Flaccidity is flabbiness and weakness of the sinews due to attack by exogenous pathogenic evils or by internal injury to the visceral organs. If prolonged, flaccidity may lead to atrophy or paralysis. Flaccidity mostly affects the lower limbs.
Etiology and Pathology
Flaccidity occurs when visceral Qi suffers damage, and damaged Qi is unable to nourish the sinews. Damage of visceral Qi leading to flaccidity is mainly due to attack by exogenous evils, improper diet, excessive passions or sexual overindulgence. Though flaccidity is located in the sinews it is closely related to the lung, the stomach, the liver and the kidney.
Lung-Heat Consuming Fluids. Exogenous Heat, persistent high fever, residual Heat following an illness, or endogenous Heat arising out of disease of zang organs can each cause burning of the lung and in turn consumption of body fluids. This leads to failure of fluids to distribute properly and to nourish the sinews.
Dampness-Heat Invasion. Dampness can invade the body when the person resides in a humid place or is caught in the rain. It can then invade the meridians and sometimes transform into Heat as well. Overindulgence in greasy, sweet, spicy foods or alcohol can injure the spleen and the stomach. Such injury readily leads to the production of endogenous Dampness and Heat. Dampness and Heat impede Qi and blood flow, leading to malnutrition of the sinews. Dampness and Heat can also attack the sinews directly.
Insufficiency of Spleen and Stomach. Constitutional weakness of these organs or long-lasting illness impairing middle-jiao-Qi may lead to inadequate generation and transformation of Qi, blood and body fluids. This in turn leads to failure to nourish the sinews adequately.
Insufficiency of Liver and Kidney. Depletion of liver and kidney essence and blood may result from a number of causes. They include inadequate prenatal endowment, sexual overindulgence, excessive passions, and injury by protracted illnesses and physical exhaustion. Depletion of liver and kidney essence and blood leads to failure to nourish the sinews adequately.
Clinical Manifestation
The key symptom is flaccidity of the sinews, which manifests flabbiness of the muscles, loss of normal muscle tone and weakness. Flaccidity may affect the sinews of one region or the entire body. It may affect just the upper body or just the lower body. It may affect only one side or both sides of the body. In severe cases, there may be atrophy of the muscles. This impairs the ability to lift heavy objects, to stand for more than a few minutes and to walk more than a short distance. Sustained and protracted disuse can further lead to paralysis of the affected muscles. There may also be numbness in the affected area, pain or spasm. In serious cases, there may be blockage of urination, difficulty with breathing or dysphagia.
Key Points of Analysis
Most cases of flaccidity are due to deficiency-Heat, although mixed deficiency and strength illnesses are not rare. Often the illness is due to Phlegm-Dampness, static blood, Heat or food retention affecting a patient in whom the zang organs have already suffered internal injury.
In general, an illness with flaccidity that begins and progresses rapidly, with weakness of the limbs or numbness and spasticity, is due to either consumption of body fluids by Lung-Heat or invasion by Dampness-Heat. An illness with flaccidity that begins and progresses gradually, with flabby sinews and muscular atrophy, is most often due to insufficiency of the spleen, the stomach, the liver or the kidney.
Certain patterns of symptoms are indicative of the location of illness. Fever, cough and sore throat at the outset, with flaccidity and weakness in the limbs during or following a febrile illness, suggest disease in the lung. Flaccidity of all four limbs, anorexia, loose feces and pale tongue suggest illness in the spleen and the stomach. Flaccidity that is more severe in the lower limbs, aching in the waist, tinnitus, and in males spermatorrhea and impotence suggest disease in the liver and the kidney.
Herbal Treatment
Consumption of Fluids by Lung-Heat
Main Symptoms. Initial fever or abrupt flaccidity and weakness of the limbs as fever subsides; dry skin; restlessness; thirst; cough that produces little sputum; dry throat; dark urine; and constipation. The tongue is red, with yellow coating, and the pulse is threadlike and rapid.
Therapeutic Principle. Cool Heat, moisten the lung and moisten and nourish the sinews.
Treatment. Qing Zao Jiu Fei Tang (Dryness-Moistening Lung-Rescuing Decoction).
If fever is high, with thirst and much sweating, use larger amount of raw shigao (gypsum) and add jinyinhua (Lonicera), lianqiao (Forsythia) and zhimu (Anemar-rhena) to cool Heat.
If dry throat and thirst are prominent, add tianhuafen (Trichosanthes), yuzhu (Polygonatum), beishashen (Glehnia) and lugen (Phragmites) to nourish Yin and generate fluid.
If anorexia and dry throat worsen despite abatement of fever, lung and stomach Yin has been injured. Use Yi Wei Tang (Stomach-Nourishing Decoction) with added yiyiren (Coix), shanyao (Dioscorea), maiya (Hordeum) and guya (Oryza sativa) to nourish the stomach and generate fluid.
Invasion by Dampness-Heat
Main Symptoms. This mostly affects the lower limbs: flaccidity, heaviness and numbness. Some have fever, chest and epigastric tightness, and scant dark urine; or, feverishness in the feet and shanks, a red and plump tongue. The tongue coating is thick and greasy and the pulse is threadlike and rapid but soft.
Therapeutic Principle. Cool Heat and eliminate Dampness to relieve the sinews.
Treatment. Jia Wei Er Miao Tang (Augmented Two-Wonders Pill).
If Dampness is prominent, with chest and epigastric tightness and heaviness and swelling in the limbs, add houpo (Magnolia), fuling (Poria) and yiyiren (Coix) to regulate Qi and eliminate Dampness.
For feverishness in the feet and shanks, restlessness, a red tongue or exofoli-ating coating, remove cangzhu and add shengdihuang (Rehmannia), maimendong (Ophiopogon) and sharen (Amomum) to nourish Yin and cool Heat.
If the limbs are numb, the tongue is purple and the pulse is impeded, add chishaoyao (Paeonia), taoren (Prunus persica) and honghua (Carthamus) to mobilize blood and remove stasis.
Insufficiency of Spleen and Stomach
Main Symptoms. Initially, weakness in all four limbs, aggravated by physical activity or strain. In time: flaccidity and debility of the limbs; poor appetite, loose feces; facial edema, lusterless complexion; shortness of breath; and general weakness. The tongue is plump, and the coating is thin and white. The pulse is threadlike.
Therapeutic Principle. Strengthen the spleen, augment Qi, tonify the middle-jiao and raise Yang.
Treatment. Bu Zhong Yi Qi Tang (Middle-Restoring and Qi-Augmenting Decoction).
For poor appetite with abdominal fullness, add shanzha (Crataegus), zhiqiao (Poncirus trifoliata), sharen (Amomum), maiya (Hordeum) and guya (Oryza sativa) to regulate Qi and relieve food retention.
For loose feces, add yiyiren (Coix), shanyao (Dioscorea) and lianzi (Nelumbo) to strengthen the spleen and eliminate Dampness.
For prominent shortness of breath and profuse sweating, increase the amount of huangqi (Astragalus).
Insufficiency of Liver and Kidney
Main Symptoms. Slow onset flaccidity and weakness of the lower limbs; aches and weakness of the back along the spine, with inability to stand for a long time. There may be blurring of vision and dizziness, dry throat and tinnitus; or, spermatorrhea and premature ejaculation; or irregular menstruation. In severe cases, inability to walk at all and atrophy of the muscles of the leg. The tongue is red, with scant coating, and the pulse is threadlike and rapid.
Therapeutic Principle. Restore and strengthen the liver and the kidney, nourish Yin and cool Heat.
Treatment. Hu Qian Wan (Hidden-Tiger Pill). It has the following basic composition: hugu (tiger bone) 6g, niuxi (Achyranthes) 10 g, suoyang (Cynomorium songaricum) 10 g, baishaoyao (Paeonia) 10 g, huangbai (Phellodendron) 10 g, zhimu (Anemarrhena) 6g, shudihuang (Rehmannia) 10 g, guiban (Chinemys) 10 g, chenpi (Citrus tangerina) 10 g, and ganjiang (Zingiber) 6g. Note: hugu may be replaced by an equal weight of gougu (dog bone) which has to be decocted first.
If endogenous Heat is strong, remove suoyang and ganjiang.
If there are lusterless complexion and palpitation of the heart, add huangqi (Astragalus), dangshen (Codonopsis), danggui (Angelica) and jixueteng (Spatho-lobus suberectus) to augment Qi and generate blood.
In protracted illness, if Yin depletion has caused Yang deficiency as well, remove huangbai and zhimu but add herbs that nourish kidney-Yang, such as lujiao (Cervus nippon), buguzhi (Psoralea), yinyanghuo (Epimedium), rougui (Cinnamomum) and processed fuzi (Aconitum). Alternately, add ziheche (human placenta) and instruct the patient to eat boiled pork or beef bone marrow mixed and mashed with rice flour and brown sugar.
If the limbs are numb, the tongue cyanotic or speckled with purpuric spots and the pulse impeded, add ruxiang (Boswellia), moyao (Commiphora), chuanshanjia (Manis pentadactyla) and dilong (Pheretima) to mobilize blood and unblock channels.
Acupuncture Treatment
Standard Acupuncture
The selection of acupoints varies with the region affected as well as the illness producing flaccidity.
For the upper limbs, select Jianyu (LI-15), Quchi (LI-11) and Hegu (LI-4).
For the lower limbs, select Biguan (ST-31), Fengshi (GB-31), Yanglingquan (GB-34) and Zusanli (ST-36).
If flaccidity is due to Lung-Heat, add Chize (LU-5) and Feishu (BL-13).
If it is due to Dampness-Heat, add Yinlingquan (SP-9).
If it is due to insufficiency of the spleen and the stomach, add Pishu (BL-20) and Weishu (BL-21).
If it is due to insufficiency of the liver and the kidney, add Ganshu (BL-18) and Shenshu (BL-23).
For flaccidity due to a strength illness, apply the reducing method. For flaccidity due to a deficiency illness, apply the reinforcing method and moxibustion.
Ear Acupuncture
Select Acupoint Lung, Acupoint Stomach, Acupoint Liver, Acupoint Kidney, Acupoint Shenmen and Acupoint Spleen.
For each treatment, select 3-5 of these acupoints. Apply strong stimulation and retain the needles for 10 min. Treat on alternate days. Each course of treatments consists of ten treatments.
Case Study
The patient was a 27-year old male who had been married for about 6 months. Three months after marrying he began noticing aches and weakness in this waist and knees. Thereafter he developed weakness in both lower limbs, which gradually increased day by day. It reached the point where he could no longer run or stand up from a crouching position. He had much difficulty boarding a bus or walking up or down stairs. It was sufficiently severe as to interfere with his work and daily life. In addition, he had constipation, defecating once in 5-6 days, and urinary incontinence. His appetite and sleep were normal. Examination revealed a thin and white tongue coating and a taut and threadlike pulse.
Diagnosis. Insufficiency of kidney-essence; the sinews losing their nourishment.
Therapeutic Principle. Restore kidney-essence, tonify the marrow and nourish the sinews.
Treatment and Course. Dihuang Yin Zi (Rehmannia Drink). It has the following composition: danggui (Angelica sinensis) 15 g, roucongrong (Cistanche deserticola) 15 g, niuxi (Achyranthes bidentata) 15 g, shudihuang (Rehmannia glutinosa) 24 g, yuanzhi (Polygala tenuifolia) 6g, fuling (Poria cocos) 12 g, shanzhuyu (Cornus officinalis) 15 g, maimendong (Ophiopogon japonicus) 15 g, wuweizi (Schisandra chinensis) 15 g, shichangpu (Acorus gramineus) 9 g, and processed fuzi (Aconitum carmichaeli) 12 g.
The dosage was one dose daily. Over the course of over 20 days he gradually regained strength in the lower limbs. The other symptoms, including aches and pain, constipation and urinary incontinence, all resolved. The formula was discontinued, and the patient was instructed to regulate his sexual activity. He did not have any recurrence.
