Traditional Chinese Medicine Case Studies / Clinical References for Learning TCM
Introduction:When the pulse is easily felt with light pressure but insufficient with deep pressure, it is termed “floating pulse”. Any pulse that is easily obtained at the floating position is referred to as “floating pulse”.
Application of Floating Pulse
01
“The Master said: There are wind water, skin water, proper water, stone water, and yellow sweat. The pulse of wind water is floating, with external symptoms of joint pain and aversion to wind; the pulse of skin water is also floating, with external symptoms of swelling, no aversion to wind, and a distended abdomen without thirst, which should be treated with sweating.” (“Jin Kui Yao Lue · Water Qi Disease Pulse Diagnosis and Treatment · One”)
“Jin Kui Yao Lue Xin Dian” (abbreviated as “Xin Dian”): Wind water refers to water affected by wind, causing water-related diseases. Wind injures the skin and dampness flows into the joints, hence the floating pulse and joint pain; skin water refers to water flowing in the skin, internally connecting with lung qi, hence the floating pulse. It does not involve wind, hence no aversion to wind. The distended abdomen indicates that it is not firm, as stated in the “Nei Jing”. Since the disease is in the skin and does not reach the intestines, there is external distension without internal fullness or wheezing. Water in the skin should be resolved through sweating, hence it is said to induce sweating.”“Pulse Studies Discussion”: Wind water is water qi externally accompanied by wind evil, hence the external symptoms of joint pain and aversion to wind; skin water is dampness on the surface without wind evil, hence the external symptoms of swelling without aversion to wind. Although there is a distinction between external evil and no external evil, both are due to water dampness on the surface, hence the pulse is floating, and both can be treated with sweating.Note:The author investigated 40 cases of acute and chronic nephritis, all of which had factors of external wind, cold, and dampness. However, simple wind dampness alone cannot constitute this disease; there must be an internal factor of deficiency of yang qi in the body. Only the combination of internal and external causes can form the etiology of edema. Wind water and skin water are due to dampness on the surface, and the general yang qi has not been severely damaged, so they can be treated with sweating, such as using formulas like “Yue Bi Decoction” and “Xiao Qing Long Decoction”. Inducing sweating will lead to urination and reduce edema.Clinical Experience: In cases of wind water affecting the whole body and face, with joint pain, even to the point where the hands cannot be touched; Western medical examinations often indicate acute nephritis. The pulse is floating and slippery, and there may also be a deep slippery pulse. The tongue tip is often red with a thin, slightly greasy coating, and urination is scant and red. Administering “Yue Bi Decoction” will lead to urination and reduce edema.
02
“Wind water with aversion to wind, the whole body is swollen, the pulse is floating and there is no thirst, and sweating continues without high fever; “Yue Bi Decoction” is the main treatment.” (“Jin Kui Yao Lue · Water Qi Disease Pulse Diagnosis and Treatment · Two and Three”)“Xin Dian”:This is quite similar to the previous syndrome but has a unique treatment. The action of Ma Huang (Ephedra) is to induce yang qi, while the tenfold dose of Fang Ji (Stephania) reduces the substantial effect of Huang Qi (Astragalus) on the surface and increases the cold and pungent nature of Shi Gao (Gypsum). Why? The phrase about the pulse being floating and not thirsty, or floating and thirsty, indicates that thirst is due to internal heat, and sweating is due to heat pressing. This is different from sweating due to surface deficiency, hence Shi Gao is used to clear heat, and Ma Huang disperses swelling without compromising the surface.”“Pulse Studies Discussion”:The floating pulse with aversion to wind and the whole body swollen is a manifestation of wind evil accompanied by water dampness on the surface. Due to the water dampness combined with heat, sweating continues, hence “Yue Bi Decoction” can induce sweating, leading to the removal of water dampness and resolution of swelling.Note:Wind water and skin water, based on the comparison of TCM and Western medicine for nephritis, mostly belong to acute nephritis, with some cases of chronic nephritis having acute exacerbations. In cases of acute nephritis with edema, the pulse is often floating and slippery or deep and slippery, the complexion is moist, and the righteous qi is not damaged, making it easy to reduce swelling. This is unlike chronic nephritis, where the complexion is dark and the urine is white, the righteous qi is weak and cannot overcome the evil, making it difficult to reduce swelling. Moreover, even if swelling is reduced, it is prone to recurrence. Therefore, when treating edema in chronic nephritis, one cannot solely focus on eliminating water; generally, one must start from warming and tonifying the spleen and kidneys. After benefiting from the water dampness, one can consolidate the treatment.“Pulse Origin”:This article discusses the pulse diagnosis and treatment of wind water. The aversion to wind and the whole body being swollen indicates that the mechanism is directed outward, hence the pulse is floating. The absence of thirst indicates that both wind and water are damaging, hence there is no thirst, and sweating continues. The absence of high fever indicates that although there is slight heat, it is not a strong heat. This decoction is used to disperse wind water.
03
“In cases of wind water, the pulse is floating and the body is heavy, with sweating and aversion to wind; use Fang Ji Huang Qi Decoction as the main treatment; if there is abdominal pain, add Shao Yao (Peony).” (“Jin Kui Yao Lue · Water Qi Disease Pulse Diagnosis and Treatment · Two and Two”)“Pulse Origin”: This article discusses the pulse diagnosis and treatment of wind dampness with surface deficiency. The evil is at the surface, hence the pulse is floating; sweating and aversion to wind indicate wind; the heaviness of the body indicates dampness. This decoction is used to drive away wind dampness and consolidate the surface.”“Pulse Studies Discussion”: This section discusses the treatment of wind water with surface deficiency. The floating pulse and heavy body indicate that water dampness is on the surface, and sweating and aversion to wind indicate surface deficiency. Fang Ji Huang Qi Decoction can be used to support the righteous qi, consolidate the surface, and drive away dampness.Note:This section does not mention swelling but indicates that the pulse is floating and the body is heavy, indicating that dampness is retained in the skin. In Fang Ji Huang Qi Decoction, Bai Zhu (White Atractylodes) works in conjunction with Huang Qi to promote dampness elimination, while Fang Ji clears heat and promotes dampness, balancing the warming nature of Huang Qi and Bai Zhu, making it quite suitable. The conditions treated by Fang Ji Huang Qi Decoction and Yue Bi Decoction are both for wind water, but the difference lies in surface deficiency versus surface excess, and the presence or absence of heat. The Yue Bi Decoction is for surface excess with heat, hence the whole body is swollen, and the pulse is floating with continued sweating; while the Fang Ji Huang Qi Decoction is for surface deficiency without heat, hence the pulse is floating, the body is heavy, and sweating occurs. Although the external pulse symptoms are similar, the pathogenesis is quite different.
04
“In cases of water disease, the pulse is deep and small, belonging to Shao Yin. The floating pulse indicates wind. If there is no water but a feeling of fullness, it is due to qi. Water can induce sweating. If the pulse is deep, use Ma Huang Fu Zi Decoction; if floating, use Xing Ren Decoction.” (“Jin Kui Yao Lue · Water Qi Disease Pulse Diagnosis and Treatment · Two and Six”)“Xin Dian”:Water qi with a deep and small pulse belongs to Shao Yin, indicating kidney water. The floating pulse indicates wind, hence wind water. If there is no water but a feeling of fullness, it indicates a qi disease rather than a water disease. Qi disease cannot be treated with sweating, while water disease can be treated with sweating; however, the methods of inducing sweating differ. For Shao Yin, one should warm the meridians; for wind water, one should open the lungs. Hence, if the pulse is deep, use Ma Huang Fu Zi Decoction; if floating, use Xing Ren Decoction. Deep indicates Shao Yin, while floating indicates wind.”“Pulse Studies Discussion”:In water qi disease, the pulse is generally seen as deep, while in wind water disease, a deep pulse may sometimes appear, such as “… the pulse at the cun (inch) position is deep and slippery, indicating the presence of water qi, with a swollen face and heat, termed wind water.” This is a clear example. However, if the pulse is deep and small, it belongs to the Shao Yin yang deficiency water qi disease. The floating pulse indicates wind evil at the surface, which is a wind water disease. If there is fullness without water, it is a qi fullness, which is different from water fullness. Wind water can be treated with sweating, while the details of Xing Ren Decoction are not specified, but it can be used with Yue Bi Decoction. A deep pulse indicates yang qi deficiency that cannot reach the surface, hence water dampness is not beneficial, and Ma Huang Fu Zi Decoction should be used to warm yang, reach the surface, induce sweating, and promote water elimination, leading to the resolution of swelling.Note:Distinguishing between fullness due to qi and fullness due to water must be done through abdominal examination, and it is best to use Western medical methods to check for ascites.In water qi disease, the deep and small pulse is absolutely different from the deep and slippery pulse. The deep and small pulse indicates yang deficiency and water cannot be transported, hence it should be warmed and yang should be supported; the deep and slippery pulse indicates wind heat accompanied by water, hence sweating should be used to clear heat and promote water elimination. One is cold, the other is heat; one is at the surface, the other is internal; they are different and should not be confused. Water qi disease may also present with a hidden pulse, often due to water dampness obstructing the pathways, which is different from the deep and small pulse indicating yang deficiency and water not being transported.
05
“In cases of cough with a floating pulse, use Hou Po Ma Huang Decoction; in cases of cough with a deep pulse, use Ze Qi Decoction.” (“Jin Kui Yao Lue · Lung Atrophy, Lung Abscess, Cough, and Shortness of Breath Disease Pulse Diagnosis and Treatment · Eight to Nine”)“Xin Dian”:This is not detailed in the symptoms, but the floating and deep pulse are used to differentiate the treatment.Note:Hou Po Ma Huang Decoction and Xiao Qing Long Decoction are quite similar, as they primarily focus on dispersing evil and eliminating fluids, while Hou Po is warm and can also assist the surface; Xiao Mai (Wheat) is sweet and neutral, hence it can stabilize and support the righteous qi.Ze Qi Decoction is primarily based on Ze Qi (Alisma), with Bai Qian (Cynanchum), Huang Qin (Scutellaria), and Ban Xia (Pinellia) as assistants, hence it has a strong downward action. Although Sheng Jiang (Ginger) and Gui Zhi (Cinnamon) are pungent, they are only used to descend qi and reduce counterflow, and cannot induce sweating.Zhong Jing’s intention is that since coughing is due to lung evil, a floating pulse indicates that qi is mostly at the surface, hence it is easier to drive it out; while a deep pulse indicates that qi is mostly internal, hence it is easier to drive it down, which is also a method of leveraging the situation.“Pulse Studies Discussion”:Coughing with a floating pulse is caused by surface evil accompanied by internal fluids, hence Hou Po Ma Huang Decoction is used to disperse external evil and drive out internal fluids. Coughing with a deep pulse indicates that water fluids are retained internally, leading to counterflow and cough, hence Ze Qi Decoction is used to eliminate fluids and reduce counterflow as the main treatment.Note:This section uses the floating and deep pulse to differentiate between surface and internal fluid evils. For surface evils, disperse the evil and drive out the fluids; for internal evils, reduce counterflow and eliminate the fluids, which is also a method of leveraging the situation.
06
“In cases of lung distension, cough, and shortness of breath, with irritability and wheezing, if the pulse is floating, it indicates that there is water in the heart; use Xiao Qing Long Decoction with Shi Gao (Gypsum) as the main treatment.” (“Jin Kui Yao Lue · Lung Atrophy, Lung Abscess, Cough, and Shortness of Breath Disease Pulse Diagnosis and Treatment · One Four”)“Pulse Origin”:This article has the same meaning as above. If there is cold fluid in the heart and external evil attacks, it leads to cough, shortness of breath, irritability, and wheezing, hence the pulse is floating. This decoction warms the cold and resolves both water and heat.“Pulse Studies Discussion”:The floating pulse indicates the presence of surface symptoms, while there is water in the heart, indicating that there is water fluid in the stomach. The external evil and internal fluid are clashing, hence the shortness of breath and cough. If there is heat evil, it leads to irritability and wheezing. Xiao Qing Long Decoction is used to resolve the external evil and drive out the internal fluids, with Shi Gao added to clear internal heat.Note:Based on clinical experience, this formula is very effective for acute and chronic bronchitis, especially when distinguishing between heat and fluid accumulation. The pulse is often seen as floating and slippery, and the tongue coating is white and greasy, indicating the presence of heat and fluid accumulation. However, the dosage of Ma Huang and Shi Gao must exceed five to ten times that of Ma Huang to achieve the effect of clearing heat and eliminating fluids. Otherwise, Ma Huang, Gui Zhi, Jiang, Xia, and Xi Xin are all pungent and drying herbs, and if Shi Gao is used in small amounts, it cannot counteract the dryness of the other herbs, hence it will not be effective for internal heat and irritability. Therefore, caution must be exercised when using this formula.
07
“The Master said: If the patient’s pulse is floating at the front, the disease is at the surface; if floating at the back, the disease is internal. If there is low back pain and stiffness, it must be shortness of breath and extreme fatigue.” (“Jin Kui Yao Lue · Zang Fu Meridians Disease Pulse Diagnosis · Nine”)“Xin Dian”:“Front” refers to the front pulse, while “back” refers to the back pulse; the front pulse is yang, and the back pulse is yin. If the front pulse is floating, it indicates that the disease is at the surface; if the back pulse is floating, it indicates that the disease is internal. However, even if it is internal, if it is yang pulse, it is still a surface condition, not a deep internal condition. Hence, if the disease is not resolved at the surface, it will eventually affect the internal organs.”“Pulse Studies Discussion”:The front refers to the cun pulse, while the back refers to the chi pulse. A floating cun pulse indicates an external evil, while a floating chi pulse indicates an internal injury. Low back pain, stiffness, and shortness of breath indicate internal deficiency of the kidneys.Note:The floating pulse at the cun position indicates a surface condition, while the floating pulse at the chi position indicates an internal condition. In clinical practice, this is often verified; however, it must also be combined with symptoms such as low back pain, stiffness, and shortness of breath, along with a floating chi pulse, indicating kidney deficiency. A floating pulse at the cun position must also be accompanied by symptoms such as headache and aversion to cold to be considered a surface condition. Zhong Jing’s intention is to convey that one should not be rigid in interpretation.
08
“If a man has a pale complexion (pale and not rosy), it indicates thirst and loss of blood. If there is sudden shortness of breath and palpitations, the floating pulse indicates internal deficiency.” (“Jin Kui Yao Lue · Blood Bi, Deficiency Labor Disease Pulse Diagnosis and Treatment · Four”)“Xin Dian”:Thirst indicates heat injuring yin qi, while loss of blood indicates a lack of luster in color, hence a pale complexion indicates thirst and loss of blood. Li Shi states: “Labor leads to depletion of both qi and blood; qi deficiency leads to shortness of breath, while blood deficiency leads to palpitations.” Sudden onset indicates an acute condition. The floating pulse indicates internal deficiency, as labor leads to the loss of true yin, leaving the solitary yang without foundation, causing qi to scatter externally and essence to be depleted internally.“Pulse Studies Discussion”:The floating pulse in deficiency labor indicates a loss of yin blood, with yang qi scattering externally. The floating pulse without strength or a large empty pulse indicates a phenomenon of blood loss and yang without attachment. A pale complexion indicates a lack of luster and spirit; thirst is due to yin deficiency and insufficient fluids, but one should not drink excessively, as this is different from thirst due to stomach heat. Sudden shortness of breath and palpitations indicate a sudden onset of shortness of breath and heart palpitations, which is due to kidney deficiency and qi not returning to the source. Comprehensive observation of the pulse diagnosis indicates a loss of yin blood internally and floating yang externally, hence it is concluded that the floating pulse indicates internal deficiency.”Note:Zhang Jie Bin states: “… Generally, a floating pulse with strength and spirit indicates an excess of yang; when yang is excessive, fire must follow, which may lead to phlegm in the middle or qi stagnation above, which can be inferred; if the pulse is floating and without strength, it indicates insufficient yin, leading to a deficiency of water, or blood not nourishing the heart, or essence not transforming into qi, indicating internal deficiency. If these are considered surface conditions, the harm is great.”Zhang’s specific proposal to distinguish between external and internal injuries based on the floating pulse should be sought from strength or weakness, spirit or lack of spirit, which is helpful for our pulse diagnosis and differentiation.“Pulse Origin”:This article discusses the pulse diagnosis of thirst and loss of blood in men. A pale complexion indicates a loss of moisture and spirit; yin blood deficiency leads to insufficient fluid transformation, hence thirst; qi injury leads to blood not being retained, hence loss of blood; if qi rises, it leads to sudden shortness of breath, indicating that true qi is not contained, hence the floating pulse indicates internal deficiency.
09
“If there is cold in the heart, the person suffers from a condition where the heart feels like it is being eaten by garlic. In severe cases, there is pain in the heart that radiates to the back, and pain in the back that radiates to the heart, like being eaten by insects. If the pulse is floating, it indicates that vomiting will lead to recovery.” (“Jin Kui Yao Lue · Five Zang Wind Cold Accumulation Disease Pulse Diagnosis and Treatment · Nine”)
“Xin Dian”:When the heart feels like it is being eaten by garlic, it indicates that cold is bound externally and fire is constrained internally, leading to a sensation of pain that is neither pain nor heat, causing frustration and helplessness. In severe cases, there is pain in the heart and back, like being eaten by insects, indicating that if the pulse is floating, there is an opportunity for the cold to exit, and if vomiting occurs, the evil will be expelled and recovery will follow. However, this is also a natural movement of qi and cannot be forced with medicine to induce vomiting. Hence, it is said that if the pulse is floating, vomiting will lead to recovery.”“Pulse Studies Discussion”:The sensation of cold in the heart, with symptoms of heart pain like being eaten by garlic, indicates severe pain. The floating pulse indicates that the evil is trying to exit from above, hence vomiting will lead to recovery.Note:The floating pulse indicates that the evil is trying to exit from above, which is similar to the meaning of “… the pulse of malaria is floating and large, indicating that it can be expelled by vomiting.” However, the condition of recovery through vomiting indicates that there is a tangible evil, such as phlegm, food, or drink; hence this section on cold in the heart also belongs to cold fluid, otherwise, it would not lead to recovery through vomiting.
10
“In cases of alcoholic jaundice, if there is no heat, the patient is calm and speaks clearly (indicating that the condition is relatively stable, and the patient is clear in speech). If there is abdominal fullness and a desire to vomit, with a dry nose; if the pulse is floating, induce vomiting first; if it is deep and wiry, induce a downward action first.” (“Jin Kui Yao Lue · Jaundice Disease Pulse Diagnosis and Treatment · Five”)“Xin Dian”:In cases of alcoholic jaundice, there must be heat in the heart; however, if there is no heat and the patient is calm and speaks clearly, it indicates that the heat is not concentrated in the heart but may accumulate below, leading to abdominal fullness or upward pressure, causing a desire to vomit and a dry nose. If there is abdominal fullness, it can be treated with downward actions; if there is a desire to vomit, it can be treated with upward actions. If there is abdominal fullness and a desire to vomit, both downward and upward actions can be taken. However, if the pulse is floating, it indicates that the evil is close to the surface, hence it should be treated with vomiting first; if the pulse is deep and wiry, it indicates that the evil is close to the interior, hence it should be treated with downward actions first.”“Pulse Studies Discussion”:In cases of alcoholic jaundice, the primary treatment is to promote urination; if the pulse is floating, it indicates that the evil is close to the surface, hence it should be treated with sweating. The pulse floating indicates that the evil is at the surface, hence it should be treated with sweating, and the floating pulse indicates that it should be treated with vomiting first. However, if there is no external wind and there is a desire to sweat, then the treatment should be with Gui Zhi (Cinnamon) to disperse, while Huang Qi (Astragalus) should be used to consolidate the surface. This is the method of harmonizing the ying and wei, and it does not necessarily indicate the presence of external evil. Gui Zhi Huang Qi Decoction is itself a formula for harmonizing the ying and wei, similar in meaning to Xiao Jian Zhong Decoction.”
11
“The Master said: In all diseases of jaundice, promote urination; if the pulse is floating, it should be treated with sweating, hence use Gui Zhi Jia Huang Qi Decoction as the main treatment.” (“Jin Kui Yao Lue · Jaundice Disease Pulse Diagnosis and Treatment · Six”)“Xin Dian”:Promoting urination indicates that damp heat is eliminated, hence jaundice resolves itself. Therefore, promoting urination is the main method for treating jaundice. However, if the pulse is floating, it indicates that the evil is close to the surface, hence it should be treated with sweating. The floating pulse indicates that it should be treated with vomiting first. However, if there is no external wind and there is a desire to sweat, then Gui Zhi should be used to disperse, while Huang Qi should be used to consolidate the surface. This is the method of harmonizing the ying and wei, and it does not necessarily indicate the presence of external evil. Gui Zhi Huang Qi Decoction is itself a formula for harmonizing the ying and wei, similar in meaning to Xiao Jian Zhong Decoction.”“Pulse Studies Discussion”:Jaundice is primarily caused by damp heat accumulation, hence promoting urination is the main method for treating jaundice; however, there may also be surface symptoms without heat in jaundice, hence the floating pulse without heat indicates that Gui Zhi Jia Huang Qi Decoction should be used to induce sweating and resolve the condition.Note:In cases of jaundice, urination must be promoted; if the pulse is floating, it indicates that the evil is close to the surface, hence it should be treated with sweating. The floating pulse indicates that it should be treated with vomiting first. However, if there is no external wind and there is a desire to sweat, then Gui Zhi should be used to disperse, while Huang Qi should be used to consolidate the surface. This is the method of harmonizing the ying and wei, and it does not necessarily indicate the presence of external evil. Gui Zhi Huang Qi Decoction is itself a formula for harmonizing the ying and wei, similar in meaning to Xiao Jian Zhong Decoction.”
12
“The Master said: If the chi pulse is floating, and the eyes are yellow and blurry, and the nosebleed has not stopped; when the yellow disappears and the eyes are clear, it indicates that the nosebleed has stopped.” (“Jin Kui Yao Lue · Shock, Vomiting, Nosebleed, Chest Fullness, and Stagnation Blood Disease Pulse Diagnosis and Treatment · Two”)“Xin Dian”:A floating chi pulse indicates that there is wandering fire in the kidneys; yellow and blurry eyes indicate that there is heat accumulated in the liver, leading to nosebleeds. If the yellow disappears and the eyes are clear, it indicates that not only has the liver heat been eliminated, but the kidney heat has also been eliminated, hence the nosebleed will stop.”“Pulse Studies Discussion”:A floating chi pulse indicates kidney yin deficiency, with wandering yang; yellow and blurry eyes indicate that there is heat in the liver (the liver opens to the eyes), and kidney yin deficiency leads to liver heat rising, forcing blood to rise, hence the nosebleed does not stop. If the liver and kidney heat are eliminated, the yellow will disappear, the eyes will be clear, and the floating chi pulse will also settle, hence the nosebleed will naturally stop.Note:Based on clinical experience, in cases of asthma with a floating and large chi pulse, it indicates kidney yin deficiency, with yang rising. The treatment should focus on kidney yin tonification to stabilize yang qi. Although the conditions discussed here are different, the principles are not contradictory. Studying TCM should be integrated and understood comprehensively for effective application.Note: Please follow medical advice for specific treatments and medications! This article is excerpted from “Pulse Method Essentials”, edited by Zhang Tang Min and Sun Ren Ping, Chemical Industry Press, July 2007.
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