金匮云。寸口脉动而弱。动则为惊。弱则为悸。
惊自外邪触入而动。故属阳。阳变则脉动。悸自内恐而生。故属阴。阴耗则脉弱。
心下悸者。半夏麻黄丸主之。
此形寒饮冷。经脉不利。水停心下而致动悸。故用麻黄以散营中寒。半夏以散心下水。与伤
寒水停心下用小青龙汤无异。首论以脉弱为悸。而此汤用麻黄、半夏散寒治水。知其脉必不弱。
非弦即紧。盖脉弱为心气不足。岂此药所宜用乎。用丸不用汤者。取缓散水。不取急汗也。
卒呕吐。心下痞。膈间有水。眩悸者。半夏茯苓汤主之。
呕逆痰饮为胸中阳气不得宣散。眩亦上焦阳气不能升发所致。故半夏、生姜并治之。悸则心
受水凌。非半夏可独治。必加茯苓以去水。水去则神安而悸愈矣。
假令瘦人脐下有悸。吐涎沫而颠眩。此水也。五苓散主之。
瘦人火水之盛。为水邪抑郁。在阴分不得升发。故于脐下作悸。及至郁发。转入于阳。与正
气相击。在头为眩。在顶为颠。肾液上逆为吐涎沫。故用五苓以伐肾邪。利水道。水去火自安矣。
悸即怔忡之谓。心下惕惕然跳。筑筑然动。怔怔忡忡。本无所惊。自心动而不宁。即所谓悸
也。心虚而停水。则胸中渗漉。水既上乘。心火恶之。心不自安。使人有怏怏之状。常筑筑然动。
是则为悸。盖水衰火动则为烦。水乘火位则为悸。原病式曰。水衰火旺。必烦渴引饮。水停心下
而为悸也。心下悸有气虚血虚。属饮属火之殊。夫气虚者。由阳气内微。心下空虚。内动为悸。
心气不定。五脏不足。甚者。忧愁悲伤不乐。忽忽喜忘。惊悸狂眩。千金定志丸、千金茯神汤。
或六君子加菖蒲、远志。血虚者。由阴气内虚。虚火妄动。归脾汤加丹参、麦冬。停饮者。水停
心下。侮其所胜。心主畏水。不能自安。故惕惕而动。半夏茯苓汤、茯苓甘草汤。或二陈汤加白
术、猪苓、泽泻。有表邪挟饮。半夏麻黄丸、小青龙汤选用。火旺者。因水不能制火。故时悸时
烦。跳动不宁。天王补心丹。不应。六味丸加五味、麦冬、远志。有邪气攻击而悸者。宜审其何
邪而后治之。有营卫涸流。脉来结代者。必补气益血生精。炙甘草汤。因痰饮而悸。导痰汤加枣
仁。有时作时止者。痰因火动也。温胆汤加川连。其脐下悸动。肾气上凌也。五苓散加辰砂。有
所求不遂。或过误自悔。 懊嗟吁。独语书空。若有所失。温胆汤加人参、柏子仁。胸中痞塞。
不能饮食。心中常有歉。爱居暗处。或倚门后。见人则惊避无地。此卑 之病。藿香正气散。虚
者。人参养荣汤。有真心跳。乃血少。非惊悸也。又或梦中如堕岩崖。或睡中忽自身体跳动。此
心气不足也。归脾汤下朱砂安神丸。肥人多属痰饮。瘦人多属血虚与阴火上冲。夫悸之证
状不齐。总不外于心伤而火动。火郁而生涎也。若夫虚实之分。气血之辨。痰与饮。寒与热。外
感六淫。内伤七情。在临证辨之。
〔诊〕沉细属饮。结代者。虚而有饮。虚弱者。属气虚。沉数者。为血热。尺中弦紧。为肾气
凌心。寸口脉动而弱。动则为惊。弱则为悸。
石顽治老僧悟庵。心悸善恐。遍服补养心血之药。不应。天王补心丹服过数斤。悸恐转增。
面目四肢。微有浮肿之状。乃求治于石顽。察其形。肥白不坚。诊其脉。濡弱而滑。此气虚痰饮
侵渍于膈上也。遂以导痰汤稍加参、桂通其阳气。数服而悸恐悉除。更以六君子加桂。水泛作丸。
调补中气而安。
The *Jin Gui Yao Lue* states: The pulse at the Cun Kou (radial artery) is moving and weak. A moving pulse indicates Jing (Startle), while a weak pulse indicates Ji (Palpitation).
Jing originates from external pathogens disturbing the mind, thus belonging to Yang; when Yang transforms, the pulse manifests as moving. Ji arises from internal fear, thus belonging to Yin; when Yin is consumed, the pulse manifests as weak.
For palpitations felt in the epigastrium (Xia Xin), Banxia Mahuang Wan (Pinellia and Ephedra Pill) is the primary treatment.
This condition results from cold affecting the body and drinking cold fluids, leading to impaired meridian circulation and fluid retention in the epigastrium causing palpitations. Therefore, Mahuang (Ephedrae Herba) is used to disperse cold in the Ying (Nutritive) level, and Banxia (Pinelliae Rhizoma) to dissipate water in the heart region. This is no different from using Xiao Qing Long Tang (Minor Green Dragon Decoction) for fluid retention in the epigastrium in Shang Han (Cold Damage) diseases. The initial discussion identifies Ji by a weak pulse, yet this decoction uses Mahuang and Banxia to dispel cold and treat water, indicating the pulse must not be weak, but rather Xian (Wiry) or Jin (Tight). Since a weak pulse signifies Heart Qi deficiency, these herbs are certainly not suitable for such a presentation. The use of a pill instead of a decoction aims to slowly dissipate water rather than induce rapid sweating.
In cases of sudden vomiting, epigastric fullness-impediment (Pi), fluid between the diaphragm, dizziness, and palpitations, Banxia Fuling Tang (Pinellia and Poria Decoction) is indicated.
Vomiting and retching due to phlegm-fluid result from the failure of Upper Jiao (Upper Burner) Yang Qi to circulate and disperse. Dizziness is also caused by the inability of Upper Jiao Yang Qi to ascend. Thus, Banxia and Shengjiang (Zingiberis Rhizoma Recens) are used together. Palpitations occur because the Heart is overwhelmed by water; Banxia alone cannot treat this, so Fuling (Poria) must be added to remove the water. Once the water is removed, the Spirit calms, and palpitations cease.
If a thin person experiences palpitations below the umbilicus, with spitting of saliva and dizziness or vertigo, this is due to water pathology, treated with Wu Ling San (Five-Ingredient Powder with Poria).
Thin individuals often have abundant Fire and Water, which are depressed by pathogenic water, unable to ascend within the Yin divisions, causing palpitations below the umbilicus. When this depression erupts and shifts to the Yang, it clashes with healthy Qi, causing dizziness in the head and vertigo at the vertex. Upward reversal of Kidney fluids manifests as spitting saliva. Therefore, Wu Ling San is used to subdue Kidney pathogens and promote urination. Once water is eliminated, Fire settles naturally.
Ji is synonymous with Zheng Chong (Palpitation/Anxiety). It feels like a timid beating in the epigastrium, a thumping vibration, restless and anxious, without any external startle, arising from the Heart itself being unsettled. This is what is called Ji. When Heart deficiency leads to fluid retention, there is a gurgling sound in the chest. As water rises to overwhelm the Heart, Heart Fire dislikes it, and the Heart becomes uneasy, causing a sense of melancholy and constant thumping. Generally, when Water is deficient and Fire moves, it causes irritability (Fan); when Water occupies the position of Fire, it causes Ji. The *Yuan Bing Shi* states: "When Water is deficient and Fire is vigorous, there must be irritability and thirst prompting drinking; when water stops in the epigastrium, it causes Ji."
Epigastric palpitations vary by Qi deficiency, Blood deficiency, Fluid retention, and Fire excess.
Qi deficiency stems from internal decline of Yang Qi, leaving the epigastrium empty, causing internal movement and palpitation. With unsettled Heart Qi and insufficiency of the Five Zang organs, severe cases involve sorrow, grief, unhappiness, absent-mindedness, forgetfulness, startle, palpitations, mania, and dizziness. Treat with Qian Jin Ding Zhi Wan (Thousand Golden Pill to Stabilize the Spirit) or Qian Jin Fu Shen Tang (Thousand Golden Poria Decoction). Alternatively, Liu Jun Zi Tang (Six-Gentlemen Decoction) plus Shichangpu (Acori Tatarinowii Rhizoma) and Yuanzhi (Polygalae Radix).
Blood deficiency stems from internal insufficiency of Yin Qi, causing deficient Fire to move recklessly. Treat with Gui Pi Tang (Restore the Spleen Decoction) plus Danshen (Salviae Miltiorrhizae Radix et Rhizoma) and Maidong (Ophiopogonis Radix).
Fluid retention involves water stopping in the epigastrium, insulting its conquered element (Fire), causing the Heart Master to fear water and lose peace, resulting in timid movement. Treat with Banxia Fuling Tang, Fuling Gancao Tang (Poria and Licorice Decoction), or Er Chen Tang (Two-Aged Decoction) plus Baizhu (Atractylodis Macrocephalae Rhizoma), Zhuling (Polypori Umbellati), and Zexie (Alismatis Rhizoma).
For exterior pathogens combined with fluid retention, select Banxia Mahuang Wan or Xiao Qing Long Tang.
For Fire excess, where Water fails to control Fire, causing intermittent palpitations and irritability with restless movement, use Tian Wang Bu Xin Dan (Emperor of Heaven's Special Pill to Tonify the Heart). If ineffective, use Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) plus Wuweizi (Schisandrae Fructus), Maidong, and Yuanzhi.
For palpitations caused by attacking pathogens, identify the specific pathogen before treating.
For depletion of Ying and Wei flows presenting with Ji Dai (knotted and intermittent) pulses, one must tonify Qi, benefit Blood, and generate Essence using Zhi Gancao Tang (Honey-fried Licorice Decoction).
For palpitations due to phlegm-fluid, use Dao Tan Tang (Phlegm-Resolving Decoction) plus Suanzaoren (Ziziphi Spinosae Semen).
For intermittent attacks, where phlegm is stirred by Fire, use Wen Dan Tang (Warm the Gallbladder Decoction) plus Huanglian (Coptidis Rhizoma).
For palpitations below the umbilicus, caused by Kidney Qi overwhelming the Heart, use Wu Ling San plus Zhensha (Cinnabar).
For unfulfilled desires or regret over mistakes, manifesting as groaning, sighing, talking to oneself, gesturing at empty space, and a sense of loss, use Wen Dan Tang plus Renshen (Ginseng Radix) and Baiziren (Biota Seed).
For epigastric fullness-impediment, inability to eat, a constant feeling of inadequacy, preference for dark places, hiding behind doors, and extreme fear upon seeing people, this is Bei Die disease. Use Huoxiang Zhengqi San (Agarweed Powder to Rectify the Qi). For deficiency, use Renshen Yangrong Tang (Renshen Decoction to Nourish Young Virtue).
True palpitations due to blood deficiency are not Jing or Ji.
Dreams of falling off cliffs or sudden bodily movements during sleep indicate Heart Qi deficiency. Treat with Gui Pi Tang administered with Zhusha Anshen Wan (Cinnabar Calming the Spirit Pill).
Obese individuals mostly suffer from phlegm-fluid; thin individuals mostly suffer from blood deficiency and upward rushing of deficient Fire.
The manifestations of Ji are diverse, but ultimately stem from Heart injury and Fire movement, or Fire stagnation generating saliva. Differentiate between deficiency and excess, Qi and Blood, Phlegm and Fluid, Cold and Heat, Exterior Six Evils, and Interior Seven Emotions during clinical practice.
[Diagnosis]
Chen Xi (Deep and Fine) pulse indicates Fluid. Ji Dai indicates deficiency with fluid. Xu Ruo (Weak) indicates Qi deficiency. Chen Shu (Deep and Rapid) indicates Blood Heat. Chi Zhong Xian Jin (Wiry and Tight at the Chi position) indicates Kidney Qi overwhelming the Heart. Cun Kou Mai Dong Er Ruo (Moving and Weak at Cun Kou): Moving indicates Startle, Weak indicates Palpitation.
Shi Wan treated an old monk named Wu An, who suffered from palpitations and excessive fear. He had taken various medicines to tonify Heart Blood without effect. After consuming several jin of Tian Wang Bu Xin Dan, his palpitations and fear worsened. His face, eyes, and limbs showed slight edema. He then sought treatment from Shi Wan. Observing his physique, he was fat and white but not firm. Palpating his pulse, it was Ru Ruo Hua (Soft, Weak, and Slippery). This indicated Qi deficiency with phlegm-fluid infiltrating above the diaphragm. Shi Wan prescribed Dao Tan Tang with slight additions of Renshen and Rougui (Cinnamon Twig) to unblock Yang Qi. After a few doses, palpitations and fear were completely resolved. Subsequently, Liu Jun Zi Tang plus Rougui was prepared as water-habit pills to regulate and tonify Middle Qi, leading to recovery.