经义
徇蒙招尤，目瞑耳聋，下实上虚，过在足少阳、厥阴，甚则入肝。○木郁之发，甚则耳鸣眩转，目不识人，
善暴僵仆。（《素问》）
上气不足，脑为之不满，耳为之苦鸣，头为之苦倾，目为之眩。（《灵枢》）
哲言
眩者，言视物皆黑；晕者，言视物皆转。二者兼有，方曰眩晕。若甚而良久方醒者，又名郁冒，谓如以
物冒其首也。（《证治汇补》）
眩晕之证，《内经》虽云皆属于肝风上攻，然体虚之人，外感六淫，内伤七情，皆能眩晕，当以脉证别
之。风则脉浮有汗，项强不仁；寒则脉紧无汗，筋挛掣痛；暑则脉虚烦闷；湿则脉沉吐逆。及其七情所伤，遂
使脏气不平，郁而生涎，结而为饮，随气上逆，令人眩晕，眉棱骨痛，眼不可开，寸脉多沉，此
为异耳。若疲劳过度，吐衄便利，妇人崩伤产后，去血过多，皆令人眩晕，当随其因治之。（严用和）
眩晕之病，悉属肝胆风火。风火属阳，阳主动，故目眩而头晕也。譬如火焰得风，则旋转不已。○有肾阴
不足，三阳之焰震耀于当前，故阴虚之人常若眩晕。目中忽见火如星炮，胸隔必多痰，晕时眼不能开，开则所
见之物非斜即倒。○有中土虚衰，下逆之光上浮巅顶，发则眩仆呕吐，而五心烦热。（《己任编》）
肥白人湿痰滞于上，阴火起于下，痰挟虚火，上冲头目，邪正相煽，故忽然眼黑生花，所谓无痰不作眩也。
○黑瘦人肾水虚少，肝枯木动，复挟相火上踞高巅而作眩晕，所谓风胜则地动，火得风而焰旋也。（朱丹溪）
头痛之病，上实证也；头眩之病，上虚证也。《内经》分别甚明，曰头痛巅疾，下虚上实；又曰上实下虚，
为厥巅疾。此以邪气在上，所以为痛，故曰上实也。至若眩晕之病，则曰上气不足，又曰上虚则眩，未闻言上
之实也。而后世诸家，有曰结而为饮，随气上逆者；有曰疲劳过度，下虚上实者；有曰肾不纳气，使诸气逆奔
而上者。即如丹溪亦曰痰在上，火在下。凡此皆言上实也。何与《内经》相反若此？噫！此后人之不明耳。夫
眩晕之证，或为头重眼黑，或为脑髓旋转，不可以动。求其言实之由，不过谓头重者为上实。不知头本不重于
往日，而惟不胜其重者，乃甚于往日耳。上力不胜，阳之虚也，岂上实乎？又何气不归元及诸气逆奔之有？盖
上实者宜降宜抑，上虚者最不宜再伐生气。此上实上虚之旨，不可不辨。○头眩有大小之异，察之可得虚实之情。
如今人之气禀薄弱者，无论少壮，或于劳倦酒色之后，每有耳鸣如磬，或头眩眼黑，倏顷而止者，乃常有之事。
至于中年之外，多见眩仆卒倒等证，亦常有之事。但忽晕忽止者，人皆谓之头晕眼花；卒倒而不醒者，人必谓
之中风中痰，不知忽止者，
以其气血未败，故旋见而旋止，即小中风也；卒倒而甚者，以其根本既亏，故遽病而难复，即大眩晕也。且必
见于中年之外，而较之少壮益又可知。于此察之，则是风非风，是痰非痰，而虚实从可悟矣。（张景岳）
补编
心下有痰饮，胸胁支满，目眩，苓桂术甘汤主之。○心下有支饮，其人苦眩冒，泽泻汤主之。（《金匮》）
眩晕一证，人皆称为上盛下虚，而不明言其所以然之故。盖所谓虚者，血与气也；所谓实者，痰涎风火也。
原病之由，有气虚者，乃清气不升，或汗多亡阳所致，当升补阳气；有血虚者，乃亡血过多，阳无所附而然，
当益阴补血。此皆不足之证也。有因痰涎郁遏者，宜导痰开郁，重则吐下；有因风火摇动者，宜清上降火。此
皆有余之证也。世有谓气不归元，而用丹药镇坠，沉香降气，盖香窜散气，丹药助火，其不归之气岂能因此而
复耶？《经》谓治病求本，气之不归，求本用药则善矣。（刘宗浓）
丹溪论眩晕曰∶无痰不作眩，虽有风者，亦必有痰挟气，虚者亦宜治痰为主。若据此论，则凡眩晕无非痰
证也。何轩岐之言，绝不及痰，故在丹溪则曰无痰不作眩，当以治痰为主。余则曰∶无虚不作眩，当以治虚为
主。（张景岳）
眩晕一证，有虚晕、火晕、痰晕之不同，治失其要，鲜不误人。曷言乎虚晕也？如纵欲脱血，痈溃产后，
老年精衰诸伤阴者，其证面赤口干，烦躁不寐，便秘溺赤，其脉弦细而数，或弦大而数，无非精血受亏，阴虚
为病。盖蒂固则真水闭藏，根摇则上虚眩仆，此阴虚之晕也。如劳倦费神，吐泻汗多，悲哀痛楚诸伤阳者，其
证面青神倦，畏寒厥冷，身面浮气，其脉沉细而迟，或浮大而空，无非元阳被耗，气虚为病。盖禀浓则真火归
藏，脏亏则气逆上奔，此阳虚之晕也。治阴虚者，用归芍六味汤加人参之类，壮水之主，以生精血；治阳虚者，
用八味养血汤加人参之
类，益火之原，以生元气，所谓滋苗者必灌其根也。曷言乎火晕也？如房劳则火起于肾，暴怒则火起于肝，思
虑则火起于脾。其证耳鸣目黑，上重下轻，眩仆卒倒，脉象细弱，无非动作烦扰，虚阳不藏。盖火藏则清明内
持，动扰则掉摇散乱，此虚火之晕也。若实火眩晕者，人必强健，证必暴发，渴必引饮，脉必洪数，呕吐酸苦
晕稍定，饮食寒凉晕稍缓，便解燥结晕稍止，无非风火相搏，实火为害。盖有余则上盛而火炎，壅塞则火炽而
旋转，此实火之晕也。治虚火者，用六味、逍遥之属，滋阴以制火，舒肝以养脾；治实火者，宜三黄、竹叶、
石膏之属，清降以抑火，辛凉以泻热，所谓虚火可补，实火可泻也。曷言乎痰晕也？如水沸水泛，则痰起于肾；
风火生涎，则痰起于肝；湿饮不行，则痰起于脾。其证头重眼花，脑转眩冒，倦怠嗜卧，食饮不甘，脉象缓滑，
无非疲劳过度，虚痰为虐。盖清升则浊阴下走，气滞则津液不行，此虚痰之晕也。若实痰眩晕者，脉证必实，
积热在阳明，阻塞在经络，郁遏在肠间，无非风火结聚，积痰生灾。盖液凝则浊阴泛上，饮停则火逆上升，此
实痰之晕也。治虚痰者，宜六味、八味、归脾之属，补肾之原以治痰之本；治实痰者，宜二陈、芩、连、滚痰
丸之属，冷肠胃之热以治痰之标。大抵虚晕者十之六、七，兼痰火者十之二、三。且今人气禀薄弱，酒色不谨，
肝肾亏而内伤剧，以致眩晕大作。望其容则精神昏倦也，闻其声则语言低微也，察其证则自汗喘促也，切其脉
则悬悬如丝也。当此之时，须执定见，毋惑多岐，参、 、归、术，重剂多进，庶可转危为安。倘病家畏补而
生疑，医家见补而妄驳，旁人因补而物议，以虚证为实火，以参、 为砒毒，卒中之变至，危脱之象见，虽有
智者，无如何矣！（《会心录》）
戴复庵云∶有眩晕之甚，抬头则屋转，眼生黑花，常见有物飞动，或见一物为两，宜《秘旨》正元散，
加鹿茸，兼进养正丹。不效，一味鹿茸，每服半两，酒煎去滓，入麝香少许。缘鹿
茸生于头，头晕而主以鹿茸，从其类也。此为虚寒也。丹溪云∶眩晕不可当者，大黄酒炒为末，茶调下，每服
一、二钱。此为实热也。（张路玉）
《经》云∶诸风掉眩，皆属于肝。头为六阳之首，耳目口鼻，皆系清空之窍，所患眩晕者，非外来之邪，
乃肝胆之风阳上冒耳，甚则有昏厥跌仆之虞。其证有夹痰夹火、中虚下虚、治胆治胃治肝之分。火盛者，用羚
羊、山栀、连翘、花粉、元参、生地、丹皮、桑叶，以清泄上焦窍络之热，此先从胆治也。痰多者，必理阳明，
消痰如竹沥、姜汁、菖蒲、二陈汤之类。中虚则兼用人参、《外台》茯苓饮是也。下虚者必从肝治，补肾滋肝，
育阴潜阳镇摄。至于天麻、钩藤、菊花之属，皆系熄风之品，可随证加入。此证原本肝风，当与肝风、中风、
头风门合而参之。（《临证指南》）
脉候
浮而散者为眩仆。○春脉太过，则令人善怒，忽忽眩冒而巅疾。（《素问》）
肝脉溢大主眩。若风浮寒紧，湿细暑虚，痰弦而滑，瘀芤而涩，数大火邪，濡大虚极。（《证治汇补》）
选案
刘允功，形体魁伟，不慎酒色，偶因劳怒，头晕仆地，痰涎上涌，手足麻痹，口干引饮，六脉洪数而虚。
余以为肾经亏损，不能纳气归原而为晕，不能摄水归原而为痰，阳气内虚而麻痹，虚火上炎而作渴，用补中益
气汤合六味丸治愈。（薛立斋）
吴添官母，时多暴怒，经行复止，气逆上厥，如畏舟船，动则晕去，久卧于床，时若天翻地覆，大热引饮，
脑如刀劈，食少泻多。余以怒甚则血菀于上，而气不返于下者，名曰厥巅疾。厥者，逆也。巅者，高也。气与
血俱逆于高巅，故动辄眩晕也。又以上盛下虚者，过在少阳，少阳者，胆也，胆之穴络于脑，郁怒
之火，上攻于脑，得补而炽，其痛如劈。同为厥巅之疾，风火相煽，故振摇而热蒸；木土相凌，故艰食而多泻。
于是会《内经》铁落镇坠之意，以代赭、龙胆、芦荟、黄连降其上逆之气，以蜀漆、丹皮、赤芍行其上菀之血，
以牡蛎、龙骨、五味敛其浮游之神。最要在每剂药中生入猪胆汁二枚，盖以少阳热炽，胆汁必干，亟以同类之
物济之，资其持危扶颠之用。连进十数剂，服猪胆二十余枚，热退身凉，食加泻止，始能行步。尚觉身轻不支，
减去猪胆、芦、龙，加入参、归、姜、枣，平调而愈。（《寓意草》）
一人常头目眩晕，步履不稳，寸脉豁大，关脉多滑。医谓老年体虚，用补。余曰∶脉大无力，固虽属虚，
然滑则多痰，徒补而不消痰，则眩晕不去，步履何由而健？必须补中兼消。方用六君汤，加菊花、川芎、酒炒
黄芩，与服十剂，证觉减轻。再加归、芍，配合丸药。熟地泥膈，肉桂助火，皆非所宜。（程星海）
【经义】
身体侧倾、视物昏蒙并伴有头摇目眩，眼睛闭合、耳朵听不见，这是下部邪气盛而上部正气虚，病位在足少阳胆经和足厥阴肝经，严重时病邪会传入肝脏。○当木气郁结发作时，严重时会出现耳鸣、头晕目眩，眼睛看不清人，容易突然僵硬跌倒。（《素问》）
上部清气不足，脑部就会感觉空虚不满，耳朵会痛苦地鸣响，头部会因无力而倾斜，眼睛会感到眩晕。（《灵枢》）
【哲言】
“眩”是指看东西都是黑的；“晕”是指看东西都在旋转。两者同时存在，才称为眩晕。如果病情严重，很久才能清醒，又叫做“郁冒”，意思是好像有东西蒙住了头一样。（《证治汇补》）
关于眩晕的病症，《内经》虽然都说属于肝风上攻，但是体质虚弱的人，外感六淫（风、寒、暑、湿、燥、火），内伤七情（喜、怒、忧、思、悲、恐、惊），都能导致眩晕，应当通过脉象和症状来辨别。如果是风邪所致，脉象浮且有汗，项背强直麻木；如果是寒邪所致，脉象紧且无汗，筋脉拘挛牵引疼痛；如果是暑邪所致，脉象虚且烦闷；如果是湿邪所致，脉象沉且呕吐逆气。至于七情所伤，使得脏腑之气不平，郁结而生痰涎，凝结成饮，随着气机上逆，令人眩晕，眉棱骨痛，眼睛无法睁开，寸脉多沉，这是不同的情况。如果是过度疲劳，吐血、鼻出血或大小便失血，妇女崩漏或产后失血过多，都会导致眩晕，应当根据病因进行治疗。（严用和）
眩晕的病，都属于肝胆的风火。风火属阳，阳主动，所以眼睛眩晕而头脑发晕。就像火焰遇到风，就会不停旋转。○如果有肾阴不足，三阳经的火势震动照耀在眼前，所以阴虚的人常常感到眩晕。眼中忽然看见如火星般的闪光，胸膈间一定多有痰，眩晕时眼睛不能睁开，一睁开所见之物不是斜的就是倒的。○如果中焦脾胃虚弱衰败，下部的浊气上浮至头顶，发作时眩晕仆倒、呕吐，并且五心烦热。（《己任编》）
肥胖白胖的人，湿痰停滞在上部，阴火起于下部，痰挟带虚火，上冲头目，邪正相互煽动，所以忽然眼前发黑生花，这就是所说的“无痰不作眩”。○黑瘦的人肾水亏虚，肝木枯槁而动，又挟带相火上踞于高巅而引发眩晕，这就是所说的“风胜则地动，火得风而焰旋”。（朱丹溪）
头痛的病，是上实证；头眩的病，是上虚证。《内经》区分得很清楚，说头痛巅疾，是下虚上实；又说上实下虚，会导致厥逆的巅顶疾病。这是因为邪气在上，所以为痛，因此叫上实。至于眩晕的病，则说上气不足，又说上虚则眩，没有说过上实的。而后世各家，有的说是凝结成饮，随气上逆；有的说是疲劳过度，下虚上实；有的说是肾不纳气，使诸气逆奔而上。即使像丹溪也说痰在上，火在下。凡此种种都是说上实。为什么与《内经》相反到这种地步？唉！这是后人不明理罢了。眩晕的病症，有的是头重眼黑，有的是脑髓旋转，不能活动。探求其说“实”的原因，不过是认为头重就是上实。不知道头本来并不比往日重，只是不胜其重，乃是因为比往日更甚。上部力量不胜任，是阳气之虚，难道是上实吗？又有什么气不归元及诸气逆奔的说法呢？大概上实者宜降宜抑，上虚者最不宜再伐伤生气。这上实上虚的宗旨，不可不辨明。○头眩有大有小之分，观察可以得知虚实的情况。如今人气禀薄弱的人，无论老少，或在劳累疲倦、饮酒色欲之后，常有耳鸣如敲磬，或头眩眼黑，片刻即止的情况，这是常有的事。到了中年以后，多见眩晕仆倒猝然昏倒等证，也是常有的事。但忽晕忽止的，人们都叫头晕眼花；猝然倒下而不醒的，人们必认为是中风中痰。不知道忽止的，是因为气血未败，所以随即出现随即停止，就是小中风；猝倒严重的，是因为根本已亏，所以突然发病难以恢复，就是大眩晕。而且必定见于中年以后，比起青壮年更加可知。在此观察，那么就不是风，不是痰，虚实就可以悟出了。（张景岳）
【补编】
心下有痰饮，胸胁支撑胀满，眼睛眩晕，用苓桂术甘汤主治。○心下有支饮，病人苦于眩晕昏冒，用泽泻汤主治。（《金匮要略》）
眩晕这一证候，人们都称为上盛下虚，但不明白说明其中的原因。所谓虚，指血和气；所谓实，指痰涎风火。推究病因，有气虚的，是清气不升，或因汗多亡阳所致，应当升补阳气；有血虚的，是因失血过多，阳气无所依附而然，应当益阴补血。这些都是不足的证候。有因痰涎郁遏的，宜导痰开郁，重的用吐法或下法；有因风火摇动的，宜清上降火。这些都是有余的证候。世间有人说是气不归元，而用丹药镇坠，沉香降气，殊不知香窜散气，丹药助火，那不归的气怎么能因此恢复呢？《内经》说治病求本，气不归元，寻求根本用药那就好了。（刘宗浓）
丹溪论述眩晕说：无痰不作眩，虽然有风，也必有痰挟气，虚者也宜以治痰为主。如果依据这个理论，那么凡是眩晕无非是痰证了。为什么岐伯的话，绝口不提痰，所以在丹溪那里说无痰不作眩，应当以治痰为主。我却说：无虚不作眩，应当以治虚为主。（张景岳）
眩晕一证，有虚晕、火晕、痰晕的不同，治疗失去关键，很少不误人的。什么是虚晕呢？如纵欲脱血，痈疽溃破产后，老年精衰等各种伤阴的情况，其症状面赤口干，烦躁失眠，便秘尿赤，脉象弦细而数，或弦大而数，无非是精血亏损，阴虚致病。根基稳固则真水闭藏，根基动摇则上部虚而眩晕仆倒，这是阴虚之晕。如劳倦费神，吐泻汗多，悲哀痛楚等各种伤阳的情况，其症状面青神疲，畏寒肢冷，身面浮肿，脉象沉细而迟，或浮大而空，无非是元阳被耗，气虚致病。禀赋浓厚则真火归藏，脏腑亏虚则气逆上奔，这是阳虚之晕。治疗阴虚者，用归芍六味汤加人参之类，壮水之主，以生精血；治疗阳虚者，用八味养血汤加人参之类，益火之原，以生元气，这就是所谓的滋润苗条必须灌溉树根。什么是火晕呢？如房劳则火起于肾，暴怒则火起于肝，思虑则火起于脾。其症状耳鸣目黑，上重下轻，眩晕仆倒猝然昏倒，脉象细弱，无非是动作烦扰，虚阳不藏。火藏则清明内持，动扰则掉摇散乱，这是虚火之晕。如果是实火眩晕，人一定强健，证候一定暴发，口渴必引饮，脉象洪数，呕吐酸苦后晕稍定，饮食寒凉后晕稍缓，大便解燥结后晕稍止，无非是风火相搏，实火为害。有余则上盛而火炎，壅塞则火炽而旋转，这是实火之晕。治疗虚火者，用六味、逍遥之类，滋阴以制火，舒肝以养脾；治疗实火者，宜三黄、竹叶、石膏之类，清降以抑火，辛凉以泻热，这就是所谓虚火可补，实火可泻。什么是痰晕呢？如水沸水泛，则痰起于肾；风火生涎，则痰起于肝；湿饮不行，则痰起于脾。其症状头重眼花，脑转眩晕昏冒，倦怠嗜卧，饮食不甘，脉象缓滑，无非是疲劳过度，虚痰为虐。清升则浊阴下走，气滞则津液不行，这是虚痰之晕。如果是实痰眩晕，脉证一定实，积热在阳明，阻塞在经络，郁遏在肠间，无非是风火结聚，积痰生灾。液凝则浊阴泛上，饮停则火逆上升，这是实痰之晕。治疗虚痰者，宜六味、八味、归脾之类，补肾之原以治痰之本；治疗实痰者，宜二陈、芩、连、滚痰丸之类，冷肠胃之热以治痰之标。大抵虚晕占十分之六七，兼痰火的占十分之二三。况且今人气禀薄弱，酒色不谨，肝肾亏而内伤剧烈，以致眩晕大作。看他的容貌则是精神昏倦，听他的声音则是语言低微，察他的证候则是自汗喘促，切他的脉则是悬悬如丝。在这个时候，必须坚持主见，不被多种歧途迷惑，人参、黄芪、当归、白术，重剂多用，才可以转危为安。如果病家害怕进补而产生怀疑，医家见到进补而妄加驳斥，旁人因为进补而议论纷纷，把虚证当作实火，把人参当作砒霜毒药，猝中的变故发生，危脱的现象出现，即使是智者，也无能为力了！（《会心录》）
戴复庵说：有眩晕非常严重的，抬头则房屋旋转，眼生黑花，常见有物体飞动，或看见一个物体变成两个，宜用《秘旨》的正元散，加鹿茸，同时服用养正丹。如果不效，单用一味鹿茸，每次服用半两，酒煎去渣，加入少许麝香。因为鹿茸生于头部，头晕而主治用鹿茸，是取其同类相从的道理。这是虚寒证。丹溪说：眩晕不可忍受的，用大黄酒炒为末，茶调服，每次一、二钱。这是实热证。（张路玉）
《内经》说：各种风病引起的震颤眩晕，都归属于肝。头为六阳之首，耳目口鼻，都是清空之窍，所患眩晕，不是外来的邪气，而是肝胆之风阳上冒罢了，严重时甚至有昏厥跌仆的危险。其证候有夹痰夹火、中虚下虚、治胆治胃治肝的区别。火盛的，用羚羊角、山栀、连翘、花粉、元参、生地、丹皮、桑叶，以清泄上焦窍络之热，这是先从胆治。痰多的，必须调理阳明，消痰如竹沥、姜汁、菖蒲、二陈汤之类。中虚则兼用人参、《外台》茯苓饮。下虚者必须从肝治，补肾滋肝，育阴潜阳镇摄。至于天麻、钩藤、菊花之类，都是熄风的药物，可根据证候加入。此证原本源于肝风，应当与肝风、中风、头风门合参。（《临证指南医案》）
【脉候】
脉浮而散的，是眩晕仆倒。○春脉太过，则使人易怒，恍惚眩晕昏冒而致巅顶疾病。（《素问》）
肝脉溢大主眩晕。如果是风浮寒紧，湿细暑虚，痰弦而滑，瘀芤而涩，数大火邪，濡大虚极。（《证治汇补》）
【选案】
刘允功，形体魁伟，不慎酒色，偶然因为劳累愤怒，头晕仆倒在地，痰涎上涌，手足麻痹，口干想喝水，六脉洪数而虚。我认为这是肾经亏损，不能纳气归原而导致眩晕，不能摄水归原而导致痰，阳气内虚而麻痹，虚火上炎而作渴，用补中益气汤合六味丸治愈。（薛立斋）
吴添官的母亲，时常暴怒，月经行后又停止，气逆上厥，像害怕坐船一样，一动就晕过去，长期卧床，时常觉得天翻地覆，大热想喝水，头脑像刀劈一样痛，食少泻多。我认为大怒则血郁于上，而气不返于下，名叫厥巅疾。厥，就是逆。巅，就是高。气与血都逆于高巅，所以动辄眩晕。又因为是上盛下虚，病在少阳，少阳就是胆，胆的穴位络于脑，郁怒之火，上攻于脑，得到补益反而火势更炽，其痛如刀劈。同为厥巅之疾，风火相煽，所以振摇而热蒸；木土相凌，所以进食艰难而多泻。于是领会《内经》铁落镇坠的意思，用代赭石、龙胆草、芦荟、黄连降其上逆之气，用蜀漆、丹皮、赤芍行其上郁之血，用牡蛎、龙骨、五味子敛其浮游之神。最关键的是每剂药中生入猪胆汁两枚，因为少阳热炽，胆汁必干，急需以同类之物济助它，资其持危扶颠的作用。连续服用十数剂，吃猪胆二十余枚，热退身凉，食欲增加腹泻停止，才能行走。还觉得身体轻飘支撑不住，减去猪胆、芦荟、代赭石，加入人参、当归、生姜、大枣，平调而愈。（《寓意草》）
一个人经常头目眩晕，步履不稳，寸脉豁大，关脉多滑。医生说是老年体虚，用补法。我说：脉大无力，固然属于虚，但滑则多痰，单纯补而不消痰，则眩晕不去，步履怎能健壮？必须补中兼消。方用六君汤，加菊花、川芎、酒炒黄芩，服用十剂，证候减轻。再加当归、白芍，配合做成丸药。熟地黄滋腻碍胃，肉桂助火，都不适宜。（程星海）
[Scriptural Meaning]
Lateral leaning, visual obscuration accompanied by head shaking and vertigo, closed eyes, and deafness indicate excess in the lower part and deficiency in the upper part. The pathology lies in the Foot Shaoyang Gallbladder Meridian and Foot Jueyin Liver Meridian; if severe, the pathogen enters the Liver. ○ When Wood Qi stagnates and erupts, it may severely cause tinnitus, vertigo, inability to recognize people, and sudden stiffness or falls. (Su Wen)
Deficiency of Upper Qi leads to a feeling of emptiness in the brain, painful ringing in the ears, tilting of the head due to weakness, and dizziness in the eyes. (Ling Shu)
[Philosophical Discourse]
"Xuan" (vertigo/darkness) refers to seeing everything as black; "Yun" (dizziness/rotation) refers to seeing everything as rotating. When both occur together, it is termed Xuan-Yun (vertigo). If severe and lasting long before recovery, it is also called Yu-Mao (depression and fullness), meaning as if something were covering the head. (Zheng Zhi Hui Bu)
Regarding vertigo, although Nei Jing states it all belongs to Liver Wind attacking upwards, individuals with weak constitutions can develop vertigo from external contraction of the Six Excesses (Wind, Cold, Summer-heat, Dampness, Dryness, Fire) or internal injury from the Seven Emotions (Joy, Anger, Worry, Pensiveness, Sadness, Fear, Fright). Differentiation should be based on pulse and symptoms. For Wind, the pulse is floating with sweating, and the neck is stiff and insensible; for Cold, the pulse is tight without sweating, and tendons spasm with pulling pain; for Summer-heat, the pulse is deficient with vexation and stuffiness; for Dampness, the pulse is deep with vomiting and reflux. Regarding injuries from the Seven Emotions, they cause imbalance of Zang-Fu Qi, leading to stagnation and generation of phlegm-fluids, which condense into drinking-water retention. Following rebellious Qi upward, this causes vertigo, pain in the supraorbital ridge, inability to open the eyes, and a typically deep Cun pulse. This is a distinct variation. Over-fatigue, hematemesis, epistaxis, or abnormal bowel/bladder bleeding, as well as excessive blood loss from uterine bleeding or postpartum conditions in women, all cause vertigo. Treatment must follow the specific etiology. (Yan Yonghe)
Vertigo diseases all belong to Wind-Fire of the Liver and Gallbladder. Wind and Fire are Yang; Yang is active, hence eye vertigo and head dizziness. It is like a flame encountering wind, rotating endlessly. ○ In cases of Kidney Yin deficiency, the flames of the Three Yang meridians blaze before the eyes, so those with Yin deficiency often feel dizzy. Sudden vision of sparks like fireworks indicates much phlegm in the chest and diaphragm; during vertigo, eyes cannot open, and upon opening, objects appear slanted or inverted. ○ In cases of Middle Earth (Spleen/Stomach) deficiency and decline, turbid Qi from below floats up to the vertex, causing vertigo, collapse, vomiting, and five-palm heat upon onset. (Ji Ren Bian)
In fat, pale individuals, damp-phlegm stagnates in the upper part, while Yin fire arises from below. Phlegm carries deficient fire upward to the head and eyes, where evil and righteous Qi fan each other, causing sudden blackouts and visual spots—this is what is meant by "No phlegm, no vertigo." ○ In thin, dark-skinned individuals, Kidney Water is deficient, Liver Wood becomes dry and moves, carrying Ministerial Fire to occupy the high vertex and cause vertigo—this is what is meant by "When wind prevails, the earth shakes; when fire meets wind, the flame rotates." (Zhu Danxi)
Headache is an Excess syndrome of the upper part; head vertigo is a Deficiency syndrome of the upper part. Nei Jing distinguishes them clearly: headache at the vertex involves deficiency below and excess above; conversely, excess above and deficiency below leads to Jue (rebellious flow) diseases of the vertex. Pain occurs because pathogenic factors are in the upper part, hence "Excess Above." Vertigo, however, is described as deficiency of Upper Qi or "Deficiency Above causes vertigo," never mentioning Excess Above. Later scholars claim phlegm-fluids condense and rise with rebellious Qi; over-fatigue causes deficiency below and excess above; Kidney failing to grasp Qi causes all Qi to rush upward. Even Danxi stated phlegm is above, fire is below. All these describe Excess Above. Why does this contradict Nei Jing so greatly? Alas, this is due to later generations' lack of clarity. Vertigo manifests as heavy head and black eyes, or rotating brain marrow unable to move. Seeking reasons for "Excess," one might argue a heavy head implies Excess Above. But the head is not inherently heavier than usual; rather, the inability to bear its weight signifies worsening beyond normal. Inability of the Upper part to bear strength indicates Yang deficiency, not Excess Above. What then of Qi failing to return to its root or rebellious Qi rushing up? Generally, Excess Above requires descending and suppressing; Deficiency Above must not have its vital Qi further depleted. The distinction between Excess and Deficiency Above is crucial. ○ Head vertigo varies in severity; observation reveals true deficiency or excess. In modern times, those with weak constitutions, regardless of age, after labor, fatigue, alcohol, or sexual indulgence, often experience tinnitus like striking a chime, or brief vertigo and blackouts, which cease quickly. This is common. After middle age, sudden falls and fainting due to vertigo are also common. However, transient vertigo is called "dizzy head and blurred vision"; sudden collapse without consciousness is called "stroke or phlegm obstruction." Transient episodes cease because Qi and Blood are not yet exhausted, appearing and disappearing quickly—this is minor stroke. Severe sudden collapse occurs because the root is depleted, making sudden illness hard to recover from—this is major vertigo. This appears mostly after middle age, more evident than in youth. Observing this, one realizes it is neither Wind nor Phlegm, allowing understanding of deficiency and excess. (Zhang Jingyue)
[Supplemental Compilation]
Phlegm-fluids in the Heart region cause distension and fullness in the chest and hypochondrium, with vertigo; Ling Gui Zhu Gan Tang is the primary formula. ○ Branch-fluids in the Heart region cause suffering from vertigo and dizziness; Ze Xie Tang is the primary formula. (Jin Gui Yao Lue)
Vertigo is commonly termed "Excess Above, Deficiency Below," but the reason is rarely explained. "Deficiency" refers to Blood and Qi; "Excess" refers to Phlegm-Saliva, Wind, and Fire. Etiologically, Qi deficiency leads to failure of Clear Qi to ascend, or excessive sweating causing Yang collapse; treatment requires raising and tonifying Yang Qi. Blood deficiency results from excessive blood loss, leaving Yang without attachment; treatment requires nourishing Yin and tonifying Blood. These are Deficient syndromes. Phlegm-saliva stagnation requires guiding out phlegm and resolving stagnation, using emesis or purgation for severe cases. Wind-Fire agitation requires clearing the Upper and descending Fire. These are Excess syndices. Some attribute Qi failing to return to its root to using mineral pills for sedation or Chen Xiang for directing Qi downward. However, aromatic herbs scatter Qi, and mineral pills assist Fire; how can displaced Qi recover thus? Nei Jing states treating disease seeks the root. For Qi failing to return, treating the root with appropriate medicine is correct. (Liu Zongnong)
Danxi argued: "No phlegm, no vertigo." Even with Wind, there must be Phlegm carrying Qi; even in deficiency, treating Phlegm is primary. If following this, all vertigo would be Phlegm syndromes. Yet Qibo never mentioned Phlegm. Thus, Danxi said treat Phlegm primarily. I say: "No deficiency, no vertigo"; treat deficiency primarily. (Zhang Jingyue)
Vertigo includes Deficient Vertigo, Fire Vertigo, and Phlegm Vertigo. Missing the key point harms patients. What is Deficient Vertigo? Cases of excessive desire, blood loss, post-abscess/postpartum states, or elderly essence depletion injure Yin. Symptoms include red face, dry mouth, vexation, insomnia, constipation, dark urine, wiry-thin-rapid or wiry-large-rapid pulses. This is essentially essence-blood deficiency causing Yin-deficiency disease. Stable roots store True Water; shaken roots cause Upper deficiency and vertigo/collapse—this is Yin-deficiency vertigo. Labor, mental exertion, vomiting/diarrhea, excessive sweating, grief, or pain injure Yang. Symptoms include blueish complexion, spiritual fatigue, aversion to cold, cold limbs, facial/body edema, deep-thin-slow or floating-large-empty pulses. This is essentially Yuan Yang consumption causing Qi-deficiency disease. Thick constitution stores True Fire; Zang deficiency causes Qi rebellion upward—this is Yang-deficiency vertigo. Treat Yin deficiency with Gui Shao Liu Wei Tang plus Ren Shen to strengthen the source of Water to generate essence-blood. Treat Yang deficiency with Ba Wei Yang Xue Tang plus Ren Shen to benefit the source of Fire to generate primal Qi. This is irrigating the root to nourish the branches. What is Fire Vertigo? Sexual exhaustion generates fire in the Kidney; violent anger generates fire in the Liver; overthinking generates fire in the Spleen. Symptoms include tinnitus, blacked-out vision, heaviness above/lightness below, vertigo/collapse, fine-weak pulses. This is essentially movement/disturbance causing deficient Yang to fail to store. Stored fire maintains inner clarity; disturbed fire causes trembling and scattering—this is deficient-fire vertigo. Real-fire vertigo presents in robust individuals with sudden onset, intense thirst, large-rapid pulses, relief after vomiting sour/bitter fluids, cool food/drink, or passing dry stool. This is Wind-Fire battling, real-fire harming. Excess leads to Upper excess and flaming fire; blockage causes blazing fire and rotation—this is real-fire vertigo. Treat deficient fire with Liu Wei or Xiao Yao formulas to nourish Yin and control fire, soothe Liver and nourish Spleen. Treat real fire with San Huang, Zhu Ye, Shi Gao formulas to clear-descend and suppress fire, use acrid-cool to drain heat. Deficient fire can be tonified; real fire can be drained. What is Phlegm Vertigo? Boiling water rises, phlegm originates in Kidney; Wind-Fire generates saliva, phlegm originates in Liver; Damp-drinking fails to move, phlegm originates in Spleen. Symptoms include heavy head, blurred vision, rotating brain, dizziness, lethargy, poor appetite, slow-slippery pulses. This is essentially over-fatigue causing deficient-phlegm tyranny. Clear ascending allows turbid Yin to descend; Qi stagnation prevents fluid movement—this is deficient-phlegm vertigo. Real-phlegm vertigo presents with solid pulse/symptoms, accumulated heat in Yangming, blockage in collaterals, stagnation in intestines. This is Wind-Fire clustering, accumulated phlegm causing disaster. Fluid coagulation causes turbid Yin to flood upward; drinking retention causes Fire to rebel upward—this is real-phlegm vertigo. Treat deficient phlegm with Liu Wei, Ba Wei, or Gui Pi formulas to tonify Kidney root to treat phlegm's root. Treat real phlegm with Er Chen, Qin, Lian, or Gun Tan Wan formulas to cool stomach/intestine heat to treat phlegm's branch. Generally, 60-70% are deficient vertigo, 20-30% combined phlegm-fire. Modern people have weak constitutions, unrestrained alcohol/sex, severe Liver/Kidney deficiency and internal injury causing severe vertigo. Appearance shows mental dullness/fatigue; voice is low; signs show spontaneous sweating/panting; pulse is thread-like. At this time, hold firm to the view, do not be confused by diversions. Use heavy doses of Ren Shen, Huang Qi, Dang Gui, Bai Zhu to turn danger to safety. If patients fear tonification and doubt, doctors refute tonification, or bystanders criticize, mistaking deficiency for real-fire, treating Ren Shen as arsenic, sudden stroke changes or critical collapse may occur, leaving even wise men helpless! (Hui Xin Lu)
Dai Fu'an stated: Severe vertigo with room spinning upon looking up, black spots in eyes, moving objects, or diplopia. Use Zheng Yuan San from Mi Zhi, add Lu Rong (Deer Antler), and concurrently administer Yang Zheng Dan. If ineffective, use single Lu Rong, half liang per dose, decocted in wine, filtered, add少许 Mos Xiang (Musk). Since Deer Antler grows on the head, using it for head vertigo follows the principle of similarity. This is Deficient-Cold. Danxi stated: Unbearable vertigo treated with Da Huang (Rhubarb) wine-fried to powder, taken with tea, 1-2 qian per dose. This is Excess-Heat. (Zhang Luyu)
Nei Jing states: All wind-induced tremors and vertigo belong to the Liver. The head is the summit of the Six Yang meridians; eyes, ears, nose, and mouth are clear cavities. Vertigo here is not from external pathogens, but Liver-Gallbladder Wind-Yang usurping upwards, risking syncope and falls. Syndromes vary: phlegm-fire binding, Middle/Lower deficiency, or treating Gallbladder/Stomach/Liver. For excess fire, use Ling Yang Jiao (Antelope Horn), Shan Zhi (Gardenia), Lian Qiao (Forsythia), Hua Fen (Tiger Lily Bulb), Yuan Shen (Polymnia Root), Sheng Di (Rehmannia), Dan Pi (Moutan), Sang Ye (Mulberry Leaf) to clear Heat in Upper Jiao orifices/collaterals, starting with Gallbladder treatment. For much phlegm, regulate Yangming, resolve phlegm with Zhu Li (Bamboo Sap), Jiang Zhi (Ginger Juice), Chang Pu (Acorus), Er Chen Tang. For Middle deficiency, add Ren Shen, Waitai Fu Ling Yin. For Lower deficiency, treat from Liver: tonify Kidney/nourish Liver, nurture Yin, subdue Yang, anchor and settle. Tian Ma (Gastrodia), Gou Teng (Uncaria), Ju Hua (Chrysanthemum) are wind-extinguishing herbs, added as needed. This syndrome originates from Liver Wind; refer to Liver Wind, Stroke, and Head Wind chapters. (Lin Zheng Zhi Nan)
[Pulse Diagnosis]
Floating and scattered pulses indicate vertigo and collapse. ○ Excessive Spring Pulse causes irritability, sudden dizziness/fullness, and vertex diseases. (Su Wen)
Overflowing-large Liver Pulse governs vertigo. Wind-floating, Cold-tight, Damp-thin, Summer-heat-deficient, Phlegm-wiry-slippery, Stasis-knife-edge-rough, Rapid-large Fire-Evil, Soft-large extreme deficiency. (Zheng Zhi Hui Bu)
[Selected Cases]
Liu Yun Gong, robust physique, careless with alcohol and sex, suddenly collapsed from labor and anger. Phlegm-saliva surged, limbs numb, mouth dry craving water. Six pulses were large-rapid but deficient. I diagnosed Kidney Meridian deficiency failing to grasp Qi to its root (causing vertigo) and failing to control water to its root (causing phlegm). Internal Yang deficiency caused numbness; deficient Fire flaring caused thirst. Cured with Bu Zhong Yi Qi Tang combined with Liu Wei Wan. (Xue Li Zhai)
Wu Tian Guan's mother, prone to violent anger, menstruation stopped. Qi rebelled upward, felt like fearing boats, fainted upon movement, bedridden, feeling world turning upside down, intense thirst, head pain like splitting, poor appetite, diarrhea. I diagnosed violent anger causing Blood stagnation above and Qi failing to return below, named Jue Dian Ji (Rebellious Vertex Disease). Jue means rebellion; Dian means height. Qi and Blood both rebel to the high vertex, causing frequent vertigo. Also, Excess Above/Deficiency Below points to Shaoyang (Gallbladder). Gallbladder collaterals connect to the brain. Depressive anger Fire attacks the brain; tonification intensifies it, causing splitting pain. Both are Jue Dian diseases; Wind-Fire fan each other causing trembling and heat steaming; Wood-Earth conflict causes difficult eating and diarrhea. Applying Nei Jing's concept of Tie Luo (Iron Filings) for sedation, use Dai Zhe Shi (Hematite), Long Dan Cao (Gentian), Lu Hui (Aloe), Huang Lian (Coptis) to descend rebellious Qi; Shu Qi (Paederia), Dan Pi (Moutan), Chi Shao (Red Peony) to move stagnant Blood; Mu Li (Oyster Shell), Long Gu (Dragon Bone), Wu Wei Zi (Schisandra) to gather floating Spirit. Crucially, add two fresh Pig Bile (Zhu Dan) per dose. Since Shaoyang heat blazes, bile dries; supplement with similar substance to support crisis management. After ten-plus doses and twenty-plus pig gallbladders, heat subsided, body cooled, appetite increased, diarrhea stopped, walking resumed. Feeling light/unstable, removed Pig Bile, Aloe, Hematite; added Ren Shen, Dang Gui, Sheng Jiang, Da Zao. Balanced and cured. (Yu Yi Cao)
A man had chronic head/eye vertigo and unsteady gait. Cun pulse was hollow-large, Guan pulse slippery. Doctor said elderly weakness, used tonification. I said: Large pulse without force indicates deficiency, but slippery indicates much phlegm. Tonifying without resolving phlegm won't stop vertigo or improve gait. Must tonify while resolving. Formula: Liu Jun Tang plus Ju Hua, Chuan Xiong, Jiu Chao Huang Qin. Ten doses reduced symptoms. Added Dang Gui, Bai Shao, made pills. Shu Di cloyed the chest, Rou Gui assisted fire; both unsuitable. (Cheng Xing Hai)