The Mysterious Floating Pulse in TCM Examination
Starting from the formula of Ma Huang Lian Qiao Chi Xiao Dou Tang (Ephedra, Forsythia, and Adzuki Bean Decoction)
Excerpted from “Lecture Notes on Cold Damage by Hao Wanshan”
In April 1976, just before the Tangshan earthquake, we were unaware that an earthquake would occur in July. At that time, I, along with Teacher Liu Duzhou, took our classmates from the 74th and 75th classes to open a school in the Tangshan area, specifically in Funing County. One of the students developed urticaria (hives). Many people now pronounce it as xún (荨麻疹), but I later asked the national language authority why it was changed from qián (荨麻疹). They said, “There was originally no path on the ground, but as more people walked, a path was formed.” This character should have been pronounced as qián, but now you hear doctors and patients alike pronouncing it as xún. Since so many people have taken this path, we have decided that xún is correct, while qián feels a bit hesitant. This student suffered from urticaria, unable to sleep at night due to itching. He came to me for treatment, and I prescribed general cooling blood, drying dampness, dispelling wind, and stopping itching herbs. After three days of medication, he still couldn’t sleep at night due to itching. Since Teacher Liu and I shared a room, the student came to me again, saying, “Teacher, I have taken your three prescriptions, but it still isn’t better.” I said, “Let the teacher take a look.” Teacher Liu felt his pulse and asked me, “What pulse pattern do you think this is?” I said, “This student is thin, and the pulse can be felt lightly.” He said, “What do you mean by lightly felt? Are you saying it is a floating pulse?” I replied, “But he doesn’t have a cold; can we say it is a floating pulse? The pulse can be felt lightly.” He said, “Isn’t it a floating pulse if he doesn’t have a cold? Where is he itching?” I said, “On the skin.” He asked, “Is the skin exterior or interior?” I said, “Of course, the skin is exterior, not interior.” Since the skin is itching, which is exterior, and the pulse is lightly felt, it must be an exterior syndrome. I said, “Teacher, this is an exterior syndrome, right?” He said, “Yes.” I asked, “What should we do?” He said, “We should induce sweating for an exterior syndrome.” I said, “This illness requires inducing sweating?” He replied, “Yes.” I asked, “What formula should we use?” He said, “Use Ma Huang Lian Qiao Chi Xiao Dou Tang, as it addresses damp-heat in the exterior.” After writing the prescription and asking Teacher Liu about the dosage, he said, “Take the medicine during the day, but do not eat it. Instead, take it before bed, drink some hot water, and cover yourself with a blanket to induce sweating for three consecutive nights.” I had never used this method to treat urticaria before. After inducing sweating for three nights, the urticaria resolved. The student had difficulty bathing due to the condition, but later I noticed he shed a lot of skin flakes, and the urticaria was cured. This student now works in a military hospital because he was a soldier at that time.
After the Tangshan earthquake, we returned to Beijing. One day, a graduate from our TCM college at Xiehe Hospital called me and said, “Teacher Hao, we have a pediatric patient with nephritis whose urine test results have not improved for a long time. We seem to see no hope for quick results with Western medicine. Can we consult a TCM practitioner?” I said, “You are at Xiehe Hospital; Zhu Lao is from your hospital, right?” He replied, “Zhu Lao is currently in Japan.” I asked, “Who do you want to see?” He said, “We want to consult Teacher Liu.” So I accompanied Teacher Liu to see the child. The child had facial edema, and the urine test results were very poor. After feeling the pulse, Teacher Liu asked me what I thought. I said, “The pulse can be felt lightly.” He said, “Lightly felt means it is a floating pulse.” I said, “But he doesn’t have a cold; what should we do for a floating pulse?” He said, “Look at him; his face is swollen, and the pulse is lightly felt. The upper body is swollen, which indicates we should induce sweating.” I asked, “What formula should we use?” He said, “Use Ma Huang Lian Qiao Chi Xiao Dou Tang.” I asked, “How many days should we induce sweating?” He said, “Induce sweating for seven days.” You see, this person induced sweating for seven days. Later, I heard from the doctors at Xiehe Hospital that after inducing sweating for those seven days, the child’s facial edema gradually subsided, and the test results improved gradually.
I remember over a decade ago, while walking in the TCM college, a young and beautiful girl approached me and asked, “Doctor Hao, do you remember me?” I said, “I have never seen you before.” She said, “You forgot? I am the child with nephritis who was hospitalized at Xiehe Hospital. At that time, my face was so swollen that you wouldn’t recognize me now with my slim and beautiful figure.” I said, “How could I remember?” She said, “You left a deep impression on me. You and Professor Liu, I am now attending a training class at the TCM college, and I always wanted to visit both of you, and I happened to run into you on the street.” I asked, “How are you now?” She said, “Since that time, my kidneys have not had any issues, and I now work at the Bank of China.” You see, this was a turning point.
After some time, a classmate from Ditan Hospital called me and said, “We have a patient with jaundice who has not improved for several months. It shouldn’t take this long.” I asked, “What do you want to do?” He said, “We want to invite Teacher Liu to take a look.” So I went with Teacher Liu. The patient had yang jaundice, acute icteric hepatitis, and it was summer, with the skin color bright yellow like an orange. Once you see it, you will never forget that kind of yellow, which is as yellow as wax dye. I always feel timid about infectious diseases. Teacher Liu said, “Feel the pulse, feel the pulse.” I bravely felt the pulse. After feeling it, I returned to the doctor’s office, and Teacher Liu asked me how the pulse was. I said, “The pulse is a bit floating. What should we do for a floating pulse?” I said, “He has icteric hepatitis, with damp-heat inside, and there is no exterior syndrome. Is he itchy?” I said, “Yes, he is itchy.” He said, “Itching and floating pulse indicate an exterior syndrome. I think he has icteric hepatitis, and the bile salts are deposited in the skin, irritating the nerve endings, which is why he is itchy.” However, Teacher Liu regarded the itching and floating pulse as an exterior syndrome. I asked, “How should we treat it?” He said, “You will treat it, right?” I said, “I will use Ma Huang Lian Qiao Chi Xiao Dou Tang.” Teacher Liu said, “Ah, now you have learned it.” So I learned to use Ma Huang Lian Qiao Chi Xiao Dou Tang three times, and Teacher Liu often said, “Your comprehension is quite poor.” In fact, this person induced sweating for seven days, and from then on, the jaundice index decreased day by day. At that time, the patient was a cadre from the Beijing Gardening Bureau, and it is said that he was still alive a few years ago.
Therefore, the floating pulse indicating an exterior syndrome has universal guiding significance in clinical practice. We should not think that only a cold is considered an exterior syndrome. Skin diseases, skin allergies, and itching, including some psoriasis, can all be treated with methods to resolve the exterior as long as the pulse is floating.
【Key Points for Examination】
Floating pulse types (pulse position is superficial) → Floating, Flooding, Soft, Scattered, Leather
Floating pulse→ Lightly felt, slightly reduced with heavy pressure but not empty, more than enough when lifted, insufficient when pressed → Exterior syndrome, deficient yang escaping outward
Flooding pulse→ Floating, large, and forceful, like surging waves, strong on arrival and weak on departure → Qi level heat excess, evil excess and righteous deficiency
Soft pulse→ Floating, thin, weak, and soft → Deficient syndrome, yin deficiency (floating and soft), essence and blood deficiency (thin and weak); damp syndrome
Scattered pulse→ Floating, scattered, without root, slightly pressed and it disappears, irregular in number → Yuan qi dispersing → Qi of the organs is about to exhaust
Leather pulse→ Floating, large, hollow, like pressing a scallion tube → Blood loss, yin injury
【Online TCM Examination Questions】
1. (Single choice) Among the following pulse groups, which has opposite pulse positions? (2015)
A. Floating pulse and deficient pulse
B. Soft pulse and weak pulse
C. Flooding pulse and thin pulse
D. Leather pulse and scattered pulse
Slide down to view the answer explanation
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[Curriculum Positioning] TCM Diagnosis—Pulse Diagnosis—Pulse Characteristics, Normal Pulse Characteristics and Physiological Variations
The characteristics of the soft pulse: floating, thin, weak, and soft
The characteristics of the weak pulse: deep, thin, weak, and soft
[Point Analysis] TCM Diagnosis, 9th Edition, P114: The characteristics of the soft pulse are superficial, thin, and weak. The pulse can be felt superficially, thin, and weak, like floating on water, lightly felt, and not prominent with heavy pressure; hence, the pulse position is floating. The weak pulse is characterized by being deep, thin, and weak. Due to the small and unfilled pulse vessel, the pulse can be felt close to the bones, and the finger feels thin and weak; hence, the pulse position is deep. The soft pulse and weak pulse have opposite pulse positions (B is correct). The floating pulse and deficient pulse both have floating positions (A is incorrect). The flooding pulse and thin pulse both have floating positions (C is incorrect). The leather pulse and scattered pulse both have floating positions (D is incorrect).
[Point Extension]Floating pulse (including floating, soft, scattered, leather) has a superficial position, lightly felt, and slightly reduced with heavy pressure; deep pulse (including deep, hidden, weak, solid) has a deep position, not felt lightly, and only felt with heavy pressure; hence, it is like a stone thrown into water.
2. (Multiple choice) Regarding the differentiation between exterior and interior syndromes, which statements are correct? (2015)
A. Exterior syndrome has a rapid onset, while interior syndrome has a slower onset
B. Exterior syndrome does not show a deep pulse, while interior syndrome does not show a floating pulse
C. Exterior syndrome has little change in tongue appearance, while interior syndrome has many changes in tongue appearance
D. Exterior syndrome is mainly characterized by aversion to cold, while interior syndrome is mainly characterized by fever
Slide down to view the answer explanation
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[Curriculum Positioning]TCM Diagnosis—Eight Principles Differentiation—Key Points for Differentiating Exterior and Interior Syndromes
[Point Analysis] TCM Diagnosis, 9th Edition, P142: Exterior syndrome refers to the invasion of external pathogenic factors through the skin and mouth, with the righteous qi resisting the evil and manifesting as superficial symptoms. Interior syndrome refers to the disease located internally, manifested by the organs, qi, blood, and marrow. Exterior syndrome is an external pathogenic disease, hence it has a rapid onset; interior syndrome is often due to internal injuries, hence it has a slower onset (A is correct). Exterior syndrome is an external pathogenic disease, hence it has little change in tongue appearance; interior syndrome is complex and variable, hence it has many changes in tongue appearance (C is correct). Exterior syndrome can be of many types; if there is yang deficiency with external invasion, a deep pulse may be seen; interior syndrome with deficient yang escaping outward may also show a floating pulse (B is incorrect). The characteristics of exterior syndrome are simultaneous cold and heat, and there can also be exterior wind-heat syndrome characterized by fever and aversion to cold; however, if there is only heat or only cold, it is considered an interior syndrome (D is incorrect).
[Point Extension]To differentiate between exterior and interior syndromes: ① In external diseases, simultaneous fever and aversion to cold indicate an exterior syndrome; however, if there is only heat or only cold, it is considered an interior syndrome; alternating cold and heat indicates a half-exterior, half-interior syndrome. ② Exterior syndrome is commonly characterized by symptoms such as headache, body aches, nasal congestion, or sneezing, while internal organ symptoms such as cough, palpitations, abdominal pain, and diarrhea are the main symptoms; half-exterior, half-interior syndrome has unique manifestations such as chest and rib fullness. ③ The tongue coating changes are not obvious in exterior and half-exterior, half-interior syndromes, while the tongue coating in interior syndromes often changes; exterior syndromes often show floating pulses, while interior syndromes often show deep pulses or other various pulse types. Additionally, the differentiation should also consider the onset speed, severity of the condition, and duration of the illness.
3. (Single choice) Which pulse is characterized by a superficial position? (2011)
A. Floating pulse, flooding pulse, leather pulse
B. Floating pulse, soft pulse, thin pulse
C. Floating pulse, scattered pulse, arterial pulse
D. Floating pulse, leather pulse, rapid pulse
Slide down to view the answer explanation
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[Curriculum Positioning]TCM Diagnosis—Pulse Diagnosis—Pulse Characteristics, Normal Pulse Characteristics and Physiological Variations
[Point Analysis] TCM Diagnosis, 9th Edition, P114: The floating pulse is lightly felt, slightly reduced with heavy pressure but not empty, more than enough when lifted, insufficient when pressed → External evil invades the skin, and the defensive yang resists the evil externally, causing the qi and blood to move towards the skin, hence the pulse is floating. The leather pulse is floating and beats against the finger, hollow in the middle and firm on the outside, like pressing a drum skin → due to the consumption of essence and blood, the pulse vessel is not filled, and the righteous qi is not solid, causing the pulse to float and beat against the finger, with urgency on the outside and emptiness on the inside, which is excessive. The flooding pulse is wide, full, and forceful, coming strong and going weak, resembling surging waves → due to excess yang qi, the righteous qi is not weak, and it rises to resist the evil, causing the pulse to expand, and the qi and blood surge, hence the pulse is large and forceful (A is correct). The soft pulse is floating, thin, weak, and soft → due to qi deficiency and inability to contain, it is weak and relaxed, and the essence and blood are deficient and cannot nourish the pulse, hence the pulse is thin and weak (B is incorrect). The scattered pulse is floating, scattered, and without root, disappearing with slight pressure; the arterial pulse is short and rapid (C is incorrect). The leather pulse is floating, large, hollow, like pressing a scallion tube → the yin blood cannot maintain the yang qi, and the yang qi disperses outward; the rapid pulse is rapid and stops irregularly → due to internal disturbance of evil qi, the organ qi is disordered, hence the pulse is rapid and forceful (D is incorrect).
[Point Extension]
Floating pulse types:
Floating pulse → lightly felt, slightly reduced with heavy pressure but not empty, more than enough when lifted, insufficient when pressed → exterior syndrome, deficient yang escaping outward
Flooding pulse → floating, large, and forceful, like surging waves, strong on arrival and weak on departure → qi level heat excess, evil excess and righteous deficiency
Soft pulse → floating, thin, weak, and soft → deficient syndrome, yin deficiency (floating and soft), essence and blood deficiency (thin and weak); damp syndrome
Scattered pulse → floating, scattered, without root, slightly pressed and it disappears, irregular in number → yuan qi dispersing → qi of the organs is about to exhaust
Leather pulse → floating, large, hollow, like pressing a scallion tube → blood loss, yin injury
4. (Single choice) The pulse that is weak when lifted and empty when pressed is (2007)
A. Floating pulse
B. Deficient pulse
C. Thin pulse
D. Leather pulse
Slide down to view the answer explanation
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[Curriculum Positioning]TCM Diagnosis—Pulse Diagnosis—Pulse Characteristics, Normal Pulse Characteristics and Physiological Variations
[Point Analysis] TCM Diagnosis, 9th Edition, P114: The deficient pulse is weak when lifted and empty when pressed, indicating a state of reduced tension in the pulse vessel and insufficient fullness in the pulse (B is correct). The floating pulse is lightly felt, slightly reduced with heavy pressure but not empty, more than enough when lifted, insufficient when pressed → external evil invades the skin (A is incorrect). The thin pulse is thin like a thread but should be clearly felt (C is incorrect). The leather pulse is floating, large, hollow, like pressing a scallion tube → the yin blood cannot maintain the yang qi (D is incorrect).
Editor: Lin Xiong
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