Si Ni San

Si Ni San

From “Shang Han Lun”

[Composition] Equal parts of chai hu, zhishi, baishao, and zhi gan cao

[Administration] Grind all ingredients into powder, sift, and steep in warm water, taking 10 grams per dose. In modern times, it is often prepared as a decoction, boiled in water.

[Indications] Liver-spleen imbalance, with heat excess and cold extremities.

[Suitable Symptoms] Bitter taste in the mouth, dry throat, chest and flank fullness, abdominal distension and pain, loss of appetite; also used for cases of internal yang depression or heavy, hot diarrhea, and cold extremities.

[Functions] ① Harmonize liver and spleen. ② Harmonize the interior and exterior.

[Formula Explanation] This formula treats both liver-spleen imbalance and heat excess with cold extremities, and is one of the representative formulas in traditional Chinese medicine for treating different diseases with the same approach.

Heat excess with cold extremities is a clinical manifestation of heat accumulating inside while cold is trapped outside—also known as yang excess and yin restraint, where the limbs feel cold and numb. Therefore, this formula is used to treat such conditions, which is why it is called Si Ni San. In this formula, chai hu opens and clears the pathways between the exterior and interior, serving as the primary treatment to allow internal heat to dissipate and external heat to reach the surface. Zhishi regulates qi and disperses blockages, helping chai hu open the pathways between the exterior and interior as an auxiliary treatment. Baishao soothes the liver and nourishes yin, replenishing the yin that has been depleted by the qi’s dissipation, while also treating the liver’s wind that causes cold extremities—this is a complementary treatment. Zhi gan cao harmonizes all the herbs and acts as a guide for harmony. Here, the focus is on opening and releasing yang qi, restoring warmth to the extremities, fully embodying the principle of treating the symptoms when they are acute.

Liver-spleen imbalance is a condition where liver wood overcomes earth; only when liver qi is stagnant can liver qi turn against the stomach, leading to liver-spleen imbalance. Symptoms of liver qi stagnation include bitter taste in the mouth, dry throat, and chest and flank fullness; when liver qi turns against the stomach, abdominal distension and pain, and loss of appetite occur. In this formula, chai hu opens the liver and serves as the primary treatment. Zhishi helps chai hu open the liver as an auxiliary treatment. Baishao soothes the liver and nourishes liver yin, as liver qi stagnation often leads to fire, and when fire is strong, it tends to damage yin—so soothing the liver and nourishing yin is a complementary treatment. Gan Cao harmonizes all the herbs and acts as a guide for harmony. Here, the focus is on opening the liver; when liver qi is opened, it cannot turn against the stomach, fully embodying the principle of treating the root cause when symptoms are acute.

[Clinical Additions and Subtractions]

① Remove Zhishi and add chuan xiong, xiang fu, and zhishi, creating Chai Hu Shu Gan San (from “Jing Yue Quan Shu”), which treats liver qi stagnation.

② For those with food stagnation, add malt and chicken gizzard; for those with blood stasis, add dan shen and shi xiao san; for those with jaundice, add Yin Chen and Yu Jin; for those with abdominal pain and acid reflux, add Zuo Jin Wan; for those with heavy, slow bowel movements, add xiebai.

[Reference Materials]

① “In cases of Shaoyin disease, with Si Ni, the patient may cough, feel palpitations, have difficulty urinating, experience abdominal pain, or suffer from heavy, slow bowel movements—Si Ni San is indicated for such cases.” (from “Shang Han Lun”)

② “Si Ni San is a formula that treats both the exterior and interior; when heat accumulates internally and yang qi cannot reach the exterior, the heat is inside while the cold is outside, and it is not appropriate to use purgatives to hinder the cold—so only Zhishi is used to disperse the stagnant heat, while chai hu is still used to release yang qi; when yang qi is released, the extremities naturally warm.” (from “Ming Yi Fang Lun”)

③ Si Ni San treated a case of nervous abdominal distension. Yang ××, female, 42 years old. Her chest and abdomen were normal in the morning, but in the afternoon, she began to experience abdominal distension, with her abdomen as large as a drum, producing sound when tapped, causing her to feel uneasy when sitting or lying down, suffering greatly. She was normally irritable and prone to anger, had poor bowel movements, and her urination varied in frequency—she only ate three portions a day, couldn’t sleep at night. Western medical diagnosis: gastric neurosis. She had tried various Chinese and Western medicines without success. Traditional Chinese medicine consultation: the patient’s expression was indifferent, her face was dull and lacking luster, she was slightly overweight, spoke little, had a deep, tense pulse, and the pulse was strong. Based on the overall pulse and symptoms, she was diagnosed with liver qi stagnation, spleen dysfunction, and a failure in the proper functioning of the central channel, leading to abnormal ascending and descending functions. The treatment should focus on opening the liver, resolving qi stagnation, regulating qi, improving the flow of qi, and restoring the proper ascending and descending functions. Given the long duration of the illness, it was advisable to treat both the exterior and interior, using Si Ni San in combination with Si Mo Yin Zi, adjusted for internal use (chai hu 3 qian, baishao 4 qian, zhishi 4 qian, gan cao 2 qian, mu xiang 3 qian, wu yao 3 qian, peng lang 3 qian, tong hua gen 6 qian, jī xue teng 1 liang, decocted in water). Additionally, half a jin of radish, one jin of scallions (with roots and stems), half a jin of orange leaves, and two liang of ginger were chopped, crushed, and heated (lightly adding baijiu), wrapped in cloth (two packages, rotated) and applied externally to the chest and abdomen. After treatment with the above formula, she frequently passed gas, her chest and abdomen felt more comfortable, her bowel movements were smooth, her abdominal distension decreased significantly, and she continued to use the formula to soothe the liver and regulate qi while promoting water drainage—using chai hu 3 qian, baishao 4 qian, zhishi 4 qian, fuling pi 8 qian, da fu pi 4 qian, dong gua pi 1 liang, chen pi 3 qian, sang pi 3 qian, yu chu 1 liang, and decocted in water, taken in two doses. After several doses, all symptoms had disappeared. Later, she added and modified the formula with Xiang Sha Six Junzi Tang to regulate the spleen and stomach, achieving good results. (New Medical Journal, 1975.7:43)

[Commentary] This formula can be used with adjustments for gastric and duodenal ulcers, acute and chronic hepatitis, intercostal neuralgia, and acute and chronic cholecystitis.