3. Syndrome of Heart-Qi deficiency
Manifestations
Main symptoms
Palpitations, restlessness, shortness of breath on exertion, mental tiredness.
Secondary symptoms
Insomnia, sweating easily, anxiety, depression.
Tongue
Pale or dull-pale with a white coating.
Pulse
Restless and weak in general; particularly weak in the Heart position. In some cases, the pulse in the Heart position is slightly forceful at the superficial level but weak at the second and third levels.
Associated disorders in western medicine
Different types of heart disease, such as rheumatic heart disease, arrhythmia; diseases of the circulatory and nervous systems, conditions where low blood pressure, anxiety and depression are present.
Analysis of the syndrome
The Heart-Qi has a close relationship with the Spleen-Qi as the Spleen-Qi is the source of the Qi in the different organs after one is born. The condition of the Heart-Qi is also directly influenced by the Heart-blood. Since an important function of the Heart is to govern the blood circulation, the relationship between Qi and blood in the Heart is very close from the start. It can be described as the Qi guides the blood and the blood carries the Qi. Thus the function of the Heart-Qi depends on sufficient blood. The Qi and the blood are generated by each other and they gain support from each other. Since the Heart houses the shen, a normal mental state and activities depend on sufficient Heart-Qi and Heart-blood.
Heart-Qi deficiency is often seen in conditions of Spleen-Qi deficiency and acute or chronic blood deficiency.
• If the Qi is too weak to promote blood circulation, palpitations start.
• If the Heart-Qi is not able to support the Lung-Qi in the Upper-Jiao, patients will have shortness of breath on exertion and will sweat easily.
• If the Heart-Qi is too weak to support the Heart-shen, patients may suffer from anxiety, restlessness, restless sleep and waking up frequently during the night, and may have a weak and restless pulse.
• When the Heart-Qi is too weak to stimulate the blood circulation, the color of the tongue turns to purple and the pulse does not flow freely.
(See Figure 5.3 on page 189 .)
Treatment principle: Tonify the Heart-Qi, nourish the Heart-blood, regulate the blood circulation and calm the mind
Herb selection principles and formula composition strategies
• First, herbs that are sweet, slightly warm and pungent, enter the Heart and Spleen meridians, and have a function of tonifying the Heart-Qi are selected.
• Second, herbs that are sweet and slightly warm, enter the Heart, Spleen and Liver meridians, are able to nourish the blood, calm the mind and improve sleep are often selected.
• Third, herbs that promote the Qi movement and blood circulation so as to maintain the proper function of the Heart are often used.
Structure of the formula and selection of herbs
Chief: Tonify the Heart-Qi directly
Ren Shen ( Ginseng radix) or Dang Shen ( Codonopsis radix)
Both Ren Shen and Dang Shen are sweet in nature and enter the Spleen and Lung meridians. They can directly tonify the Spleen-Qi and can therefore generate the Heart-Qi. They can tonify the Lung-Qi as well, which stimulates the blood circulation and influences the function of the Heart. They are often selected in the formula as chief to tonify the Heart-Qi. Compared with Dang Shen, Ren Shen is warm; as it also tonifies the Source-Qi, its function of tonifying the Heart-Qi is stronger than that of Dang Shen. However, some patients cannot bear its strong tonification and the symptoms of restlessness and insomnia can get worse. Dang Shen is sweet and neutral. It can gently tonify the Heart-Qi, does not have the side effects of Ren Shen, and is suitable for chronic conditions.
Zhi Gan Cao ( Glycyrrhizae radix preparata)
Zhi Gan Cao is sweet and slightly warm, which are the principal properties of herbs that can tonify the Qi. It enters all the ordinary meridians, can tonify the Qi, moderate the speed of Qi and blood, and harmonize the functions of the internal organs. It is particularly selected in the formula with a large dosage as chief to calm the mind and relieve the palpitations and restlessness caused by Heart-Qi deficiency.
Long Yan Rou ( Longanae arillus)
Lou Yan Rou is a sweet and neutral fruit. It enters the Heart and Spleen meridians and can gently tonify the Spleen-Qi, the Heart-Qi and the blood. At the same time, it can calm the mind and treat restlessness, anxiety and insomnia. As this sweet fruit is neither cloying nor dry in property, it can be used in the diet for chronic conditions.
Deputy: Tonify the blood and generate the Heart-Qi
Wu Wei Zi ( Schisandrae fructus)
Wu Wei Zi is sour and warm, and enters the Lung, Heart and Kidney meridians. It has no function to tonify the Qi, but it can stabilize the Heart-Qi, especially when it is used with tonifying herbs. This herb is especially effective to treat palpitations, shortness of breath after exertion and sweating due to weakness of the Heart-Qi.
Fu Shen ( Poriae cocos pararadicis)
Fu Shen is neutral and bland, and enters the Heart and Spleen meridians. It is able to tonify the Heart-Qi and Spleen-Qi and calm the mind, thereby treating restlessness and insomnia. Since it is neutral and bland, and gentle in property and action, it is often used in the diet for chronic conditions of Heart-Qi deficiency.
Suan Zao Ren ( Ziziphi spinosae semen)
Suan Zao Ren is sweet, sour and neutral, and enters the Heart and Liver meridians. It nourishes the blood of the Heart and Liver and improves sleep. It is very useful in formulas to treat restlessness and insomnia caused by blood deficiency.
Mai Men Dong ( Ophiopogonis radix)
Mai Men Dong is sweet and cold, and enters the Heart, Lung and Stomach meridians. Although it is often used to nourish the Yin and reduce heat, it has a gentle function of tonifying the Qi of the Heart and Lung. It is a perfect choice in a formula when both the Qi and Yin are deficient.
Assistant: Calm the mind
Long Chi ( Mastodi fossilia dentis), Fu Shen ( Poriae cocos pararadicis) and Xiao Mai ( Tritici semen)
These three substances are all able to calm the mind. Of the three, Long Chi is the strongest and is used in acute conditions; Fu Shen can be used over a longer period of time and it can also gently tonify the Spleen-Qi; Xiao Mai is cold in temperature and it is principally used to treat restlessness with irritability when there is slight excess heat or empty-heat in the Heart.
Sheng Di Huang ( Rehmanniae radix) and Xuan Shen ( Scrophulariae radix)
The stable relationship between the Heart and Kidney is important in maintaining the normal mental state. It is described as the Heart-fire descends to the Lower-Jiao to warm the Kidney-water; and the Kidney-water ascends to the Upper-Jiao to calm the Heart-fire. Both herbs are cold in nature and enter the Heart and Kidney meridians. They are able to nourish the Heart-Yin and reduce the excess fire and empty-fire there. They are often chosen in formulas to treat restlessness and palpitation caused by Yin deficiency with heat in the Heart.
Chuan Xiong ( Chuanxiong rhizoma), Gui Zhi ( Cinnamomi cassiae ramulus) and alcohol
When the Heart-Qi is too weak to stimulate the blood, blood stagnation may appear, thus directly causing palpitations and restlessness.
Chuan Xiong is warm and pungent, and enters the Heart and Liver meridians. It is called a Qi moving herb in the blood. A small amount of Chuan Xiong can be used in formulas that tonify the Heart-Qi as it can stimulate the blood circulation and Qi movement.
Gui Zhi and alcohol are pungent and warm. They enter the Heart meridian and can stimulate spreading of the Yang and Qi movement. A small amount of Gui Zhi or alcohol can be used as assistant in the formula to tonify the Heart-Qi in order to stimulate the blood circulation and Qi movement.
Alcohol is pungent and warm. Since it has a quick moving ability, it is considered to enter all meridians. It can stimulate the Yang and spread the Yang and Qi.
Since these substances are pungent and can consume the Qi, they should be used with a large number of herbs that tonify the Qi and blood of the Heart and their dosages should be small.
Yuan Zhi ( Polygalae radix) and Shi Chang Pu ( Acori graminei rhizoma)
These two herbs are pungent, bitter and warm, and enter the Heart meridian. They are able to eliminate the invisible phlegm, open the chest and calm the mind. They can be applied in the formula if phlegm is generated by deficiency of the Spleen-Qi and Heart-Qi, and the phlegm covers the mind and leads to insomnia, palpitations and restlessness.
Envoy: Harmonize the herbs in the formula
Zhi Gan Cao ( Glycyrrhizae radix preparata) and Wu Wei Zi ( Schisandrae fructus)
As the sweet Zhi Gan Cao can harmonize the herbs in a formula, and the sour Wu Wei Zi can stabilize the actions of the herbs in a formula, they are often used as envoys.
Common accompanying symptoms and treatment
• Liver-Qi stagnation: add Xiang Fu ( Cyperi rhizoma) and Chai Hu ( Bupleuri radix) to spread the Liver-Qi.
• Liver-blood deficiency: add Shu Di Huang ( Rehmanniae radix praeparata) and Bai Shao Yao ( Paeoniae radix lactiflora) to nourish the blood.
• Sadness or depression due to Lung-Qi deficiency: add He Huan Pi ( Albiziae cortex) and Bai He ( Lilii bulbus) to moisten the Lung and spread the Qi.
• Reduced appetite with distension of the stomach: add Chen Pi ( Citri reticulatae pericarpium) and Ban Xia ( Pinelliae rhizoma) to soothe the Stomach-Qi.
Examples of classical formulas
Zhi Gan Cao Tang (Radix Glycyrrhizae Uralensis Decoction) 
Source: Shang Han Lun 
Composition
Zhi Gan Cao ( Glycyrrhizae radix preparata) 12 g
Ren Shen ( Ginseng radix) 6 g
Da Zao ( Jujubae fructus) 5–10 pieces
Sheng Di Huang ( Rehmanniae radix) 30 g
Mai Men Dong ( Ophiopogonis radix) 10 g
E Jiao ( Asini corii colla) 6 g
Hei Zhi Ma ( Sesami semen nigricum) 10 g
Sheng Jiang ( Zingiberis rhizoma recens) 9 g
Gui Zhi ( Cinnamomi cassiae ramulus) 9 g
Rice wine ( Vinum orizae) 10 ml
Analysis of the formula
This is a formula to treat chronic palpitations and irregular pulse. The symptoms are directly caused by deficiency of the Heart-Qi. As the Qi is supported by the blood and Yin, and stimulated by the Yang, in this syndrome there is also blood, Yin and Yang deficiency.
In this formula:
• The chief herbs are Zhi Gan Cao, Ren Shen and Da Zao. Since they directly tonify the Heart-Qi, they can stimulate the Qi movement.
• Sheng Di Huang, Mai Men Dong, E Jiao and Hei Zhi Ma serve as deputies to tonify the blood and nourish the Yin so as to house and carry the Qi.
• Sheng Jiang and Gui Zhi together with rice wine are assistants. They stimulate the Heart-Yang, and promote the Qi movement and blood circulation so as to treat the palpitations which are partially caused by the Qi and blood stagnation.
Commentary on strategies
This formula, devised by Dr Zhang Zhong Jing, has existed for more than 2000 years. Although the symptoms and signs are mentioned briefly, the deficiency of Qi and blood, Yin and Yang can be found in the analysis of this formula.
• This formula demonstrates the treatment strategies of relieving palpitations in a chronic case by tonifying the weakness and stabilizing the relationships of the Qi and blood, Yin and Yang. It considers the function of the Qi as well as its substantial base, the Yin and blood.
• It should be borne in mind that the herbs which stimulate the Yang should be used in small dosage as they can consume the Qi and Yin. In cases of obvious Yin deficiency, where patients have a red tongue without coating and a thready and rapid pulse, warm and pungent herbs should not be used.
Gui Pi Tang (Restore the Spleen Decoction) 
Source: Ji Sheng Fang 
Composition
Ren Shen ( Ginseng radix) 15 g
Huang Qi ( Astragali radix) 30 g
Bai Zhu ( Atractylodis macrocephalae rhizoma) 30 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 8 g
Fu Shen ( Poriae cocos pararadicis) 30 g
Suan Zao Ren ( Ziziphi spinosae semen) 30 g
Long Yan Rou ( Longanae arillus) 30 g
Dang Gui ( Angelicae sinensis radix) 3 g †
Yuan Zhi ( Polygalae radix) 3 g †
Mu Xiang ( Aucklandiae radix)** 15 g
Sheng Jiang ( Zingiberis rhizoma recens) 6 g
Da Zao ( Jujubae fructus) 3–5 pieces
Analysis of the formula
This is a formula to treat chronic Spleen-Qi deficiency, which is unable to generate the Qi and blood to support the Heart. The main manifestations are palpitations, anxiety, forgetfulness, insomnia, feverishness and night sweats, prolonged menstruation with pale blood, poor appetite, tiredness, a pale complexion, a pale tongue with a thin white coating and a weak pulse.
In this formula:
• The chief is a group of herbs, a variation of the principal formula Si Jun Zi Tang (Four-Gentlemen Decoction). They are Ren Shen, Huang Qi, Bai Zhu and Zhi Gan Cao. These herbs can directly tonify the Spleen-Qi, strengthen the foundation of life and accelerate the process of generating Qi and blood.
• Fu Shen, Long Yan Rou and Suan Zao Ren are all deputies and they particularly tonify the Heart-Qi, calm the mind and improve sleep.
• Dang Gui, Suan Zao Ren, Long Yan Rou and Da Zao form another group of deputy herbs that particularly tonify the blood of the Heart and therefore strengthen the Heart-Qi and calm the mind.
• Mu Xiang and Yuan Zhi serve as assistants: the former can regulate the Qi movement in the Middle-Jiao to prevent tonifying herbs obstructing the Qi movement; the latter can remove the invisible phlegm and connect the Heart with the Kidney, thereby calming the mind.
• Sheng Jiang and Da Zao are also assistants. They can harmonize the Middle-Jiao and promote digestion so as to strengthen the tonifying function of the chief herbs.
Commentary on strategies
This is a well-organized formula for a chronic condition.
• It concerns the relationship in the physiological and pathological aspects between the Spleen, Heart and Kidney, as well as the Qi and blood of the Heart and Spleen.
• It balances the composition and dosage to reach the optimal result of tonifying the Heart-Qi and blood in order to improve all the symptoms in this syndrome.
Sheng Mai San (Generate the Pulse Powder) 
Source: Nei Wai Shang Bian Huo Lun 
Composition
Ren Shen ( Ginseng radix) 10 g
Mai Men Dong ( Ophiopogonis radix) 15 g
Wu Wei Zi ( Schisandrae fructus) 6 g
Analysis of the formula
Sheng Mai San is a small but very effective formula for treating many different disorders and conditions. When treating a disorder of the Heart, it is able to tonify the Heart-Qi, nourish the Heart-Yin and treat a syndrome where both Yin and Qi are deficient. This syndrome often arises during a hot summer or after a febrile disease when the excess heat or pathological heat consumes the Yin and Qi of the Lung and Heart. This syndrome is also seen in chronic diseases where the Heart-Yin and Heart-Qi are injured by a long-term imbalance between the internal organs. The main symptoms and signs are shortness of breath, tiredness, sweating, palpitations, anxiety, sadness and depression, a red tongue without coating, and a thready and restless pulse.
• Ren Shen, as chief, can directly tonify the Heart-Qi. It can be replaced by a large dosage of Dang Shen ( Codonopsis radix), which tonifies the Spleen-Qi so as to tonify the Heart-Qi.
• Mai Men Dong, as deputy, is sweet and cold. It enters the Heart meridian directly and can generate the Qi and nourish the Yin of the Heart. It may enhance the ability of the chief in tonifying the Qi.
• Wu Wei Zi, which is sour and warm, serves as assistant. It is able to stabilize the Heart-Qi and Yin. It enhances the actions of the sweet and cold herbs to tonify the Qi and the Yin.
Commentary on strategies
The treatment strategy in this formula is presented by using combinations of herbs that are sweet, cold and sour in nature. Although there are only three herbs in this formula, the result of tonifying the Yin and Qi is significant due to the perfect combination.
Yang Xin Tang (Nourish the Heart Decoction) 
Source: Zheng Zhi Zhun Sheng 
Composition
Ren Shen ( Ginseng radix) 12 g
Huang Qi ( Astragali radix) 15 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 15 g
Dang Gui ( Angelicae sinensis radix) 12 g
Chuan Xiong ( Chuanxiong rhizoma) 12 g
Fu Ling ( Poria) 15 g
Yuan Zhi ( Polygalae radix) 6 g
Bai Zi Ren ( Platycladi semen) 12 g
Suan Zao Ren ( Ziziphi spinosae semen) 12 g
Wu Wei Zi ( Schisandrae fructus) 6 g
Rou Gui ( Cinnamomi cassiae cortex) 6 g
Analysis of the formula
Yang Xin Tang is a formula to treat mental disorders caused by deficiency of the Spleen-Qi, the Heart-Qi and blood. The manifestations are palpitations and restlessness, mental confusion, insomnia, dream-disturbed sleep, tiredness and depression, a pale tongue with a thin white coating and a restless, weak pulse.
In this formula:
• The chief herbs are Ren Shen, Huang Qi and Zhi Gan Cao. They strongly tonify the Spleen-Qi in order to generate the Qi and blood to support the Heart.
• Dang Gui and Suan Zao Ren serve as deputies. As they can tonify the blood of the Heart directly, they can enhance the ability of the herbs that tonify the Heart-Qi.
• Rou Gui and Chuan Xiong can promote the blood circulation; Chuan Xiong can also strengthen the Kidney-Yang so as to stabilize the Heart-Qi. They are used as assistants in the formula.
• Suan Zao Ren, Bai Zi Ren, Fu Ling and Yuan Zhi also serve as assistants to calm the mind and improve sleep.
• Wu Wei Zi is sour and warm, and enters the Heart meridian. It can stabilize the Heart-Qi and Heart-Yin so as to calm the Heart-Shen. It is used as an assistant in the formula.
Commentary on strategies
Yang Xin Tang is a thoughtful formula in composition:
• It takes into consideration that the Qi and blood are the foundation materials of Heart-shen and therefore it tonifies the Qi and blood firstly.
• It tonifies the Qi by taking into consideration the source (the Kidney and the Spleen), which is demonstrated by the use of Ren Shen and Huang Qi.
• It tonifies the blood by taking into consideration the source (the Kidney and the Liver) and therefore it tonifies the Liver blood.
• It considers the nature of blood which prefers warmth and movement. This is demonstrated by the use of Rou Gui, Chuan Xiong and Dang Gui.
• Building on the foundation of Qi and blood, which has been strengthened and balanced, herbs that calm the mind are then used. The Qi tonifying herb (Ren Shen, Huang Qi), blood tonifying herb (Dang Gui) and balancing blood circulation herbs (Rou Gui, Chuan Xiong, Dang Gui) insure that the herbs that calm the mind can work steadily and effectively.
• Moreover, Zhi Gan Cao and Wu Wei Zi stabilize the Qi and blood, and can reduce the speed of the tonifying herbs and warm herbs. They insure the stable effect of calming the mind of the formula.
When all these herbs are used together, the Heart-Qi and blood are sufficient and the mind is settled.
