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Li Dongyuan treated a patient. In the prime of life, he suffered from flaccidity and weakness of the legs and knees. The area below the umbilicus, the sacrum, and the buttocks all felt cold. There was sweating in the genital region with a foul, musky odor, and seminal emission without firmness. Someone suggested treating him with Lurong Wan (Deer Antler Pill).
It was ineffective. Li Dongyuan palpated the pulse: deep, rapid, and forceful. He immediately prescribed Zishen Wan (Kidney-Nourishing Pill). Using the method of "treating heat with cold by administering it hot" (Han Yin Re Yong), he guided the medicinal properties into the Lower Jiao to reach the seat of the disease. This cleared the excessive fire of the Ministerial Fire (Mingmen Xiang Huo) at the Gate of Life. After taking it for a few more doses, he recovered.

Yu Zhen's commentary: Genital sweating with a musky odor, seminal emission without firmness, and a deep, rapid, forceful pulse clearly indicate damp-heat in the Lower Jiao. Li Dongyuan himself stated that this clears the excess of Ministerial Fire. This is what is meant by "kidney heat leads to bone flaccidity."

Zhu Danxi treated a patient. He was obese, had rich dietary habits, and suffered from frequent worry and anger. His pulse was often deep and choppy. In spring, he developed phlegm-Qi disorders. Physicians considered it deficiency-cold and used drying, heating, aromatic, and penetrating medicines. By summer, his two legs became weak, Qi rushed upward, and his appetite decreased. Zhu Danxi said: This is heat stagnation with spleen deficiency; the syndrome of flaccidity and reversal will arise. Although obesity with a deep pulse is not necessarily a death sign, the pathogenic effect of the drugs was too strong. During the season when fire is prosperous, survival would be difficult. He administered Zhuli (Bamboo Juice) with Baizhu Gao (Atractylodes Macrocephala Paste). After consuming two jin (approx. 1 kg), the Qi descended and appetite improved. However, one month later, he died from profuse sweating. This case is recorded as a warning against erroneous medication.

Yu Zhen's commentary: Qi rushing upward is panting and counterflow. Coupled with reduced appetite, the illness was already severe. Moreover, there was weakness in both legs. This is a pattern of deficiency below and excess above. When he said obesity with a deep pulse is not a death sign, it aligns with the principle in *Ping Mai Pian* (Chapter on Pulse Diagnosis) regarding fat people having floating pulses indicating internal heat. It likely means the pulse itself was not indicative of impending death; rather, he died due to medication errors.

Hua Borén treated a woman. Initially, she suffered from malaria during the summer. Physicians attributed it to spleen cold and stomach weakness, causing her to take Guizhi (Cinnamon Twig) and Fuzi (Prepared Aconite Root) for a long time. Although the malaria subsided, accumulated fire blazed intensely, leading to polyphagia (excessive hunger and eating). She ate dozens of meals daily yet remained hungry. She sat upright all day like a normal person, but her vision was blurred, her legs were too weak to walk, her waist and hips felt heavy and soft, and her muscles appeared plump but were actually deficient. By early winter, Hua Borén palpated her pulse: surging, large, yet empty and soggy. He said: This is a flaccidity syndrome caused by excessive intake of hot medicines during the late summer. Since dampness dominates in summer, the overly rigid and hot medicines caused both fire and dampness to become severe, leading to lung heat with scorched lung leaves, resulting in flaccid legs that could not function. He then treated her using Li Dongyuan’s method for flaccidity caused by damp-heat in late summer. Her food intake gradually decreased, and her vision slowly improved. By the end of winter, she suddenly got out of bed and walked as before.

Yu Zhen's commentary: Li Dongyuan’s method for flaccidity caused by damp-heat in late summer is Qingzao Tang (Clear Dryness Decoction). It is most appropriate for this case. Combined with the previous cases, it serves as a warning for those who favor pungent, drying, and hot medicines.

Shishan treated a man. Due to prolonged sitting, he suffered from lower back pain, which gradually spread to the right leg, then the left leg, and further to both arms, rendering him immobile. Some treated it as wind syndrome using medicinal wine; others treated it as blood deficiency using Siwu Tang (Four Substances Decoction). Swallowing the medicine caused immediate pain; even slight warmth from covering aggravated it. Acupuncture and cupping increased the pain. Taking cooked Rehmannia or swallowing Huqian Wan (Tiger-Hiding Pill) added severe pain to the right teeth and face. In late autumn, Wang palpated his pulse: soggy, slow, and weak. The left pulse was smaller than the right, sometimes choppy, and the chi (cun-kou) pulse was particularly weak. He said: This is a flaccidity syndrome. Others claim flaccidity should not involve pain. Wang said: All flaccidities originate from lung heat. You drink alcohol frequently, so lung heat can be inferred. The Classics state: "In treating flaccidity, focus solely on the Yangming." Yangming refers to the Stomach. The Stomach governs the four limbs, not just the feet. In flaccidity with heavy dampness, tendons relax leading to flaccidity; with excessive heat, tendons contract causing pain. He showed him the biography of Ju Quan, convincing him that flaccidity can indeed involve pain. The Classics also state: "Those accustomed to wine do not favor sweet substances." Shu Dihuang (Prepared Rehmannia Root) is sweet, and Huqian Wan adds honey, so excessive sweetness aids dampness and stirs stomach fire, causing pain in the right teeth and face. He prescribed Renshen (Ginseng Root) 2 qian, Huangqi (Astragalus Root) 1.5 qian, Baizhu (Atractylodes Rhizome), Fuling (Poria), Sheng Dihuang (Raw Rehmannia Root), and Maidong (Ophiopogon Tuber) each 1 qian, Danggui Shen (Angelica Sinensis Root Heart) 0.8 qian, Huangbai (Phellodendron Bark) and Zhimu (Anemarrhena Rhizome) each 0.7 qian, and Gancao (Licorice Root) 0.4 qian. After five decoctions, the illness vanished. He stopped taking medicine. In late winter, the illness recurred, and he recovered by taking the same formula again.

Yu Zhen's commentary: This case explains the pathology exquisitely, but I dare not fully trust the prescription. If heat causes tendon contraction and pain, and there is currently pain in the right teeth and face, why use heavy doses of Renshen and Gancao (sweet-warm herbs)? Do the minute amounts of Zhimu and Huangbai offer any benefit?

A patient was obese with dark skin, usually feared heat, and liked drinking alcohol. In his thirties, he suddenly developed spontaneous sweating like rain, complete flaccidity of the four limbs, aversion to cold, short dark urine, alternating loose or constipated stools, and reduced diet. Physicians treated it as wind syndrome using Duhuo Jisheng Tang (Notopterygium and Porium Decoction) and Xiao Xuming Tang (Minor Rescue Life Decoction) without effect. In midsummer, Wang palpated his pulse: deep, fine, and rapid, approximately seven beats per breath. He said: This is a flaccidity syndrome. Danxi said: It must not be treated as wind syndrome. The Classics state: "There are five types of flaccidity, all originating from lung heat." Just this sentence reveals the treatment method. The Classics also state: "In treating flaccidity, focus solely on the Yangming." Yangming refers to the Stomach and Large Intestine. The Stomach belongs to Earth, the Lung to Metal, and the Large Intestine to Yang Metal. Metal relies on Earth for generation; if Earth is deficient, Metal loses nourishment and cannot generate Water downward. Kidney water dries up, fire becomes excessive, and the Lung is further damaged. Furthermore, the Stomach governs the four limbs, and the Lung governs the skin and hair. Now, the inability to move the limbs indicates Stomach Earth deficiency. Spontaneous sweating like rain indicates Lung Metal injury. Therefore, the method for treating flaccidity focuses solely on the Yangming while simultaneously clearing lung heat. This perfectly matches Li Dongyuan’s Qingzao Tang. After taking 100 doses, he recovered.

Yu Zhen's commentary: The pulse is deep, fine, and rapid, about seven beats per breath, indicating deep stagnant heat. Why not clear the heat directly, but only use Qingzao Tang, which clears and tonifies? Flaccidity is essentially a deficiency syndrome. Added to spontaneous sweating and reduced diet, the Lung and Stomach become even more deficient. Thus, this formula tonifies Earth to generate Metal and benefits Water to control Fire, treating the root. Lianluo (Coptis Rhizome) and Huangbai are bitter-cold; Fuling and Zexie are bland and draining, treating the branch. Ancient physicians were so prudent and thorough in treating diseases. They knew they would hit the mark, hence they persisted to achieve success.

Xue Lizhai treated his teacher, Gaoruzhai, Vice Commissioner. Returning from Datong, he told Xue Lizhai: "I have contracted wind disease. My legs are flaccid and weak when resting, but painful like needle pricks when exerted. My pulse is surging, rapid, and forceful." Xue Lizhai said: "This is caused by yin deficiency of the Liver and Kidney with hyperactive fire. Flaccidity and weakness are the true form of the disease; pain like a awl is the manifestation of evil fire." He used formulas to strengthen water and nourish the Kidney, and the patient recovered. Gaoruzhai said: "Previously residing in official quarters, everyone thought it was wind. I regretted lacking proper medicine; if I had taken wind medicines, wouldn't it have been dangerous?"

Yu Zhen's commentary: Because the pulse was surging, rapid, and forceful, strengthening water and nourishing the Kidney was used. If the pulse were rapid but weak, one should have used Dihuang Tang combined with Shengmai San and Buxue Tang. In the following two cases, the deficiency signs were obvious, yet wind medicines were still used. Death was inevitable.

A man had flaccid legs and afternoon fever. Xue Lizhai said: "This is deficiency of the three Yin meridians of the foot. Use Liuwei Dihuang Wan (Six-Ingredient Pill with Rehmannia) and Zhibai Dihuang Wan to tonify." A woman had weak legs and feet, fatigue upon exertion. Xue Lizhai said: "The four limbs belong to Earth. This is spleen deficiency. Use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) and Huan Shao Dan as the main treatment." Neither listened. Each insisted on using Soufeng Tianma Er Wan (Wind-Searching Gastrodia Two-Pill) and Yufeng Dan (Wind-Resisting Pill), resulting in their deaths.

Jiang Yingsu traveled north to Yan, passing through Shandong. Sun Shangshe’s eldest son, Wenxue, suffered from emaciation. Jiang was invited to diagnose. He said: "Nothing can be done. The Classics state: 'If the great muscles are depleted, even if the nine pulses are harmonious, death ensues. How much more so if they are not harmonious?' It was mid-summer. The six pulses were wiry and rapid. He had diarrhea and dysentery. Spleen transmitted to Kidney, called thief-pathogen. The disease was extreme. Within August, Earth and Water would both fail, and he would die at the appointed time. I dare not decline." Sun said: "Let my wife invite you to feel her pulse." Her appearance was pleasant, voice clear, showing no obvious symptoms. After diagnosis, Sun asked the disease. Jiang said: "Cun and Guan pulses are surging and rapid; Chi pulse is faint and nearly absent. The three Yang meridians of the foot reverse and ascend. Excess above, deficiency below. This is a flaccidity syndrome. Though chronic, it is treatable." Sun asked: "What caused this?" Jiang said: "The Classics state: 'Excessive grief severs the Bao Luo (Pericardium Collateral). Severance of Bao Luo causes internal movement of Yang Qi, manifesting as heart collapse and frequent bloody urination. Great vessels become empty, manifesting as muscle bi, transmitting to vessel flaccidity. Loss or unfulfilled desires cause lung resonance; resonance leads to lung heat and scorched lung leaves, manifesting as flaccidity.' This is what is meant." Sun said: "Indeed, due to grieving the loss of a son, my legs have been weak and unable to rise for seven years. Some treated it as wind using aromatic-drying herbs; others diagnosed deficiency-cold and gave warming-tonifying herbs, with no effect." Jiang said: "Damp-heat causing flaccidity fits Li Dongyuan’s Qingzao Tang example. But the medicinal power is mild, making rapid recovery difficult. Use Du Zhong (Eucommia Bark) alone, decocted half with wine and half with water, taken on an empty stomach. Daily administer Qingzao Tang, combined with Qianxing San. After twenty days, he could leave the room. Soon after, his sick son died, and grief returned."

Yu Zhen's commentary: There are many cases of excess above and deficiency below. How did we know it was flaccidity? Likely because her appearance was pleasant, voice clear, yet she refused to get out of bed. One can weigh these factors to decide.

[Appendix] Ge Kejiu treated the daughter of a wealthy man in the same county. Age seventeen or eighteen. She suffered from flaccidity and numbness of the four limbs, could not feed herself, and stared blankly. Many physicians could not treat her. Ge looked and smiled, saying: "This is easy to treat." He ordered all incense boxes and tassels removed from the room. He dug a pit in the floor, placed the girl inside, closed the door, and warned the family to report when her hands and feet moved and made sounds. After a long time, her hands and feet indeed moved and she called out. He administered one pill. The next day, she emerged from the pit herself. This girl usually loved fragrance, and her Spleen was eroded by the aroma.

Yu Zhen's commentary: Fragrance is the smell of the Spleen. How does it erode the Spleen? I suppose fragrance opens the orifices. Extreme fragrance opens all orifices, causing pulse relaxation and tendon laxity, removing all constraints, thus resulting in a soft body, staring eyes, and refusal to eat. Placing her in the earth pit works because various toxins transform in soil, and Earth is the mother of all things. The four limbs and bones receive Earth Qi, restoring vital energy naturally. This also aligns with the meaning of "focus solely on Yangming in treating flaccidity."

Li Shicai treated Zhu Xiuzhi, a student at the Imperial Academy. He had been paralyzed for eight years with no effect from repeated treatments. Li palpated his pulse: all six positions were forceful, diet was normal. This was internal steaming of excess heat, with solitary hyperactivity of Heart Yang. The syndrome is named Mai Wei (Vessel Flaccidity). He used Chengqi Tang (Order the Qi Decoction) to purge 6-7 times. The left foot could then flex and extend. He used Da Chengqi Tang again, purging another 10+ times. He could then hold objects. He then used Huanglian (Coptis Rhizome) and Huangqin (Scutellaria Root) each 1 jin, and Jiuzheng Dahuang (Wine-steamed Rhubarb Root) 8 liang, made into honey pills. Taken 4 qian daily with Renshen Tang (Ginseng Decoction). Within a month, the amount of accumulated stagnation expelled was countless. All four limbs could stretch and relax. Li said: "Now the stagnation is exhausted. Decoct 10 jin of Santai Gao (Three Capabilities Paste) for him." After finishing it, he resumed social engagements as usual.

Ni Junchou from Chongming. Bedridden for four years. Daily medications consisted of 16 parts cooling/clearing and 13 parts tonifying Liver/Kidney. Li palpated his pulse: large but weak. This was mutual deficiency of Ying and Wei. He used Shiquan Dabu Tang (Ten Complete Tonification Decoction) plus Qinjiao (Magnolia Flower) and Shu Fuzi (Prepared Aconite) each 1 qian. Taken in the morning. Evening: Shuiwei Wan (Eight-Ingredient Pill) plus Niuxi (Achyranthes Root), Duzhong (Eucommia Bark), Yuanzhi (Polygala Root), Bibi (Dioscorea Hypoglauca Rhizome), Hugu (Tiger Bone - *historical term*), Guiban (Tortoise Shell), and Huangbai each dose sent down with warm wine, 7 qian. Over three months, joints became flexible.

He also treated Gao Xuanpu, a military official. He suffered from sore and soft legs and insufficient spirit. Previously taking Anshen Zhuanggu (Calming Spirit and Strengthening Bone) medicines without effect. Changed to Zishen Er Miao San (Kidney-Nourishing and Two Marvels Powder) plus Niuxi and Yiren (Coix Seed) without effect. Purely using blood-invigorating herbs failed to solidify the Spleen/Stomach. Li palpated his pulse: all were harmonious, pressing did not reveal significant deficiency. Only the Spleen position, when pressed heavily, was soggy and weak. This is Earth deficiency with sinking, failing to control Water, causing dampness to sink into the Lower Jiao, thus affecting the knees and shins. He administered Buzhong Yiqi Tang, doubling Shengma (Cimicifuga Rhizome) and Chaihu (Bupleurum Root). He recovered in a few days. For Spleen deficiency with sinking, using descending agents like Niuxi would cause further sinking and worsen the disease.

Yu Zhen's commentary: These three cases are exquisitely wonderful. Matching medicine to pulse, precise and unchanging. The first case uses Chengqi Tang repeatedly, followed by cold-purgatives sent down with Ginseng Soup, all methods of focusing on Yangming. The last case uses Buzhong Yiqi Tang, differing in tonification/purging from Rhubarb, but ultimately returning to focusing on Yangming. *Lin Zheng Zhi Nan* (Guide to Clinical Practice) lists two light-clearing formulas for the Lung, truly inheriting the principle of lung heat causing flaccidity. However, their strength may be too thin to be effective. Their use of Ermiao San, Yinchen (Artemisia Capillaris), Bibi, Fuling Pi (Poria Peel), Can Sha (Silkworm Frass), Haijinsha (Lygodium Spore), Fangji (Stephania Root), Dan Cao (Gentian Root), Hanshui Shi (Halloysitum Rubrum) directly clears damp-heat, surpassing Qingzao Tang. For cases not involving deficiency, imitating this is appropriate. Another method treats deficiency below and excess above using Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) minus Shaoyao, adding Xuanshen (Scrophularia Root), Lianqiao (Forsythia Fruit), Sangye (Mulberry Leaf), and Gouteng (Uncaria Ramulus). This seems to focus solely on upper excess, ignoring lower deficiency. However, it states head and eyes feel covered, worsening in summer when Yang rises. The proposal is to clear Ying heat to extinguish internal wind. Presumably, the pulse was wiry and rapid, showing signs of heat generating wind. One cannot attend to lower deficiency at this moment. Perhaps later diagnosis will allow tonifying the lower Jiao. As for formulas tonifying the lower Jiao, some use modified Huqian Wan, some use Sijin Jingang Jianbu Wan and Dihuang Yinzi, some use Shu Di, Rongrong (Cynomorium), Bajiji (Morinda Root), Yuanzhi, Lu Jiaoshuang (Deer Horn Frost), Sangshen (Mulberry Fruit), Cangzhu (Atractylodes Lancea), Xiaohui (Fennel), steamed with Jinmaoji (Golden-haired Fern Rhizome) in wine, boiled into paste for pills. Some use Rongrong, Jitian, Gouqi (Wolfberry), Nixi, Qingyan (Blue Salt), Xianjiao (Donkey-hide Gelatin), Fuling, Shayuan (Astragalus Complanatus Seed), Lujinjiao (Deer Tendon Gelatin), Yangroujiao (Mutton Gelatin), Niu Guisui (Ox Marrow), Zhu Guisui (Pig Marrow). None use Renshen and Baizhu to tonify Yangming, nor Chengqi Tang to purge Yangming. Only Shipen Shuangbu Wan contains Renshen. However, its case focuses on dizziness, numbness, masses, and diarrhea, not yet flaccidity/reversal, so it is not for treating flaccidity. Overall, it does not exceed clearing damp-heat and benefiting Liver/Kidney. Are these two conditions predominant? Or are there missing cases, lacking detail?