Vertigo is a condition that results from disturbance of the upper orifices induced by Wind, Fire, Phlegm, blood stasis or a state of deficiency. Its main symptoms are dizziness and blurring of vision. In mild cases, dizziness may disappear upon closing the eyes. In more severe cases, the sensation resembles that of seasickness or carsickness. The patient feels as though incessantly rotating and is unable to stand upright. There may be accompanying nausea or vomiting, tinnitus, a pallid complexion and sweating. When very severe, there may be abrupt fainting.
Etiology and Pathology
Hyperactive Liver-Yang. The Wood Element, to which the liver belongs, tends to ascend and spread. Also, the substance of the liver is Yin but its function is Yang. The kidney belongs to the Water Element. If kidney-Yin is deficient, Water is unable to generate Wood and deficiency-Wind can stir in the interior. Pent-up rage or melancholy may block the movement of liver-Qi. Blocked liver-Qi can transform into Fire and lead to stirring of Wind-Yang. Chronically hyperactive Yang also fosters hyperactive liver-Yang. In all these conditions, liver-Yang can ascend and disturb the upper orifices and induce vertigo.
Deficient Qi and Blood. Protracted illness or continued blood loss can consume Qi and blood and lead to their deficiency. Insufficiency of the spleen and the stomach may compromise the sources for Qi and blood generation. If Qi is deficient, pure Yang cannot act effectively. If blood is insufficient the upper orifices may not be properly nourished. In all these circumstances vertigo may result.
Insufficient Kidney-Essence. The kidney is the foundation of prenatal heredity and has the functions of storing essence and generating marrow. If prenatal heredity is inadequate, kidney-essence is insufficient, chronic illness afflicts the elderly or excessive sexual activity wears down kidney-essence, the sea of marrow becomes depleted and the brain loses nourishment. Vertigo ensues.
Blockage by Phlegm-Dampness. Addiction to alcohol, fatty or sweet foods can injure the spleen and the stomach. Irregular starvation and satiation or physical exhaustion also injures the spleen and the stomach. Impairment of spleen and stomach functions results in the formation of endogenous Phlegm and Dampness. These can obscure the upper orifices and induce vertigo.
Blood Stasis. Traumatic injury of the head and the brain can cause blood to overflow its channels and become static blood. In turn, static blood from this or another cause can obstruct the brain blood channels and lead to loss of nourishment of the upper orifices. Vertigo ensues. This is especially severe if Phlegm joins blood stasis in obstructing the upper orifices.
In summary, the location of illness is in the upper orifices, but the cause of vertigo also involves the liver, the spleen and the stomach. The basic pathological mechanism is the depletion of brain marrow leading to loss of nourishment of the upper orifices, or upward attack by Phlegm and Fire.
Clinical Manifestation
Vertigo may begin abruptly or gradually. In mild cases, there may be only blurring of vision, heaviness in the head with lightness in the feet or a rocking-swaying sensation. These tend to stop upon closing the eyes. In severe cases, the sensation is like that of being seasick or carsick and the outside world revolving about incessantly. This may lead to falling down. Common accompanying symptoms include tinnitus, eye irritation, insomnia, forgetfulness, weakness and aching in the waist and knees, nausea and vomiting, a pallid complexion, or sweating with cold limbs.
Vertigo tends to attack repeatedly, but the interval between attack varies unpre-dictably. Most patients have it every few months or years, but some have it several times a month. During an attack of vertigo the tongue coating is mostly white and greasy or yellow and greasy. During remission, the tongue coating is thin and white. The tongue is red or is speckled with petechiae or purpura. The pulse is usually taut, but may be threadlike and feeble.
Key Points of Analysis
Vertigo mainly arises in a state of deficiency. The basic mechanism is deficiency of liver or kidney Yin or deficiency of Qi and blood. In Yin deficiency the tongue is usually red, with scant coating, and the pulse is taut and rapid. In Qi and blood deficiency the tongue is usually pale and tender and the pulse threadlike and weak.
The state of deficiency may be complicated by stirring of endogenous Wind, flaming up of Fire, blockage by turbid Phlegm or by blood stasis. It is important to differentiate these conditions carefully. These are related to dysfunction of the viscera, principally the liver, the spleen and the kidney. In disturbance of the liver by passions liver-Qi is pent-up and may transform into Fire, or in deficiency of liver-Yin liver-Yang may become hyperactive. Either can induce vertigo accompanied by distending headache and flushed face. If the spleen fails to generate and transform Qi and blood, vertigo is readily induced by fatigue. In this case, it is usually accompanied by anorexia, lassitude and pale complexion. If the spleen fails to transport and transform body fluids, endogenous Phlegm may form and obstruct the middle-jiao. This may lead to heaviness in the head, anorexia, nausea and vomiting. If kidney-essence is insufficient and the sea of marrow is depleted, there may be aching weakness in the loins and knees and tinnitus in addition to vertigo.
In an obese patient with pale complexion, Qi deficiency is common and often accompanied by Phlegm. In a thin patient with darkish complexion, blood deficiency is common and often accompanied by Fire.
Herbal Treatment
Hyperactive Liver-Yang
Main Symptoms. Vertigo and distending headache, aggravated by overstrain or rage; flushed face, red eyes; agitation, irascibility; dry and bitter mouth; insomnia and much dreaming when asleep; and tinnitus. The tongue is red, with yellow coating. The pulse is taut or taut, threadlike and rapid.
Therapeutic Principle. Calm the liver, suppress Yang and nourish the liver and the kidney.
Treatment. Tianma Gouteng Yin (Gastrodia and Uncaria Drink).
If Liver-Fire is especially strong, with prominent flushed face and red eyes, add longdancao (Gentiana), mudanpi (Paeonia suffruticosa) and xiakucao (Prunella) to purge Liver-Fire or use Longdan Xie Gan Tang instead.
If Yin deficiency is severe, with a red tongue, scant coating and a threadlike and rapid pulse, add shengdihuang (Rehmannia), maimendong (Ophiopogon), xuanshen (Scrophularia), heshouwu (Polygonum), raw baishaoyao (Paeonia lactiflora) and similar herbs that nourish Yin.
Deficient Qi and Blood
Main Symptoms. Dizziness and blurred vision, aggravated by activity and precipitated by fatigue; pallid complexion; lassitude, weakness; palpitations of the heart; and insomnia. The tongue is pale, with thin white coating. The pulse is threadlike and feeble.
Therapeutic Principle. Strengthen the spleen, augment Qi, nourish the heart and generate blood.
Treatment. Gui Pi Tang (Spleen-Restoring Decoction).
If the feces are watery, add yiyiren (Coix), zexie (Alisma) and fried biandou (Dolichos lablab).
If blood insufficiency is more severe, add heshouwu (Polygonum), ejiao (Equus asinus) and powdered ziheche (human placenta) to nourish and generate blood.
If deficient Qi has sunk, with shortness of breath, weakness and rectal prolapse, add Bu Zhong Yi Qi Wan (Middle-Restoring Qi-Augmenting Pill). This is wrapped in gauze and decocted along with the herbs.
Insufficient Kidney-Essence
Main Symptoms. Persistent vertigo; lassitude; forgetfulness; and aching weakness in the loins and knees. If Yin is particularly deficient, there are hotness in the five centers, dry irritated eyes, dry mouth, night sweats, nocturnal emissions in males, and early menses in females. If Yang is particularly deficient, there are cold body, cold limbs, impotence, cold pain in the loins and knees, a pale tongue, and a deep, threadlike and forceless pulse.
Therapeutic Principle. Yin deficiency: strengthen the kidney and nourish Yin. Yang deficiency: warm the kidney and augment Yang.
Treatment. Yin deficiency: Zuo Gui Wan (kidney-Yin-Augmenting Pill). Yang deficiency: You Gui Wan (kidney-Yang-Augmenting Pill). The composition of Zuo Gui Wan is as follows: shudihuang (Rehmannia) 20 g, shanzhuyu (Cornus) 10 g, shanyao (Dioscorea) 10 g, tusizi (Cuscuta) 10 g, gouqizi (Lycium) 10 g, guiban (Chinemys) 10 g, andniuxi (Achyranthes) 10 g.
If Fire is prominent due to Yin deficiency, add zhimu (Anemarrhena) and huang-bai (Phellodendron) to purge kidney-Fire.
If symptoms of Cold are not prominent in Yang deficiency, replace rougui and fuzi with yinyanghuo (Epimedium) in You Gui Wan to avoid damage to essence by excessive acridity and drying.
Blockage by Phlegm-Dampness
Main Symptoms. Vertigo; heaviness in the head as though wrapped; chest tightness; nausea, vomiting of sputum and saliva; anorexia; and heaviness in the limbs. The tongue coating is white and greasy, and the pulse slippery and taut.
Therapeutic Principle. Dry Dampness, dissipate Phlegm, strengthen the spleen and settle the stomach.
Treatment. Banxia Baizhu Tianma Tang combined with Er Chen Tang. The joint prescription has the following composition: processed banxia (Pinellia) 10 g, baizhu (Atractylodes) 10 g, tianma (Gastrodia) 10 g, chenpi (Citrus tangerina) 10 g, fuling (Poria) 10 g, gancao (Glycyrrhiza) 10 g, shengjiang (Zingiber) 6 g, and dazao (Ziziphus) 6 g.
If vomiting is severe, add daizheshi (hematite) and zhuru (Phyllostachys nigra) to enhance the actions of settling the stomach, suppressing the abnormally risen and stopping vomiting.
If there is epigastric fullness with anorexia, add baidoukou (Amomum cardamo-mum) and sharen (Amomum villosum) to promote appetite by their aromaticity.
If there is tinnitus with partial deafness, add yujin (Curcuma) and shichangpu (Acorus) to open the orifices.
If gelled Phlegm has transformed into Heat, which attacks upward and blocks the upper orifices, producing agitation, bitter taste, yellow and greasy tongue coating and taut and slippery pulse, use Huanglian Wen Dan Tang (Coptis Gallbladder-Warming Decoction) to cool Heat and dissipate Phlegm.
Blood Stasis
Main Symptoms. Persistent vertigo resistant to treatment or dizziness due to traumatic injury; headache with fixed location; cyanotic complexion and lips; palpitations; and forgetfulness. The tongue is speckled with petechiae or ecchymosis, and the pulse is taut and impeded or threadlike and impeded.
Therapeutic Principle. Eliminate stasis, generate blood and unblock the orifices and the channels.
Treatment. Tong Qiao Huo Xue Tang (Orifice-Unblocking Blood-Enlivening Decoction). It has the following composition: chishaoyao (Paeonia) 6 g, taoren (Prunus persica) 10 g, honghua (Carthamus) 10 g, chuanxiong (Ligusticum) 12 g, shexiang (Moschus) 0.15 g, congbai (Allium fistolosum) 6 g, and dazao (Ziziphus) 10 g.
If there are significant lassitude, weakness, shortness of breath and spontaneous sweating, add raw huangqi (Astragalus) 30-60 g to augment Qi and mobilize blood.
If there are cold-aversion and cold limbs, add guizhi (Cinnamomum) and processed fuzi (Aconitum) to warm the channels and mobilize blood.
Acupuncture Treatment
Hyperactive Liver-Yang
Select the acupoints Ganshu (BL-18), Shenshu (BL-23), Fengchi (GB-20), Xingjian (LR-2) and Xiaxi (GB-43). Use filiform needles and apply both the reducing and the reinforcing methods.
Blockage by Phlegm-Dampness
Select the acupoints Touwei (ST-8), Neiguan (PC-6), Zhongwan (CV-12), Fenglong (ST-40) and Yinlingquan (SP-9). Use filiform needles and apply the even method.
Insufficient Kidney-Essence
Select the acupoints Baihui (GV-20), Xuanzhong (GB-39), Shenshu (BL-23) and Taixi (KI-3). Use the filiform needles and apply the reinforcing method. Moxibustion may also be applied at Shenshu (BL-23) and Baihui (GV-20).
Deficient Qi and Blood
Select the acupoints Baihui (GV-20), Zusanli (ST-36), Pishu (BL-20) and Weishu (BL-21). Use filiform needles and apply the reinforcing method. Moxibustion may also be applied at Baihui (GV-20), Zusanli (ST-36) and Pishu (BL-20).
Blood Stasis
Select the Ashi Acupoints, Geshu (BL-17) and Sanyinjiao (SP-6). Use filiform needles and apply the even method.
Case Study
The patient was a 33-year old married laborer. He suffered from paroxysmal vertigo for more than 6 years, worse during the past 2 years. Each attack was preceded by a sensation of hot air rising from the lower abdomen to the vertex of the head. This was followed by vertigo with the sensation of the surroundings revolving about him, and dimness in front of his eyes. During more severe attacks he would fall but retained consciousness. He was diagnosed at another hospital to have Meniere Disease and was treated with a variety of western drugs. Each time, he had good initial response, but the response gradually diminished.
At the time of consultation, he had vertigo, tinnitus with partial deafness, forgetfulness, nausea, expectoration of sputum on arising in the morning, restlessness, bitter taste, constipation, dark urine, palpitations and shortness of breath. He also had intermittent hotness in the palms and lumbar aches.
He had a gray and lusterless complexion. His tongue was red, with slight yellow and greasy coating in the middle. His pulse was deep and slippery on the right side, and taut and threadlike on the left. The pulse rate was 80/min, regular in rhythm, and the blood pressure 100/80 mmHg. The cardiac border by percussion was normal. The heart sounds were normal to auscultation. The abdomen and the extremities were normal. Neurological examination showed bilateral horizontal nystagmus. Vestibular function test showed diminished function on the right side. Audiometry showed perceptive deafness.
Diagnosis. Vertigo due to Yin deficiency, with Phlegm and Fire.
Therapeutic Principle. Nourish Yin, cool Heat, dissipate Phlegm and purge Fire.
Treatment and Course. Augmented Wen Dan Tang (Gallbladder-Warming Decoction). The augmented composition is as follows: fuling (Poria) 6g, prepared banxia (Pinellia) 9g, juhong (Citrus tangerina) 6g, fried zhishi (Citrus aurantium) 4.5 g, shichangpu (Acorus) 3 g, zhuru (Phyllostachys nigra) 6 g, xiakucao (Prunella) 9 g, zhenzhumu (Pteria magaritifera) 12 g, xiangfu (Cyperus) 3 g, and fried gancao (Glycyrrhiza) 1.5 g. In addition, mangxiao (Mirabilite) 6 g is administered by infusion. Note: zhenzhumu is decocted early.
Following three daily doses, vertigo ended and all the other symptoms improved. Treatment was continued with the same prescription with added huanglian (Coptis) 3 g. After 19 daily doses, all symptoms resolved. On follow-up 3 months later, there had been no relapse.
