Author: Zhao Yinming
In Si Ni San (Four Reversal Powder), Chai Hu (Bupleurum) is used.
Sha Yao (Peony), Zhi Shi (Bitter Orange), and Gan Cao (Licorice) are essential.
This addresses Yang constraint leading to reversal.
It smooths the liver and regulates the spleen, achieving remarkable effects.
Wen Zhong San Han (Four Reversal Decoction) is used.
Fu Zi (Aconite), Gan Cao (Licorice), and Gan Jiang (Dried Ginger) are included.
The pulse is weak and nearly absent, but can be restored.
Extremities in reversal can return to Yang.
When I present these two formula songs together, you might have a habitual thought, isn’t it just comparing Si Ni San and Si Ni Tang? This seems simple, so the following content might just roll off your tongue. Of course, this does not exclude the possibility that your learning ability needs improvement, and you might not be able to recite it~(￣▽￣～)~
Si Ni San, composed of Chai Hu, Sha Yao, Zhi Shi, and Gan Cao, is a harmonizing formula that has the effects of regulating the liver and spleen, dispelling pathogens, and relieving constraint. It is indicated for Yang constraint and reversal syndrome, with cold extremities, abdominal pain, or diarrhea with heavy stools, and a wiry pulse; for liver and spleen Qi constraint syndrome, with rib-side distension, abdominal pain, and a wiry pulse. Si Ni Tang, composed of Fu Zi, Gan Jiang, and Gan Cao, is a warming formula that has the effects of warming the middle, dispelling cold, and rescuing Yang from reversal. It is used for Yang deficiency with impending collapse, spontaneous sweating, cold extremities, diarrhea with clear stools, and a weak pulse.
Most people analyze them based on their composition and therapeutic effects, but if you ask a freshman who hasn’t studied any professional courses, they might say, what’s the difference? Ah! (Silently nitpicking…) Si Ni San and Si Ni Tang, isn’t one a powder and the other a decoction? At first glance, it might seem laughable, but upon reflection, there is profound meaning here. Anyone with a certain understanding of dosage forms knows that “powder” and “decoction” are two different forms. To speak professionally, powders are solid forms, while decoctions are liquid forms.
I also later discovered from the original text of Shang Han Lun that the opening question is often overlooked by many, as they skip the small print regarding decoction methods, which often includes some medicinal components like ginger and jujube. Importantly, there are some fundamental principles. Similarly, why is it called “San” (powder) and not “Tang” (decoction)? “Take the four ingredients, pound and sift, and take with white drink (rice soup), three times a day.” The original formula was to prepare the medicine as a powder to be taken with white drink (rice soup), which reduces the irritation of the powder on the throat and also implies that when the middle Qi is harmonized, the Yin and Yang energies connect smoothly. However, nowadays, very few people in outpatient clinics will prescribe Chai Hu, Sha Yao, Zhi Shi, and Gan Cao as a powder; most directly prescribe it as a decoction, leading to a chaotic situation where Si Ni San has become Si Ni Tang.
At this point, you might wonder, will such changes in dosage forms affect efficacy? The answer is certainly yes. We all know that different administration routes affect drug absorption; external application is not as effective as oral administration, and oral administration is not as effective as injection. The direct oral intake of powders and the oral intake after composing decoctions have already changed the components. Some scholars conducted animal experiments comparing the effects of Si Ni San as a water decoction, powder, rice soup with Si Ni San powder, and rice soup alone. Among them, the rice soup with Si Ni San powder, following the method in Shang Han Lun, showed the best effect, indicating that the ancient method of Si Ni San, taken with white drink, is indeed more effective than the modern method of water decoction.
Unclear processing and uncertain medicinal properties lead to ineffective decoctions. When we studied the processing of Chinese herbs, many of my classmates in TCM said that the separation of medicine and pharmacy has led them to neglect the study of processing, let alone dosage forms. Nowadays, many dosage forms are directly mass-produced, simplified in outpatient clinics to water decoction, pre-decoction, or granules, and the pros and cons of these should be examined. The ancients were meticulous in their use of medicine. Xu Dachun pointed out in Yao Yi Yuan Liu Lun that “the method of decocting medicine should be deeply discussed; the efficacy of the medicine depends entirely on this… The methods recorded at the end of ancient formulas are all different.” Shang Han Lun provides detailed discussions on the decoction methods for each formula, which should not be overlooked.
Traditional dosage forms of Chinese herbal formulas are mostly decoctions and are widely used in clinical practice, along with forms like “pills, powders, pastes, and elixirs.” During the Song Dynasty, traditional decoctions were transformed into water-prepared powders, and in modern times, most powders have been converted into decoctions. Changes in dosage forms can significantly alter the material basis or component ratios within formulas, thereby changing the characteristics and properties of the formulas, and may even fail to achieve the expected therapeutic effects. In modern clinical and experimental research, many scholars have studied the impact of changes in dosage forms from powders to decoctions, which can be categorized into three situations: 1. Traditional powders converted to decoctions. 2. Traditional decoctions converted to powders. 3. Traditional pills and other forms converted to powders and decoctions. Most studies indicate that the efficacy decreases when traditional powders are converted to decoctions, and the dissolved components are reduced. However, when traditional decoctions are converted to powders, the therapeutic effects are comparable, but the economic cost is significantly better than that of sliced forms. Traditional pills and other forms converted to powders and decoctions still show better effects with powders. For example, both Xiao Yao San and its decoction can improve clinical symptoms in patients with liver Qi constraint and spleen deficiency, but the powder is more effective than the decoction; the differences in low-polarity chemical components between Wu Ling San in decoction and powder forms are significant, with low-polarity components severely lacking in the decoction; and Zuo Jin Wan powder shows better anti-ulcer effects in rats than the water decoction. In studies aimed at improving external powders, converting them into ointments and patches generally shows better percutaneous absorption characteristics than powders.
In the improvement of powder dosage forms, two well-known medicines must be mentioned—Yunnan Baiyao and Huo Xiang Zheng Qi. Since its inception, Yunnan Baiyao has been supplied to the market as a powder, convenient for internal and external use, and easy to mix with other medicines. Despite a century passing, it continues to be produced and supplied to the market. However, due to the difficulty in accurately measuring the dosage of powders and the discomfort during internal use, Yunnan Baiyao has been made into capsule form, which retains the advantages of powders while overcoming the discomfort of internal use, allowing for accurate dosage in multiple uses, and is convenient for storage, transport, and use, gaining widespread popularity. The external use of Yunnan Baiyao has developed into an aerosol, which has now become its main dosage form.
Huo Xiang Zheng Qi San originates from Tai Ping Hui Min He Ji Ju Fang, with a formula that has over a thousand years of history. It is named Huo Xiang Zheng Qi because it uses Huo Xiang (Agastache) as the main ingredient, which can rectify the Qi. It has long been regarded as an excellent remedy for preventing heat stroke and treating vomiting and diarrhea. Its modern dosage form, Huo Xiang Zheng Qi Shui (Huo Xiang Zheng Qi Water), has long surpassed its original name, indicating the effectiveness of this dosage form improvement. However, due to its strong stimulating odor, it has now been converted into soft capsules, but it is generally believed that its efficacy is inferior to that of Huo Xiang Zheng Qi Shui.
“Generally speaking, decoctions are for major illnesses; powders are for acute illnesses; pills are for chronic conditions, which cannot be treated quickly, and their use is more gradual, reflecting the intention of treatment.” Based on the characteristics of powders being absorbed quickly and taking effect rapidly, they have historically been used for emergencies, such as inducing vomiting, expelling phlegm, unblocking passages, and opening orifices, as seen in emergency formulas like Xi Yan San, Tong Guan San, and Gua Ti San. “For substances that need to remain in the stomach, powders are the best.” Powders can stay in the stomach for a long time, providing local treatment while also having a systemic regulatory effect. For the use of toxic substances, “non-toxic substances are best as decoctions, mildly toxic substances as powders, and highly toxic substances must be in pill form.” For conditions of wind, cold, and dampness, due to the interplay of these three pathogenic factors, dampness is difficult to eliminate, and since the pathogenic factors have long been entrenched in the body, a gradual approach is often taken, which also frequently employs powders to gently dispel pathogens, such as Qiong Fu San and Yi Yi Ren San.
In the preface of Shen Nong Ben Cao Jing, it is stated: “Medicinal properties are suitable for pills, powders, decoctions, wine infusions, and ointments; some substances are suitable for multiple forms, while others cannot be used in decoctions or wines, and this must follow the properties of the medicine and not be violated.” This theory has been an important basis for the selection of Chinese herbal compound dosage forms and single herb slices for over two thousand years. The application of dosage forms is directly related to the properties of the medicines. To modernize Chinese medicine, the improvement of traditional Chinese medicine dosage forms has already undergone significant changes. How to avoid “improvement without progress” is something we must think about, and how to flexibly and skillfully apply powders in clinical practice requires continuous summarization and improvement by physicians in practice.
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