In addition to the eight principle differentiation, there are many other tools that an acupuncturist can use to generate an accurate clinical diagnosis. In fact, it is my belief that a diagnosis is not complete until certain parameters have been thoroughly evaluated. Among these parameters are of course pulse diagnosis and examination of the ear. But also included are blood pressure, heart rate, temperature, color, and skin texture. At a glance, these extra diagnostic measures may seem more western than TCM. However, they reveal vital information that may not necessarily be established from traditional methods alone. In part I of this discussion, I will explain the relevancy and applications of how taking the blood pressure and heart rate of patients can establish a more accurate diagnosis.
Blood pressure and heart rate can help to determine excess or deficiency, hot or cold in a patient. This is useful for diagnosing the true underlying condition of a patient whose subjective complaints contradict objective findings. Normal blood pressure of an adult is around 120/80 mmHg, 120 being the systolic pressure, and 80 being the diastolic pressure. According to the American Heart Association, a normal resting heart rate for an adult ranges from 60-80 beats per minute. Based on the different combinations of blood pressure and heart rate, we are able to distinguish four distinct types of patients.
Type I patients have relatively high systolic pressures (above 140 mmHg), and high diastolic pressures (above 90 mmHg). They also have relatively fast heart rates (over 85 bpm). This type of patient definitely has some sort of excess heat in the body. Even if the patient complains of feeling cold, if they present with this type of blood pressure and heart rate, their underlying condition is still heat. The sensation of cold may be an exogenous pathogenic cold factor affecting the body, in which case you would release the exterior cold first before sedating the excess internal heat. If the patient is coming in for chronic fatigue, and looks pale, tired, and deficient, but they present with this type of blood pressure and heart rate, you still sedate them. Giving tonic herbs to this type of patient will exacerbate his or her condition.
Type II patients have relatively low systolic blood pressures (below 95 mmHg) and low diastolic blood pressures (below 60 mmHg). They also have relatively slow heart rates (below 60 bpm). This type of patient is deficient and cold in nature, and must be given tonics such as Shi Quan Da Bu Tang (All-Inclusive Great Tonifying Decoction), or Ren Shen Yang Ying Tang (Ginseng Decoction to Nourish the Nutritive Qi). Do not use any sort of cold medicine for these patients.
Type III patients have relatively high systolic blood pressures (above 140 mmHg) but they have normal diastolic pressures. Their heart rates are generally slow (below 65 bpm), and the patient is not on any type of blood pressure medication. It is difficult to determine whether this is excess or deficient, hot or cold without any other parameters. However, these types of patients typically have blood stagnation. The flow of blood is stagnated due to the low heart rate not being able to pump the blood, but the pressure within the vessels is high because the volume of blood is not being circulated adequately, creating higher blood pressure. In these cases, the patient should take blood movers such as Xue Fu Zhu Yu Tang (Drive Out Stasis in the Mansion of Blood Decoction), Ge Xia Zhu Yu Tang (Drive Out Blood Stasis Below the Diaphragm Decoction), and Shao Fu Zhu Yu Tang (Drive Out Blood Stasis in the Lower Abdomen Decoction). For cases of blood stasis, the Liver must be addressed because it is the organ that stores blood, and can often be the center of dead blood, especially in cases of trauma. Fu Yuan Huo Xue Tang (Revive Health by Invigorating the Blood Decoction) or Zheng Gu Zi Jin Dan (Purple and Gold Pill for Righteous Bones) are excellent formulas for trauma.
The last type of patients, Type IV, manifests with relatively low systolic blood pressures (below 90 mmHg), and low diastolic pressures (below 60 mmHg), but they have fast heart rates (over 80-100 depending on the age, sex, and physical constitution of the person). This type of patient has yin deficiency heat. The blood pressure is low because there is not enough substance (represented by blood and yin) in the body, but the heart rate is fast from the underlying heat. Usually this type of patient is thin, tends to be fatigued easily, and may have sleep issues. Formulas to tonify the yin should be used. Herbs with sour properties to tonify the Liver, such as Wu Wei Zi (Fructus Schisandrae Chinensis) and Shan Zhu Yu (Fructus Corni), are also good to use for fast recovery of the Liver to produce more energy. It is possible for patients with hepatitis to manifest with this type of blood pressure and heart rate. In that case, Wu Wei Zi (Fructus Schisandrae Chinensis) should be used at 30% or higher of the overall formula to boost Liver function.
In part I of this discussion, we went over the diagnostic applications of blood pressure and heart rate. In the second part, we will discuss applications of regional body temperature, color, and texture, and how they can lead the practitioner to form a better, more accurate clinical diagnosis.
Body temperature is one of the vital signs that the practitioner should check in each patient. There are four different areas of the body where body temperature should be checked: the dorsal aspect of the arm directly above the elbow, the LI 10 area, the palmar aspect of the hand, and the dorsal aspect of the hand. When I say check the temperatures here, it can be done with either a digital laser thermometer, or it can be done more subjectively by touch. In a healthy individual, the temperatures at these four different areas should be around the same. If one particular area varies too much in temperature from the rest, then there is sickness in the part of the body the area represents.
The palmar aspect of the hand represents the ventral aspect of the body, the abdominal and pelvic cavities. The dorsal aspect of the hand represents the dorsal aspect of the body, especially the back.
The LI 10 area of the arm represents the stomach. If this area feels hot, it is an indication of stomach fire. If LI 10 is hot but the palmar aspect of the hand is cold, then there is the possibility of a parasite in the patient’s system. The patient will present with digestive issue and sleeping problems. If the LI 10 area and the palmar aspect of the hand are both hot, then it is an indication that the immune system is out of balance, and may also indicate that there are allergies. In this case Xiao Chai Hu Tang (Minor Bupleurum Decoction) is a great formula to use. It works on both the hold and cold aspects of the body to harmonize it.
If the LI 10 area and palmar aspect of the hand are both very hot, it indicates stomach fire. The palm can also represent the lower jiao or pelvic region, which indicates that the hormones are out of balance, and the patient may experience hot flashes, especially in the evening. Zhi Bai Di Huang Wan (Anemarrhena, Phellodendron, and Rehmannia Pill) and Huang Lian Jie Du Tang (Coptis Decoction to Relieve Toxicity) should be used in combination.
If both the LI 10 area and palmar aspect of the hand are cold, it represents a hormone deficiency, or kidney yang deficiency. In cases like this, it is important to evaluate the blood pressure and heart rate as well to confirm true deficiency. If it happens that blood pressure and heart rate indicate excess heat, it means the patient’s constitution is cold, but they are being affected by a hot exogenous pathogenic factor that is in excess.
If the blood pressure and heart rate are both low, but LI 10 area is hot, 20% of Huang Lian Jie Du Tang (Coptis Decoction to Relieve Toxicity) should be added to the treatment formula to clear the underlying heat. If the blood pressure and heart rate are both low but the palmar aspect of the hand is hot, 20% of Zhi Bai Di Huang Wan (Anemarrhena, Phellodendron, and Rehmannia Pill) should be added to counteract the underlying yin deficiency.
The color of the skin and blood vessels, as well as the texture of the skin and muscles are also useful diagnostic tools. The color of the forearm, the color of the veins around the Neiguan (PC 6) area, and the texture of skin and muscles should always be checked.
In general, a red color indicates heat and inflammation, and a blue color is indicative of blood stagnation. On the dorsal aspect of the arm, the area around the elbows represents the neck and shoulders. the PC 6 area of the arm should be checked for color of skin as well as color of the blood vessels underneath.
For women, if the skin there is dark, and the veins beneath are blue and green, it represents stagnation of menstrual blood. If the skin and veins are pale, it represents blood deficiency.
When examining the skin, dryness indicates a blood or yin deficiency, and a sand-like texture is indicative of water retention. Another way to find water retention is by trying to make a depression in the skin along the tibial surface. If the depression does not rebound right away, or remains visible for any amount of time, it is indicative of water retention.
About the Author
Master Jimmy Wei-Yen Chang has over 25 years of concentrated clinical experience applying his expertise in differential diagnosis and herbal prescription. The author of a pulse diagnosis manual, Pulsynergy, Master Chang currently pursues his specialties in private practice in Hacienda Heights, California, and is widely recognized for his skills in correlating expert pulse taking and herbal prescription.