Speak Out Rheum: Musings on Our Past & Rheumatology

A replica of a hand painting found in Chauvet Cave, Ardéche, France. (Click to enlarge.)

I have been reading Yuval Harari’s thought-provoking and engaging book, Sapiens: A Brief History of Humankind, about our species’ struggles and the path that led to our emergence as the predominant species.

I was captivated by the drawing of the hand of one of our ancestors and mused about what that forebear was thinking as they placed their hand on the wall. The depiction of that ancient hand seems so similar in its shape and size to our own modern hand. Was syndactyly present between the third and fourth fingers? It seems they could forage and hunt for food. Did they have time to play any games? Were they able to paint, sculpt or draw? The stories they might tell have captured my imagination.

Thinking about our prehistoric relative, I also consider the patients we care for every day. Each day we begin our office visits with a handshake and a smile. My dear friend and colleague William (Bill) Arnold, MD, reminded me of the aphorism, “The hand is the calling card of the patient with arthritis.” The chief concern of our patients is often centered on pain and discomfort in their hands. We see in their faces the distress and anguish at not being able to do simple tasks about their home, the absence of pleasure in their inability to play with family and friends or having to make difficult choices to continue their work.

They come to us for help to turn their lives around. As we inspect the skin of the fingers, we look for subtle changes of thickening and tautness or, perhaps, the woody texture of scleroderma. We are vigilant to find different, colorful, eye-catching rashes (e.g., periungual telangiectasia, psoriasis, purpura, petechiae and many others). Thick, and often bulky, friction rubs of tendons and hard, firm nodal enlargement are familiar signposts. In the next few moments, we may observe the wasting and atrophy of thenar muscles and consider carpal tunnel syndrome.

We have witnessed the decline and disappearance of many severe hand complications, such as the digital infarcts of rheumatoid arthritis (RA), the mutilans and pencil-in-cup deformities of psoriasis, and the transformation to much less generalized boggy and mushy synovitis at the first visit in our patients with RA to just the appearance of symmetric second and third metacarpophalangeal joint involvement. Possibly, these findings are today’s rheumatology relics.

Rheumatologists have said goodbye to our jewelers’ rings to measure changes in joint structure. Today, we use musculoskeletal ultrasound and magnetic resonance imaging to show very precise images of joint pathology and monitor disease activity.

In this brief moment in our time of practice—just the past 40–50 years, a blink of an eye in the long history of our species—we and our patients have enjoyed the apparent miraculous discoveries of the many causes of rheumatic diseases. Our current biologic therapies have been life changing for millions of our patients and have given them their lives back. Intravenous pegloticase can eliminate golf-ball sized tophi with a Drano action in weeks. Collagenase clostridium injections provide a meat tenderizer-like softening effect, and within a few days a Dupuytren contracture is gone and the finger is straightened.

Many patients today extend and grasp our hands with a firm grip and a glint in their eye of thanks.

Rheumatology is at the beginning of adopting precision medicine, and I can only imagine what new discoveries and treatments there will be in the next 40 years for our patients and future rheumatologists. Perhaps, thousands of years from now, a physician will examine an old picture of a hand with severe arthritis from a digital archive and, like us today, find themselves bemused by how far we have progressed and yet how similar we remain.

David R. Mandel, MD, FACR, has been providing care to patients with rheumatic diseases in Northeast Ohio since 1982. He is a member of the medical staffs of University Hospitals, Lake and Hillcrest Hospitals. He is a past president of the Ohio Association of Rheumatology.