东垣治一人。壮年病脚膝痿弱。脐下尻臀皆冷。阴汗臊臭。精滑不固。或以鹿茸丸治。
不效。李诊之脉沉数而有力。即以滋肾丸治之。以寒因热用。引入下焦。适其病所。泻命门
相火之胜。再服而愈。
震按阴汗臊臭。精滑不固。脉沉数有力。显系下焦湿热。东垣自云。泻其相火之胜。所
谓肾热则骨痿也。
丹溪治一人。形肥味浓。多忧怒。脉常沉涩。春病痰气。医以为虚寒。用燥热香窜之药
至夏两足弱。气上冲。食减。朱曰。此热郁而脾虚。痿厥之证作矣。形肥而脉沉。未是死
证。但药邪太盛。当此火旺之令。实难求生。且与竹沥下白术膏。尽二斤。气降食进。至一
月后。仍大汗而死。书此为误药之戒。
震按气冲即是喘逆。又复食减。病已重矣。况兼两足弱乎。此下虚上盛之候。其谓形肥
而脉沉。未是死证。即平脉篇肥人责浮之义。盖指脉非应死之脉。实死于药也。
滑伯仁治一妇。始病疟。当夏月。医以脾寒胃弱。久服桂、附等药。后疟虽退。而积火
燔炽。致消谷善饥。日数十饭犹不足。终日端坐如常人。第目昏不能视。足弱不能履。腰胯
困软。肌肉虚肥。至初冬。伯仁诊之。脉洪大而虚濡。曰。此痿证也。长夏过服热药所致。
盖夏令湿当权。刚剂太过。火湿俱甚。肺热叶焦。故两足痿易而不为用也。遂以东垣长夏湿
热成痿之法治之。日食益减。目渐能视。至冬末。忽下榻行步如故。
震按东垣长夏湿热成痿法。即清燥汤也。用于此证最妥。合上案观之。可谓喜用辛燥热
药者戒。
石山治一人。因久坐腰痛。渐次痛延右脚。及左脚。又延及左右手。不能行动。或作风
治而用药酒。或作血虚而用四物。一咽即痛。盖覆稍热。及用针砭。痛甚。煎服熟地黄。或
吞虎潜丸。又加右齿及面痛甚。季秋。汪诊之脉濡缓而弱。左脉比右较小。或涩。尺脉尤弱
曰。此痿证也。彼谓痿证不当痛。汪曰。诸痿皆起于肺热。君善饮。则肺热可知。经云。治
痿独取阳明。阳明者胃也。胃主四肢。岂特脚耶。痿兼湿重者。则筋缓而痿软。兼热多者。
则筋急而作痛。因检橘泉传示之。始信痿亦有痛。又经云。酒客不喜甘。熟地味甘。而虎潜
丸益之以蜜。则甘多助湿而动胃火。故右齿面痛也。遂以人参二钱。黄 一钱五分。白术、
茯苓、生地黄、麦门冬各一钱。归身八分。黄柏、知母各七分。甘草四分。煎服五帖。病除
彼遂弃药。季冬复病。仍服前方而愈。
震按此案讲病最精。用药则未敢深信。既云热多者筋急而痛。且现下右齿面痛。何以重
用参、 甘温之药。其些微之知柏。宁有益耶。
一人形肥色黑。素畏热而好饮。年三十余。忽病自汗如雨。四肢俱痿。且恶寒。小便短
赤。大便或溏或结。饮食亦减。医作风治。用独活寄生汤、小续命汤罔效。仲夏。汪视之脉
沉细而数。约有七至。曰。此痿证也。丹溪云。断不可作风治。经云。痿有五。皆起于肺热
只此一句。便知其治之法矣。经又云。治痿独取阳明。盖阳明。胃与大肠也。胃属土。肺
属金。大肠亦属阳金。金赖土生。土亏金失所养。而不能下生水。肾水涸火盛。肺愈被伤。
况胃主四肢。肺主皮毛。今病四肢不举者。胃土亏也。自汗如雨者。肺金伤也。故治痿之法
独取阳明。而兼清肺经之热。正合东垣清燥汤。服百帖。果愈。
震按脉沉细而数。约有七至。郁热深矣。何不直清其热。而仅用清燥汤清补兼施之药耶
盖痿本虚证。加之自汗如雨。饮食减少。则肺胃愈虚。故用此方补土以生金。益水以制火
治其本也。连、柏苦寒。苓、泻淡渗。治其标也。古人治病。审慎周到如此。亦知其必中
故能持久以收功。
立斋治其师佥宪高如斋。自大同回。谓薛曰。余成风病矣。两腿逸则痿软而无力。劳则
作痛如针刺。脉洪数而有力。立斋曰。此肝肾阴虚火盛而致。痿软无力。真病之形。作痛如
锥。邪火之象也。用壮水益肾之剂而愈。高曰。向寓宦邸。皆以为风。恨无医药。若服风剂
岂不殆哉。
震按此脉洪数而有力。故用壮水益肾之药。若脉数而无力。当用地黄汤合生脉散补血汤
矣。下案二证。虚象显然。犹用风药。死复何疑。
一男子足痿软。日晡热。薛曰。此足三阴虚。当用六味滋肾二丸补之。一妇人腿足无力
劳则倦怠。薛曰。四肢者土也。此属脾虚。当用补中益气及还少丹主之。俱不从其言。各
执搜风天麻二丸并愈风丹而殒。
江应宿北游燕。路过山东。孙上舍长子文学病察。延江诊视。曰。无能为矣。经云。大
肉已脱。九候虽调。犹死。而况于不调乎。时夏之半。六脉弦数。既泄且痢。脾传之肾。谓
之贼邪。病已极矣。不出八月。水土俱败。至期而逝。敢辞。孙曰。内人请脉之。形容豫顺
语音清亮。不显言何证。诊毕。孙问何病。江曰。寸关洪数。尺微欲绝。足三阳脉逆而上
行。上实下虚。此痿证也。病虽久可治。孙曰。何因而得此。江曰。经云。悲哀太过则胞络
绝。胞络绝则阳气内动。发则心下崩。数溲血也。大经空虚。发为肌痹。传为脉痿。有所失
亡。所求不得。则发肺鸣。鸣则肺热叶焦。发为痿 。此之谓也。孙曰。果因哭子忧伤。两
脚软弱无力。不能起者。七越岁矣。或以风治而投香燥。或认虚寒而与温补。殊无寸效。江
曰。湿热成痿。正合东垣清燥汤例。但药力差缓。难图速效。以独味杜仲。空心酒水各半煎
服。日进清燥汤。下潜行散。兼旬。出房门。无何。病瘵子死。哀伤复作。
震按上实下虚之病甚多。何以知为痿证。殆于形容豫顺。语音清亮而不起床。可权衡以
决之。
〔附〕葛可久治同郡富人女。年可十七八。病四肢痿痹。不能自食。目瞪。众医莫能治
葛视之。笑曰。此不难治。乃令悉去房中香奁流苏之属。发地板掘土为坎。畀女子其中。
扁其扉。戒家人。俟其手足动而作声。当报我。久之。手足果动而呼。投药一丸。明日。自
坎中出矣。盖此女平日嗜香。而脾为香气所蚀故也。
震按香为脾臭。何以蚀脾。意者香能开窍。香极则诸窍大开。脉缓筋弛。关键尽撤。故
身软目瞪不食也。畀入土坎者。诸毒得土而化。且土为万物之母。四肢百骸。得土气则生气
自复也。仍合治痿独取阳明之义。
李士材治太学朱修之。八年痿废。累治不效。李诊之。六脉有力。饮食如常。此实热内
蒸。心阳独亢。证名脉痿。用承气汤下六七行。左足便能伸缩。再用大承气。又下十余行。
手中可以持物。更用黄连、黄芩各一斤。酒蒸大黄八两。蜜丸。日服四钱。以人参汤送。一
月之内。去积滞不可胜数。四肢皆能展舒。李曰。今积滞尽矣。煎三才膏十斤与之。服尽而
应酬如故。
崇明倪君俦。四年不能起于床。日服之药。寒凉十六。补肾肝者十三。李诊其脉。大而
无力。此营卫交虚。以十全大补加秦艽、熟附各一钱。朝服之。夕用八味丸加牛膝、杜仲、
远志、萆 、虎骨、龟板、黄柏。温酒送七钱。凡三月而机关利。
又治兵尊高悬圃。患两足酸软。神气不足。向服安神壮骨之药。不效。改服滋肾合二妙
加牛膝、苡仁之属。又不效。纯用血药。脾胃不实。李诊之。脉皆冲和。按之亦不甚虚。
惟脾部重取之则涩而无力。此土虚下陷。不能制水。则湿气坠于下焦。故膝胫为患耳。进补
中益气。倍用升、柴。数日即愈。夫脾虚下陷之证。若用牛膝下行之剂。则愈陷而病愈甚矣
震按此三案。精妙绝伦。以药对脉。确切不移。首案连用承气。继用参汤送寒下药。皆
是独取阳明治法。末案补中益气。与大黄补泻不同。总归乎取阳明也。临证指南首列轻清治
肺二方。实宗肺热成痿之旨。第恐力薄难效。其用二妙、茵陈、萆 、茯苓皮、蚕砂、海金
砂、防己、胆草、寒水石等。直清湿热。较之清燥汤。反胜一筹。不涉虚者。允宜仿此。又
有治下虚上实。而用犀角地黄汤去芍药。加元参、连翘、桑叶、钩藤。似乎专理上实。罔顾
下虚。然云头目如蒙。入夏阳升为甚。议清营热以熄内风。想其人脉必弦数。有热甚生风之
象。未可兼顾下虚。或他日再诊而后滋填下焦。亦未可定。至于滋填下焦方。有用虎潜加减
者。有用四斤金刚健步及地黄饮子加减者。有用熟地、苁蓉、巴戟、远志、鹿角霜、桑椹、
苍术、小茴。以金毛脊酒蒸熟。水熬膏为丸者。有用苁、戟、杞、膝、青盐、线胶、茯苓、
沙苑、鹿筋胶、羊肉胶、牛骨髓、猪脊髓者。却无参、术补阳明法。亦无承气泻阳明法。惟
脾肾双补丸有人参。然其案重在晕麻瘕泄。尚未痿厥。非以治痿也。统观之。不外清湿热。
益肝肾。岂二种病情偏多耶。或案有遗逸。未能详备耶。
李东垣治疗一个人。正值壮年，却患脚膝痿弱无力。脐下、尾闾及臀部都感觉寒冷。阴部出汗且有臊臭味。精液滑泄不固。有人建议用鹿茸丸治疗。
没有效果。李东垣诊察其脉象沉数而有力。随即使用滋肾丸治疗。采用“寒因热用”的方法（即寒性药物热服），引导药力进入下焦，直达病所。以此泻除命门相火的亢盛之邪。再服用几剂后痊愈。
俞震按语：阴汗臊臭，精滑不固，脉象沉数有力，明显是下焦湿热证。李东垣自己说这是泻除相火的亢盛。这就是所谓的“肾热则骨痿”。
朱丹溪治疗一个人。形体肥胖，口味浓厚，多忧怒。脉象常呈沉涩。春季患痰气病。医生认为是虚寒证，使用燥热香窜的药物。到了夏季两足软弱无力，气机上冲，食欲减退。朱丹溪说：这是热邪郁结而脾气虚弱，痿厥之证即将发作。形体肥胖而脉象沉，还不是死证。但药邪太盛，正当火旺的时令，实在难以求生。于是给予竹沥送服白术膏。服完二斤后，气机下降，食欲增进。到一个月后，仍然大汗而死。记录此案作为误用药物的警戒。
俞震按语：气上冲就是喘逆，又加上食欲减退，病情已经很重了。何况兼有双足软弱呢。这是下虚上盛的征候。他说形体肥胖而脉象沉，不是死证，这符合《平脉篇》中对于肥人脉浮责其内热的义理。大概是指脉象并非应死的脉象，实际上是死于误药。
滑伯仁治疗一位妇女。起初患疟疾。正值夏季。医生认为脾寒胃弱，长期服用桂枝、附子等药物。后来疟疾虽然退去，但积火燔炽，导致消谷善饥（吃得多饿得快），每天吃几十顿饭还不够。整天端坐像正常人一样。只是眼睛昏花不能视物，脚弱不能行走，腰胯困软，肌肉看似丰满实则虚胖。到了初冬，滑伯仁诊察其脉象洪大而虚濡。说：这是痿证。是由于长夏时节过服热药所致。因为夏令湿气当令，刚燥之药太过，导致火湿俱盛，肺热叶焦，所以两足痿废而不能使用。于是采用李东垣关于长夏湿热成痿的治疗方法。饮食逐渐减少，眼睛渐渐能视物。到了冬末，忽然下床行走如故。
俞震按语：李东垣治疗长夏湿热成痿的方法，就是清燥汤。用于此证最为妥当。结合上面的医案来看，可以作为喜欢使用辛燥热药的医生的警戒。
石山治疗一个人。因为久坐腰痛，逐渐疼痛蔓延至右脚，再到左脚，又延及左右手，不能行动。有人当作风证治疗而用药酒，有人当作血虚治疗而用四物汤。一咽药就痛，盖被子稍热也痛，以及使用针砭，疼痛剧烈，煎服熟地黄，或者吞服虎潜丸，又加上右齿及面部疼痛剧烈。季秋时节，汪诊察其脉象濡缓而弱，左脉比右脉更小，或者涩，尺脉尤其弱。说：这是痿证。别人说痿证不应当疼痛。汪说：诸痿皆起于肺热。您善于饮酒，那么肺热就可以知道了。经书说：治痿独取阳明。阳明指的是胃。胃主四肢，岂止是脚呢？痿证兼湿重的，则筋缓而痿软；兼热多的，则筋急而作痛。于是检阅橘泉的传记展示给他看，他才相信痿证也有疼痛的情况。又经书说：酒客不喜甘。熟地黄味甘，而虎潜丸又加入蜂蜜，则甘味过多助湿而动胃火，所以出现右齿和面部疼痛。于是用人参二钱，黄芪一钱五分，白术、茯苓、生地黄、麦门冬各一钱，当归身八分，黄柏、知母各七分，甘草四分。煎服五帖，病除。于是他停药。季冬时节病情复发，仍服用前方而痊愈。
俞震按语：这个医案讲病最精妙，但对于用药我不敢深信。既然说热多者筋急而痛，且现下右齿和面部疼痛，为什么重用参、草等甘温之药？那微量的知母、黄柏，难道有益处吗？
一个人形体肥胖肤色黑，素来怕热而喜欢饮酒。三十多岁，突然患病自汗如雨，四肢全部痿废，并且恶寒，小便短赤，大便或溏或结，饮食也减少。医生当作风证治疗，使用独活寄生汤、小续命汤都没有效果。仲夏时节，汪诊察其脉象沉细而数，大约每息七至。说：这是痿证。丹溪说：断不可当作风证治疗。经书说：痿有五，皆起于肺热。只这一句，就知道治疗的方法了。经书又说：治痿独取阳明。阳明指的是胃与大肠。胃属土，肺属金，大肠亦属阳金。金赖土生，土亏则金失所养，而不能下生水。肾水枯竭火盛，肺更被损伤。况且胃主四肢，肺主皮毛。现在病四肢不能举动的，是胃土亏虚。自汗如雨的，是肺金受伤。所以治痿之法独取阳明，而兼清肺经之热。正符合李东垣的清燥汤。服用一百帖，果然痊愈。
俞震按语：脉象沉细而数，约有七至，说明郁热深重。为什么不直接清热，而仅用清燥汤这种清补兼施的药物呢？大概痿证本是虚证，加上自汗如雨，饮食减少，则肺胃更加虚弱。所以用此方补土以生金，益水以制火，这是治其本。黄连、黄柏苦寒，茯苓、泽泻淡渗，这是治其标。古人治病，审慎周到如此。也是知道必能中病，所以能持久以收功。
薛立斋治疗他的老师佥宪高如斋。从大同回来，对薛立斋说：我患上风病了。两腿休息时则痿软无力，劳累时则疼痛如针刺。脉象洪数而有力。薛立斋说：这是肝肾阴虚火盛所致。痿软无力是真病的表现，疼痛如锥刺是邪火的现象。使用壮水益肾的药剂而痊愈。高如斋说：以前寓居官邸，大家都以为是风证，遗憾没有医药，如果服用风证药剂，岂不是危险吗？
俞震按语：此脉洪数而有力，所以用壮水益肾的药。如果脉数而无力，应当用地黄汤合生脉散补血汤了。下面两个医案，虚象显然，仍然使用风药，死亡还有什么疑问？
一个男子足部痿软，日晡时分发热。薛立斋说：这是足三阴虚，应当用六味地黄丸和知柏地黄丸补之。一个妇人腿足无力，劳累则倦怠。薛立斋说：四肢属土，这属于脾虚，应当用补中益气汤及还少丹主治。都不听从他的建议。各自执着于搜风天麻二丸并愈风丹，最终因此丧命。
江应宿向北游历燕地，路过山东。孙上舍的长子文学患病消瘦。请江应宿诊视。说：无能为力了。经书说：大肉已脱，九候虽调，犹死。何况脉不调呢？当时正值盛夏过半，六脉弦数，既腹泻又痢疾，脾传之肾，谓之贼邪。病已经极重了。不出八月，水土俱败，到期而逝。不敢推辞。孙氏说：让内人请您把脉。形容喜悦顺适，语音清亮，不显露什么病症。诊毕，孙氏问是什么病。江应宿说：寸关脉洪数，尺脉微弱欲绝。足三阳脉逆而上行，上实下虚，这是痿证。病虽然久但可以治疗。孙氏问：什么缘故得此病？江应宿说：经书说：悲哀太过则胞络绝。胞络绝则阳气内动，发则心下崩，数溲血也。大经空虚，发为肌痹，传为脉痿。有所失亡，所求不得，则发肺鸣，鸣则肺热叶焦，发为痿躄。说的就是这个意思。孙氏说：果真是因为哭子忧伤，两脚软弱无力，不能起床已经有七年多了。有人当作风证治疗而投用香燥药，或者认作虚寒而与温补药，完全没有一点效果。江应宿说：湿热成痿，正符合李东垣清燥汤的例法。但药力差缓，难图速效。以独味杜仲，空腹酒水各半煎服。每日进服清燥汤，配合潜行散。过了二十天，走出房门。不久，因病子去世，哀伤复发。
俞震按语：上实下虚的病很多，怎么知道是痿证？大概在于形容喜悦顺适，语音清亮而不肯起床，可以权衡以此决断。
〔附〕葛可久治疗同郡富人的女儿。年龄十七八岁。患四肢痿痹，不能自己进食，眼睛瞪着不动。众医不能治。葛可久看后，笑着说：这不难治。于是让人去掉房中所有的香奁流苏之类的东西。挖地板掘土为坎，把女子放在其中。关上房门，告诫家人，等到她手足动而发声时，应当报告我。很久之后，手足果然动而呼叫。投药一丸。第二天，自己从土坎中出来了。大概这个女子平日嗜好香气，而脾脏被香气侵蚀的缘故。
俞震按语：香是脾的气味，怎么会侵蚀脾脏？我想香气能开窍，香气极浓则诸窍大开，脉缓筋弛，关键尽撤，所以身体柔软、眼睛瞪着、不进食。放入土坎中，是因为各种毒气遇到土而化解，而且土为万物之母，四肢百骸得到土气则生气自然恢复。这也符合治痿独取阳明的意义。
李士材治疗太学朱修之。八年痿废，多次治疗无效。李士材诊察其脉，六脉有力，饮食如常。这是实热内蒸，心阳独亢，证名脉痿。用承气汤攻下六七次。左足便能伸缩。再用大承气汤，又下十余次。手中可以持物。更用黄连、黄芩各一斤，酒蒸大黄八两，蜜丸。每日服四钱，用人参汤送服。一个月之内，排出的积滞不可胜数。四肢都能舒展。李士材说：现在积滞尽了。煎三才膏十斤给他服用。服完后应酬如故。
崇明倪君俦。四年不能起床。每日服药，寒凉药占十六份，补肾肝的药占十三份。李士材诊察其脉，大而无力。这是营卫交虚。用十全大补汤加秦艽、熟附子各一钱。早晨服用。晚上用八味丸加牛膝、杜仲、远志、萆薢、虎骨、龟板、黄柏。温酒送服七钱。共三个月而关节灵活。
又治疗兵尊高悬圃。患两足酸软，神气不足。先前服用安神壮骨的药物，无效。改服滋肾合二妙散加牛膝、苡仁之类，又无效。纯用血药，脾胃不实。李士材诊察其脉，皆冲和，按之也不甚虚。只有脾部重取之则涩而无力。这是土虚下陷，不能制水，则湿气坠于下焦，所以膝胫为患。进服补中益气汤，倍用升麻、柴胡。数日即愈。夫脾虚下陷之证，若用牛膝下行之剂，则愈陷而病愈甚矣。
俞震按语：这三个医案，精妙绝伦。以药对脉，确切不移。首案连用承气汤，继用参汤送服寒下药，都是独取阳明的治法。末案补中益气汤，与大黄补泻不同，总归乎取阳明。《临证指南》首列轻清治肺二方，实宗肺热成痿之旨。只怕力薄难效。其用二妙散、茵陈、萆薢、茯苓皮、蚕砂、海金沙、防己、胆草、寒水石等，直清湿热，较之清燥汤，反胜一筹。不涉及虚证的，适宜仿照此法。又有治疗下虚上实，而用犀角地黄汤去芍药，加元参、连翘、桑叶、钩藤，似乎专理上实，不顾下虚。然而说头目如蒙，入夏阳升为甚，议清营热以熄内风。想其人脉必弦数，有热甚生风之象，未可兼顾下虚。或者他日再诊而后滋填下焦，也未可知。至于滋填下焦方，有用虎潜丸加减者，有用四斤金刚健步丸及地黄饮子加减者，有用熟地、苁蓉、巴戟天、远志、鹿角霜、桑椹、苍术、小茴香，以金毛脊酒蒸熟，水熬膏为丸者，有用苁蓉、戟天、枸杞、牛膝、青盐、线胶、茯苓、沙苑蒺藜、鹿筋胶、羊肉胶、牛骨髓、猪脊髓者。却没有人参、白术补阳明法，也没有承气汤泻阳明法。只有脾肾双补丸有人参。然而其医案重在晕麻瘕泄，尚未出现痿厥，不是用来治痿的。统观之，不外清湿热，益肝肾两种情况偏多吗？或者是医案有遗漏，未能详备呢？
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?