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

Daudet tried all sorts of therapy, including mashed bulls’ testicles and elixir of guinea pig. Nothing worked, with the exception of large quantities of morphine and chloral hydrate, which made his life bearable. Daudet also coped with his intractable pain by writing about it. He planned to write a complete memoir of his life with pain, but by the time of his death in 1897, he hadn’t gotten farther than 60-odd pages of notes and reflections. About twenty-five years ago, the English author Julian Barnes translated and collected these fragments into a small jewel of a book called In the Land of Pain.¹

The title is illustrative. Those who suffer from chronic pain live in a different country from the healthy, and they gradually find themselves speaking a language that others don’t understand. At first, Daudet introduces details of his discomfort into conversation but soon realizes how repetitive and boring this is to his friends. “Pain is always new to the sufferer,” he writes, “but loses its originality for those around him. Everyone will get used to it, except me.” (p. 19) Daudet finds himself living in a land where suffering is pervasive, “Pain finds its way everywhere, into my vision, my feelings, my sense of judgment; it’s an infiltration.” (p.23) Toward the end he writes, “I’ve passed the stage where illness brings any advantage or helps you understand things; also, the stage where it sours your life, puts a harshness in your voice, makes every cogwheel shriek.” (p. 65)

Although Daudet was not known as a poet, many of these presumably random notes are, in fact, miniature poems. Consider this example: “In the dining room: the man who quite suddenly finds himself unable to read the menu. His wife bursts into tears and leaves the table…” (p. 63) And here is another: “The hotel. The bell-board. The bath times. / Solitude. / Encroaching darkness.” (p. 65)

One of the more depressing aspects of medicine today is the fact that many doctors are still “very poor at discerning things,” at least when it comes to pain. I get a knot in the pit of my stomach whenever I hear a resident discussing whether a patient’s pain is “real” or “imaginary,” or making a cynical comment about drug seeking behavior, especially when the resident herself has prescribed a grossly inadequate course of analgesia. Some of my colleagues believe that a person has to be visibly anguished before they take seriously his reported experience of severe pain. And others get exasperated with patients who describe having more pain than their condition (according to the doctor) warrants, and tell them, “You’re overreacting,” or “It’s all in your head.” When I hear this, I want to shake the physician by their shoulders and yell, “Of course it is! All pain, no matter what causes it, exists in the head. Where else could the experience be generated?”

In the Land of Pain illustrates that chronic pain sufferers can live calm, productive lives despite constant agony. Daudet continued writing, publishing, and socializing until the end of his life, even though he wrote, near the beginning of his journal, “My friends, the ship is sinking, I’m going down, holed below the water line.” (p.7) At the same time, the author’s strength, compassion, and humor illuminate his little book. He emerges as a generous person, who was well loved by his contemporaries. If you were his physician, what would your assessment be?

Would you accuse him of exaggerating his pain because he doesn’t appear desperate?

Daudet refers to his pain as an “unwanted guest,” to whom he intends to give “no special attention.” (p. 79) At another point he reflects on “the ingenious efforts a disease makes in order to survive.” (p. 26) The writer never questions his enemy’s ultimate victory, but neither does he turn in upon himself. He remains a source of joy to others, especially his family, as indicated in this note: “I only know one thing, and that is to shout to my children, ‘Long live life!’ But it’s hard to do so while I am ripped apart by pain.” (p.49)

Chronic pain remains challenging for doctors to treat. One set of barriers are the moral and legal concerns about overuse of opioid analgesics. Questions about the threat of addiction, or the possibility of being manipulated, favor resisting the patient’s suffering, rather than responding with compassion. Many are uncertain about how to proceed because they lack knowledge of treatment protocols that include nonpharmacologic modalities, or referral to pain control clinics for invasive procedures. Alphonse Daudet’s little book invites us to imagine ourselves living, at least for a little while, in the land of pain.

1. Daudet A. In the Land of Pain. Edited and translated by Julian Barnes. New York, Alfred K. Knopf, 2002. (page numbers indicated in the text).

Photo of Alphonse Daudet from Wikicommons.

The nature of phantom limb pain has bedeviled amputees and bewildered physicians and surgeons for centuries; up to 87% of amputees experience it during their lifetime. Consistently effective treatments remain elusive. Biomedical texts on the subject are at once complex and speculative. Olga Tokarczuk, in her 2018 novel, Flights, imagines what phantom limb pain could be like for someone, and the desperate search for relief it can produce. 

Flights centers mostly on the narrator’s travels among different places and across different times. It comprises mostly packets of individual story vignettes and fragments; some short, some long; some fictional; some real, some both. And though many different stories are told with many different characters about many different subjects, something about travel connects them all.  

Certain preoccupations manifest themselves in various parts of the book. One in particular concerns the technical aspects of preserving human body parts, which comes into play in a story fragment involving phantom limb pain. The main character is Philip Verheyen, who is a real historical figure known as a renowned Flemish surgeon and anatomist of the late seventeenth and early eighteenth centuries, and as the author of Corporis humani anatomiae (1710).  

As Tokarczuk tells the story, Verheyen was twenty-eight-years old in 1676 during his second year of university in Leiden when he scraped his left calf on an exposed nail of the stairway leading to his rented lodgings. His pants were torn and his skin broken. Though the injury seemed minor at first, it evolved into a raging infection that later required below-the-knee amputation.  

With the care of his landlady, Verheyen recovered after which he was seen “tapping his peg over the uneven paving stones of Leiden,” to attend lectures on the subject of anatomy at the university medical center.” (p. 195) In a matter of a few weeks after the amputation, however, the pain started. 

The pains came at night as his body was relaxing and slipping across the uncertain boundary between waking and sleep…He would have the impression that his left leg was numb, and that he absolutely had to get it into the right position—he felt his toes tingling, an unpleasant sensation. He fidgeted, half conscious. He wanted to move his toes, but the unperformability of that movement awoke him completely. He would sit on the bed, tear the blanket off himself, and look at the aching place—it was some thirty centimeters below the knee, there over the rumbled sheet. He would close his eyes and try to scratch it, but he touched nothing, his fingers combed the void in despair, giving him no relief. (p. 203) 

In imagining how Verheyen could respond to his desperation for relief, Tokarczuk draws on his intense interest in preserving human body parts. Before the amputation, he begs the surgeon to “preserve the removed leg.” (p. 193) The surgeon followed Verheyen’s detailed instructions for preparing his amputated limb by placing it “in a glass vessel filled with a balm of Nantes brandy and black pepper.” (p. 193) Verheyen kept it “on his headboard or stretched scarily out on the table.” (p. 196) Eventually, he looks to it as a possible source of relief. 

Once, in a fit of despair, when the pain and itching were driving him mad, he stood and with trembling hands lit a candle. Hopping on one foot, he moved to the table the vessel with the cut-off leg [rested]…He extracted the limb and in the candlelight tried to locate in it the reason for the pain…He sat down on the floor, stretched his legs out before him, and laid the amputated limb on the place just below his left knee. He closed his eyes and groped for the painful place. His hand touched the cold piece of flesh—but could not reach the pain. (pp. 203-204) 

Verheyen’s maneuvers and observations did not provide him relief. With his medical training, he begins thinking about mechanisms that could be causing this excruciating and frustrating phenomenon. 

What is it that awakens me, when I feel pain and suffering, since my leg has been separated from me and is floating now in alcohol? There is nothing pinching it, no reason for its suffering, no such pain that can be logically justified, and yet it exists. Now I look at it and simultaneously feel in it, in the toes, unbearably hot, as though I were submerging it in hot water, and this experience is so real, so obvious, that if I were to shut my eyes, I would see in my own imagination the bucket of water overly heated and my own foot submerged from toes to ankle. I touch my bodily existing limb in the guise of a lump of preserved flesh—and I don’t feel it. I feel, meanwhile, something that does not exist, it is in a physical sense an empty place, there is nothing there that might give any sensation whatsoever. The thing that hurts does not exist. A phantom. Phantom pain. (p. 208)  

He comes up empty. 

Tokarczuk cannot imagine Verheyen would let the issue lie and accept it simply because he is without an anatomical or pathophysiological explanation. She knows that before he began his schooling in medicine, he was studying theology towards becoming a Catholic priest. In fact, in the book and in his real life, the amputation disqualified him from Catholic priesthood. So, Tokarczuk brings his theological training into thoughts he could have about this phenomenon that is torturing him from spiritual realms, and in this way leaving Verheyen to contemplate the mind / body relationship. He concludes, “The body is something absolutely mysterious.” (p. 209)  

It still is.  

Web image generated with Dall-E 2