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.

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Graham C. Fraser, FRCS, FACS

Dr Fraser is a retired pediatric surgeon.