Rehabilitation can be a complicated and often lengthy journey. It involves addressing not only the physical challenges—such as tissue damage, compromised physiological functions, lingering effects of injury, trauma, surgery, or debilitating illness—but also the emotional components that accompany these experiences. These emotional aspects are crucial to the healing process and can significantly influence outcomes.

The formula Li Zhong Wan offers valuable support during this journey. It strengthens both the physical body and emotional resilience, helping patients navigate the obstacles they may face. This formula is particularly beneficial for individuals who feel weak, deflated, or lost in the rehabilitation process. By fortifying the body and boosting emotional confidence, Li Zhong Wan helps patients reconnect with their inner strength and regain trust in their bodies and themselves.

Li Zhong Wan, translated as “the pill to regulate the middle,” lives up to its name by addressing imbalances in the body’s middle burner. This formula warms, supplements, raises, and harmonizes, creating an optimal environment for the middle burner to function effectively. While not explicitly linked in the Shanghan Lun to any one of the six conformations, it is often associated with the Tai Yin conformation due to its effectiveness in treating digestive issues.

The formula is introduced in the Shanghan Lun line 386 in a section on sudden turmoil disorder. It is recommended for acute diarrhea and vomiting caused by spleen yang deficiency. Additional symptoms often accompanying this digestive disorder include headaches, body aches, and a lack of thirst.

Li Zhong Wan is mentioned again in line 396 of the Shanghan Lun, where its broader potential becomes evident. This section of the text focuses on strategies and formulas designed to address the diverse challenges patients may encounter during recovery from debilitating illnesses (差后劳复病).

“After a major illness is cured, frequent spitting that endures without clearly resolving, indicates cold above the chest, so one should warm with a pill medicine, therefore li zhong wan is appropriate.”

Translation by Craig Mitchel, Feng Ye and Nigel Weisman

In this passage the weakness of yang following a severe disease manifests as accumulation of fluids and cold in the throat area. These symptoms may point to a wide range of diseases, including neurological, muscular and respiratory conditions. The scope and clinical potential of this formula becomes clearer from the analysis of its components.

Li Zhong Wan is one of only seven formulas in the Shanghan Lun that include detailed instructions for different versions according to the clinical manifestations. It is unknown why such instructions were not given to all 112 formulas in the text. Perhaps it is testimony to the popularity of these seven formulas and their broad clinical potential. 

Ingredients

The formula Li Zhong Wan is composed of four main ingredients with equal dosage:

• Gan jiang
• Ren shen
• Bai zhu
• Zhi gan cao

Gan jiang

Dried ginger, is hot and spicy in quality and acts to warm the yang of the middle jiao.

When gan jiang is paired with zhi gan cao in a ratio of 2:1 in favor of zhi gan cao, it composes the formula called Gan Cao Gan Jiang Tang. This formula is mentioned in the Jingui Yaolue for damage to the yang of the middle and upper burner with symptoms including excessive saliva and difficulty in breathing. Gan Cao Gan Jiang Tang is also mentioned in the Shanghan Lun line 29, where it is instructed for restoring yang in a situation where there is internal damage to both yin and yang with symptoms of excessive dryness in the mouth and throat, vomiting and cold extremities.

This combination supports the recovery of the yang force of the middle jiao, enhancing the body’s ability to ingest and digest effectively. This allows the body to receive the necessary substances vital for its rehabilitation process. I believe these substances extend beyond nutrients from food. Our bodily yang relies on our capacity to absorb and integrate the abundance of the world, encompassing the cosmic forces of yang, as well as the material, emotional and spiritual qualities present in our environment.

The modifications given in the text relate to the dosage. The dosage of gan jiang can be increased according to the severity of cold. This can manifest in sensations of cold in the stomach or extremities. This can also manifest in the functional implications of cold: inability to eat and ingest, tendency to curl up as if protecting the yang of the middle. On a behavioral level yang depletion can result in a demeanor of defeat, a result of insufficient energy to make the effort necessary for improvement.

Ren shen

Sweet and warm, strengthens qi and enhances fluid generation. It is indicated for critical loss of body fluids, including blood. An important herb for tissue and functional rehabilitation, this herb also strengthens the qi of the heart and is important for enhancing sense of security and self-confidence, emotional factors that have been shown to be crucial for rehabilitation.

This herb can also be modified by changing its dosage. The text instructs to increase the dose to a ratio of 4.5:3 in case of pain. I explained the significance of ren shen in the treatment of chronic pain through the analysis of the formula Xin Jia Tang. It is especially important when the pain is due to yang deficiency affecting muscle strength.

Bai zhu

Bitter, sweet and warm. It strengthens qi, dries dampness and has an upward motion. It complements ren shen by strengthening the spleen, and helping to establish the proper conditions for its function. There are several guidelines in the text to the use of this herb, all of which improve our understanding of how to accurately use this herb:

• It is important in case of diarrhea because of its upward lifting motion.
• In case of excessive thirst with a desire to drink, the dosage of bai zhu should be increased to a ratio of 4.5:3. It is, however, important to determine that this thirst is a result of inability of spleen to raise fluids to the upper jiao. A possible sign for this is excessive urination of clear fluids. If the thirst is caused by heat damaging the fluids, then bai zhu is not appropriate, nor is the use of Li Zhong Wan.

Despite the importance of bai zhu in supporting spleen functions, there are situations of spleen deficiency where it should not be used:

• A feeling of pounding in the area of the navel. This contraindication for the use of bai zhu is repeated in several places in the Shanghan Lun. In this line it is explained that this contraindication is due to fluid accumulation causing the pounding sensation. Considering fluid accumulation is a common symptom of the condition related to Li Zhong Wan, this is an important guideline. The text suggests that when there is a sign of excess accumulation of fluid, bai zhu should be removed and replaced with gui zhi at a dosage of 4:3 compared to the other herbs in the formula. Gui zhi is well-known for its ability to stimulate wei qi and the functions of the tai yang conformation, however in the Shanghan Lun, the formula Gui Zhi Tang is also used as a tai yin formula. Gui zhi stimulates the flow of blood to the muscular tissue, both skeletal muscles as well as internal organs. Gui zhi combined with zhi gan cao, that is also present in this formula, forms the formula Gui Zhi Gan Cao Tang, a formula for strengthening the yang of the heart (mentioned in line 64 of the text).
• Frequent vomiting. The formula Li Zhong Wan is indicated for digestive problems which include both diarrhea and vomiting. However, if the vomiting is pronounced, the uplifting motion of bai zhu could actually worsen the situation. In this case bai zhu should be removed and replaced with sheng jiang in an equal dosage compared to the other herbs of the formula. It should be noted that in this case both gan jiang and sheng jiang are present in the formula. In a situation where both vomiting and diarrhea are severe, then bai zhu is not removed and is used together with sheng jiang that addresses the vomiting.
• Abdominal fullness. The text instructs to replace bai zhu with fu zi in case of abdominal fullness. This indicates that the nature of the fullness is kidney yang deficiency causing the qi and fluids to stagnate. Hot and acrid fu zi stimulates motion and ignites the strength of the ming men to reinforce the functions of the body. The removal of bai zhu indicates that in some situations it could actually be an obstruction to restoring movement.

While I do not always recognize when bai zhu is a hindrance and when it is beneficial to the rehabilitation process, I do keep these contraindications in mind and carefully observe my patients’ reaction when I use bai zhu in the formula.  

Zhi gan cao

Sweet, warm, nourishing and harmonizing. It contributes to establishing the harmonious nature of the earth phase, creating a sense of stability, balance and reassurance in the body’s capabilities. It creates a synergistic combination with the warm and acrid herbs to enhance their abilities of yang strengthening effect. It is always present in every one of the variations of this formula.

Additions

In addition to the four basic components and their variations, the text also specifies additions to the formula.

Fu ling should be added when there are palpitations. This can indicate both a physical heart condition rooted in the yang deficiency, or an emotional condition of anxiety often present in situations of rehabilitation.

Honey is also added to the formula. It is used as an adhesive to form pills out of the grounded herbal ingredients. However, honey also has a nourishing and balancing quality that enhances resilience, a much needed quality in lengthy processes of recovery.  

Other herbs can be added according to specific symptoms of individual patients.

Instructions for use

The text provides important instructions for taking the formula properly:

This formula should be prepared as a pill, roughly the size of an egg yolk (egg yolks in Zhang Zhongjing’s time were most likely smaller in size than today’s eggs). The pill is melted in hot water, and the patient drinks the decoction.

After ingestion there should be a comforting warm sensation in the stomach. This is a sign that the formula is appropriate for the situation. If there is no sense of warmth, the formula might be to weak or the dose too low.

 If there is fullness and discomfort after taking the formula, another strategy should be applied.

About half an hour after taking the formula, warm rice porridge should be eaten and the patient should be covered to maintain a warm sensation. These instructions were also mentioned in relation to Gui Zhi Tang. Rice porridge encourages the blood flow and supports the yang of the middle burner.

It should be noted that the same four ingredients in form of a decoction compose a formula named Ren Shen Tang mentioned in the Jingui Yaolue. The significance of the form the formula is taken is demonstrated when comparing these two formulas. Ren Shen Tang is used for pain and fullness or oppression in the chest. This appears to describe a heart condition resulting from the weakness of yang.

Conclusion

The information provided in the two passages describing Li Zhong Wan highlights its versatility, leading me to observe its application across a wide range of disorders. These include general fatigue, weakness, digestive disorders, chronic pain disorders, and the rehabilitation process for restoring both physical and emotional functions.

Proper use of this formula requires a differential diagnosis to confirm an underlying condition of spleen yang deficiency. Symptoms identified in the Shanghan Lun for this diagnosis include a sensation of cold, lack of thirst, and fluid accumulation. Additionally, I find that an emotional state characterized by disheartenment and a lack of belief in one’s ability to overcome challenges is an important clinical indicator.

It is important to remember that while Li Zhong Wan can be beneficial for rehabilitation following debilitating trauma or disease, in cases of progressive diseases with an active disease factor, there is need to supplement or modify the formula to address the additional conformation(s) involved.

Li Zhong Wan provides the strength and support for enduring the long and arduous recovery process following events that have left us weak and broken, offering hope for a better and healthier future.