|Home | About | Journals | Submit | Contact Us | Français|
Have you ever had that idle but interesting conversation about whether you would rather be blind or deaf? I can imagine that either one would severely curtail my abilities as a doctor, but perhaps I could adapt. Far more devastating would be to lose the sense of touch, that mysterious channel for the gathering of information and the exchange of emotion.
It seems to me that this sensory modality and the memories it imprints are under-represented in what we read. We are used to detailed visual portraits, character analyses, passages descriptive of sights and sounds, but rarely do we read a celebration of textures and temperatures, rigidity and softness: all those subtle tactile sensations. In the practice of medicine, they come into their own.
There is a diagram in many textbooks of physiology showing the mapping of the body onto the sensory cortex, in which a homunculus with enormous hands, large feet, tiny limbs and a grossly swollen tongue reminds us of our needs and appetites. Barring the few oddballs who like to taste a patient's urine rather than use a dip test, we have little diagnostic use for our tongues, but those hands are priceless.
As medical students, we crossed many hurdles, and one of them was to overcome the social conventions surrounding touch. Once we were legitimised to lay a hand on a patient's chest or abdomen, the next challenge was to make some sense of what we felt under our fingers. Twenty-five years on, my brain contains a memory bank of sensory information derived through my hands, filed — I suppose — somewhere close to that collected by my eyes, and another by my ears.
In abdomens, I know the hard edge of a liver full of metastases; the odd elongated gallbladder stuffed to bursting with stones; the swill of ascites; the turgidity of a full bladder; the bloat of a volvulus; the drum of intestinal obstruction; the throb of an abdominal aortic aneurysm; the startling enormity of a huge spleen; the heaviness of a haematoma and the heat of an abscess.
In chests I have met the dullness of a pleural effusion; the heave of a hypertrophied left ventricle; the crepitus of fractured ribs and the crackle of overlying surgical emphysema; and in the breast all manner of things: the mice, the cysts, the nodules, the engorgement of lactation, the hardness and heat of mastitis, the lumpiness, and the craggy cancers.
Crossing further boundaries, my fingers have probed the uterine fullness of pregnancies both wanted and unwanted; the irregular bulkiness of fibroids; varieties of ovarian and tubular swellings; and — although never with the subtlety of my midwifery colleagues — the mysterious softenings and widenings of the cervix in labour. They have traced the smoothness of a benign but hypertrophied prostate, and run across the shocking irregularity of a malignant one. They have delved in faeces, blood and pus in their multiplicity of textures. Across the expanses of the skin I have felt rough scales and woody plaques, rubbery lipomata and firm cysts; warts, moles, melanomas, the lines of lichen planus and the papules of urticaria. I recall the coldness of an ischaemic foot, the warmth of cellulitis and deep vein thrombosis; the slipperiness of a cold sweat accompanying myocardial infarction; the beads of perspiration in one fever, the dry heat of another.
And so it goes on: an endless catalogue of sensory data, carrying varying amounts of information. But there is another side to touch that has to do with communication and emotion. We are all taught the importance of greeting our patients and the potential value of shaking hands. If we want to add an extra degree of warmth, we cup the other's hand with both of ours, doubling the surface area in contact. A minor variation in pressure, a brief squeeze perhaps, conveys yet more meaning.
My hand has held the hand of many a tearful patient. At the bedside this form of silent communication, this laying on of hands, is even more powerful for both parties. In transcending the awkwardness of words it expresses trust, compassion, sympathy and a promise — a promise, literally, to stay in touch. Embraces, hugs, an arm across the shoulder, a hand on the head of a child, sometimes — may the GMC forgive me — even a kiss can have its place.
You recognise all this stuff, it's all second nature, it's what we do. It's what we're for. Or did someone mention QOF?