To Clear the Flow, Cleanse the Source
The Mysterious 2-3-4
Simple, short formulas that have a straightforward mechanism of action are often effective in clinical use. They often act quickly, having relatively few ingredients, and can be used as an initial prescription in a course of therapy or as a building block for larger, more complex formulas.
An example that I use often is the formula family Èr /Sān /Sì Miào Wán, usually indicated for gout and hot swollen knees, but effective in almost any case where there is dampness and heat lodged in the lower burner.
The Name of the Formula
The character 妙 miào has connotations of something subtle, profound, mysterious, marvelous or wonderful. Scheid et al. (2009) thus render Èr Miào Sӑn as “Two-Marvel Powder” where Wiseman (2022) translates it as “Mysterious Two Powder”.
Èr Miào Sӑn
The first mention of Èr Miào Sӑn comes from Dān Xī Xīn Fǎ [丹溪心法, Dān Xī’s Heart Methods], a collection of the formulas and methods of Zhū Dānxī [朱丹溪], compiled by his student Dài Sīgōng [戴思恭] in the late Yuán to early Míng, published in 1481. The formula appears in the chapter on painful wind:
二妙散 治筋骨疼痛因濕熱者，有氣加氣藥，血虛者加補藥，痛甚者加生薑汁，熱辣服之。
黃柏（炒） 蒼朮（米泔浸炒）
上二味為末，沸湯，入薑汁調服。二物皆有雄壯之氣，表實氣實者，加酒少許佐之。
Èr Miào Sӑn: Treats cases of sinew and bone aching and pain caused by dampness and heat. If there is qì [stagnation] add qì [rectifying] medicinals; in cases of blood vacuity add supplementing medicinals; if there is severe pain add Shēng Jiāng Zhī [Succus Zingiberis Recens], [to make the] dose hot and spicy.
Huáng Bǎi [Cx Phellodendri] (fried), Cāng Zhú [Rz Atractylodes] (soak and fry in rice water)
Grind the above two ingredients into a powder; with boiled water take after mixing in Jiāng Zhī. Both of the two ingredients have magnificent qì; in cases of exterior repletion or qì repletion add a little wine as an assistant.
A quick comment: Scheid et al. (2009) interprets the line 有氣加氣藥, “if there is qì add qì medicinals” as referring to qì vacuity; my guess here is that since the following line specifies supplementing medicinals, Dānxī is talking about qì stagnation/depression in this line. It was he, after all, who was associated most closely with the theory of six depressions. It is certainly possible that the authors of the formula monograph used a different version of Dān Xī Xīn Fǎ, or that I’m jut plain wrong (wouldn’t be the first nor the last time). Either way, the basic idea is to modify in accordance with the patient’s presentation.
There is also mention of a Sì Miào Sӑn in the chapter, for cases of painful wind traveling influx [痛風走注] but the formula is different from the one we know today. It contains Wēi Líng Xiān [Rx Clematidis], Yáng Jiǎo Huī [Cornu Caprae Carbonisatus, goat horn burnt to ashes], Bái Jiè Zǐ [Sm Sinapis Albae], and Cāng Ěr [Fr Xanthii], ground to a powder, taken with boiled water and a slice of ginger together with Èr Miào Sàn. This formula has been largely forgotten.
Sān Miào Wán and Sì Miào Wán
The formula we know as Sān Miào Wán [Mysterious Three Pill] is listed in Scheid et al (2009) as having come from Fāng Shì Mài Zhèng Zhèng Zōng方氏脈症正宗 [1749], which is translated there as Fang’s Orthodox Lineage of Pulse and Symptoms. I was unsuccessful in finding an e-text of the work, so I moved on to Sì Miào Wán, which was listed in Scheid et al (2009) as coming from Chéng Fāng Biàn Dú [成方便讀, Convenient Reader of Established Formulas] by Zhāng Bǐngchéng [張秉]成in the late Qīng era, 1904. The entry there gives a good summary of all three formulas:
二妙丸 三妙丸 四妙丸
二妙丸中蒼朮先，和同黃柏兩相兼。若增牛膝名三妙，苡薏加之四妙賢。
二妙丸 蒼朮 黃柏 治濕熱盛於下焦而成痿證者。夫痿者萎也，有軟弱不振之象，其病筋脈弛長，足不任地，步履歪斜，此皆濕熱不攘，蘊留經絡之中所致。然濕熱之邪，雖盛於下，其始未嘗不從脾胃而起。故治病者必求其本，清流者必潔其源。方中蒼朮辛苦而溫，芳香而燥，直達中州，為燥濕強脾之主藥。但病既傳於下焦，又非治中可愈，故以黃柏苦寒下降之品，入肝腎直清下焦之濕熱，標本並治，中下兩宣，如邪氣盛而正不虛者，即可用之。
Èr Miào Wán, Sān Miào Wán, Sì Miào Wán
Èr Miào Wán first includes Cāng Zhú, harmoniously combined with Huáng Bǎi. If it is augmented with Niú Xī [Rx Achyranthis], it is called Sān Miào; it is Sì Miào xián [the sage-like Mysterious Four] with Yǐ Yì [Rén, Sm Coicis] added.
Èr Miào Wán: Cāng Zhú, Huáng Bǎi, treats cases of damp heat exuberance in the lower burner becoming wěi zhèng [wilting syndrome]. Wěi is atrophy, there is weakness and devitalized appearance, it is an illness where the sinews and vessels are constantly slack, the feet cannot bear [one’s weight on the] ground, the gait is askew, this is all due to damp heat not eliminated and retained in the channels and network vessels. Although the damp heat evil is in the lower, its beginning never fails to arise from the spleen and stomach. So the one treating illness must seek the root, the one clearing the flow must cleanse the source. In the prescription is Cāng Zhú, acrid bitter and warm, aromatic and drying; it directly reaches the central prefecture, it is the governing medicinal for drying dampness and strengthening the spleen. But since the illness has passed to the lower burner, then it is a mistake [to believe] that [only] treating the center can cure this, so using Huáng Bǎi, a bitter cold downbearing substance that enters the liver and kidney and directly clears the lower burner damp heat, treats the root and branch together, draining both the central and lower burners. If one has exuberant evil qì and the correct is not vacuous, one can use this approach.
本方加牛膝，為三妙丸。以邪之所湊，其氣必虛，若肝腎不虛，濕熱決不流入筋骨。牛膝補肝腎，強筋骨，領蒼朮、黃柏入下焦而祛濕熱也。
再加苡仁，為四妙丸。因《內經》有云：治痿獨取陽明。陽明者主潤宗筋，宗筋主束筋骨而利機關也。苡仁獨入陽明，祛濕熱而利筋絡，故四味合而用之，為治痿之妙藥也。
To the root formula add Niú Xī [Rx Achyranthis], and it becomes Sān Miào Wán. Because for evil to encroach, qì must be vacuous, if there were no vacuity in the liver and kidney, damp heat would never flow into the sinews and bones. Niú Xī supplements the liver and kidney, strengthens sinew and bone, and leads Cāng Zhú and Huáng Bǎi to enter the lower burner and dispel dampness and heat.
Additionally, adding Yǐ Rén [Sm Coicis] makes it Sì Miào Wán. Because in “Nèi Jīng” it says: To treat wilting, [one need] only choose yángmíng. Yángmíng governs moistening the ancestral sinew, the ancestral sinew governs binding of the sinews and bones and disinhibits the hinges. Yǐ Rén alone enters yángmíng, dispels damp heat and disinhibits the sinew network vessels, so the combined use of these four ingredients are marvelous medicinals to treat wilting.
Recent Research
A meta-analysis by Wang et al. (2020) on 15 studies using modifications of Sì Miào Wán demonstrated that combining the formula with standard biomedicine was safer and more effective in treating rheumatoid arthritis (RA) than using standard biomedicine alone. Biomarkers of RA, such as sedimentation rate (ESR), C-reactive protein (CRP), and rheumatoid factors (RF) as well as the subjects’ signs and symptoms were more significantly improved with the use of Sì Miào Wán than without.
Applications of the formula are not limited to joint pain or atrophy. A research paper using network pharmacology (Jin et al., 2023) showed that Sì Miào Wán can potentially reduce obesity-related insulin resistance. Han et al. (2021) focused on Sì Miào Wán's effects in ameliorating non-alcoholic fatty liver disease (NAFLD) caused by a high-fat high-sucrose diet.
Prepared Formula Versions
Sì Miào is the most common version in terms of availability; it can be found in prepared form from Herbal Times, Golden Flower, Plum Flower, Evergreen, and Sun Ten. Sān Miào is available from KPC. I generally use the Sì Miào pills from Herbal Times or Golden Flower. It makes for a good combining formula, having only four ingredients (none of which are common harmonizing herbs like Gān Cǎo [Rx Glycyrrhizae]). So, for example in a case of liver-spleen disharmony with accumulation of dampness and heat in the lower burner one could combine it with Xiāo Yáo Sӑn (Free Wanderer Powder) with no worries of duplicating medicinals. Sometimes I will use Sì Miào Wán as a first-stage formula for a couple of weeks and follow up with Shēn Líng Bái Zhú Wán or something similar to strengthen the spleen and dispel dampness.
As was mentioned at the top of the article, Sì Miào Wán is mostly thought of as a formula for gouty arthritis, but at various times I have also used it for diabetic patients, cases of prostate swelling, urinary and gynecological patterns, and consider it in any condition that presents with a red tongue with thick yellow coat in the rear and a pounding pulse in the proximal positions.
That’s all for now, thanks for reading.
Note: this publication is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have.
References
Han, R.T, Qiu, H.H., Zhong, J., Zheng, N.N., Li. B.B., Hong, Y., Ma, J.L., Wu, G.S., Chen, L.L., Sheng, L.L., & Li, H.K. (2021). Si Miao Formula attenuates non-alcoholic fatty liver disease by modulating hepatic lipid metabolism and gut microbiota. Phytomedicine, 85, 2021, 153544. https://doi.org/10.1016/j.phymed.2021.153544.
Jin, J., Xu, Y.Y., Liu, W.P., Hu, K.H., Xue, N., & Zheng, Z.G. (2023). Simiao Wan alleviates obesity-associated insulin resistance via PKCε/IRS-1/PI3K/Akt signaling pathway based on network pharmacology analysis and experimental validation. Traditional Medicine Research. 2023;8(10):60. doi: 10.53388/TMR20230512002.
Scheid, V., Bensky, D., Ellis, A., & Barolet, R. (2009). Chinese herbal medicine: Formulas & strategies (2nd ed.). Eastland Press.
Wang, H., Huang, Y., Shen, P., Wang, Y., Qin, K., Huang, Y., Ba, X., Lin, W., Chen, Z., & Tu, S. (2020). Modified Si-Miao Pill for rheumatoid arthritis: A systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine, 2020, 7672152. https://doi.org/10.1155/2020/7672152
Wiseman, N. (2022). Chinese-English dictionary of Chinese medical terms. Paradigm Publications.
Zhāng, B. (1904). Chéng fāng biàn dú. Retrieved July 19, 2024 from https://jicheng.tw/tcm/book/%E6%88%90%E6%96%B9%E4%BE%BF%E8%AE%80/index.html
Zhū, Z., & Dài, S. Dānxī xīn fǎ. Retrieved April17, 2024, from https://jicheng.tw/tcm/book/%E4%B8%B9%E6%BA%AA%E5%BF%83%E6%B3%95/index.html