心下悸者。心下筑筑惕惕。怔忡不宁之状也。
邵评∶悸者。心中跳动也。有虚实之分。心虚血少。则悸。水饮凌心亦悸。肝胆痰火上逆亦悸。
务须辨清用药。
伤寒厥而心下悸者。宜先治水。当服茯苓甘草汤。却治其厥。不尔。水渍在胃。必作利也。
邵评∶伤寒寒胜则厥。心下有水则悸。厥而心悸者。寒中于阴。而水聚于心下也。
宜以茯苓甘草汤先治其水。水去然后治厥。否恐水渍入胃而作利。利作。则厥不回矣。盖心下悸。是有水
气。乘其未渍胃时先治之。不致厥利相连。此治法之次第也。
如饮水多而小便少。心下悸。乃水停心下。水气犯心也。茯苓甘草汤以治其水。
邵评∶饮水多而小便少。水无出路而停于心下。水气上逆作悸。亦用茯苓甘草汤。甘淡利水。而益
中气。水去则心悸自止。
若心下悸而厥冷。身 动者。因虚而肾水上犯也。宜真武汤。以镇肾水。
邵评∶心下悸。是水气之征。此肾阳外亡。肾水凌心。故厥冷而身 动。心属火而
水乘之则悸。肾虚火炎。水邪因得上侵。用真武汤降火利水而镇逆。此治少阴阳虚。肾水凌心而悸
之正法。以上数条。水气凌心作悸。
若汗后。心中悸而烦者。虚也。宜小建中汤。以补心气。
邵评∶阳气内虚则心悸。阴气内虚则心烦。悸而烦者。正不足而欲入内也。不可
攻其邪。当用小建中汤。温养中气之虚。中气立。则邪自解。即不解。而攻取之法。亦可因之而施矣。
又评∶小建中汤。治虚悸虚烦。若水气冲心而悸。热邪壅膈而烦者。此汤不宜轻用。
若伤寒邪入厥阴。已成败症。脉结代。心动悸者。阴液涸也。炙甘草汤主之。
邵评∶脉结代者。邪气阻滞。营卫之气涩少也。心动悸者。神气不振。都城震惊也。
此邪气深入厥阴。阴液几涸。故用复脉汤阴阳并调之。然此邪入深沉。阴阳并耗。脉失常度而见结代。
是阴脉也。伤寒有此。是阳症见阴脉。故多死。不得已。用此方以背城借一耳。
若病后心气虚。而怔忡不宁。闻声即惊者。宜镇心神以补心气。如茯神、远志、枣仁、
丹参、当归、龙齿、辰砂、金箔之类。
邵评∶病后阴伤营弱。血少不能养心。心气大虚。虚火上扰而怔忡惊悸也。治以
养营补心安神一法。此病后心虚营弱而怔忡心悸之正法。
如因惊而得怔忡者。亦由心虚有痰也。宜茯神、枣仁、川贝、天竺黄、钩藤、丹参、竹茹、
半夏、辰砂、金箔之类。镇心神以去惊痰。
邵评∶惊则气乱、扰动。肝火上逆。其人心气素虚。内有伏痰。肝胆木火乘虚凌心。
而怔忡心悸也。宜以清心涤痰降火之剂。此治心虚有痰。因惊而怔忡者。的是良法。以上四条。由虚而心悸。
Palpitations in the epigastrium refer to a sensation of throbbing, uneasiness, and constant palpitations (Zhenchong, 怔忡) without peace.
Shao's Commentary: Palpitation refers to the sensation of the heart beating within the chest. It is divided into deficiency (Xu, 虚) and excess (Shi, 实) types. Deficiency of heart blood and insufficient blood lead to palpitations; water-fluid retention overwhelming the heart also causes palpitations; upward reversal of phlegm-fire from the Liver and Gallbladder similarly results in palpitations. One must clearly differentiate the pattern before prescribing medication.
In Taiyang disease (Taiyang Bing, 太阳病), if there are cold extremities accompanied by palpitations in the epigastrium, one should first treat the water retention by administering Fuling Gancao Tang (Poria and Licorice Decoction), and subsequently treat the cold extremities. If this order is not followed, water fluids will infiltrate the Stomach, inevitably leading to diarrhea.
Shao's Commentary: In Taiyang disease, excessive cold leads to cold extremities; water accumulation in the epigastrium causes palpitations. The presence of both cold extremities and palpitations indicates that cold pathogens have invaded the Yin aspect, causing water to gather in the epigastrium. One should first use Fuling Gancao Tang to treat the water retention. Only after the water is eliminated should the cold extremities be treated. Otherwise, there is a risk that water infiltration into the Stomach will cause diarrhea. Once diarrhea occurs, the cold extremities will not recover. Since palpitations in the epigastrium are a sign of water qi, treating it before it infiltrates the Stomach prevents the consecutive occurrence of cold extremities and diarrhea. This illustrates the proper sequence of treatment.
If excessive drinking leads to scanty urination and palpitations in the epigastrium, this is due to water stagnation in the epigastrium and water qi invading the Heart. Fuling Gancao Tang should be used to treat the water retention.
Shao's Commentary: Excessive drinking with scanty urination means the water has no outlet and stagnates in the epigastrium. Upward reversal of water qi causes palpitations. Fuling Gancao Tang is also indicated here. Its sweet and bland properties promote diuresis and benefit Middle Qi. Once the water is eliminated, the palpitations will cease naturally.
If palpitations in the epigastrium are accompanied by cold extremities and tremors/shaking of the body, this is due to deficiency allowing Kidney water to invade upwards. Zhenwu Tang (True Warrior Decoction) should be used to subdue the Kidney water.
Shao's Commentary: Palpitations in the epigastrium are a sign of water qi pathology. Here, Kidney Yang has escaped outward, and Kidney water overwhelms the Heart, resulting in cold extremities and bodily tremors. The Heart belongs to Fire; when Water overcomes it, palpitations occur. Kidney deficiency allows Fire to flare, enabling Water pathogens to invade upwards. Zhen Tang descends Fire, promotes diuresis, and suppresses rebellious qi. This is the standard method for treating Shaoyin Yang deficiency where Kidney water overwhelms the Heart, causing palpitations. The above points discuss palpitations caused by water qi overwhelming the Heart.
After sweating, if there are palpitations in the Heart and irritability (Fan, 烦), this is a deficiency pattern. Xiaojianzhong Tang (Minor Construct the Middle Decoction) should be administered to tonify Heart Qi.
Shao's Commentary: Internal deficiency of Yang Qi causes palpitations; internal deficiency of Yin Qi causes irritability. The combination of palpitations and irritability indicates insufficient righteous Qi and an impending inward invasion of pathogens. One must not attack the pathogens directly. Instead, Xiaojianzhong Tang should be used to warm and nourish the deficiency of Middle Qi. Once Middle Qi is established, the pathogens will resolve spontaneously; even if they do not, methods of purging can then be applied.
Additional Commentary: Xiaojianzhong Tang treats deficiency-type palpitations and deficiency-type irritability. If palpitations are caused by water qi rushing to the Heart, or irritability by heat pathogens obstructing the Diaphragm, this decoction should not be used lightly.
If Taiyang pathogens enter the Jueyin channel and have developed into a complicated disease (Bai Zheng, 败症), characterized by knotted and intermittent pulse (Jie Dai Mai, 结代脉) and violent palpitations (Xindong Ji, 心动悸), this indicates exhaustion of Yin fluids. Zhigancao Tang (Roasted Licorice Decoction) is the primary prescription.
Shao's Commentary: A knotted and intermittent pulse indicates obstruction by pathogens and sluggish scarcity of Ying and Wei Qi. Violent palpitations indicate lack of vitality of Shen Qi and shock to the "Capital City" (the Heart). Because pathogens have deeply entered Jueyin and Yin fluids are nearly exhausted, Fumai Tang (Pulse-Recovering Decoction, i.e., Zhigancao Tang) is used to harmonize both Yin and Yang. However, since the pathogens are deep and both Yin and Yang are depleted, the pulse deviates from normal rhythm showing knotting and intermittency, which is a Yin pulse. In Taiyang disease, presenting with a Yin pulse indicates a Yang disease manifesting as a Yin pulse, which often portends death. Therefore, this formula is used only as a last resort.
If after illness, Heart Qi is deficient, leading to constant palpitations and startle upon hearing sounds, one should calm the Spirit and tonify Heart Qi using herbs such as Fushen (Poria with Hostwood), Yuanzhi (Polygala Root), Suanzaoren (Ziziphus Seed), Danshen (Salvia Root), Danggui (Angelica Sinensis), Longchi (Dragon Bone), Chen Sha (Cinnabar), and Jinbo (Gold Leaf).
Shao's Commentary: Post-illness injury to Yin and weakness of Ying Blood, with insufficient blood failing to nourish the Heart, leads to severe Heart Qi deficiency. Deficient Fire harasses upward, causing Zhenchong and startle palpitations. The treatment principle is to nourish Ying, tonify the Heart, and calm the Spirit. This is the standard method for post-illness Heart deficiency and Ying weakness causing Zhenchong and palpitations.
If Zhenchong is induced by fright, it is also due to Heart deficiency combined with Phlegm. Suitable herbs include Fushen, Suanzaoren, Chuan Bei Mu (Fritillaria Cirrhosa Bulb), Tian Zhu Huang (Bambusa Textilis Calculus), Gouteng (Uncaria Rhynchophylla), Danshen, Zhuru (Bamboo Shavings), Banxia (Pinellia Rhizome), Chen Sha, and Jinbo, to calm the Spirit and dispel fright-induced phlegm.
Shao's Commentary: Fright causes Qi disorder and disturbance, with Liver Fire reversing upward. If the person has inherent Heart Qi deficiency and latent Phlegm internally, Liver-Gallbladder Wood-Fire may overwhelm the Heart due to deficiency, leading to Zhenchong and palpitations. Formulas that clear the Heart, eliminate Phlegm, and descend Fire are appropriate. This is indeed an excellent method for treating Zhenchong caused by fright in cases of Heart deficiency with Phlegm. The above four points discuss palpitations arising from deficiency.