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B Chinese medicine is not too slow to address acute illness1 Dizziness for 17 years C Case History Patient Ms Xu 28 year old woman cadre When she was 8 years old she accidentally fell into the water was frightened and caught a cold She was bedridden for more than a month and her health generally deteriorated At age 11 she started to experience dizziness The dizziness was accompanied by tinnitus and nausea These episodes occurred 5 6 times per year When she was 20 she was prescribed lead powder by an itinerant physician to treat the dizziness and she took 6g each day for 3 days As a result she contracted lead poisoning She was treated for 4 months at Huaxi University Associated Hospital and at the end of that time the main symptoms of lead poisoning had resolved but the dizziness had gotten worse She frequently experienced dizziness and when it was severe she would experience severe vertigo and be reluctant to open her eyes She had distending pain in the eyes as well as fluttering vision tinnitus blocked ears trembling of the arms and legs retching and vexation She was diagnosed with inner ear dizziness and treated in many different Western and Chinese hospitals She was treated with many different Chinese medicinals such as those that calm the Liver and subdue yang extinguish wind and relieve spasms nourish Liver and Kidney fortify the Spleen and transform phlegm and use insect medicinals to search and to dig out stagnation in the channels and collaterals After taking hundreds of bags there was no significant effect and generally she was unable to work C Intake Examination Intake Date February 17 1986 The symptoms were as described above Her tongue was red with a thin white coat Her pulse was sunken and fine C Differentiation of Patterns and Discussion of Treatment Physician A In general dizziness patients respond quickly to Western medicine and many cases resolve spontaneously Dr Yu It is true that some cases resolve spontaneously but this is actually uncommon In cases of severe acute dizziness commonly used Western drugs such as sedatives antiemetics and anticholinergic drugs are often ineffective Furthermore it is not uncommon that these patients are referred into the Chinese medicine department 1 This phrase describes a situation in which upon contracting an acute illness the person encounters a physician who is too slow to effectively address the issue

Physician B But isn t it true that we cannot draw an equivalence between dizziness in Western medicine and Chinese medicine Dr Yu What do we mean by dizziness The term in Chinese 2 includes two parts the first refers to visual disturbances and blurred vision the second refers to a spinning sensation that originates in the head Nonetheless when you carefully investigate both classical books and modern textbooks you find that the broad category labeled dizziness includes not only muzzy headedness but also patterns such as heavy headedness with lightness in the lower body and a lack of any spinning sensation In Western medicine there is a clear differentiation between true dizziness and false dizziness True dizziness which is also referred to as rotational vertigo is the result of vestibular nerve disease or labyrinthine disease True dizziness is characterized by symptoms such as dizziness with a feeling that the person himself is spinning or that the room is spinning nausea vomiting tinnitus hearing loss nystagmus headache and ataxia Dr Ji ng believed that muzzy headedness and patterns such as heavy headedness with lightness in the lower body but lacking any spinning sensation should not be included in the category of dizziness in order to insure correct pattern identification Dr Ji ng believed in using knowledge from Western medicine in the service of Chinese medicine He frequently said that stones from other mountains may be used to polish jade This is not just a trite old saying but contains a useful idea Physician C Dr Ji ng s clarification of the definition of dizziness is original and thought provoking How can we use the theories of Chinese medicine to correctly identify and distinguish true dizziness Dr Yu The first thing to do is to explore the historical literature discussing dizziness and then carefully analyze what we find While we can appreciate the beauty of the literature we must avoid simply reading things at random and accepting what we read without critical thought For example it is written that there is no dizziness without wind there is no dizziness without fire there is no dizziness without phlegm and there is no dizziness without deficiency While there is truth in each of these statements each is incomplete Further because these statements relate to the broad category of dizziness were we to use these ideas to explain the etiology and pathodynamic of true dizziness it would necessarily be overly general and abstract 2

Dr Ji ng believed that we should especially attend to the writing of Zh ng Zh ng J ng He approached dizziness from the perspective of shao yang ministerial fire flaring upward and upward counterflow of phlegm and thin mucous Zh ng Zh ng J ng used formulas such as Minor Bupleurum Decoction xi o ch i h t ng Poria Cinnamon Twig Atractylodes and Licorice Decoction l ng gu zh g n t ng Alismatis Decoction z xi t ng and Minor Pinellia plus Poria Decoction xi o b n xi ji f l ng t ng which seem to match up with these conditions quite well From this idea of shao yang ministerial fire flaring upward and upward counterflow of phlegm and thin mucous we can pull out the overarching etiology and pathodynamic of true dizziness wind fire phlegm and deficiency On the basis of Dr Ji ng s teaching I diagnosed this patient as having Spleen and Kidney deficiency with upward harassment of wind fire and phlegm C Treatment and Outcome I used a modification of Bupleurum Dried Tangerine Peel and Alismatis Decoction ch i ch n z xi t ng 3 Bupleuri Radix ch i h 10g Scutellariae Radix hu ng q n 6g Pinelliae Rhizoma preparatum zh b n xi 10g Codonopsis Radix d ng sh n 15g Poria f l ng 12g Citri reticulatae Pericarpium ch n p 10g Glycyrrhizae Radix g n c o 3g Atractylodis macrocephalae Rhizoma b i zh 10g Alismatis Rhizoma z xi 30g Uncariae Ramulus cum Uncis g u t ng 12g add last Chrysanthemi Flos j hu 10g Gastrodiae Rhizoma ti n m 10g grind and take as a draft Zingiberis Rhizoma recens sh ng ji ng 10g Paeoniae Radix alba b i sh o 12g Ostreae Concha m l 30g Results After 3 packs there was a significant reduction in the dizziness distending pain in the eyes retching and vexation After 25 packs of the formula all symptoms had resolved I followed up with the patient two years later and she reported that occasionally when she 3 The formula is a modified combination of Minor Bupleurum Decoction xi o ch i h t ng Two Aged Herb Decoction r ch n t ng Six Gentleman Decoction li j n z t ng and Alismatis Decoction z xi t ng

encountered emotional problems she would sometimes have a sensation of muzzy headedness or mild dizziness These episodes were quickly addressed with 2 3 packs of the original formula Disease Name Dizziness Pattern Treatment Selected Formula Identification Method Upward flaring of ministerial fire upward Bupleurum Dried Muzziness Dispel wind counterflow of Tangerine Peel and dizziness clear fire phlegm and thin Alismatis tinnitus nausea dislodge phlegm mucous and Decoction ch i and vomiting tonify the Spleen Spleen and ch n z xi t ng Kidney deficiency Main Symptoms C Reflections and Clarifications Physician C There is something that I don t completely understand Is there really any difference between shao yang ministerial fire flaring upward and upward counterflow of phlegm and thin mucous and there is no dizziness without phlegm Dr Yu From the idea of shao yang ministerial fire flaring upward and upward counterflow of phlegm and thin mucous we can derive the entire etiology and pathodynamic of true dizziness wind fire phlegm and deficiency How can you possibly equate that with the extremely narrow idea of there is no dizziness without phlegm Physician B You said that shao yang ministerial fire flaring upward and upward counterflow of phlegm and thin mucous describes the entire etiology and pathodynamic of true dizziness wind fire phlegm and deficiency I have never heard this idea before Where does it come from Dr Yu Shao yang ministerial fire and jue yin wind wood have an exterior interior relationship The presence of wind increases the momentum of fire The presence of fire increases the threat of wind This represents mutual causality Upward counterflow of phlegm and thin mucous generally has Spleen and Kidney deficiency at its root Wouldn t you say that this explains the derivation of the concept of wind fire phlegm and deficiency Over the years people studying this idea have always considered the work of Ch n Xi Yu n In

his discussion of dizziness he considers wind as primary with fire phlegm and deficiency mixed in I think that his work reveals some subtle ideas and contains critical information He says This type of wind does not come from the exterior but is from jue yin wind wood When wood flares it generates wind Furthermore because jue yin wind wood shares a common location with shao yang ministerial fire qi counterflow of jue yin creates wind which then gives rise to fire With regards to deficiency he writes that The creation of wind influences the dynamic of wood such that wood overcomes earth Further The Kidney is the mother of the Liver The Kidney governs the storage of essence When essence is deficient the brain becomes empty resulting in heaviness of the head This situation is the child stealing the mother s qi With regards to phlegm When earth is diseased pooling thin fluids become phlegm To summarize wind fire and phlegm are the branches of dizziness while Spleen and Kidney deficiency is its root Ch n Xi Yu n ends by saying Deficiency is the root and excess is the manifestation4 Dr Ji ng felt that these ideas of Ch n Xi Yu n were incredibly subtle and that the application of them to understanding the cause of true dizziness was fairly accurate He emphasized though that the onset of dizziness was not the product of wind fire phlegm and deficiency as individual factors but when they combined as a group Thus he did not agree with the statement from Zh ng J ng Yu that For patients with dizziness deficiency accounts for 80 90 while fire and phlegm are only implicated in 10 20 In clinic patients with dizziness generally present with a whole set of symptoms indicating upward harassment of wind fire and phlegm Is it possible that we could use deficiency alone to explain this Physician C But he did not dispute the importance of deficiency correct Dr Yu Of course he did not dispute its importance Without deficiency it becomes very difficult to satisfactorily explain the genesis of upward harassment of wind fire and phlegm As I said Ch n Xi Yu n considered deficiency to be the root of dizziness As we think about this we might think of deficiency as a latent disease cause or even a constitutional disease cause No matter how we understand it we should remember that dizziness includes wind fire phlegm and deficiency Fundamentally it is a pattern of root deficiency with branch excess And we must treat it by simultaneously addressing both root and branch Physician C I have a significant confusion about the case If this pattern involves phlegm and thin mucous should we not expect to see evidence of this in the pulse and on the tongue I would expect to see a greasy tongue coat and a wiry or slippery pulse but in this case the tongue is red with a 4

thin white coat and the pulse is sunken and fine Dr Yu In clinic there is no fixed tongue and pulse associated with true dizziness caused by shao yang ministerial fire rising and counterflow of phlegm and thin mucous Although it is true that a greasy tongue coat is common in phlegm and thin mucous patterns the absence of a greasy coat or even a complete absence of tongue coat does not mean that phlegm and thin mucous are also absent Dr Ji ng treated many dizziness patients who had a pale red tongue with a thin white coat or no coat Tonifying qi and blood or enriching yin and settling yang were ineffective Switching to a strategy of scouring phlegm driving out thin mucous dispelling wind and clearing fire produced effective results That the pulse is also not fixed goes without saying The mechanisms involved in this pattern are certainly worthy of further study which may reveal additional information Physician C You mentioned simultaneous root and branch treatment I have to say that when considering opinions from both ancient and modern physicians about exactly what this means the opinions are wide varied and often conflicting It has left me feeling unsure of what to do Could you comment on this a bit Dr Yu Well that is a long story Ch n Xi Yu n offered the critique that H Ji n and his followers would clear fire dispel wind and flush phlegm in their treatments but they did not understand the etiology of these things He also said I have taken a look at the works of Zh ng J ng Yu and his idea about primarily tonifying deficiency in these cases His method does not work Having sought the answers in the works of antiquity it seems that Zh ng J ng Yu s understanding of deficiency and excess is inflexible and dead Further he just does not thoroughly understand the workings of wind and fire However it should be noted that when treating dizziness Ch n Xi Yu n did not always do simultaneous root and branch treatment and the same could be said about Zh D n X Sometimes they would use just Rhei Radix et Rhizoma d hu ng in order to drain fire Sometimes they would use Cervi Cornu pantotrichum l r ng wine modified Restore the Left Kidney Drink z o gu y n Six Ingredient Pill with Rehmannia li w i d hu ng w n or Kidney Qi Pill sh n q w n in order to supplement the Kidney Sometimes they would use Tonify the Middle to Augment the Qi Decoction b zh ng y q t ng in order to supplement the Spleen Ch ng Zh ng L ng and Y Ti n Sh proposed the use of simultaneous root and branch treatments such as strengthening the Spleen and augmenting the qi in combination with transforming phlegm and descending counterflow or enriching the Liver and Kidney in combination with calming the Liver and anchoring yang While these seem like well considered

and excellent treatment methods I would say that these approaches may be insufficient to the task of effectively reducing the symptoms during an acute episode of dizziness In modern discussions of the treatment of dizziness there has been a tendency to emphasize the branch treatment For example using Inula and Haematite Decoction xu n f d i zh t ng for upward counterflow of Liver qi caused by phlegm congestion Another example is the use of Alismatis Decoction z xi t ng to treat prodding thin mucous Also some people propose the strategy of using Warm Gallbladder Decoction w n d n t ng for the acute phase of the illness and Two Aged Herb Decoction plus Ginseng and Astragalus sh n q r ch n t ng once the illness has abated These different strategies each demonstrate something worthwhile and should be considered Physician C Which method do you use Dr Yu Dr Yu Dr Ji ng s methodology differs somewhat from the the previously described methods In the acute phase he emphasized simultaneous root and branch treatment focusing on dispelling wind clearing fire dislodging phlegm and supplementing the Spleen After the dizziness has abated he would then slowly treat the root Physician A In the previous discussion around the deficiency root you mentioned both the Spleen and the Kidney However in the root branch treatment that you suggested there is only treatment of the Spleen not the Kidney Why is that Dr Yu In Dr Ji ng s opinion during the acute phase of dizziness the upward counterflow of phlegm and thin mucous is a very important aspect of the pathology Medicinals that supplement the Kidney would not only be relatively slow acting in this situation but they would also tend to impede progress due to their cloying nature thereby making it difficult to achieve a rapid resolution of the branch symptoms Thus it is best to wait for the dizziness to abate before supplementing the Kidney Dr Ji ng has told me about using a variety of formulas such as Six Ingredient Pill with Rehmannia li w i d hu ng w n Eight Ingredient Pill with Rehmannia b w i d hu ng w n Restore the Left Kidney Drink z o gu y n and Restore the Right Kidney Pill y u gu w n in an effort to resolve dizziness However the effects were minimal or even completely absent The problem was not with the formulas but with the timing of the usage Thus Dr Ji ng places the emphasis on the Spleen when treating the root in these cases But this must be done with some skill so as to emphasize improving the Spleen s transporting function and harmonizing the Stomach By improving the Spleen s transporting function one can transform phlegm and by harmonizing the Stomach one can arrest retching When the Spleen s

transporting function is working well it is better able to resist the Liver As a result the wanton movement of wind wood is reduced As wind wood is calmed ministerial fire becomes tranquil Once this has happened the branch manifestations of wind fire and phlegm quickly dissipate This method illustrates the principle of directly treating the root so as to indirectly treat the branch Physician A In the case the patient not only had dizziness for seventeen years but she also had lead poisoning Further her constitution seemed relatively weak Given that she had undergone Western and Chinese treatment without any relief this seems to qualify as stubborn dizziness Although your treatment was not extremely rapid it took 25 packs before she was cured the treatment and the formula were consistent from start to finish This outcome seems to me relatively good I understand that Dr Ji ng s formula Bupleurum Dried Tangerine Peel and Alismatis Decoction ch i ch n z xi t ng has been used on hundreds of patients and generally has an excellent clinical effect often resolving the dizziness within two four packs It seems that this method should be more widely known I would like to know the basic ingredients of the formula the typical dosage range the formula dynamics and the typical usage Dr Yu Bupleurum Dried Tangerine Peel and Alismatis Decoction ch i ch n z xi t ng is composed of Minor Bupleurum Decoction xi o ch i h t ng Two Aged Herb Decoction r ch n t ng Six Gentleman Decoction li j n z t ng and Alismatis Decoction z xi t ng To this base we add Gastrodiae Rhizoma ti n m Uncariae Ramulus cum Uncis g u t ng and Chrysanthemi Flos j hu Bupleuri Radix ch i h 10g Scutellariae Radix hu ng q n 6 10g Pinelliae Rhizoma preparatum zh b n xi 10g Codonopsis Radix d ng sh n 12 15g Glycyrrhizae Radix g n c o 3 5g Jujubae Fructus d z o 10 12g Zingiberis Rhizoma recens sh ng ji ng 6 10g Citri reticulatae Pericarpium ch n p 10g Poria f l ng 15g Atractylodis macrocephalae Rhizoma b i zh 10 15g Alismatis Rhizoma z xi 10 15g Gastrodiae Rhizoma ti n m 10g finely ground and taken as a draft Uncariae Ramulus cum Uncis g u t ng 12g added last Chrysanthemi Flos j hu 10g

Minor Bupleurum Decoction xi o ch i h t ng acts on the shao yang pivot mechanism to vent constrained fire to raise the clear and to cause the turbid to descend Two Aged Herb Decoction r ch n t ng transforms phlegm and resolves counterflow Alismatis Decoction z xi t ng flushes thin fluids and moves water Within the formula there is also Minor Pinellia plus Poria Decoction xi o b n xi ji f l ng t ng which resolves counterflow transforms phlegm flushes thin fluids and arrests retching It also contains Six Gentleman Decoction li j n z t ng which treats the root by improving the transporting function of the Spleen and harmonizing the Stomach Gastrodiae Rhizoma ti n m Uncariae Ramulus cum Uncis g u t ng and Chrysanthemi Flos j hu soften and lubricate in order to extinguish Liver wind According to the principle of treating different diseases with the same treatment we can expand the range of suitable conditions It can be used for dizziness from hypertension or from cerebral arterial insufficiency as long as it fits with the clinical presentation of true dizziness Recently I used this formula to treat dizziness associated with disease of the cervical vertebrae In these situations I removed Citri reticulatae Pericarpium ch n p Chrysanthemi Flos j hu Poria f l ng Glycyrrhizae Radix g n c o and Uncariae Ramulus cum Uncis g u t ng I added a large dose of Puerariae Radix g g n 30 60g which guides fluid up to the head and neck so as to soothe the sinews and to alleviate spasms I also added a large dose of Chuanxiong Rhizoma chu n xi ng 30 45g in order to invigorate blood to transform stasis to unblock the collaterals and to relieve pain I have used this strategy with more than ten patients and it seems quite effective END