Addressing Idiopathic Vestibular Syndrome with Chinese Medicine

Yin, Yang, and Pinocchio

Pinocchio was the first movie I ever saw on my own. I was probably six. On your own??? At six??? Don’t judge my mother too harshly. What can I say? They were simpler times.

She left me at the movie theater in our local mall while she went shopping, likely figuring, “What harm can come to him watching a Disney cartoon for an hour and change?” So, I dutifully went inside and learned about boys (including a would-be-boy-but-currently-puppet) journeying to Pleasure Island where they smoked, drank, and gambled the hours away until they eventually all turned literally into jackasses. I guess she never saw it herself!

Actually, come to think of it, it’s probably the perfect movie to show a little kid left to his own devices for the first time in his life. I mean it worked, didn’t it? To this day, I don’t smoke, drink or gamble, so who knows? Maybe she was onto something.

Anyway, Pinocchio manages to escape Pleasure Island before becoming fully jackass-ified. He returns home to discover, courtesy of the Blue Fairy, that Geppetto, the wood carver who created him, has gone off looking for Pinocchio at Pleasure Island and ended up instead in the belly of a whale. Pinocchio, held in sway by the conscience given him by the Blue Fairy, runs off to rescue Geppetto, narrowly escaping death-by-whale himself. When he finally comes to, in return for his self-less efforts, he is finally transformed into a real boy with the help of the Blue Fairy

You might think an article on Chinese medicine is an odd place to discuss Pinocchio. You might also think the moral of the Pinocchio story is the redemptive power of love; or at least how hard it is to conceal a lie, because everyone ‘nose’ about it. For our purposes, though, the key point is this: when boys are left to their devices, they will get up to no good, were it not for their personal Blue Fairies. More particularly, Yang, when living up to its essential nature, regularly sends the body off the rails, or would do so, without the Yin element to keep it grounded. One of these scenarios when Yang energy goes awry is Idiopathic Vestibular Syndrome in dogs.

Yang: All Aboard for Pleasure Island!

In the Tai Ji symbol, Yang is the white half - the rising half that is moving up and out, as though it is trying to escape. And it would, too, were it not anchored to the black Yin half, which is moving decidedly downwards and inwards. This cyclical centrifugal movement of Yang happens on a daily basis in the body, ending when Yang is attracted inwards again by the Yin element. These outward movements are amplified each summer, when Yang moves that much farther outward and closer to the hot, dry, external environment before coming back in again in response to the beckoning call of Yin. Occasionally, Yang goes so far up and out in late summer to the head and extremities that it doesn’t move inwards properly anymore. When that happens, vestibular syndrome is the result.

Actually, I’m not being entirely fair to Yang. Under normal circumstances, Yang does have some ‘self-control’. It’s not all coming from Yin. The aspect of Yang that permits this internalization is called Shao Yang.

Figure 1. The Tai Ji Symbol

The Shao Yang phase of Yang movement can be viewed as a type of pump. When properly functioning, the Shao Yang moves Yang energy from its current exterior Tai Yang location and internalizes it into the Yang Ming in the body core. This internalization process happens in the evening and wee hours of the morning, permitting sleep to eventually occur. If the Shao Yang pump is broken, though, we have too much Yang energy left in the head, and that creates issues, including nighttime pacing, restlessness, and insomnia, making Shao Yang disharmony, an important cause of so-called Sundowner’s Syndrome in dogs. Idiopathic vestibular disease is another manifestation of Shao Yang disharmony and is exceedingly common in the late summer and fall months, when the outward movement of Yang is that much more extreme, and when there may be that much less Yin to attract it back inwards.

Figure 2. Stages of externalization of Yin and Yang

Yin: The Blue Fairy Beckons

In the Pinocchio story, the Blue Fairy represents Yin – that element that quietly gives Yang pause in the pursuit of its distractions. if an animal is Yin deficient, excesses of Yang in the upper and outer body become accentuated, making Yin deficiency a common aggravating factor in Shao Yang disharmony, or even one of its root causes.

Yin has its own circadian rhythm, moving to its externalized Tai Yin layer when the environment is most cool, and the dew is heaviest on the grass. In forenoon, it is already beginning to get too hot outside for Yin, and it begins its retreat to the body core, moving through the intervening Shao Yin layer to spend the evening and wee hours in the Jue Yin core.

Yin thus moves slightly out of step with Yang, since Yang remains externalized until the late afternoon. This makes it that much harder to internalize Yang, since the distance between Yin and Yang weakens the bond between them. If the patient is additionally Yin deficient, then the stage is set for Yang not internalizing at all, or only with great difficulty, if the Shao Yang is also compromised.

An animal is most likely to be Yin deficient if they are geriatric. They have had a lifetime for their Yin and Essence to slowly be consumed and not adequately replaced. It’s thus not surprising, in hindsight, that idiopathic vestibular syndrome is most likely to appear in elderly animals in the late summer through fall, with attacks usually occurring in the evening through the wee hours of the morning.

Western medicine uses the phrase ‘Idiopathic’ to denote that it really doesn’t understand where the problem comes from, or why it (hopefully) goes away again. Since the Chinese medical model of the movements of Yin and Yang can readily explain these nuances of presentation, it is in a much better position to treat address vestibular syndrome.

Pulse Diagnosis in Vestibular Syndrome

The acute onset of loss of balance accompanied by nystagmus during the late summer and fall months is highly suggestive of idiopathic vestibular syndrome due to Shao Yang disharmony. Patients frequently exhibit a red tongue, signs of pacing, restlessness, the craving of ice-cold water or snow, heat intolerance and even heat stroke. Confirmation that Shao Yang disharmony is behind these symptoms of Yang trapped in the Upper Burner can be found in the pulse.

When Yang is trapped on the body surface, the pulse feels wide, strongest with only light digital pressure, and is at least initially resistant to digital compression. This is known as the Drumskin pulse. It is similar to a Floating pulse but often has more width and force to it. If this pulse moderates with tonification using acupuncture or acupressure of a key Gall Bladder point like GB 20, then the diagnosis of Shao Yang disharmony causing vestibular syndrome is confirmed

Rarely, but occasionally, the pulse feels strongest at mid-depth, and is relatively large in diameter, toned, and resistant to compression. This is the Full pulse, normally arising in Shao Yang disharmony cases when Yang is trapped internally instead of on the surface. Zhang Zhong-Jing called it a Wiry pulse in the Shang Han Lun. Full pulses are more likely to be seen in a vestibular patient during the first half of the day, when Yang has finally had a chance to internalize the previous evening, but is now having trouble emerging, since the Shao Yang ‘gate’ sticks both ways. If the pulse moderates with sedation using acupuncture or acupressure of key GB points like GB 20, then the diagnosis of Shao Yang disharmony causing vestibular syndrome is likewise confirmed.

Intervention

Even if the pulse is Full at the time of examination, the ultimate goal is still to restore the ability of the Shao Yang to internalize Yang later that day. Shao Yang structures will thus need to be strengthened, through tonification of key GB points such as GB 20, GB 34, GB 25, and BL 19. Tai Yang points in head should be sedated, including GV 20, although the pulse may improve with tonification of GV 3 at the same time. This combination of sedating a superior GV point and tonifying a lower GV point has the effect of descending Yang from the head to the base of spine, ameliorating the situation. Yang Ming points like ST 36 can be tonified, to help draw Yang energy deep inside the body to the Yang Ming, instead of it being trapped on the body surface.

Herbal consideration of idiopathic vestibular syndrome is accomplished with the use of Chai Hu Jia Long Gu Mu Li Tang (Bupleurum, Dragon Bone and Oyster Shell Combination), or Settle the Yang in the Kan Essentials line. The formula was first published in the Shang Han Lun about two thousand years ago as a treatment for patients with no self-control, underscoring the appropriateness of the Pleasure Island analogy in understanding Shao Yang disharmony.

Settle the Yang contains within it the exemplar formula of the Harmonizing Method in Chinese medicine, Minor Bupleurum (Xiao Chai Hu Tang). Minor Bupleurum, by employing Huang Qin (Scutellaria) is able to clear excesses of Heat from the Upper Burner (i.e., the head) and guide them downwards. It also, however, can clear excess Heat and Yang from the Yang Ming (Stomach, Large Intestine) in the body core.

Figure 3. Minor Bupleurum (Harmonize the Qi)

Bupleurum balances this descending action of Scutellaria by raising Yang all the way from the interior to the exterior, accounting for the herb being listed in older materia medicae as a cooling herb that vents to the exterior. Taken together, the two herbs allow the precipitation of Yang trapped in the Yang Ming, but also the mobilization and internalization of Yang excess on the body surface, making it the quintessential formula for harmonizing the inward and outward movement of Yang in the body.

Minor Bupleurum (Xiao Chai Hu Tang, or Kan Essentials’ Harmonize the Qi) could be used on its own to treat address idiopathic vestibular syndrome from Shao Yang disharmony. Zhang Zhong-Jing saw fit, though, to embellish Minor Bupleurum with additional herbs, in the process creating a formula committed to the internalization of Yang.

In particular, the addition of the mineral laden herbs of Long Gu (Dragon Bone, fossilized bone) and Mu Li (Oyster Shell) help precipitate Yang internally, with the salty taste of these two guiding Yang all the way to the lower burner. Meanwhile, a pinch of bitter descending Da Huang is added to return the Yang to the Yang Ming. Cinnamon Twig (Gui Zhi) homes to the Tai Yang and helps stir the Yang trapped there into motion, so it can be grasped by the descending herbs. Fu Ling (and later, Fu Shen) contributes to this downward leaching action on Yang by calming the Spirit.

Figure 4. Bupleurum, Dragon Bone and Oyster Shell Combination (Settle the Yang)

Follow Up

Vestibular patients generally respond quickly to this approach, so the clinical presentation will commonly change from one of Yang excess (or the so-called Fire pathogen) to one of Yin deficiency. Instead of the pulse being Drumskin or Full, it will often become soft, thin and weak, signalling that a Yin deficiency is part of the root cause of the Shao Yang disharmony.

Clinical signs and symptoms of Yin deficiency that accompany this deficient pulse may include:

• Advancing age
• Perhaps thin body condition
• Cognitive decline
• Dryness of the skin and mouth (causing frequent licking or regurgitation)
• Bilious vomiting in the morning on an empty stomach
• Loud borborygmi
• A pale or red tongue
• Tendencies to gastric ulceration
• Restless or shallow dream-filled sleep

If the pulse moderates with tonification of SP 6, BL 23 or BL 18, the diagnosis of Yin deficiency is confirmed. An excellent herbal medicine for these cases is Yi Guan Jian (One Linking Decoction) sold in the Kan Essentials line as Glehnia and Rehmannia. Besides tonifying the Yin of all three Burners, it moistens and cools the Yang Ming (i.e., Stomach), which commonly suffers Dryness as a result of Yang being regularly trapped there due to Shao Yang disharmony.

About The Author

Dr. Steve Marsden, DVM, ND, MSOM, Lac. Dipl.CH, CVA, AHG lectures for IVAS, the AHVMA, the AVMA, and numerous other organizations. He is co-founder of the College of Integrative Veterinary Therapies (CIVT) and is a director emeritus of the National University of Natural Medicine in Portland OR. He is a contributing author to numerous textbooks and is author of Manual of Natural Veterinary Medicine (Mosby, with Dr. Susan Wynn) and Essential Guide to Chinese Herbal Formulas (published by CIVT). Dr. Marsden is extensively trained in alternative medicine, including Chinese herbology, acupuncture and naturopathic medicine. In 2010, Dr. Marsden was named Teacher of the Year by the AHVMA; and in 2009, the Small Animal Veterinarian of the year by the Canadian Veterinary Medical Association.