Si Jun Zi Tang – The Four Gentlemen
Alex Owen
BSc. (Hons) TCM, Bachelor of Medicine (Beijing), MATCM
22nd April 2003
Introduction
Herbal Formulary is a method of treating disease by administering individual herbs in
specific combinations called formulae. The content of each formula is governed by
the symptoms presented by the patient which the practitioner is able to classify into a
syndrome. Once the syndrome is identified a treatment method is deduced that aims to
deal with the symptoms and reinstate balance, returning the patient to health. A
formula that best meets the demands of the treatment theory can then be selected. The
four aspects of ‘herbs’, ‘formula’, ‘treatment theory’ and ‘syndrome differentiation’
are all intertwined. So much so that even a minor alteration in one will lead to
necessary modification of the others in order for the treatment to be successful. This
article will investigate this interrelationship by showing how changes in the syndrome
necessitate modification of formulae.
Changes in Syndrome Differentiation
As explained above if there is a change in the presentation of a disease the syndrome
differentiation will alter, this in turn will lead to a reworking of the treatment method
which will finally end by the modification of a formula by the altering of its
components. If the disease changes or an inaccurate syndrome differentiation is made,
there will be a high probability that the formula selected will have a diminished effect
or be totally ineffective. Therefore it is crucial that accurate diagnosis is made and that
all symptoms are taken into account. This article will use the formulae Si Jun Zi Tang
to illustrate how even minor changes in the syndrome will lead to modification of the
formula.
四 君 子 汤 (Si Jun Zi Tang)
Si Jun Zi Tang is translated as the ‘Four Gentlemen Decoction’, it was given this
name as the herbs within the formula have a mild and balanced action of tonifying the
qi. It is indicated for use in cases of spleen and stomach qi deficiency syndrome. This
syndrome means that the spleens ability to transform food into blood is deficient
leading to symptoms of pallor, and a low soft voice. The deficient function of the
spleen also means that its duty of transporting is inadequate manifesting as poor
appetite and loose stools. The spleen is also responsible for maintaining the four
limbs, with insufficient supply of nutrition from the spleen the muscles will become
weak, and the patient becomes lethargic. A pale tongue and a soft and weak pulse will
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also be exhibited. These symptoms can appear in such biomedically-defined disorders
as chronic gastritis, diabetes mellitus and peptic ulcer.
The formula is made up of four herbs. Ren Shen is the principal herb, with a sweet
and warm nature, it is a strong tonic invigorating the spleen qi. Bai Zhi, the assistant
herb, is bitter, sweet and warm and is able to strengthen the spleen, dry dampness and
harmonises the spleen and stomach. Ren Shen and Bai Zhi work synergistically to
promote the transforming and transporting functions of the spleen. Fu Ling, the
adjuvant herb, is sweet and bland. It excretes dampness while supporting the function
of Ren Shen and Bai Zhi in strengthening the spleen. Finally Zhi Gan Cao, the
dispatcher herb, is sweet and warm and helps to nourish the spleen, replenish qi and
harmonise all the herbs in the formula.
香 砂 六 君 子 汤 (Xiang Sha Liu Jun Zi Tang)
The syndrome of spleen and stomach qi deficiency with cold-damp stagnating in the
middle jiao presents symptoms that necessitate the basic formula of Si Jun Zi Tang to
be modified. In combination with symptoms of spleen qi deficiency, the cold causes
coagulation of qi and blood within the middle jiao impeding its flow and causing pain
and distension in the abdomen. In addition the ability of the spleen to transform water
is diminished leading to an accumulation of dampness overflowing from the stomach
and further impeding the flow of qi around the chest and middle jiao. The stomach qi
is no longer harmonised, it adversely rises leading to belching, nausea and sometimes
vomiting. The dampness also flows downward causing loose stools.
Si Jun Zi Tang does not have herbs that can directly deal with the causes of these
additional symptoms so four herbs are added to the original formula to form Xiang
Sha Liu Jun Zi Tang. Ban Xia and Chen Pi are the two main herbs from the formula
Er Chen Tang which specifically deals with phlegm-dampness due to spleen qi
deficiency. Together they are able to dry the dampness, regulate and lower the adverse
qi, harmonising the stomach to stop vomiting. Alone they are not enough to stop all of
the symptoms though, so Mu Xiang and Sha Ren are also added. Mu Xiang promotes
the movement of spleen and stomach qi to alleviate abdominal pain and distension,
promote appetite and stop nausea and vomiting. Sha Ren transforms dampness that is
impeding the spleen and stomach and promotes the movement of qi strengthening the
stomach. Together they have a strong action to regulate the qi to alleviate pain and
distension in the abdomen, which is the key differentiating symptom of this
syndrome. The four additional herbs all help to expel the cold-damp, regulate the qi
and strengthen the middle jiao.
參 苓 白 术 散 (Shen Ling Bai Zhu San)
Spleen qi deficiency leading to internally generated dampness is a condition again
stemming from spleen qi deficiency. The presentation has very similar symptoms as
the previous formulae yet subtle differences. Again this calls for modification of Si
Jun Zi Tang.
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The weakened transforming function of the spleen leads to the accumulation of fluids
which transform into dampness in the middle jiao. Distension and a stifling sensation
are encountered in the chest and epigastrium due to the dampness obstructing the flow
of qi. The dampness also travels downward causing diarrhoea. These symptoms are
encountered in addition to the symptoms of spleen qi deficiency. Shen Ling Bai Zhu
San’s primary focus is to tonify the spleen and Si Jun Zi Tang is incorporated to
achieve this.
In addition, other herbs are present to excrete the dampness, replenish the qi and stop
diarrhoea. Shan Yao, Yi Yi Ren, Bai Bian Dou and Lian Zi support the functions of Bai
Zhu and Fu Ling by strengthening the spleen, helping to excrete dampness and
stopping diarrhoea. Sha Ren is added to assist the transformation of dampness and
promotes the movement of qi to alleviate the distension and stifling sensation. Finally
Jie Geng helps protect the lungs from deficiency, which is often a sequela of spleen
deficiency.
理 中 丸 (Li Zhong Wan)
The syndrome of deficient cold in the spleen and stomach sees cold encroaching the
middle jiao due to deficiency of spleen yang. Clear yang is unable to ascend causing
diarrhoea and turbid yin does not descend inducing vomiting and nausea. The cold
entering the abdomen causes an absence of thirst and induces contractions, which in
turn causes pain. Due to the lack of functional activity of the spleen, its transporting
function is not carried out and appetite is reduced.
Although the presentation of the symptoms is similar to spleen qi deficiency the
underlying cause is different and Si Jun Zi Tang must be modified to effectively deal
with the new syndrome.
Li Zhong Wan places Gan Jiang as the principal herb and removes Fu Ling. Gan Jiang
is pungent and hot and has the action of warming the spleen and stomach and
expelling cold. Gan Jiang is able to combine with Ren Shen to stop vomiting due to
cold, Bai Zhu to stop diarrhoea and Gan Cao to ease epigastric pain and vomiting due
to cold.
Conclusion
Si Jun Zi Tang is an exceptionally versatile formula, which is incorporated into many
different formulae. Treating a range of syndromes from spleen qi deficiency to qi and
blood deficiency and even deficiency of yang. These formulae cannot all be looked at
in this article, so a few have been chosen to demonstrate how changes in formula are
necessary if changes in syndrome occur, whether they be small or large. Although
deficient spleen function is best treated with Si Jun Zi Tang, the variation in the extent
of this deficiency and the symptoms that arise from it, demand that the formula be
modified to effectively treat the condition.
The key is accurate diagnosis, the identification of the correct syndrome
differentiation and an effective treatment strategy. The syndromes identified above,
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on the surface may appear to have very similar symptoms. Most have poor appetite,
nausea, vomiting and possibly some discomfort in the abdomen. However it has been
demonstrated that although the symptoms may appear to be the same, the factor that
causes them can change. With this change in syndrome the treatment strategy must be
modified leading to an inevitable change in the component of the formula.
If the physician is not thorough in his diagnosis it will be easy to misdiagnose the
syndromes, which will lead to a formation of an inaccurate differentiation and
treatment strategy. If Si Jun Zi Tang is chosen to treat the other syndromes it may
have diminished effect, or nearly no effect at all in the case of attempting to treat
deficient spleen yang. This emphasises the interconnection between the four aspects
of formulary. For without accurate differentiation of the syndrome allowing the
practitioner to arrive at the correct treatment strategy, the correct herbs cannot be
selected to form the most effective treatment for the patient.
Bibliography
Bensky D. and Barolet R. (1990). Chinese Herbal Medicine Formulas and Strategies.
Seattle: Eastland Press
Bensky D. and Gamble A. (1986). Chinese Herbal Medicine Materia Medica. (9th ed).
Seattle: Eastland Press
Geng J.Y. (1996). Herbal Formulas. (2nd ed). Beijing: New World Press
Liu Z.W. and Jiang Y.A. (1998). Formulas of Traditional Chinese Medicine. Beijing:
Academy Press
Meng Y.F. (1998). Diagnostics of Traditional Chinese Medicine. Beijing: Academy
Press
Qiao Y. (2000). The Traditional Chinese Medicine Formula Study Guide. Boulder:
Snow Lotus
Qu J.F., Zhang S.H. and Xie R. (1990). The Chinese Materia Medica. Shanghai:
Publishing House of Shanghai College of Traditional Chinese Medicine
The author wishes to remind readers that no one reading this article should try to diagnoses themselves
or take herbal formula unless they have been prescribed by a professional Chinese medicine
practitioner.
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