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Cheng Wuji's commentary: Ji (palpitation) refers to a state of inner panic and unease, where the heart beats palpably and fearfully, with restlessness and inability to feel at ease. It may arise from Qi deficiency, fluid retention (accumulation of pathological fluids), or excessive sweating/purging. (Sweat is the fluid of the Heart; excessive loss depletes Heart Qi, akin to a fish without water, thus causing palpitations.) In Cold Damage disease, if palpitations accompanied by vexation occur on the second or third day, Xiao Jian Zhong Tang (Minor Construct the Middle Decoction) is indicated. In Sha Yin (Lesser Yin) disease, if there are cold extremities or palpitations, Si Ni San (Frigid Extremities Powder) with Gui Zhi (Cinnamon Twig) is indicated; this is palpitation due to Qi deficiency. (Internal weakness of Yang Qi and emptiness below the Heart cause palpitations.) Drinking too much water leading to palpitations below the Heart is due to fluid retention. (The Heart belongs to Fire and dislikes Water; when Water stagnates internally, the Heart cannot remain at peace, resulting in palpitations.) When the pathogenic factor is severe, excessive sweating may cause the patient to cross their hands over the chest/heart area, experiencing palpitations below the Heart; this pertains to Tai Yang (Greater Yang) disease. If purging was performed previously, resulting in heaviness of the body and palpitations below the Heart, sweating should not be induced again. For Shao Yang (Lesser Yang) disease, sweating is contraindicated; inducing sweating leads to delirious speech, which indicates involvement of the Stomach. If Stomach Qi harmonizes, recovery ensues; if not, vexation and palpitations occur. For Shao Yang disease, vomiting and purging are contraindicated; doing so causes palpitations and fright. These cases all involve palpitations caused by residual pathogens following improper sweating or purging. Treatments may involve stabilizing/astringing methods or resolving/dispersing methods. However, palpitation caused by water/fluid retention is more severe than that caused by other pathogens. Even if residual pathogens exist, the palpitation must be treated first. Why? Because water stagnating below the Heart invades everywhere: invading the Lung causes wheezing and coughing; transmitting to the Stomach causes hiccups and dysphagia; overflowing into the skin causes edema; infiltrating the intestines causes diarrhea. Treatment must not be delayed. Thus, the classics state: "When there are cold extremities and palpitations below the Heart, treat the water first with Fu Ling Gan Cao Tang (Poria, Licorice, and Cinnamon Twig Decoction), then treat the cold extremities." If the condition is severe, water treatment comes first; how much more so for mild conditions?

In Tai Yang Cold Damage, if palpitations and vexation occur in the heart/mind within two to three days, Xiao Jian Zhong Tang is used. (Formula see Abdominal Pain section.) In Cold Damage, if the pulse is Jie Dai (knotted and intermittent) and there is Xin Dong Ji (violent palpitation), Zhi Gan Cao Tang (Honey-Fried Licorice Decoction) is the primary treatment. (Cheng Wuji notes: The Jie and Dai pulses have interruptions during beating. If they resume spontaneously, it is called Jie; if not, it is called Dai. This results from deficiency and decline of Blood and Qi, unable to continue sequentially. Palpitations indicate internal deficiency of True Qi. Zhi Gan Cao Tonifies deficiency and nourishes Blood/Qi to restore the pulse.)

Zhi Gan Cao Tang Formula (also known as Mai Mai Huan Jing Tang / Pulse-Restoring Decoction):
Gan Cao (Honey-fried, 4 liang), Sheng Jiang (Fresh Ginger, sliced), Gui Zhi (Cinnamon Twig, bark removed, each 3 liang), Ren Shen (Ginseng Root), E Jiao (Donkey-Hide Gelatin, each 2 liang), Sheng Di Huang (Rehmannia Root, one piece), Mai Men Dong (Ophiopogon Tuber, core removed), Huo Ma Ren (Hemp Seed, each half sheng), Da Zao (Jujube Fruit, 12 pieces, split). The above nine ingredients are boiled in 7 sheng of clear wine and 8 sheng of water. First boil the eight ingredients to obtain 3 sheng, strain, add E Jiao and melt completely. Take 1 sheng warm, three times daily. (Sheng Ji Jing states: Consumption of fluids leads to withering; weakness of the Five Zang organs and stagnation of Ying and Wei require moistening agents. The sweet-moistening nature of Huo Ma Ren, E Jiao, Mai Men Dong, and Sheng Di Huang nourishes meridians, tonifies Blood, restores the pulse, and unblocks the Heart.)

In Tai Yang disease, if urination is free and copious, drinking too much will inevitably cause palpitations below the Heart; if urination is scanty, there will be distressing sensation of fullness/tightness in the interior. (Cheng Wuji notes: If drinking is high but urination is free, water does not retain internally; rather, excess water in the chest causes palpitations below the Heart. *Jin Gui Yao Lue* states: Eating little and drinking much leads to water stagnation below the Heart; severe cases cause palpitations. If drinking is high but urination is obstructed, water accumulates internally and cannot move, causing distressing tightness. Scanty urination is treated with Fu Ling Gan Cao Tang; distressing tightness is treated with Shi Zao Tang.) If the pulse is floating and rapid, recovery should normally come through sweating. If purging is mistakenly applied, causing body heaviness and palpitations, sweating is contraindicated. Recovery occurs only when spontaneous sweating happens. This is because the pulse at the Chi position (cun-kou) is faint, indicating interior deficiency. The exterior and interior must become solid, fluids must harmonize, and spontaneous sweating will lead to recovery. (See Spontaneous Sweating section.) If excessive sweating causes the patient to cross hands over the chest, experience palpitations below the Heart, and desire pressure, Gui Zhi Gan Cao Tang (Cinnamon Twig and Licorice Decoction) is indicated. (Cheng Wuji notes: Excessive sweating leads to loss of Yang. Yang Qi originates in the chest; insufficiency here causes crossing hands over the chest and palpitations desiring pressure. Gui Zhi Gan Cao Tang regulates insufficient Qi.)

Gui Zhi Gan Cao Tang Formula:
Gui Zhi (Cinnamon Twig, bark removed, 4 liang), Gan Cao (Licorice Root, honey-fried, 2 liang). The above two ingredients are boiled in 3 sheng of water to obtain 1 sheng, strained, and taken in one dose. (Gui Zhi's pungency enters the Lung to benefit Qi; Gan Cao's sweetness enters the Spleen to moderate the center.) After sweating, if the patient experiences palpitations below the umbilicus and desires an attack of Ben Tun (Rushing Pig - a sensation of Qi rushing upward), Fu Ling Gui Zhi Gan Cao Da Zao Tang (Poria, Cinnamon Twig, Licorice, and Jujube Decoction) is indicated. (Cheng Wuji notes: Sweat is the fluid of the Heart. Post-sweating palpitations below the umbilicus indicate Heart Qi deficiency triggering Kidney Qi movement. The Kidney accumulation named Ben Tun rises from the lower abdomen to the epigastrium due to rebellious Kidney Qi attempting to oppress the Heart. Current palpitations below the umbilicus signal Kidney Qi activation, hence "desiring to become Ben Tun." Fu Ling Gui Zhi Gan Cao Da Zao Tang subdues Kidney Qi.)

Fu Ling Gui Zhi Gan Cao Da Zao Tang Formula:
Fu Ling (Poria, 8 liang), Gui Zhi (Cinnamon Twig, bark removed, 4 liang), Gan Cao (Licorice Root, honey-fried, 2 liang), Da Zao (Jujube Fruit, 15 pieces, split). The above four ingredients are boiled in 1 dou of "Gan Lan Shui" (Gentle Rotting Water). First boil Fu Ling until reduced by 2 sheng, then add remaining herbs, boil to obtain 3 sheng, strain, and take 1 sheng warm, three times daily. Method for making Gan Lan Shui: Take 2 dou of water, place in a large basin, ladle and splash the water until thousands of small bubbles chase each other on the surface; use this water. (Fu Ling attacks Kidney pathogenic factors; Gui Zhi drains Ben Tun; the sweetness of Gan Cao and Da Zao nourishes Spleen Earth to calm Kidney Qi. Using Gan Lan Shui, which has been agitated and lost its heavy/yin nature, avoids assisting Kidney Water.)

In Tai Yang disease, if sweating fails to resolve the condition, and the patient still has fever, palpitations below the Heart, dizziness, muscle twitching, and trembling instability (wanting to fall to the ground), Zhen Wu Tang (True Warrior Decoction) is indicated.
In Shao Yang Wind Strike, with deafness, red eyes, chest fullness, and vexation, vomiting and purging are contraindicated. Mistaken vomiting or purging causes palpitations and fright. (Zhao Sizhen notes: Shao Yang channel diseases prohibit vomiting and purging; doing so causes palpitations and fright. Also, if not yet vomited/purged and pulse is deep and tight, use Xiao Chai Hu Tang. Also, if delirium occurs after vomiting, purging, sweating, or moxibustion, it is a damaged disease. "Contraindicated" is a prohibition. "Not yet" means no error occurred, only harmonization is needed. "Already" means error led to damaged disease. *Huo Ren Shu* says "not yet suitable for vomiting/purging"; adding "suitable" is unstable.) In Cold Damage or Wind Strike lasting five to six days, with alternating chills and fever, chest/hypochondriac fullness, silence, poor appetite, vexation, frequent vomiting, or palpitations below the Heart, thirstlessness, slight body heat, or cough, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is indicated. In Cold Damage, if the pulse is string-taut and fine with headache and fever, it belongs to Shao Yang. Sweating is contraindicated; inducing sweating causes delirium, indicating Stomach involvement. If Stomach Qi harmonizes, recovery ensues; if not, vexation and palpitations occur. (Tiao Wei Cheng Qi Tang may regulate the Stomach.)

In Shao Yin disease, with cold extremities, and optionally cough, palpitations, difficult urination, abdominal pain, or diarrhea with rectal heaviness, Si Ni San (Frigid Extremities Powder) is indicated. (Add Gui Zhi 5 fen if palpitations are present.)
In Jue Yin disease, in Cold Damage with cold extremities and palpitations below the Heart, treat the water first with Fu Ling Gan Cao Tang, then treat the cold extremities. Otherwise, water infiltration into the Stomach will cause diarrhea. For cold extremities with palpitations, use Fu Ling Gan Cao Tang. For cold extremities that are not warm, use Si Ni San with added Gui Zhi. For Huo Luan (Cold-Heat Complex Disorder) with vomiting, diarrhea, and palpitations, use Li Zhong Wan with added Fu Ling.