Traditional Chinese Medicine Case Studies / Medical Discussions / Reference Articles for Clinical Learning
Introduction: Today we introduce three common pulse types in clinical practice.01 Floating Pulse Does Not Always Indicate Exterior Disease According to the “Shang Han Lun” (Treatise on Cold Damage), it states: “If the pulse is floating, the disease is in the exterior.” Subsequent pulse literature has primarily interpreted floating pulse as indicative of exterior conditions.However, the “Jin Gui Yao Lue” (Essential Prescriptions of the Golden Cabinet) states: “If a patient’s pulse is floating at the front, the disease is in the exterior; if floating at the back, the disease is internal. If there is low back pain and inability to walk, it must be due to shortness of breath and extreme fatigue.”Generally, various schools interpret the front and back in terms of the cun (寸) and chi (尺) positions. Due to the different locations of the floating pulse, the reflected pathological changes can vary significantly.Therefore, I believe that the interpretation of “floating pulse indicates exterior disease” should be re-evaluated.Floating pulse is easily obtained, and in terms of its location, it appears at the muscle surface.The exterior refers only to the location of the pulse; as for whether it is an exterior syndrome, internal syndrome, external pathogen, or internal injury, one must observe the accompanying signs, such as floating and slack, floating and tight, floating and slow, floating and rapid, and analyze them in conjunction with the symptoms presented.Thus, the “Shang Han Lun, Tai Yang Disease Chapter” states: “If there is a sensation of fullness below the heart, and the pulse is floating and soft, then Da Huang Huang Lian Xie Xin Tang (Rhubarb and Coptis Decoction to Drain the Heart) is indicated.”Furthermore, the “Yang Ming Disease Chapter” states: “If the pulse is floating with fever, thirst for water, and difficulty urinating, then Zhu Ling Tang (Polyporus Decoction) is indicated.”The “Jin Gui Xue Bi Chapter” states: “If a man has a pale complexion, it indicates thirst and loss of blood, sudden shortness of breath, and a floating pulse indicates internal deficiency.”Additionally, the “Jaundice Chapter” states: “A floating pulse at the chi position indicates kidney damage.”All these floating pulses do not belong to the category of exterior syndromes.As stated in the “Jing Yue Quan Shu, Pulse Spirit Chapter”: “Floating indicates it is at the surface, yet in cases of true wind-cold external pathogens, the pulse is actually not floating; rather, it is tight and rapid with slight floating characteristics, indicating exterior evil, and the symptoms must include fever, no sweating, and body aches as indicators.If the pulse is floating and slack, it is not an exterior evil. Generally, a floating pulse that is strong and spirited indicates excess Yang, thus fire must follow, or phlegm may be present internally, or Qi may be obstructed above, which can be inferred.If the pulse is floating but weak and empty, it indicates insufficient Yin; insufficient Yin leads to signs of water deficiency, or blood not nourishing the heart, or essence not transforming into Qi, indicating internal deficiency. If one considers these as exterior syndromes, the harm would be great.”This discussion by Jing Yue is based on certain experiences.The reason the pulse is floating is primarily due to an excess of Qi rising and not descending, often reflecting excess above and deficiency below, with strong Yang and weak Yin.As stated in the “Jin Gui”, “shortness of breath and extreme fatigue” is precisely due to Yang deficiency and Yin not reaching, causing Qi to be forced upwards and not being absorbed.Floating is indeed a Yang pulse, but there is a distinction between having Yin excess rejecting Yang externally and having Yin deficiency with Yang exceeding externally.In cases of Yin excess, there is internal cold; treatment should focus on warming and dispersing, either guiding out the water, attacking the food, or moving the stasis of blood and phlegm, forcefully opening the blockages, with slight clearing to assist the floating Yang in internal harmony,such as Bai Tong Jia Zhu Dan Zhi Tang (White Atractylodes Decoction with Pig Bile) (Scallion White, Dried Ginger, Aconite, Human Urine, Pig Bile, etc.).In cases of Yin deficiency, the Yin is weak and cannot reach the Yang; it is advisable to warm and moisten, replenishing essence and blood, with slight assistance from warming and heating, to allow the Yang to emerge from the Yin and accept the Yang Qi back to its root,such as Gui Fu Ba Wei Wan (Cinnamon and Aconite Eight Flavor Pill).I once treated a young impoverished farmer who had continuous fever for four days without sweating, regularly working without rest, and not taking medicine. On the fifth day, he was exhausted and finally came for treatment. His skin was hot, lung Qi was obstructed, breathing was rapid, and the pulse was leaping at the skin, extremely rapid, with slight pressure yielding no response. The tongue coating was thin with little moisture, but he was not thirsty, indicating dryness of fluids and the condition of Yin and Yang not interacting.Immediately, I prescribed: Dang Shen (Codonopsis) 18g, Fu Pian (Aconite) 9g, Mai Men Dong (Ophiopogon) 18g, Wu Wei Zi (Schisandra) 3g, Zhi Gan Cao (Honey-fried Licorice) 9g, Gan Di Huang (Rehmannia) 15g, Xi Xin (Asarum) 3g.After taking the medicine twice, the next morning he sweated and the fever subsided, the pulse was no longer rapid, and upon further pressure, it was distinct. However, he had intermittent sweating and slight aversion to cold, and the pulse remained floating. I then used Gui Zhi Jia Fu Zi Tang (Cinnamon Decoction with Aconite) for one dose, and he recovered.The formula was a combination of Shen Fu Tang (Ginseng and Aconite Decoction) and Sheng Mai San (Generate the Pulse Powder) with modifications to warm and nourish the original Yang, and to generate body fluids, using only a small amount of Xi Xin to penetrate Yin and reach Yang.This was originally an external pathogen, but due to his persistent labor without rest and not taking medicine in a timely manner, it led to internal heat burning, resulting in a deficiency of both Yin and Yang.If one merely observes the pulse as floating and applies sweating methods, the outcome would be unpredictable.Therefore, my understanding is: Floating indicates it is at the surface, referring to the location of the pulse (i.e., position), and one must observe the accompanying signs of the floating pulse, analyze whether it belongs to cold, heat, deficiency, or excess syndromes. It is incorrect to assume that “floating pulse is exterior disease, and exterior disease is only seen with floating pulse.” 02 Differentiating Ruo Pulse from Weak Pulse The term “Ruo” means soft, and its pronunciation and meaning are the same; pronouncing it as “Ru” is incorrect.Wang Shuhe in the “Mai Jing” (Pulse Classic) refers to it directly as soft pulse, only noting in the annotations that “soft is also called Ruo.”Looking at Cheng Wujis’ annotations on the “Shang Han Lun, Differentiating Pulse Method”, it becomes clearer.In his explanation of “blood governs Ruo”, he states: “Ru Zhu Qie, meaning moistening,” and in the same section, he explains “Yang Yin pulse is large and Ruo” as “the sound is soft, meaning gentle.”Therefore, it is essential to accurately pronounce and interpret; they should not be confused.The Ruo pulse is soft, weak, and has little strength; the tactile sensation under the fingers is “like cotton floating on the water surface, light touch comes and heavy touch goes.” Therefore, it appears as a pulse at the floating position.It is neither like the weak pulse which is large and powerless, nor like the fine pulse which is thin as a thread, nor like the weak pulse which is deep, thin, and weak.Thus, the differentiation between Ruo pulse and weak pulse begins with the floating and sinking distinction; Ruo pulse appears at the floating position, while weak pulse appears at the sinking position, requiring “pressure to obtain”.Secondly, it is differentiated by the pulse body and pulse quality; Ruo pulse is fluffy and soft like cotton, while weak pulse is deep, thin, and weak. There is still a distinction to be made.However, some pulse literature does not differentiate between Ruo and weak, treating them as weak pulses regardless of their body characteristics or main diseases, which does not align with clinical practice.Based on personal experience, I have made a brief comparison as follows:1.From the perspective of main diseases, Ruo pulse often reflects an excess of dampness, while weak pulse is commonly seen in patients with Qi deficiency.Because Ruo pulse indicates dampness, in cases of limb fatigue, skin edema, and sores or skin diseases, the pulse is often Ruo.As recorded in historical texts: “If the pulse feels like mud, dampness combined with heat indicates that Ruo pulse leans towards evil excess.” Also, because weak pulse indicates Qi deficiency, in cases of shortness of breath, inability to endure labor, and spontaneous sweating or night sweats, the pulse is often weak, indicating insufficient righteous Qi.2.From the perspective of pathological changes, Ruo pulse indicates dampness, and excess dampness can stagnate Qi, so the pulse is felt as floating and solid; weak pulse indicates Qi deficiency, and deficiency can generate cold, although the pulse may be deep and thin, it does not necessarily feel soft.If the Ruo pulse is floating but does not appear too weak, it must be due to dampness combined with heat, indicating turbid Qi rising. If the weak pulse is deep and thin but does not appear too soft, it must be due to deficiency combined with cold, as cold leads to urgency.There are also cases where Ruo pulse and weak pulse appear simultaneously, with Ruo being more pronounced than weak, often seen in cases of dampness invading the liver and spleen, while lung and stomach Qi is obstructed, presenting clinical manifestations such as chest fullness, limb joint soreness, etc. Conversely, weak being more pronounced than Ruo is often seen in cases of true Yang deficiency in the heart and kidney, while spleen and lung Qi is deficient, presenting clinical manifestations such as food not being digested, abdominal pain with diarrhea, etc.However, it does not exclude the possibility of Yin deficiency damaging dampness, where the pulse can be seen as deep and Ruo, or Qi deficiency damaging wind, where the pulse can also be seen as floating and weak.With countless variations, careful examination is essential.3. From the perspective of treatment principles,In cases of excess dampness with Ruo pulse, the treatment should focus on aromatic herbs, supplemented with sweet and warm herbs; aromatic herbs are used to transform dampness, while sweet and warm herbs are used to benefit Qi, as excess dampness often originates from Qi deficiency.In cases of Qi deficiency with weak pulse, the treatment should focus on sweet and warm herbs, supplemented with aromatic herbs; sweet and warm herbs are used to benefit Qi, while aromatic herbs are used to awaken the spleen, as Qi deficiency generally requires warming the middle.The Ruo pulse that is not too weak may require slight bitter and cold herbs to clear the heat it carries, while the weak pulse that is not too soft may require slightly spicy and warm herbs to transform the internal cold it carries. The mixture of Ruo pulse and weak pulse often presents in this manner.Note: This article is excerpted from “Selected Lectures on Traditional Chinese Medicine, Volume 1”, compiled by the Graduate Class of Traditional Chinese Medicine Research Institute, published by the People’s Health Publishing House, October 1980.You May Also Like, click to read the original text:Qian Yuanming: Traditional Chinese Medicine “Pulse Diagnosis” is Not Mysterious, It Concerns “Qi and Blood” (with 22 Pulse Analyses)Ren Yingqiu: Summary of Experience in Treating Various Pains//////////[ Read Previous Exciting Articles ]#Traditional Chinese Medicine Entry Collection #Twelve Meridians Explained in Simple Terms #Donghai Medical Collection #Old TCM Practitioners’ Experiences #Wonderful TCM Formulas #Secret Formulas #Masters of Traditional Chinese Medicine#Famous Cases from Shang Han Lun #Selected Famous Cases from Jin Gui#Si Jun Zi Tang (Four Gentlemen Decoction) #Etiology Assignment #Herb Properties Assignment #Herb Properties Song for 400 Herbs #Medical Three-Character Classic #Daily Insights from Mentorship#Daily Insights on Principles, Methods, Formulas, and Herbs#Traditional Chinese Medicine Serialization CollectionHe Ren Master: What is the Essence of Using Warming Meridians Decoction?Zhou Zhongying: Insights and Techniques from 60 Years of TCM Diagnosis (All Essentials)Ding Guangdi: Qiang Huo Sheng Shi Tang for Treating “Five Morning Diarrhea”Unexpectedly, “Qing Gu San” is indeed the remedy for fever after bone fractures!Dan Zha San for Treating Hyperlipidemia (with Four Hyperlipidemia Formulas)Shanghai Shen’s Gynecology 600-Year Family Secret FormulaMiraculous! 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