xiè xīn tāng) formulas for mixed cold and heat.   Although it was correct to say that this was a pattern of stomach cold with spleen deficiency,   Regulate the Middle Decoction (lǐ zhōng tāng) uses Ginseng Radix (rén shēn) and Atractylodis macrocephalae Rhizoma (bái zhú).  If we take these out we have Glycyrrhizae Radix (gān cǎo) and Zingiberis Rhizoma (gān jiāng).  This becomes Licorice and Ginger Decoction (gān cǎo gān jiāng tāng)  This has the ability to warm the stomach yang and supplement the spleen deficiency.

drink warm, 2 large doses a day.

The diarrhea decreased and after 2 more days of the herbs it stopped.  I used different herbs to regulate the interior and all was calmed.

Case six: Lung Atrophy

Dr. Zhang Ying-Rui  张应瑞

This was a case of a 45 year-old woman from the spring of 1951.  She had difficulties since giving birth.  She gradually became emaciated and her facial color was very sallow.  He had dizziness and frothy saliva.  Her throat was dry and her mouth was bland.  At night she was not able to rest peacefully.  Her tongue had no moss and had slight fluids.  A previous doctor had mistakenly considered this a case of blood depletion and Yin damage and gave him large doses of herb to nourish blood and enrich Yin.  After 10 days the illness did not change and the frothy saliva increased.  Her spirit was despondent and her body was weak.  When I examined her, her pulses were thin and moderate.  The right cun was weak.  This was a case of lung emaciation and I obeyed Zhong Jing’s method.  I gave her Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) to harmonize the middle and absorb fluids.

After 1 dose in the morning, by noon the saliva greatly decreased.  I gave her one more package and the saliva stopped.  She was able to peacefully sleep and did not wake up until the next day.  I continued with herbs to enrich the lungs and supplement Qi.  I regulated and nourished for a few days and she was cured.

Discussion:  Lung wilt can be from deficiency cold or deficiency heat and these must be differentiated.  In this case, because there was vomiting of white saliva with a sallow complexion, dizziness, bland mouth, thin moderate pulse with a weak cun position and because the patient had already been given large doses of herbs to enrich Yin with an opposite effect, I knew this was lung wilt from deficiency cold.  This is why I gave her Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) .

Case seven: Dispersion Thirst

Dr. Tao Zheng-Zhui 陶政锥

The patient was a man age 43.   He was suffered from dispersion thirst and a previous doctor had diagnosed him with lack of movement of the middle Yang and lower warmer Yang deficiency.  He used the method of supplementing and warming the spleen and kidneys.  He used Regulate the Middle Pill (lǐ zhōng wán) and Kidney Qi Pill from the Golden Cabinet (jīn guì shèn qì wán) with no effect.  It was then decided that he had middle fullness with indigestion.  Then he came to see me for a diagnosis.  He had mouth thirst.  He would drink and drink but the thirst was difficult to bear.  His nose was dry without mucous.  His breath felt cold.  His tongue was pale with scanty fluids.  His pulse was slightly floating, hesitant and thin.  This was a case of lung cold with dispirited Qi. The fluids had become cold and congealed.

I asked him to drink it like his usual tea.  He had his second visit after 10 days.  The thirst had diminished and the amount he drank decreased.  His nose was moist with mucous and his breath was warm.  I advised him to continue the formula until the end of the month and he recovered.

From: Julin Zhong Yi Yao 1986; (3) :28

Discussion:  This illness was in the upper warmer but the treatment focused on the middle and lower and therefore it was ineffective.  We did use a warming method but applied a Zang Fu diagnosis as well.  This shows that Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) treats lung cold with cold qi patterns.  For this it is truly effective.

Case Eight: Dizziness

Dr. Zhu Yan 朱颜

Mr. Wang was a 50 year old male who came for his first visit on April 12, 1965.  In the afternoon of the previous day he began to feel dizzy with a desire to vomit.  He asked a doctor to diagnose and treat him.  He was given Clear Dizziness Pill (qing xuan wan) without any results.  His pulse was hesitant at 47 beats/minute.  His tongue was pale and he had a desire to vomit.  He had no thirst or fever.  His body temperature was 36.4 C.  He feared cold.  This was a cold pattern and treatment needed to warm and scatter.  I gave him Licorice and Ginger Decoction (gān cǎo gān jiāng tāng).

Drink one package warm.  He returned for a visit the next day and the dizziness had stopped.  The vomiting also stopped.  His pulse was now 67 beats/minute.  He was able to return to his job of building walls.  I gave him one more package of the original formula and there was no recurrence.

From Zhong Yi Za Zhi 1965; (11): 6

Discussion:

In the Jing Yue Quan Shu (Complete Works of Jing Yue) chapter of dizziness, it is pointed out that “眩运一证，虚者居其八九，而兼火、兼痰者，不过十中·二耳”.  This case is due to cold deficiency of the middle jiao.  The clear Yang was unable to spread out.  Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) warms the cold in the middle and spreads the clear Yang.  This cured the problem.

Case Nine:  Stomach Duct Pain

Dr. Hu Xue Ceng 胡学曾

This is a case of a 16 year-old young man.  After eating cold and raw food over a long period of time he developed stomach duct pain.  This was caused by cold  and it would come and go.  Heat made it feel better.  This was accompanied by abdominal distention and a desire to vomit.  He vomited clear fluids.  He also had heart and chest vexation and oppression, dizziness, poor appetite, weight loss and pasty stool.  His tongue was burned red with white moist moss.  His pulse was deep and wiry.  This was spleen and stomach Yang deficiency with cold fluids stopping internally.  The evil fluids were upwardly harassing.  It was suitable to fortify the spleen and stomach, dispel cold and down bear rebellion.  I used Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) with added flavors.

From Tian Jian Zhong Yi 1986; (4) : 14

Discussion:  In asking questions to determine the cause and differentiate the syndrome we can see that this case of stomach duct pain is due to spleen and stomach deficiency cold.  Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) is Regulate the Middle Decoction (lǐ zhōng tāng) without the sticky cloying Ginseng Radix (rén shēn) and Atractylodis macrocephalae Rhizoma (bái zhú).  This will make the formula’s warm the middle action to be even more speedy.  The addition of Pinelliae Rhizoma preparatum (zhì bàn xià) warms the stomach and stops rebellion.  In this case it was effective.