A New Perspective on Gancao Xiexin Decoction

Today I had the privilege of studying several clinical cases by the late TCM Master Zhang Qi. One case in particular left a deep impression on me — a patient with a duodenal bulb ulcer treated with Gancao Xiexin Decoction (Licorice Drain the Heart Decoction). The patient’s primary symptoms included epigastric pain that worsened with hunger, acid regurgitation, bowel rumbling, and constipation. Ordinarily, when I encounter presentations like this, I would prescribe a Chaihu formula, or perhaps Banxia Xiexin Decoction. But Master Zhang’s choice of Gancao Xiexin Decoction genuinely puzzled me, so I decided to dig deeper.

Zhang Zhongjing created three Xiexin Decoctions. Their principal differences in composition are as follows:

Banxia Xiexin Decoction: Banxia (Pinellia) 12g, Ganjiang (dried ginger) 9g, Huangqin (Scutellaria) 9g, Huanglian (Coptis) 3g, Renshen (Ginseng) 6g, Zhi Gancao (honey-fried Licorice) 6g, Dazao (Jujube) 5 pieces. Decoct in water and divide into two doses.

Shengjiang Xiexin Decoction: Same as Banxia Xiexin Decoction, but reduce Ganjiang to 3g and add Shengjiang (fresh ginger) 12g. Same method of administration.

Gancao Xiexin Decoction: Same as Banxia Xiexin Decoction, but increase Zhi Gancao to 9g. One version omits Renshen. Same method of administration.

According to mainstream perspectives, all three Xiexin Decoctions were designed for the pi syndrome (distention and fullness). Banxia Xiexin Decoction is inclined toward the pi syndrome of intermingled cold and heat; Shengjiang Xiexin Decoction targets the water-heat binding type of pi; and Gancao Xiexin Decoction primarily addresses the deficiency-type pi. While these distinctions appear clear-cut in theory, they are remarkably difficult to differentiate in clinical symptomatology — especially the deficiency-type pi, which I believe is quite easy to confuse with the others. Looking at the formula modifications, the only difference between Gancao Xiexin and Banxia Xiexin Decoctions is an increase of one liang of licorice. Where exactly does the force and directional specificity of this single liang manifest?

After careful study and contemplation, I discovered an interesting indicator: the degree of abdominal distention.

The abdominal distention in cases suited for Gancao Xiexin Decoction should be considerably harder and more pronounced than that of Banxia Xiexin Decoction. Some renowned veteran practitioners have used Gancao Xiexin Decoction to treat constipation — note: using it for constipation. This type of constipation is a deficiency-pattern constipation, typically without bowel rumbling. The stool may not be excessively hard; rather, the patient lacks the urge to defecate yet experiences persistent abdominal fullness and distention. Purging methods may offer temporary relief, but the constipation returns once laxatives are stopped. In mid-2017, I treated a female patient with exactly this pattern of constipation — unfortunately, I was unable to cure her at the time. A humbling reminder that my studies were insufficient.

Of course, during my studies of the Jingui Yaolüe (Essentials from the Golden Cabinet), my teachers consistently emphasized that Gancao Xiexin Decoction is an excellent formula for treating Behçet’s syndrome. From a Western medicine perspective, gastric ulcers are ulcers, and Behçet’s syndrome also manifests as ulcers — different presentations of a similar pathological process. But what is the deeper significance that connects them?

I will continue to explore this question in depth.

今日拜读了国医大师张琪先生的几个医案，其中一个十二指肠球溃疡运用甘草泻心汤案令我印象深刻。在此案中，患者主要表现是胃脘疼痛、饥饿时痛甚、反酸、肠鸣、便秘，一般我遇到情况会给柴胡剂，有些时候会给半夏泻心汤，但张老运用甘草泻心汤着实令我难以理解，随研究了一番。

张仲景创立了三个泻心汤，成分上主要区别如下：

半夏泻心汤：半夏12克，干姜、黄芩各9克，黄连3克，人参、炙甘草各6克，大枣5枚。水煎取汁，分2次服。

生姜泻心汤：即半夏泻心汤干姜用量为3克，加生姜12克，用法同上。

甘草泻心汤：即半夏泻心汤加甘草用量至9克，一方无人参。用法同上。

从目前主流的观点看，三个泻心汤都为了痞证而设立，半夏泻心汤偏向寒热错杂的痞证，生姜泻心汤偏向于水热互结之水气痞证，甘草泻心汤主要责之虚痞证，看似有明显区别，但在症状表现上确是很难衡量，尤其是这个虚痞，个人认为很容易混淆。从方剂变化上看，甘草泻心汤较半夏泻心汤只是在甘草的用量上增加了一两，这一两的力道和指向到底在何处体现？

我仔细研读琢磨，发现了一个有意思的指征，那就是腹胀的程度。

甘草泻心汤的腹胀程度应该比半夏泻心汤要硬的多，有一些名老专家曾运用甘草泻心汤治疗便秘，请注意，这里是用甘草泻心汤治疗便秘，这种便秘的表现就是虚秘，一般是没有肠鸣的便秘，不一定多秘结，应该是没有便意但又有腹部胀满。这种便秘用下法可以缓燃眉之急，但不吃泻药又会秘结，2017年中旬我曾治疗一位女性便秘，就是这种情况，可惜没有治好，真是学业不精。

当然了，我在学习金匮要略的时候老师一直在跟我们灌输，这个甘草泻心汤是治疗白塞氏综合征的良方。从西医思路上看，确实胃溃疡也是溃疡，白塞氏也表现为溃疡，异曲同工，但其中的内涵究竟是什么呢？

我将会继续深入研究。