On the one hand (and on the other)

What we can learn from a more tactile approach to bedside medicine.

One evening after a pleasant dinner, a classmate and I were reminiscing as we leafed through our medical class yearbook.

“Remember him?”

“I wonder what became of her.”

“He was a terrible lecturer. My god, what a bore!”

Then we paused and, examining a certain photograph, looked up and said, “Now there was a real doctor. What a teacher and a real prince of a man. No one like him, before or after!”

The person we looked upon so fondly and spoke of so respectfully was Harold Fullerton, Regius Professor of Medicine at Aberdeen University in Scotland in the 1940s and 1950s.

A tall, distinguished-looking man, he was revered by all who encountered him. Colleagues, nursing staff, lecturers, students, and moreover, porters, attendants, and ambulance drivers thought the world of him. The consummate physician-internist, he was the undisputed master of the true clinical diagnosis. This, before the advent of ultrasound or a time when a scribbled request can lead to a computerized dissection of a patient’s body in under an hour.

He would enter the ward elegantly clad in a dark checked suit and waistcoat with a crisp white shirt and perfectly knotted tie. His white coat was so starched that it crackled when, as was his custom, he would gently sit down on a patient’s bed then reach out and take the person’s hands in his own.

While this may have seemed an admirable gesture of kind reassurance, there was an even more valid reason for this action: the hands themselves.

Fullerton was of the opinion that the hands, not the eyes, were, if not the mirror of the soul, then certainly an accurate reflection and indication of our health and activities and even our vices.

Slowly, carefully, silently, he would examine the patient’s hands. What volumes they told him and us, his students. For example, “Let us examine the back of the hand, the dorsal surface,” he’d say. “What is the color of the skin? Is it unduly pale or yellow? Has the skin retained its elasticity or, with advancing age, become wrinkled and lax? Have additional discolorations appeared, the so-called liver spots? Are the veins prominent? Are the joints deformed by arthritis? Are the fingertips clubbed by lung disease? Are the nails brittle, split, deformed, or with small splinter hemorrhages under them from blood or heart disease?”

Then turning the hand over, “Further information may be gleaned from this, the palmar surface. Are the muscles wasted by neurological disease? Is the surface abnormally reddened by liver problems, perhaps alcohol induced? Are there calluses, general or local, indicating the subject’s occupation or favorite sport? And what about the grip? Is it strong, weak, equal, or not?”

These are but a few of the questions asked of the hands, the answers being readily available to the trained eye.

Driving home the other day, I glanced at my own hands on the steering wheel, noting with more than detached interest that they were starting to exhibit some of the features to which I have referred. When I was in practice and teaching, I used to upbraid residents and students who, when at a patient’s bedside, had their hands in their pockets. I thought it slovenly and disrespectful of the patient and me. But perhaps it’s not such a bad habit in an elderly, retired surgeon.

hidden


Graham C. Fraser, FRCS, FACS

Dr Fraser is a retired pediatric surgeon.

Graham C. Fraser, FRCS, FACS. On the one hand (and on the other). BCMJ, Vol. 47, No. 8, October, 2005, Page(s) 462 - Back Page.



Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.

An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.

BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:

  • Only the first three authors are listed, followed by "et al."
  • There is no period after the journal name.
  • Page numbers are not abbreviated.


For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org

BCMJ Guidelines for Authors

Leave a Reply