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From the patient's main symptoms, one is nausea and vomiting, and the other is vertigo and headache. These two often occur simultaneously, which indicates that they are likely different symptoms caused by the same etiology. The vomitus consists of thin, white saliva/phlegm fluid (Xianmo) and feels cold, indicating that the pathology is excessive accumulation of turbid phlegm (Tan Zhuo) internally. Throughout the course of the disease, there are no signs of heat such as fever, thirst, restlessness, constipation, dark urine, or scorched tongue and mouth; instead, the four extremities are cold, the patient prefers warmth and fears cold, the condition alleviates with heat, and aggravates with cold. This sufficiently demonstrates that this syndrome is purely cold without heat. After each episode, the patient feels more exhausted and weak, with lazy and drooping limbs, which is clearly a manifestation of Spleen-Stomach Qi deficiency (Pi Wei Qi Xu). From the above analysis, it can be known that this syndrome involves both excessive internal turbid phlegm and deficiency-cold of the Spleen and Stomach. So, what is the relationship between these two? The ancients said, "The Spleen is the source of phlegm production." The reason why the Spleen can generate phlegm lies in the deficiency and decline of Spleen Yang. *Yi Lin Sheng Mo* states, "When flowing, it is body fluid; when accumulating, it is phlegm; when moving, it is dregs; when stopping, it is saliva." Saliva and phlegm fluid are both generated from the Qi of food and water in the human body. If the Yang Qi of the Zang-Fu organs (especially the Spleen and Kidney) is vigorous and circulation is unimpeded, then the essence of food and water will be fully utilized by the body, transforming into Jin-Ye (body fluids), blood, and essence; if the Yang Qi of the Zang-Fu organs is deficient and transformation is sluggish, then Yin fluids will stagnate and accumulate to form Yin (fluid retention), Tan (phlegm), Shui (water), and Xian (saliva). This patient has had chronic Spleen-Stomach deficiency-cold and weak Yang Qi. External exposure to cold may constrain the Yang Qi, consumption of raw/cold foods may further injure the Yang Qi, or emotional anger/depression may cause further stagnation of Spleen Qi. All these can lead to Yang Qi deficiency, failing to transform the essence of food and water, thereby generating phlegm and retaining fluids. Excessive internal phlegm-fluid obstructs the Qi mechanism of the Middle Jiao, resulting in chaotic reversal of Middle Jiao Qi. The so-called chaotic reversal of Middle Jiao Qi refers to the failure of Spleen Qi to ascend when it should, and the failure of Stomach Qi to descend when it should. When Stomach Qi fails to descend and rebels upward, symptoms such as epigastric/abdominal distension/fullness, nausea, and vomiting of saliva/phlegm arise; when Spleen Qi fails to ascend and sinks downward, diarrhea occurs. Moreover, the Spleen governs muscles and the four limbs. Now, due to Spleen-Stomach deficiency-cold, Yang Qi is insufficient to warm the four limbs, hence the coldness of the extremities; the insufficiency of food-water essence to nourish muscles leads to bodily and limb fatigue and lethargy. Phlegm-dampness obstructing the middle prevents Clear Yang Qi from ascending to the brain, causing the brain to lose nourishment. Additionally, turbid phlegm carrying Stomach Qi attacks upward, leading to vertigo and headache. This type of vertigo is called turbid phlegm vertigo or phlegm-fluid vertigo. This type of headache is called Phlegm-Jue Headache. If the headache is mainly located at the vertex, it is called Jueyin Headache, also known as Liver-Jue Headache or Jue Headache. It is believed that the mechanism of this headache arises from chronic Stomach Qi deficiency-cold, leading to Disharmony between Liver and Stomach, where Liver Qi carries cold-turbid Qi from the Stomach to rush up along the Jueyin Meridian. Since the Liver Meridian ascends from the lower abdomen, passes through the Stomach, connects to the Liver, links to the Gallbladder, and goes straight up to the vertex, Jueyin Headache presents with vertex pain, coldness of the four extremities, and vomiting of saliva/phlegm.

Doctor Yi asked the teacher to discuss the treatment for this syndrome.

Teacher: Through the previous analysis, we know that the key points of this syndrome lie in "deficiency" and "cold," and attention must also be paid to "phlegm." Therefore, in treatment, the primary goal is to resolve deficiency, cold, and phlegm. One should not merely see the symptoms manifesting as nausea, vomiting, vertigo, and headache, treating the head when seeing head issues and the feet when seeing foot issues ("Treat the root of the disease," "Subdue the master cause and address the origin first"). The deficiency-cold of this disease primarily resides in the Spleen and Stomach; thus, treatment focuses on resolving Spleen-Stomach deficiency-cold. Once Spleen-Stomach deficiency-cold is resolved, the Middle Jiao Qi mechanism returns to normal; descending Stomach Qi naturally stops rebellion/vomiting, and ascending Spleen Qi facilitates the transformation of phlegm-fluid. The prescription above is actually a combination of Wuzhuyu Tang (Evodia Decoction) and Banxia Tianma Baizhu Tang (Pinellia, Gastrodia, and Atractylodes Macrocephala Decoction). The intent is to combine warming and tonifying the Spleen-Stomach with resolving phlegm and extinguishing wind. This formula uses Renshen (Ginseng Radix), Baizhu (Atractylodis Macrocephalae Rhizoma), Fuling (Poria), and Gancao (Licorice Root) to strengthen the Spleen and benefit Qi. Wuzhuyu (Evodiae Fructus) and Shengjiang (Zingiberis Rhizoma Recens) are acrid-warm (hot) substances capable of warming the Stomach, dispersing cold, directing Qi downward, and descending turbidity. Chenpi (Citri Reticulatae Pericarpium), Banxia (Pinelliae Rhizoma), Fuling, Gancao, and Shengjiang in the formula constitute Erchen Tang (Two-Aged Decoction), which functions to dry dampness and resolve phlegm, regulate Qi and harmonize the Middle. Tianma (Gastrodiae Rhizoma) is used to extinguish internal wind and relieve vertigo. If we carefully categorize the herbs in the prescription, we will find it includes several commonly used formulas. Among them is the main formula for strengthening the Spleen and benefiting Qi, Sijunzi Tang (Four Gentlemen Decoction: Renshen, Baizhu, Fuling, Gancao); Yigong San (Extraordinary Efficacy Powder: Sijunzi Tang plus Chenpi), which strengthens the Spleen, benefits Qi, and harmonizes the Stomach; Liujunzi Tang (Six Gentlemen Decoction: Sijunzi Tang plus Chenpi and Banxia), which strengthens the Spleen, benefits Qi, stops vomiting, resolves phlegm, and is particularly effective for Spleen-Stomach Qi deficiency complicated by phlegm-dampness. There is also Xiaobanxia Tang (Minor Pinellia Decoction: Banxia, Shengjiang), good at descending Stomach Qi and stopping vomiting, and Xiaobanxia Ji Fuling Tang (Minor Pinellia Decoction plus Poria). Additionally, there is Erchen Tang (Two-Aged Decoction), the main formula for drying dampness and resolving phlegm mentioned earlier; Wuzhuyu Tang (Evodia Decoction), which warms the center, tonifies deficiency, directs rebellious Qi downward, and stops vomiting; and Banxia Tianma Baizhu Tang, which is adept at drying dampness, resolving phlegm, and extinguishing internal wind/vertigo. Overall, these formulas focus on tonifying Spleen deficiency, warming the center, dispersing cold, directing rebellious Qi downward, and resolving phlegm, which perfectly matches the deficiency, cold, and phlegm of this syndrome, thus achieving good results.

Doctor Bing carefully examined the prescription above and noticed that the dosages of Baizhu, Banxia, Shengjiang, and Tianma were relatively high. Could the teacher explain the reasons for this?

Teacher: It appears this doctor is very meticulous. The heavy use of these herbs in this prescription is intentional. Baizhu is used in heavy dosage because it is bitter, sweet, and warm, excelling at drying dampness, strengthening the Spleen, promoting diuresis, and resolving phlegm. Huang Gongxiu referred to it as the "number one herb for tonifying Qi in the Spleen organ" (*Bencao Qiuyi*). In all formulas that tonify Spleen Qi, eliminate phlegm and retain fluids, and promote diuresis and leach out dampness, it serves as the principal herb. Other Spleen-tonifying and Qi-benefiting herbs like Renshen, Fuling, and Gancao can be adjusted according to symptoms, but Baizhu is essential. Common clinical formulas for tonifying Spleen and benefiting Qi, such as Sijunzi Tang, Liujunzi Tang, Buzhong Yiqi Tang, and Guipi Tang, all utilize Baizhu. Even in various Spleen-strengthening, center-warming, phlegm-resolving, and diuretic formulas from *Shanghan Lun* and *Jingui Yaolue*, it acts as the pillar, such as Lizhong Tang, Linggui Zhugan Tang, Wuling San, Zhizhu Tang, and Baizhu Fuzi Tang. Since this syndrome belongs to Spleen-Stomach deficiency-cold with turbid phlegm obstruction in the middle, it is necessary to use Baizhu in heavy dosage. Banxia is acrid, warm, and drying; it excels at drying dampness and resolving phlegm, and is particularly skilled at descending Stomach Qi and stopping vomiting. Given the phlegm-dampness obstruction in the middle, nausea, and vomiting in this case, Banxia is indispensable. For this patient's Phlegm-Jue Headache, Banxia possesses special efficacy. Li Dongyuan stated, "For Phlegm-Jue Headache, only Banxia can treat it." Hence, it is used heavily in this syndrome. Shengjiang is used in heavy dosage for this patient because it excels at warming the middle and stopping vomiting. Paired with Renshen, Baizhu, and Gancao, it treats Middle Jiao deficiency-cold; paired with Banxia, it enhances phlegm removal and vomiting cessation. Xiaobanxia Tang in *Jingui Yaolue* treats various vomiting and inability to swallow grain, composed solely of Banxia and Shengjiang. Together, they synergistically increase the effects of warming the middle, opening the appetite, directing rebellious Qi downward, and stopping vomiting, while Shengjiang also effectively mitigates the toxicity of Banxia. Thus, benefits are increased, and drawbacks eliminated. Tianma is sweet, acrid, and neutral, serving as a wind-calming herb for the Qi aspect of the Liver. For dizziness, blurred vision, speech difficulties, and numbness of the body and limbs caused by phlegm-Qi stagnation in meridians or impaired Liver Qi dispersion, using this ascending, Yang-natured herb is appropriate. Li Dongyuan said, "For blackouts and spinning vertigo caused by internal wind deficiency, only Tianma can remove it." This refers to such situations. However, it must be clarified that if Liver Yin-blood is insufficient, Liver Yang is hyperactive, or Yin-blood deficiency fails to moisten leading to internal stirring of Liver Wind, Tianma should not be applied. *Bencao Qiuyi* calls it a "wind-calming herb for the Qi aspect of the Liver," which implies this meaning.

Constipation, abdominal fullness, chest tightness, dizziness

Professor Xiao Yonglin, Changchun University of Chinese Medicine

Xia Wenjing, Jilin Provincial People's Hospital

Patient Ding XX, female, 62 years old, visited in April 1983. The patient presented with constipation, abdominal fullness, chest tightness, and dizziness/blurred vision, with poor efficacy from long-term treatment, prompting her visit. Two years prior, she began experiencing dry and difficult bowel movements, initially occurring every two to three days, gradually progressing to once every five to six days, accompanied by frequent sensations of epigastric and abdominal distension and discomfort. Food intake decreased; slight increases led to worsened fullness, frequent belching, and occasional nausea and vomiting. Subsequently, she felt chest tightness, distending pain in both hypochondria, occasional inner heat/restlessness, and coarse, unsmooth breathing. She also felt gas frequently rushing from the lower abdomen to the chest and epigastrium. Over the past year, she developed dizziness, tinnitus, head distension, occasional facial flushing, irritability, bitter taste, and swollen tongue. Symptoms aggravated after anger or "internal fire." Examination revealed an obese body, robust constitution and Qi, red and enlarged tongue with thick white-yellow coating, puffy face and eyes, and a wiry and forceful pulse.

Inquiry into previous treatments: Due to dry stools, she had used Qingning Wan, Senna Leaf, Dulcolax, honey, etc., and also enemas. These medications induced bowel movements temporarily, but constipation returned afterward. Due to chest/epigastric stuffiness and abdominal bloating, she took Zikou Wan, Shugan Wan, Kuanxiong Shunqi Wan, Muxiang Shunqi Wan, Baohe Wan, etc., Qi-regulating and depression-relieving agents. These provided temporary relief in the chest and abdomen, but blooming persisted without medication. For dizziness and upper Jiao fire, she used Shangqing Wan, Qingxuan Wan, Longdan Xiegan Wan, etc. Fire was slightly cleared after medication, but returned upon cessation. She also took several doses of decoctions for regulating Qi, relieving depression, purging bowels, and clearing fire, with similar effects. Based on symptoms and medication history, the pathology was identified as Stomach Qi failing to descend, leading to unclear Lung Qi, Chong Mai Qi rebelling upward, Liver Qi stagnating and transforming into fire, and heat in the Upper Jiao. The method employed was descending Stomach Qi, calming the Chong Mai, clearing Metal (Lung), and soothing the Liver.

Prescription: Raw Daizheshi (Ostreae Concha) fine powder 30g, Raw Shanyao (Dioscoreae Rhizoma) 30g, Banxia (Pinelliae Rhizoma) 15g, Zhuru (Bambusae Folium) 10g, Xuanshen (Scrophulariae Radix) 20g, Baishao (Paeoniae Radix Alba) 20g, Cundong (Ophiopogonis Radix) 15g, Danggui (Angelicae Sinensis Radix) 15g, Niuxi (Achyranthis Bidentatae Radix) 15g, Sheng Maiya (Hordei Fructus Germinatus) 15g, Yichen (Artemisiae Scopariae Herba) 10g. Decocted in water, one dose daily, taken three times. After three doses, upward-rushing Qi decreased, bowel movements slightly improved, distension eased slightly, and dizziness/lightness of head improved. Added Bai Ren (Pruni Semen) 15g to the previous formula, and Daizheshi fine powder 5g taken orally each time, remaining ingredients decocted. After three more doses, bowel movements became smooth, once daily, abdominal fullness and chest tightness greatly improved, nausea and vomiting ceased, and the head felt clear. After another three doses, all symptoms resolved. Nao Li Qing was subsequently used for convalescence.

Doctor Jia asked the teacher to discuss the differentiation and reasoning for this syndrome.

Teacher: In clinical practice, patients frequently present with severe constipation, occurring every three to five days or seven to eight days, with dry and difficult passage, accompanied by abdominal fullness, chest/epigastric stuffiness, inner heat, frequent belching, vomiting, reduced appetite, distending pain in hypochondria, or coarse/unsmooth breathing, gradually developing dizziness, tinnitus, or head distending pain. This is not uncommon, especially among the elderly. Severe constipation treated with purgatives or moistening laxatives may provide temporary relief but worsens afterward. Chest/abdominal fullness, poor appetite, belching, and vomiting resemble Qi stagnation and food retention, but Qi-regulating and digestion-promoting agents provide only temporary relief, with symptoms returning after stopping medication. Dizziness, tinnitus, and bitter taste suggest Upper Jiao heat, but heat-clearing and fire-purging agents fail to sustain efficacy. Such cases should be considered as this syndrome. Constipation that does not sustain improvement after purgatives and moisteners indicates the pathology is neither Heat-Excess nor Intestinal Dryness. If it were Heat-Excess constipation, bitter-cold purgatives would clear heat as stool moves, preserving fluids and preventing recurrence. If it were Intestinal Dryness due to Yin deficiency, yin-nourishing and moistening agents would restore fluids and lubricate stools. However, in this case, initial improvement followed by ineffectiveness indicates the constipation is neither Heat-Excess nor Intestinal Dryness. Chest/abdominal fullness, hypochondriac discomfort, belching, and vomiting that remain stagnant despite Qi-regulating and digestion-promoting agents indicate the pathology is not Qi stagnation or food retention. Furthermore, there is no history of overeating; whether eating little or nothing, symptoms do not diminish. Dizziness, tinnitus, and bitter taste, if due to Upper Jiao heat, should clear with heat-purging agents, restoring clarity to the head and eyes. In this case, however, symptoms clear with medication but return afterward. Where is this heat so hard to eradicate? Why does it return so easily? Where is the heat hidden? All these stem from Stomach Qi failing to descend, causing excessive rising and insufficient descending of Qi in all Zang-Fu organs, gradually stagnating and transforming into fire. Therefore, heavy, descending substances are selected to descend Stomach Qi and restore its function. Then, all rebellious Qi descends smoothly, Zang-Fu Qi mechanisms gradually normalize, stools become naturally moist, and fullness/stuffiness disappear. As Qi descends, fire descends, and symptoms like dizziness, tinnitus, bitter taste, and chest restlessness resolve without cooling agents.

Doctor Yi asked the teacher to discuss the mechanism of Stomach Qi descending and the resulting symptoms.

Teacher: To clarify this, we must start with the Spleen and Stomach. The Spleen and Stomach are a Zang and Fu organ pair, Yin and Yang, opposing yet complementary, jointly responsible for receiving water and food, digesting and transforming, ascending clear and descending turbid, serving as the foundation of postnatal existence and the source of essence, fluids, Qi, and blood. The Spleen governs ascending clear Qi, primarily relying on Yang Qi; it prefers dryness and dislikes dampness, prefers warmth and dislikes cold. Thus, failure of Spleen Qi to ascend is mostly due to insufficient Yang Qi, leading to cold and dampness formation, preventing Clear Yang from ascending, causing essence of food/water to flow downward, resulting in diarrhea or loose stools, fatigue, shortness of breath, and heavy/weak limbs. The Stomach governs descending turbid Qi, primarily utilizing Yin fluids; it prefers moisture and dislikes dryness, prefers coolness and dislikes heat. Thus, failure of Stomach Qi to descend is mostly due to insufficient Yin fluids leading to heat and dryness formation, preventing turbid Yin from descending, causing waste to fail to move downward, resulting in constipation, fullness, belching, vomiting, and poor appetite. Many factors cause Stomach Qi failure to descend: congenital predisposition, leading to lifelong constipation habits; dietary factors, such as excessive spicy food injuring Yin and generating fire, or overly refined food lacking vegetables and roughage; emotional factors, such as irritability and anger causing Liver/Gallbladder fire to rise excessively, impeding Stomach Qi descent; Lung Qi failing to descend and rebelling upward, affecting Stomach Qi descent; and advanced age with Kidney Yin deficiency, a common scenario.

The Classics state, "At forty, Yin Qi naturally halves, and daily activities decline." Particularly, insufficient Kidney Yin weakens the power of convergence and retention. This causes Qi of the Chong Mai to rush upward, subsequently leading to Stomach Qi failure to descend. The Chong Mai originates in the uterus and runs alongside the Foot-Shaoyin Kidney Meridian, flanking the navel upward. If Kidney Yin deficiency weakens retention power, Chong Qi easily rebels upward. Chronic upward rebellion of Chong Qi can cause Yangming Qi to rebel upward. Because the Chong Mai emerges from the体表 at the Qichuan point of the Foot-Yangming Meridian and runs alongside the Yangming meridian. Conversely, Stomach Qi failure to descend can also cause Chong Qi rebellion. The patient's sensation of gas rushing from the lower abdomen is a sign of Chong Qi rebellion. Human Qi mechanism involves both ascending and descending. Generally, Liver and Spleen Qi should ascend, while Lung and Stomach Qi should descend. Continuous ascending and descending allow Qi to circulate, harmonizing Zang-Fu Qi and ensuring health. If various causes lead to Stomach Qi failure to descend, initial episodes may resolve, but if untreated, they recur frequently. Over time, this becomes a chronic Stomach Qi failure to descend syndrome. Failure of Stomach Qi to descend hinders downward transmission, causing Large Intestine Qi to stagnate, resulting in constipation. Qi stagnation in the intestines and stomach accumulates in the middle, presenting as stuffiness and fullness. Since downward flow is blocked, Qi must reverse upward, causing poor appetite, belching, and vomiting. Stomach Qi failure to descend affects Lung Qi descent, causing chest tightness, breathing difficulty, or chest restlessness. Failure of Lung and Stomach Qi to descend impedes Liver dispersion, causing stagnation. Moreover, excess Qi transforms into fire, leading to dizziness, distending pain, vertigo, tinnitus, and bitter taste. Qi rebellion can also cause blood to follow Qi upward, leading to hematemesis or epistaxis. Thus, the causes of Stomach Qi failure to descend are manifold. The consequences are not limited to gastrointestinal lesions but involve dysfunction of Qi ascending/descending in all Zang-Fu organs, characterized by excessive rising and insufficient descending.

Doctor Jia asked the teacher to discuss the treatment principles for this syndrome.

Teacher: As mentioned earlier, Stomach Qi failure to descend is caused by multiple factors and can lead to Zang-Fu Qi disharmony, with excessive rising and insufficient descending. Therefore, in treating this syndrome, one must grasp the key, focusing on descending Stomach Qi, while appropriately considering the etiology and consequences, supplementing with corresponding treatments. From the patient's previous medication, it can be seen that if...