New Reflections on Knotted and Intermittent Pulses

Knotted and intermittent pulses are common clinical findings and relatively easy to identify. Their characteristics are distinct, and their corresponding Western medical conditions are well-established. They may appear straightforward at first glance, but I have recently gained some fresh insights.

The first insight is that the appearance of knotted or intermittent pulses does not necessarily indicate a serious condition. Ancient descriptions of these pulses tend to carry grave implications, such as:

“When the pulse comes and pauses, unable to resume on its own — it pauses and then returns — this is the intermittent pulse. Those who present with this pulse are invariably difficult to treat.”

“Like a sesame seed trembling, spinning and gathering, dispersing irregularly — this is called the knotted pulse, and it presages death. These three pulses share a name but differ in substance.”

“If kidney qi fails to reach, it pauses once every forty beats; if liver qi fails to reach, it pauses once every thirty beats. When the qi of one organ declines, the qi of another organ arrives in its stead.”

The ancients’ caution remains valid. After all, certain cardiac conduction blocks and premature ventricular contractions carry significant hidden risks, and premature atrial contractions can be especially harmful. Clinically, encountering such pulses certainly warrants careful attention.

Compared to the intermittent pulse, the knotted pulse can be harder to master, as it contains a greater density of information. It commonly appears in individuals with imbalances of zang-fu qi and blood. Distinguishing whether a knotted pulse is occasional or chronic requires considerable clinical skill.

Before the Spring Festival this year, I treated an elderly woman whose chief complaint was headache and fatigue. Hospital examinations — including cranial CT and ECG — were all normal. Upon pulse diagnosis, I found an intermittent pulse. On closer questioning, the patient reported experiencing marked fatigue every early spring, with occasional palpitations but no chest tightness or pain. For the previous year, she had been receiving treatment for dry mouth and tongue pain without improvement.

Following Zhang Zhongjing’s reasoning, the first response to encountering knotted or intermittent pulses is Zhi Gan Cao Tang (Honey-Fried Licorice Decoction). This patient did indeed have dry mouth, which seemed to match the indication. Yet after careful deliberation, I concluded otherwise. The reason she now presented with this pulse pattern was insufficient heart blood — qi and blood lacked the strength to propel the pulse forcefully. Each spring, as liver qi rises, inadequate liver-stored blood means the organ has no substance to work with, naturally leading to headache and fatigue. When wood fails to generate fire adequately, heart qi goes unreplenished, and the knotted pulse appears.

The second insight is that knotted and intermittent pulses often do not persist. Many patients complain of cardiac discomfort, yet their hospital ECGs come back normal — this is perfectly understandable. At many Beijing hospitals, patients must wait in long queues; by the time they are seen, their internal qi and blood have already rebalanced, unless the condition is rapidly progressive. My clinic is on the second floor, and recently patient volume has been low. Many people climb the stairs and immediately sit down for pulse reading. At that moment, their qi and blood are unsettled, which actually reflects the true state of depletion or excess. Yet if you let these patients rest a while before retaking the pulse, the knotted or intermittent quality often disappears. The logic is straightforward.

The current consensus holds that Zhi Gan Cao Tang tonifies both qi and blood, with particular emphasis on replenishing heart blood and warming heart yang. I believe this view is slightly biased. Looking at the formula’s composition, Di Huang (Rehmannia) has the largest dosage — a Zhi Gan Cao Tang without Di Huang can hardly be called Zhi Gan Cao Tang. In recent years, many classical formula scholars have been fond of citing the late Master Liu Duzhou’s example, claiming that Master Liu multiplied the dosage of Zhi Gan Cao (honey-fried licorice) in the formula and the patient was cured. This completely overlooks the role of Di Huang and the contribution of the other ingredients.

That said, the efficacy of Zhi Gan Cao Tang for knotted and intermittent pulses with palpitations is beyond dispute. Years ago, I used this formula to treat a young man with nocturnal severe palpitations. Despite his greasy white tongue coating — a finding that might seem contraindicated — I prescribed the original Zhi Gan Cao Tang. One dose produced results, and after five doses, all symptoms vanished along with the greasy coating. Truly remarkable.

结代脉是临床中常见的脉象，而且非常容易掌握，结脉和代脉的特征也很明显，对应的西医疾病比较确切，看起来好像很简单的样子，但我最近又有了新的体会。

体会之一是，结代脉的出现并不意味着身体有严重状况，古人对结代脉的描述都比较严重，例如

脉来动而中止不能自还，此动而中止复来，代也，得此脉者必难治

有如麻子动摇，旋引旋收，聚散不常者曰结，主死。此三脉，名同实异也。

肾气不能至，则四十动一止；肝气不能至，则三十动一止。盖一脏之气衰，而他脏之气代至也

古人的提醒还是对的，毕竟一些心脏传导阻滞和室早都会有极大地隐患，房早更是危害甚大，临床上见到此类脉象确实需要注意。

相比于代脉来说，结脉可能更难以掌握，里面包含的信息量较大，在许多脏腑气血不平衡的人身上都容易出现结脉，如何判定这种结脉是偶发的还是长期存在的，需要一定功夫。

今年春节前曾治疗一老年妇女，门诊主诉是头痛，乏力，医院检查颅脑CT和心电图都正常，号脉时发现为代脉，仔细询问，患者每年到初春时节都会出现明显的乏力，偶尔有心悸的感觉，没有胸闷胸痛的症状，此前一年都在治疗口干和舌痛，不见好转。根据仲景的思想，见到脉结代的首先反应是炙甘草汤，而且此人确有口干的症状，似乎对症，但我思来想去觉得并非如此，她之所以现在会表现出这种脉象，是心血不足，气血鼓动无力的原因，每年到春天，肝气升发，而肝藏血不足，体用无物，自然会造成头痛、乏力，木生火不足，心气得不到补充，就会出现结脉。

体会之二是，结代脉在许多情况下并不会持久出现。很多人抱怨心脏难受但是去医院做心电图确都正常，这很正常。北京的许多医院都要排队等待，在等待的过程中，体内气血已经调和了，除非需要尽快的病情。我的诊室在二楼，最近就诊患者不多，许多人刚爬上楼就坐下来号脉，这时候气血不定，能够真实地反映体内气血盛衰状况，很多结代脉的病人让他休息一会之后再摸脉反而就摸不到了，道理就在这。

现在一般认为炙甘草汤是气血双补，着重于补充心血，温通心阳，我认为这还有略有偏颇，从组方上看，地黄的用量最大，没有地黄的炙甘草汤不能认为是炙甘草汤。几年来，许多经方学者喜欢抬出刘渡舟先生的例子，说刘老给人家把方子里炙甘草的量翻了几倍，病人的病就好了。这完全忽视了地黄的作用，忽视了其他药物的存在。当然了，炙甘草汤对于脉结代、心悸的疗效是毋庸置疑的，多年前我曾用此方治疗一年轻男性夜间怔忪，在其舌苔白腻的情况下使用了炙甘草汤原方，一剂见效，五剂后症状全无，腻苔消失，真可谓神奇。