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。
邵评：悸，是指心中跳动的感觉。悸证有虚证和实证的区别。心血亏虚、阴血不足，则发为悸；水饮之邪上凌于心，也会引起悸；肝胆痰火上逆，同样会导致悸。必须仔细辨证，才能准确用药。
伤寒病出现四肢厥冷且伴有心下悸的，应当先治疗水饮，服用茯苓甘草汤，然后再治疗四肢厥冷。如果不这样做，水湿浸渍于胃，必然导致腹泻。
邵评：伤寒病中，寒邪盛则导致四肢厥冷；心下有停水则引起心悸。既有厥冷又有心悸，说明寒邪侵入阴分，导致水液聚积在心下。应当先用茯苓甘草汤治疗水饮，待水饮去除后再治疗厥冷。否则，恐怕水湿浸渍入胃而导致腹泻。一旦腹泻发生，四肢厥冷就难以回温了。因为心下悸是水气存在的征象，趁水气尚未浸渍胃部时先进行治疗，就不会导致厥冷与腹泻相继出现。这是治疗步骤的先后次序。
如果是饮水过多而小便量少，伴有心下悸，这是水液停聚在心下，水气侵犯心脏所致。应用茯苓甘草汤来治疗水饮。
邵评：饮水多而小便少，说明水液没有出路而停聚在心下。水气上逆引发心悸，也使用茯苓甘草汤。该方甘淡利水，并能补益中气。水饮去除后，心悸自然停止。
如果心下悸且伴有四肢厥冷、身体震颤动摇，这是由于正气虚弱，肾水上犯所致。应当使用真武汤，以镇摄肾水。
邵评：心下悸是水气为患的征象。此处是肾阳外亡，肾水凌驾于心，所以出现四肢厥冷和身体震颤动摇。心属火，水来乘克则悸；肾虚火炎，水邪因此得以上侵。使用真武汤可以降火利水并镇摄逆气。这是治疗少阴阳虚、肾水凌心所致心悸的正法。以上几条，论述的是水气凌心引起心悸的情况。
如果在发汗之后，出现心中悸动且心烦，这是虚证。应当使用小建中汤，以补益心气。
邵评：阳气内虚则心悸，阴气内虚则心烦。既悸又烦，说明正气不足，邪气欲向内深入。此时不可攻逐邪气，应当用小建中汤温养中气的虚损。中气确立，邪气自然解除；即使不解，后续攻邪的方法也可以随之实施。
又评：小建中汤用于治疗虚性悸动和虚性心烦。如果是水气冲心导致的心悸，或热邪壅滞胸膈导致的心烦，此方不宜轻易使用。
如果伤寒邪气传入厥阴经，已经发展为坏病，脉象结代，心动悸，这是阴液枯竭的表现。主用炙甘草汤。
邵评：脉象结代，是因为邪气阻滞，营卫之气涩滞稀少。心动悸，是因为神气不振，心神受到震惊。这是因为邪气深入厥阴，阴液几乎枯竭，所以使用复脉汤（即炙甘草汤）阴阳并调。然而，邪气已深入，阴阳俱耗，脉象失常而出现结代，这属于阴脉。伤寒病出现这种情况，是阳证见到阴脉，所以预后大多不良。不得已才使用此方，作最后的一搏。
如果病后心气虚弱，出现怔忡不宁，听到声音就惊恐，应当镇心安神并补益心气。如使用茯神、远志、酸枣仁、丹参、当归、龙齿、辰砂、金箔等药物。
邵评：病后阴伤营弱，血少不能滋养心脏，导致心气大虚，虚火上扰而引起怔忡惊悸。治疗应采用养营补心、安神的方法。这是治疗病后心虚营弱所致怔忡心悸的正法。
如果是因受惊吓而导致的怔忡，也是由于心虚且有痰浊所致。宜使用茯神、酸枣仁、川贝母、天竺黄、钩藤、丹参、竹茹、半夏、辰砂、金箔等药物，以镇心安神并祛除惊痰。
邵评：惊则气机紊乱、扰动，肝火上逆。其人平素心气虚弱，体内有伏痰，肝胆木火乘虚凌心，从而导致怔忡心悸。适宜使用清心涤痰、降火的方剂。这是治疗心虚有痰、因惊致怔忡的确切良法。以上四条，论述的是由虚证引起的心悸。
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.