Diagnosis is the basis for hand and foot massage. Symptoms can be relieved and diseases can be cured by applying the proper massage to the correspondent acupoints and reflecting areas of the hand and foot only after a correct diagnosis is made by the methods of hand and foot diagnosis. Otherwise, the treatment may be useless, the disease may worsen, and the patient may lose the chance for a cure. This can occur because of oversight in reading positive pathological responses and signs on the hand and foot or by mistaking normal physiological responses for pathological responses.

Four diagnostic methods--inspection, touching, moving, and pressing are discussed as follows:

1. Inspection method:

This is a method of observing the shape, condition, creases and prints, nails, color and luster at different locations on the hand and foot to discover abnormal changes and specific responses for making diagnoses. In general, the diagnostic information can be obtained by observing the general appearance, color, shape, and condition of the hand and foot.

1) Observing general appearances:

In traditional Chinese medicine, this is known as observing "Shen." Shen is the combined appearance of color and luster, but it is difficult to describe in ordinary terms, as it is a mixture of obscure color and blurred luster.

In modem physics, a weak visible light with a wave length of 3800-4200 angstrom (equal to the wave length of blue light) can be irradiated from the body's surface. The brightness of this light is related to the age, sex, physique, and physiological condition of the individual. This is a specific phenomenon showing the body's functional condition. This weak visible light irradiated from the body is similar to Shen described in traditional Chinese medicine, and it may be the scientific explanation for Shen.

In normal people, the hand and foot are bright and moist. The bightness of the skin should be gentle and viable to indicate the richness of essence and blood, and the fullness of spirit and energy described as Deshen (obtaining Shen) in traditional Chinese medicine.

If the hand and foot skin is dull, dry or haggard due to a reduction of luster and moisture, it is called "Shishen" (loss of Shen) in traditional Chinese medicine. This indicates the worsening of diseases, with a poor prognosis and difficult to cure.

If the hand and foot are dark, lusterless, and appear covered with a layer like dark frost, this indicates a reduction of immunity and a high susceptibility to viral influenza, high fever, nephritis, leukemia, tumor or rheumatic fever.

If the dull appearance and reduction of luster occurs in only a localized area of the hand and foot, this indicates the dysfunction of the organ related to this area, producing a serious disease in that organ and a poor prognosis.

The luster of the hand and foot may change with temperature, climate, or emotional and physiological conditions. However, these changes are usually only present in small areas and are of short duration. Therefore, it is important to determine changed general appearances of the hand and foot over a long period of time for correct clinical diagnosis.

In addition, a change in the luster of the hand and foot can also show the development of a disease. As the hand and foot gradually turn brighter and more lusterous and moist, the disease is subsiding to a certain extent and the health of the patient is gradually improved; but as the hand and foot turn gradually darker and less lusterous and dry, the disease is apparently gaining by degrees. This should draw the attention of the practitioner for timely and adequate treatment.

2) Observing color:

This is a method of diagnosis by observing the change of color on different areas of the hand and foot to diagnose diseases in their correspondent related organs.

The observation of color is combined with the observation of Shen (general appearance) in traditional Chinese medicine. Color is an observable change in Shen, and they are mutually correlated. Traditional medical literature says the "increase, decrease, appearance and disappearance of Shen can be shown by the correspondent changes of color." A correct diagnosis can be made only after the observation of both Shen and color in combination.

As with the change of hand and foot luster, color is also constantly being changed by various factors. In clinical practice, the color of the palmar side of the middle pharlanx of the middle finger is considered the "constant color," the standard color for clinical diagnosis.

The colors of the hand and foot can be divided into blue, red, yellow, white, and black.

Blue: Indicates diseases of liver and gallbladder With pain, cold pathogens, stasis of blood, convulsions and chronic injury with pain.

Red: Indicates diseases of heart and small intestine with fever, local inflammation, bleeding, and the early stages of some progressive diseases.

Yellow: Indicates diseases of spleen and stomach with deficient syndrome, damp pathogens, symptoms due to deficiency of trace elements, anemia, and chronic .hemorrhage.

White: Indicates diseases of lung and large intestine with deficient syndrome, cold pathogens, pain, and loss of qi and blood.

Black: Indicates deficiency of kidney with cold pathogens, pain, retention of water, blood stasis, and longstanding chronic injuries.

3) Observing shape:

This is a method of diagnosis by observing the changing shape of different parts of the hand and foot. The observation of shape includes the shape of hand, foot, palm, nail, fingers and toes, as well as fingerprints and creases of the fingers, palms and soles. Because of space limitations, it will not be discussed in this chapter.

4) Observing conditions:

If the patients hesitate to show their hands, and their fingers move irregularly and their joints are flexed with a slight tremor, this indicates nervousness. These patients are nervous, sensitive, timid, suspicious, restless and highly irritable people, lacking independence and decisiveness and easily caught in contradictions. Modern medical science has shown that long-standing nervousness may cause functional disturbances of the endocrinal and nervous systems and can produce peptic ulcers, hyperthyroidism, neurasthenia, headache, insomnia, diabetes mellitus, hypertension, coronary heart disease, and even cancer.

Automatic hand tremor indicates lesions in the central nervous system such as parkinsonism and chorea due to rheumatism.

Contraction and stiffness of the fingers indicate hemiplegia of cerebral hemorrhage, thrombosis and embolism, or belong to their prodromal symptoms.

Claw hand or monkey paw is due to injury of ulnar and median nerves, carpal tunnel syndrome, progressive myatrophy, paralysis of median nerve, amyotrophic lateral sclerosis, or poliomyelitis.

Arcuate foot is usually found in nerve paralysis of the lower limbs, bifid spine, or heriditary ataxia.

Flatfoot is usually found in myasthenia, paralysis of the lower limbs, muscular spasms, shortened heel tendon or secondary to knock knee, medial rotation of tibia, and looseness of sole tendons.

The inspecting method should be combined with other methods of diagnosis to avoid misdiagnosis. Abnormal conditions of the hand and foot are usually caused by lesions in the nervous system, but may also be caused by bone fracture, sprain injury, or rheumatoid diseases for differential diagnosis.

2. Touching method:

This is a diagnostic method for examining the temperature, and tactile and pain sensations in the hand and foot.

1) Examination of temperature:

The temperature of the hand and foot is adjusted by both the central nervous system and other specific body structures. Therefore, a change of temperature in the hand or foot is more marked than on other parts of the body.

Hand and foot temperatue may be adjusted by the feedback nerve impulses from the central nervous system and local specific structures when the body is affected by high fever, cold, irritation, depression and fury, or attacked by virus, pathogens or metabolic products. Hand and foot temperature also may be changed when functional body balance is disturbed.

The tip of the index finger is used to detect temperature changes at different parts of the hand and foot because the tip of the index finger is very sensitive to these changes. The normal body temperature is taken as the standard when evaluating temperature changes in the hand and foot. Sometimes this gives only a rough idea about the change of temperature, because it is much less sensitive than a thermometer. However, it is very convenient to use.

The sequence for examining temperature is from distal to proximal end and from radial to ulnar side of fingers; from peripheral to central part of palm and sole; from palm or sole to dorsum of hand or foot; and from left side to right side of hand and foot.

An increase of local temperature on the hand and foot indicates infection, inflammation or progression of a pathological process to its climax in the correspondent organ of that area; and a decrease of local temperature indicates an attack of cold pathogens to the correspondent organ, or the deficiency of Yang in that organ. For example, an attack of cold pathogens in the upper abdominal region may cause coldness and pain as well as chronic diseases in this region, including chronic gastritis, ptosis of the stomach, and chronic nephritis.

If the "hand and foot temperature in an individual is always higher than normal this usually indicates the person suffers from hyperthyroidism, hemorrhage in pons, febrile diseases, hyper-tension, diabetes mellitus, rheumatoid arthritis, or polycythemia.

If the temperature of hand and foot is always lower than normal this usually indicates they are suffering from shock, hypothyroidism, obstruction, stenosis or compression of artery, syringomyelia, scleroderma, dermatomyositis, disseminated lupus erythematosus, Raynaud's disease, cervical rib syndrome, or heart failure.

If the decrease of temperature is limited to the peripheral part of the hand and foot, this indicates the vital energy of the patient is not completely exhausted and the disease is still cur-able; but if the central part of the palm or sole is very cold, with pale color and cold sweat, this indicates the exhaustion of vital energy with syncope, impotence, and diarrhea.

2) Examination of superficial sensation:

Pain, temperature and tactile sensations should be examined and analyzed in combination for clinical diagnosis. A hot or cold substance, or pin and bone needle are used to touch or scratch the skin to produce sensations and determine the lesion on the correspondent segment of nerve innervation over the affected skin of the hand and foot.

The thumb, thenar prominence, and radial side of the index finger of the hand are innervated by the 6th cervical spinal nerve (C6), the middle finger is innervated by the 7th cervical spinal nerve (C7), the ulnar side of the ring finger, little finger, and hypothenar prominence are innervated by the 8th cervical spinal nerve (C8). A disturbance of cutaneous sensation on the hand indicates a lesion on C6 to C8 spinal nerves. For example, patients with diseases of the cervical spinal column often show a disturbance of sensation on their hands. The discovery of the area with disturbed sensation may show the segment of injured or compressed nerve and provide treatment indications.

The medial portion of the dorsum and sole of foot is innervated by the 4th and 5th lumbar spinal nerves (L4 and L5), and the lateral portion of foot is innervated by the 1st to 3rd lumbar spinal nerves (L1 to L3). The disturbed area of skin on the foot may indicate the location of the lesion in the lumbar and sacral region, such as the prolapse of lumbar intervertebral disc, proliferative osteo-arthritis, and tumor of cauda equina.

As a clue, in patients with a subjective sensation of numb-ness in the hand and foot, this may be the prodromal symptom of cerebral thrombosis, even though the examination of cutaneous sensation is normal. These patients should have a thorough physical examination to obtain an early diagnosis and determine treatment.

This is a method of diagnosis by examining the active and passive movement of the hand and foot joints, especially the joints of the fingers and toes.

1) Examination of active movement:

When the wrist joint assumes a neutral position, the range of active movement of this joint is flexion to 50-60 degrees, dorsiflexion to 40 degrees, deviation to ulnar side to 30 degrees, and deviation to radial side to 15 degrees ( Fig. 4-1).

Fig. 4-1 Examination of wrist joint movement

3. Moving method:

When the fingers are extended in a neutral position, the range of active movement of the metacarpophalangeal joints are flexion to 90 degrees and dorsi-flextion to 0 degree or within a small angle, and some degree of medial and lateral deviation. The range of active movement of the proximal interphalangeal joints is flexion to 120 degrees, and the movement of the distal interphalangeal joints is flexion to 60 degrees.

Particular to human beings is the very flexible movement of the carpometacarpal joint of the thumb. When the thumb assumes a neutral position with its ulnar border kept in contact with the radial border of the index finger, it may dorsi-flex as the palm is pressed fiat on a table; it can also flex to assume an opposing posture with the palm; and it can again adduct and abduct (Fig. 4-2).

Fig. 4-2 Examination of thumb movement

When the foot assumes a neutral position with the sole perpendicular to the longitudinal axis of the leg, the ankle joint can dorsi-flex to 40-50 degrees, plantarly flex to 20-30 degrees, invert to 35 degrees, and evert to 35 degrees as a combined movement with the subtalar joint (Fig. 4-3).

Fig. 4-3 Examination of ankle joint movement

The normal range of movement of the metatarsophalangeal joint of the big toe is dorsiflexion to 60-90 degrees. The movement of the big toe is abnormal if it is not within this range.

The normal range of movement of various hand and foot joints mentioned above may be used as a standard for making clinical diagnoses, ff the examination shows limited movement of a certain joint, this may indicate a pathological change in the local structure or its correspondent organ, and a diagnosis can be made in combination with other diagnostic methods.

2) Examination of passive movement:

(1) Comparative examination of passive wrist movement:

Fig. 4-4a Passive wrist joint movement

The patient's palms are placed face to face in a neutral position, and both elbows are then raised up with the wrist joints gradually dorsi-flexed until reaching 90 degrees on each side. If the dorsi-flextion of one wrist is limited, the palms will deviate to the normal side at an angle greater than 90 degree between the forearm and palm of the abnormal side (Fig. 4-4a).

For examination of palmar flexion of the wrist joint, the dorsum of the hands are put face to face in a neutral position, and are then gradually raised until both forearms are on a horizontal level and an angle of 90 degree is formed between palm

Fig. 4-4b

and forearm. If palmar flexion of the hand is limited on one side, the hands will deviate to the normal side, at an angle greater than 90 degree on the abnormal side between the dorsum of the hand and the forearm (Fig. 4-4b).

Limitation of palmar flexion of the hand with pricking or explosive pain indicates carpal tunnel syndrome or a fracture of the lunar bone.

(2) Examination of passive movement of ankle joint:

The heel of the patient is held in one hand of the practitioner and the instep is held in the other to plantarly flex, dorsiflex, invert and evert the foot. The range of movement of each foot is examined for limitation of movement.

If the range of invertion is too large and the ankle joint is very loose, this may be due to malnutrition on laceration of lateral collateral ligament of ankle joint; if the range of movement is reduced by a stiff joint, or the patient refuses this examination, this may be due to local pain caused by hyperosteogeny of the ankle joint or bursitis.

The moving method of examination can be used not only for diagnosing locomotive disturbances of the hand and foot, but also for general diseases of the body. The diagnosis of/a disease in the correspondent organs and tissue can be made by combining other diagnostic methods with the observation of flexibility, movability, stiffness, and locked joints.

4. Pressing method:

This is a technique for finding concealed color, uneven-ness, and nodules and abnormal sensations including soreness, numb distension, and pain in the hand and foot by pressing them with the pad or radial border of the distal phalanx of the thumb. The sequence of examination is from the proximal end to the distal end, along a vertical direction, and then along a horizontal direction, and from hand to foot.

Concealed color can be observed after the local skin and underlying tissue are pressed by finger as the superficial color fades away. If the concealed color is fresh red, this indicates good health with normal functions of the internal organs; if the concealed red color is pale or dull, this indicates the early stage of disease without symptoms, or an inflammation in the correspondent organ. If the concealed color is normal and the original superficial color can be quickly restored after the release of pressure, this indicates that the vital energy is rich and vatality is exuberant; if the original color is only slowly restored, this indicates that the body is weak and qi and blood are insufficient. If the concealed color is abnormal and the original superficial color can be quickly restored, this indicates that the disease is still in the early stage, the body's resistance is not much impaired, and the disease can be easily cured; and if the original color is only slowly restored, this indicates a chronic disease with a long clinical history.

If a depression is found at the spleen and kidney reflecting areas' when the pressing method is applied at the holographic points and areas this indicates the possibility of a congenital single kidney or the removal of the spleen or one kidney by surgery, if sandy nodules are found on the gallbladder, kidney or urinary bladder reflecting area, this indicates the presence of stones in those organs. A movable mass with persistent abnormal feeling indicates the possible presence of a tumor in the body, and a diagnosis of tumor can be made after evaluating the age, physique, and sex of the patient.

An abnormal feeling induced by the pressing method also indicates the presence of pathological lesions. A sore and numb feeling indicates chronic and deficient diseases; numbness indicates stubborn diseases or diseases of the nervous or circulatory system; and distention and pain indicates the presence of inflammation or febrile diseases. If an abnormal sensation is simultaneously present on both hands, the chance for an accuracy diagnosis is much higher.

Among these four diagnostic methods, the inspecting method is the principal technique while the harld examination is most convenient. Therefore, they are the principal methods of diagnosis worth mastering and practicing.