The hand’s importance in daily activities is often overlooked even as I look down at my fingers typing these very words. Rudimentary at first glance, the expansive nature of the hand is as complicated as its anatomy and not in the palm reader sense. Its complexity manifests in the intricate duties it performs when acted upon by the user’s brain, and yet there is so much to learn by its simple examination in its resting splendor. The beautiful dichotomy of the hand is illustrated in the simple gesture of hand-holding, a parent’s single finger grasped in their infant’s small palm contrasted with the loose grip of the dying parent with their child. It is in the soft caress that hands are capable of, but also the solid fist of a hard punch, and the complexity of playing instruments, weaving, programming AI and painting.

My office visits begin and end with a post-COVID handshake if the patient is agreeable. The essential job of the clinician begins with listening followed by thorough examination. For it is in examination that the patient map unfurls. From the initial handshake, to how one holds their hands during the visit, little clues are imperceptibly directed at me. The wringing of the patients’ hands is the tip off for anxiety, along with tightly picked nails or scars. The slight hand tremor can be the giveaway of Parkinson’s disease, alcohol withdrawal or thyrotoxicosis. Then there is the yellow-stained thumb and index finger of the habitual smoker. The tiny muscle fasciculations below the skin are the tip off for advanced carpal tunnel syndrome, advanced neck arthritis, amyloidosis or the more devastating amyotrophic lateral sclerosis. The feel and look of the callus distribution on the palm of the construction worker as opposed to the soft and supple feel of the secretary’s palm or those of the computer programmer are all documented subconsciously, while noting the fissuring and hyperkeratotic papules and scale of the mechanic’s hand, or the similar changes on the non-mechanic’s hand suggesting dermatomyositis or anti-synthetase syndrome. Tell me how AI could perceive most of this without the input of touch and observation?

Whether in the office, grocery store or at dinner, examination proceeds whether the person is willing or not, or even aware. Examining the hand is like picking up an oak leaf in the fall with its midrib, venules and variegation all telling you about the health of the tree from which it has fallen. We won’t discuss ornaments that adorn the hands such as rings or nail paintings as this is quite illustrative in and of itself. Rather, I am more interested in scars, irregularities and deformities. Each small finger joint so intricate and important in function, working simultaneously together like the worker bees in a hive or an orchestra.

From the fingertip alone, Terry’s nail, with its loss of the crescent half-moon, ground glass white appearance, and the darker line at the very tip of the nail, suggests underlying liver issues. Move that line of demarcation proximally to affect half of the nail, it transitions into Lindsay’s nail and communicates underlying kidney dysfunction. Should that half-moon crescent change to a blue tinge or even completely change to blue, the patient may be being slowly poisoned by silver or copper. The pale nail bed alone is a tip-off for anemia. A murky longitudinal dark stain, like a comet and its tail tracing from the cuticle to the free nail edge, can be the forewarning of a melanoma. Smaller dark stripes distributed throughout the nail are the potential signs of endocarditis, lupus or vasculitis. Should the patients’ nails look like a pock-marked battlefield, the likelihood of psoriasis as a verdict is greater, especially if they are accompanied by joint aches or a reddish-silver raised skin rash. If the same patient did not choose to paint their nails yellow, and it spontaneously occurred, my pondering moves to lung pathology or autoimmune issues. Lastly, horizontal linear grooves on the nail, named after our friend Joseph Beau, tells me the patient is zinc deficient or enduring chemotherapy. While AI can certainly catalogue each of these physical exam signs and what they indicate, my examination can transpire on a soccer field, train or exam room and without the need for a computer.

Ascending from the fingertips, I look at the profile of the fingers. Do they keep their standard characteristic orientation, straight as an arrow or do they angle? Simply the direction of that angle can tell me so much, as the rearrangement of the interphalangeal joints offers countless clues. Should the patient get angry at all the meddling with his finger and point that finger at me, does his finger hyperextend backwards from the middle joint while the fingertip itself bends forward? Quickly I am carried pondside to see the swan neck of rheumatoid arthritis, lupus or scleroderma. However, should that fingertip hyperextend while the middle joint flexes, this represents the boutonniere deformity of injury or other connective tissue disorders. Moving from the quaint pondside to the opera house, I consider the shortened collapsing finger joints crumpling in a telescoping manner like an erstwhile opera-glass. This is the finger joint destruction of arthritis mutilans or advanced psoriatic arthritis. Now envision that same finger, fat and round like a sausage, and you have the less than delectable exemplar of dactylitis, which may be another sequelae of psoriatic arthritis, lupus or even tuberculosis.

Lest we forget the palm, it can serve as a mirror into superficial and deeper matters both physically and professionally. If there are a collection of cords slowly stealing a digit’s extension, you’ll find the fascial condensations of Dupuytren’s contracture. This patient has either had a long career of intense work with their hands or has been long afflicted with diabetes or may just have one more thing to thank a parent for. Should one of the fingers flex and become locked, trigger finger is now the diagnosis, although no marksmanship is required.

Both AI and I could go on for pages with the exam findings of the hand if necessary, particularly if we wanted to discuss congenital hand deformities or telltale characteristic findings on x-rays such as the appropriately named boxer’s fracture or the hand surgeon’s bane of the scaphoid given its peculiar blood supply. Oh, the many amusing mnemonics to remember the bones of the wrist can be quickly recited, both from AI and by the medical student! Ultimately, the power of observation is vital and a trusted companion of the doctor alone. The world is the clinician’s exam room and once one puts on these glasses and truly observes, it is hard to unsee the pathology vexing us humans. So, I say go forth and learn. Always start with a handshake as this key unlocks so much during the visit and then sit and watch. We physicians are a fortunate few beholden in full to our patients, who are granted access to this vast vocational milieu and this is what sets us apart from machines.

Web image by Medhum.org

Actor Clark Middleton wrote this autobiographical dramatic monologue in collaboration with Robert Knopf. Stricken with juvenile rheumatoid arthritis at age four, Middleton enacts his early painful experience — painful physically and emotionally. He takes us through an adolescence complicated by physical difference, his interaction with medical professionals over the years, and his craving to become an actor. Middleton struggles with the medical establishment, the pain and humor of coming-of-age, and ultimate self acceptance. Eventually, he was able to have both hip replacement surgery and a career in theater and film. The play is funny, poignant, and instructive.

Miracle Mile was performed in New York City in Fall, 1997 at Theater Row. The New York Times review called the play, “an enriching chronicle of a man who refuses to let the world take him at face value.” Middleton performed his monologue at New York University School of Medicine and at other institutions. Clips of a videotape of the theater performance are available at this web site.

Archive Videos from the Play

Actor Information
Clark Middleton (actor/author) performed MIRACLE MILE Off-Broadway in the fall of 1997. He has appeared in Sam Shephard’s CURSE OF THE STARVING CLASS as well as Mr. Shephard’s CHICAGO at the Signature Theatre Company. Clark was in William Hoffman’s AFTER THE ORCHARD and performed MIRACLE MILE at the Invaluable Cape Cod Theater Project. He began his professional career performing with the late Geraldine Page in productions of THE MADWOMAN OF CHAILLOT, PARADISE LOST, and VIVAT VIVAT REGINA. Since that time he has appeared in more than 40 NYC productions, most notably at the New York Shakespeare Festival, The Public Theatre, LaMaMa and Circle Rep, where he appeared with Olympia Dukakis in THE HOPE ZONE. In NYC Clark has directed LONE STAR, OUR DALY BREAD, DOMINO COURTS, CALL IT CLOVER and KIDNAPPED. He also directed MARVIN’S ROOM at The Wayside Theatre in Virginia. Clark can be seen in the films BAIL JUMPER, STORIES FROM NEW YORK, THE CONTENDERS and DON’T SHOOT DARLING. Clark plays the forensics expert Ellis on NBC-TV’s LAW & ORDER. He is a native of Tucson, Arizona and a member of both the Lab Theater Company and the 42nd Street Workshop.

Clark died on October 4, 2020. He was 63 years old.

Director Michael Warren Powell
Leading Actors Clark Middleton
Video Courtesy of Michelle Bouchard
Original Date of Entry 07/12/06

An earlier version of this review was published in the NYU Literature, Arts, and Medicine Database (Litmed).

Web Photo by Alex Radelich