The Hand in Clinical Medicine

It is no wonder that the diagnostic value of the facies has often been emphasised, for expression, form, colour, condition of the skin and hair and many other features can be studied from the beginning of the interview. In clinical practice it is common, after examination of the face, to take up the hand and feel the pulse. The experienced clinician may gain almost as much information from the hand as from the face, for the hands also show expression and character. Furthermore the hands are so highly developed that the blind and the dumb may use them as effective substitutes for reading and for speech, and many of us gesticulate for emphasis. Indeed, gestures made by patients to indicate the site and character of symptoms can be most helpful. Thus the flat of the hand is pressed upon the vertex of the head with psychogenic headache, both hands squeezing across the front of the chest commonly indicates ischaemic heart pain, or the tips of two or three fingers pressed into the epigastrium suggest the pain of peptic ulcer. Copyright Royal Medical Society. All rights reserved. The copyright is retained by the author and the Royal Medical Society, except where explicitly otherwise stated. Scans have been produced by the Digital Imaging Unit at Edinburgh University Library. Res Medica is supported by the University of Edinburgh’s Journal Hosting Service: http://journals.ed.ac.uk ISSN: 2051-7580 (Online) ISSN: 0482-3206 (Print) Res Medica is published by the Royal Medical Society, 5/5 Bristo Square, Edinburgh, EH8 9AL Res Medica, April 1967, 5(4): 33-37 doi: 10.2218/resmedica.v5i4.499 THE HAND IN CLINICAL MEDICINE E d w ard B. French, B.A., M.B., B .C L., B.Ch., F.R .C .P .E ., F.R .C.P. Physician, W estern G eneral Hospital It is n o wonder that the diagnostic value of the facies has often been emphasised, for expression, form, colour, condition of the skin and hair and many other features can be studied from the beginning of the interview. In clinical practice it is common, after examination of the face, to take up the hand and feel the pulse. T h e experienced clinician m ay gain almost as much information from the hand as from the face, for the hands also show expression and character. Furtherm ore the hands are so highly developed that the blind and the dum b may use them as effective substitutes for reading and for speech, and many of us gesticulate for emphasis. Indeed, gestures made by patients to indicate the site and character of symptoms can be most helpful. Thus the flat of the hand is pressed upon the vertex of the head with psy­ chogenic headache, both hands squeezing across the front of the chest com m only indicates ischaemic heart pain, or the tips of two or three fingers pressed into the epigastrium suggest the pain of peptic ulcer. A study of all the conditions in which examination of the hand m ay contribute sub­ stantially to diagnosis would result in a long, dull catalogue. It is proposed therefore first to consider variations in form and function and then to give a sufficient number of illustrations to indicate the diversity of the specialties which may be concerned. G E N E R A L O BSERVATION S T h e firm determined grip or the soft flabby handshake so often reflect the personality. T h e manicured or the careworn hand, the tobacco stains, the bitten nails, the nervous tremor, the the ring on the finger and the foreign tattoo each tell their story. T h e circular tattoo in the first left interdigital space made by pen and ink at school can be distinguished from injuries contaminated by coal dust. This may well pro­ vide an essential clue to the cause of breath­ lessness in a patient, previously a miner, who has not divulged that he has changed his job. Conversely the occupation may indicate the cause of many hand lesions such as the pilonidal sinus of barbers, erysipeloid of butchers or anthrax of tanners. A transverse ridge at the same level on each of the nails may date a forgotten illness by the fact that the nails take about six months to grow.


Physician, W estern G en eral Hospital
It is n o w onder that the diagnostic value of the facies has often been emphasised, for expression, form , colour, condition of the skin and hair and m any other features can be studied from the beginning o f the interview.In clinical practice it is com m on, after exam ination o f the face, to take up the hand and feel the pulse.T h e experienced clinician m ay gain alm ost as m uch inform ation from the hand as from the face, for the hands also show expression and character.Furtherm ore the hands are so highly developed that the blind and the dum b m ay use them as effective substitutes for reading and for speech, and m any of us gesticulate for emphasis.Indeed, gestures m ade by patients to indicate the site and character o f sym ptom s can be m ost helpful.T h u s the flat o f th e hand is pressed upon the vertex of the head w ith psy chogenic headache, both hands squeezing across the front of the chest com m only indicates ischaem ic heart pain, or the tips of tw o or three fingers pressed into the epigastrium suggest the pain of peptic ulcer.
A study of all the conditions in which exam ination of the hand m ay contribute sub stantially to diagnosis w ould result in a long, dull catalogue.It is proposed therefore first to consider variations in form and function and then to give a sufficient num ber o f illustrations to indicate the diversity of th e specialties which m ay be concerned.

GENERAL OBSERVATIONS
T h e firm determ ined grip or the soft flabby handshake so often reflect the personality.T h e manicured or the careworn hand, the tobacco stains, the bitten nails, the nervous tremor, the the ring on the finger and the foreign tattoo each tell their story.T h e circular tattoo in the first left interdigital space m ade by pen and ink at school can be distinguished from injuries contam inated by coal dust.T h is m ay well pro vide an essential clue to the cause of breath lessness in a patient, previously a m iner, who has not divulged that he has changed his job.Conversely the occupation m ay indicate the cause of m any hand lesions such as the pilonidal sinus of barbers, erysipeloid of butchers or anthrax of tanners.A transverse ridge at the same level on each of the nails m ay date a forgotten illness b y the fact that the nails take about six m onths to grow.

Movements
In addition to gesticulation and the nervous tremor already m entioned, there m ay be a fam ilial trem or so easily and unkindly mistaken for the shaky hand of the chronic alcoholic.T h e hyperkinetic hand o f the thyrotoxic patient plucks and twines a handkerchief or nearly tears off the buttons in haste to undo the vest.T h e flapping, darting m ovem ents of the out stretched hand are characteristic of renal or h epatic or respiratory failure and m ay be bad enough to cause articles to be flu n g to the ground.T h e jerky m ovem ent o f rheum atic chorea m ay be exaggerated by picking up an object, w h ile the rh ythm ic pill rolling of paralysis agitans w ill cease during a purposeful m ovem ent.T h e finger-nose test and dysdiadokokinesis arc am ong the standard tests for d em onstrating sensory and cerebellar ataxias, m ade worse in the form er by closing th e eyes.

Figu re 1
S iz e a n d S h a p e A d isproportionately broad hand and fingers m ay be helpful confirm ation of acrom egaly.T h e long thin fingers (arachnodactyly) of M a rfan 's syndrom e (Fig. 1 ) could be useful corroboratory evidence of dissection of the aorta in a young person.A great variety of other inherited disorders such as polydactyly, a bent little finger, or a stum py, broad-nailed, term inal phalanx of the th um b arc useful genetic m arkers.Sym phalangism is rare but evid en tly persistent as show n by the fam ous T a lb o t fam ily whose illustrious ancestor from the 14th century is alleged to have shown fusion o f the phalanges w hen the skeleton was disinterred in Salisbury C ath ed ral.It is a pity that this story has recently been doubted and the fam ily tree pruned by a few hundred years.
C o lo u r P allor of the hands, especially of the nails and the palm s, is a useful clinical check for anaem ia.C yan o sis indicates an unusual degree of oxygen desaturation of the blood.O n ly if the hand is warm in a tem perate clim ate can it be deduced th at the cyanosis is central in origin.E ven then there is the rare exception of polycythaem ia rubra in w hich it is the d ensity of colour that gives the cyan otic appearance.It is w ell to rem em ber in assessing colour that any dark pigm ent deep to the skin looks blue due to th e rearrangem ent of ligh t as it passes through a turbid m edium .T h e light w hich is transm itted contains a greater proportion of the longer w avelengths (red), w h ile that w hich is scattered to the sides and back to the surface contains a correspondingly large proportion of shorter w avelength (blue).F o r exam ple, the dark blue o f a tattoo is m ade by lam pblack (Indian ink) while the blue colour o f the veins is due to the dark red blood w ithin them .If the skin of the back of the hand becom es very thin in the elderly or in sufferers from rheum atoid arthritis then the veins m ay be red.B row n pigm entation due to an abnorm al am o u n t of m elanin is a feature of a num ber of local and system ic disorders; it is characteristically seen, especially over the knuckles and in the palm ar creases, in m any cases of A d d iso n 's disease.

T e m p e ra tu re
T h e exam iner's hand is a superb therm o m eter and it is usually easy to observe by p alpation that a patient is febrile.In a tem p erate clim ate the tem perature o f the p atien t's hand is a good guide to the m ean blood flow through it, and in appropriate circum stances it m ay be a helpful indication of peripheral blood flow in general.
H o t m oist palm s often indicate hvperthyroidism , w hile cold and clam m y ones m ay be due to nervousness.It is a rem arkable fact, not always appreciated, that therm al sw eating does not affect the palm s.

Figu re 2 F i g u r e
Structure of the Hand A n y of the structures of the hand m ay be affected by a variety of local and system ic dis orders, all of w hich m ust be recognised in order that th e im portance o f each m ay be assessed.Sex and age changes m ay occur.T h u s the sm ooth hairless hands o f the child should change to a m ore lined and hairy hand in the adult m ale unless hypogonadism is present.In the elderly an atrophy of the collagenous sup porting tissue leads to w rinkling, to a charact eristic type of purpura and a m ottled brown and w hite pigm entation.T h e nails, joints, bones, m uscles, tendons, nerves, and arteries m ay be affected b y system ic disorder and as exam ples of each are koilonychia (due to iron deficiency), gout, sarcoidosis, m otor neurone disease, xanthom atosis, leprosy and disorders of the pulse.

THE DIFFERENT SPECIALITIES
It is not too fanciful to suggest that in cardiology a diagnosis of subacute bacterial endocarditis could be m ade from the hand alone.N o doubt a well taken clinical history should be leading in the right direction, but a pale hand, a w aterham m er pulse, clubbin g of 5 the fingers, w ith several splinter haem orrhages beneath the nails and sm all tender lum ps on the palm ar aspect of the fingers (O sier's nodes) would provide th e full house.R eferen ce has already been m ade to acromegalv, hypogonadism and hyperthyroidism and there are other endocrine changes such as hypopituitarism , m yxoedem a, tetany and hyper parathyroidism .B efore the days of P .B .I. estim ations and radioiodine studies som e surgeons judged the severity of thyrotoxicosis w ith greater confidence by shaking hands w ith th e p atient than by accepting a figure derived from a dubiously perform ed B .M .R .estimation.T h e tachycardia, the bounding pulse, irregular perhaps due to atrial fibrillation, the hot sweaty palm s and the fine trem or are still very useful signs.
In hyperparathyroidism , absorption of bone m ay som etim es be sufficient to shorten the term inal phalanx.T h e soft tissues arc then redundant, the end of the finger becom es bulbous and the nail curved.Spo ttin g this pseudoclubbing of the hand led to the diagnosis in a m atter of seconds in the case of a w om an who previously had been investigated in three hospitals, w ith out success.(Fig. 2) T h e derm atologist could have a field day w ith the hand alone.T h e am ateur suspecting scabies w ill find that the hand is helpful in providing lesions between the fingers where the characteristic burrows m ay be seen as thin sinuous lines, from the active end of which the m ites m ay be obtained.
The forensic expert, in league w ith the C .I.D ., m ay be able to identify a body or a crim e from the fingerprints.Indeed, it was this fact that led D r. R uxto n to attem pt to get away w ith m urder by rem oving, am ong other things, the term inal phalanges of his victim s.F lap p in g trem or, central cyanosis, finger clubbing, leuconychia, spider telangiectases, erythem atous palm s and D u p u ytren 's contrac ture m ay alert the gastroenterologist to the cause of haem atem esis, for any or all of these signs m ay be present in conjunction with hepatic cirrhosis.
D ilated veins on the abdom inal wall, som e ascites and a palpable spleen would be com forting confirm ation to the clinician.
The geneticist has good reason to be inter ested in the hand, for inherited abnorm alities are so easily seen.R eference has already been m ade to som e of them , but there are m any others such as w ebbed fingers (Fig 3) or the nail-patella syndrom e. T h e latter is a quaint com plex of dystrophic or absent nails, small patellae and bony outgrowths on each ilium , which is transm itted as a dom inant syndrom e.
Finger nails which are concave on the upper surface, thin and brittle (koilonyehia) indicate to the clinician that iron deficiency is present before the haem atologist com es to the rescue.T h e reason for the iron deficiency m ust then of course be sought, but when koilonychia is present the condition is of long standing and is usually due to dietetic deficiency.
Industrial and occupational m edicine is com m only concerned w ith a great variety of Figure 4 causes of dermatitis, and in the case of tar workers this may lead on to the formation of an epithelioma.Injuries to the hands are extremely common, especially in miners and sawyers, and there are other local hazards such as chrome ulcers and the occupational diseases mentioned under the general inspection.
The nephrologist must at present be satisfied with the pale, brownish, dry hand with uraemic twitching as a minor contribution to diagnosis.However, chronic renal disease, which was con sidered to be due to tuberose sclerosis, was first suspected in a woman in her sixties by noting the characteristic periungual fibro mata: minor lesions present on the face had not been observed.
T h e neurologist has plenty of observations available including, among others, the spontan eous movements already mentioned, sensory and motor changes, muscle wasting and fasciculation, or the very rare azure blue lunulae of hepato-lenticular degeneration.
The obstetrician may be consulted about sterility and may observe the short metacarpal and receding knuckle of Turner's syndrome (Fig. 4) while the opthalmologist may notice the long spider-like fingers of M arfan's syn drome in association with dislocated lenses.It might seem too far fetched to include otorhino laryngology, but a woman who was first referred to that specialty for deafness, the cause of which was overlooked, had myxoedema with very little to see in the face; her speech and thought seemed unimpaired though she admitted that her singing voice had deterior ate for two years.T he hands were slightly swollen in appearance, the skin was dry, and paraesthesiae were present in the fingers due to compression of the median nerve in the carpal tunnel.All these symptoms disappeared on treatment with thyroxine.
The paediatrician has interests in common with the geneticist, but has pink disease all to himself for it occurs only in babies and young children.T h e hands and the feet are so strik ingly red, cold and later peeling as to be responsible for the name of the disease.
T he psychiatrist may find interest in nervous tremor, bitten nails, dermatitis artefacta or barbiturate blisters.In respiratory disorders the combination of cyanosis and clubbing with multiple telangiectasia on the fingers as well as around the mouth and face may direct atten tion to an associated pulmonary arteriovenous fistula.The rheumatologist and the ortho paedic surgeon have common ground in the various forms of arthritis.
The list is long and could be be lengthened both with regard to the number of specialists and the variety of lesions in the hand which is of interest to them.However, m o re.than enough has already been written to draw attention to the diagnostic value which may be found in a careful examination of the hand.It is a part which deserves special consideration for among the major evolutionary features, it is one that has enabled man to control his en vironment and to rise above all other living creatures.

M esmerism
" T he first night I attended to witness a Frenchman, M r.Lafontaine, perform magnetic experi ments; as it was quite possible that the whole of the phenomena exhibited by his patients might have been the result of collusion or illusion, I set the whole down as such.A week thereafter I had another opportunity of watching his performance, when I saw' an effect produced upon a stranger, which I believed to be a genuine phenomenon -viz.the inability of the patient to open his eyelids after they had closed.I could not then comprehend the cause of this.N ext night I watched very closely whilst he mesmerised this same patient, and before the end of the experiment, I thought that I had discovered the cause of this curious phenomenon." This paragraph is taken from the opening section of fames Braid's " Essay on Hypnotic and Mesmeric Phenomena" , a manuscript copy written by the author and presented to the Society in 1853.Braid became renowned in this field and the original article was " read and discussed by them (the members) during three nights of session, 1853."