HUTCHISON’S

CLINICALMETHODS

Bailliere Tindall

Hutchison's Clinical Methods

Hutchison's Clinical MethodsNineteenth Edition

Michael Swash m d , f r c p , MRCPath

Consultant Physician to The London Hospital

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First published 1897 Eighteenth edition 1984 Nineteenth edition 1989

B ritish L ibrary C ataloguing in P ub lication DataHutchison, Sir, Robert 1871-1960

Hutchison; clinical methods 1. Medicine. Diagnosis I. Title II. Swash, Michael 1939- 616.07'5ISBN 0-7020-1329-3

English Language Book Society Edition of Nineteenth Edition ■

Typeset by Paston Press. Loddon, Norfolk Printed in Singapore by Times Printers Pte Lid

Contents

List o f plates viSir R obert H u tch ison viiPreface ixA cknow ledgem ents xi

1 Doctor and pa tien t 12 T h e psychiatr ic assessm ent 403 T h e skin, the nails and the ha ir 674 T h e gas tro in testina l t rac t and ab dom en 805 T h e kidneys a n d urine 1476 T h e respiratory system 1867 T h e ca rd iovascu la r system 2188 T h e nervous system 2849 T h e unconscious pa tien t 381

10 T h e ear, nose an d th roa t 39111 T h e eye 42012 T h e locom otor system 43813 T h e blood ' 46614 T h e exam ina tion of w om en 49815 T h e exam ina tion o f children 51916 T h e genita lia a n d sexually t ransm itted diseases 55217 U sing the labo ra to ry 569

A ppend ix 576 Index 585

V

List of PlatesI Viscera of T h o rax and

A bdom en, as seen from the front in the C ad av er

II Viscera of T h o rax andA bdom en , as seen from behind in the C ad av er

I I I Acute central a rteryocclusion

C hron ic simple g laucom a C onjunc tiva l injection due

to hyperca lcaem ia

IV N orm al F undus Pr im ary optic a trophy Papilloedem a

V O p a q u e (m yelinated) nerve fibres

B ranch retinal vein occlusion

Retinal emboli

V I H ypertens ive re t inopa thy Diabetic re t inopa thy X a n th e la sm a ta

p a lp e b ra ru m and ca ta rac t D ysthyro id lid re traction

V I I I m petigo Erysipelas

V I I I Basal cell carc inom a Herpes zoster

IX Bacterial endocard itis P u rp u ra in H enoch-

Schonlein disease K aposi’s sa rcom a

X Norm al periphera l blood N orm al bone m arrow

aspirate

X I I ron deficiency a n a e m ia (per iphera l blood)

M acrocy tic a n a e m ia (per iphera l blood)

X I I M ega lob las t ic bone m arro w G la n d u la r fever (pe r iphe ra l

blood)

X I I I Sickle h a em o g lo b in disease(pe riphera l blood)

/3 -T halassaem ia m a jo r (p e r iphe ra l blood)

X I V Spherocytosis (pe r ip h e ra lblood)

M yelom atosis (bone m arrow )

X V C h ro n ic lym phocy ticleukaem ia (p e r ip h e ra l blood)

C h ro n ic g ran u locy tic (myeloid) leukaem ia (pe r iphera l b lood)

X V I A cute m yeloblasticleukaem ia (p e r ip h e ra l b lo o d )

H aem olv tic a n a e m ia (sickle h aem og lob in disease)

X \ I I S m e a r from u te r in e cervix S p u tu m cytology

X V I I I Ascites cytologyC ereb ro sp in a l fluid cytology

X I X In tes t ina l Parasites

X X Parasites o f the blood

VI

f

< r

SIR ROBERT H UTCHISON MD FRCP (1871-1960)

Clinical Methods began in 1897, three years after R obert H utch ison was ap po in ted Assis tant Physician to T h e London Hospital. He was ap po in ted full physician to T h e London an d to the H ospita l for Sick C hild ren , G rea t O rm o n d Street, in 1900. He steered Clinical Methods th rough no less th an 13 editions, at first w ith the assistance of D r H. Rainy and then, from the 9th edition, pub lished in 1929 with the help of D r D onald H u n te r . A lthough H u tch ison retired from hospital practice in 1934 he con tinued to d irect new editions o f the book with H u n te r , and from 1949 with the assistance also of D r R ichard Bomford. T h e 13th edition, the first p roduced w ithout H u tc h iso n ’s gu id ing hand , was pub lished in 1956 u n d e r the direction of H u n te r and Bomford. D r A. S tu a r t M ason and the present au th o r jo ined Bomford on H u n te r ’s re t irem en t to produce the 16th edition, published in 1975. and following B om ford 's re tirem ent p repa red the 1 7th and 18th editions.

D u r in g the m an y years of its con tinuous publica tion Clinical Methods has been t rans la ted into m any languages. Indeed it is one of the great p leasures of association w ith the book to receive letters from far p arts o f the world, offering friendly advice, criticism and correction. S tudents have som etim es noted errors tha t have escaped the eye of the editors d u r ing several editions.

v i i

viii Sir Robert Hutchison

H utchison died in 1960 a n d there are now few w ho rem em b er him in the years of his active and p roductive life. It is evident from the m em oirs of his contem poraries tha t he h ad a rem arkab le persona lity a n d m an v o f his clinical sayings became, in their day , aphorism s to be rem em bered and passed on to u tu re generations o f s tudents . O f these the best know n is his petition, w ritten

in his 82nd year:

From inability to let well alone; from too much zeal for the new and contempt or w at is old, from putting knowledge before wisdom, science before art. and

c everness before common sense; from treating patients as cases, and from ma ing t e cure of the disease more grievous than the endurance of the same, Oood Lord, deliver us.”

Michael Swash The London Hospital London E l IB B

Preface

Clinical Methods is a book for s tudents o f all ages an d all degrees of experience. W e all have gaps in ou r knowledge and this book should help fill them . It is in tended to provide insight a n d instruction on the acquisition o f clinically useful inform ation w he the r ob ta ined by the trad itional clinical skills of h istory-taking and physical exam ination , or by the increasingly complex and accura te m ethods available to the m odern clinician with help from the biochemist, physicist, physiologist or com pu te r engineer. Clearly, it is not possible to inc lude all this in form ation within the covers of a single book. Yet if m odern investigative m ethods are to be applied to pa tien t care, intelligently, with econom y and w ith com passion, they m ust be in tegra ted with traditional m ethods. T h e la t te r rem ain invaluable and irreplaceable clinical skills. Ex tended investigations a n d m ore complex m anagem en ts m ust be both useful an d hum ane . T h e a r t o f the clinician, m entioned by R obert H u tch ison in his petition, is essentially the art o f com m unica tion and explanation.

In his own day H u tch ison was concerned to explain those tests tha t were im p o r tan t in his clinical practice, particu larly bacteriology, urine testing, radiology, an d the beginnings o f electrical tests o f m uscu la r function. Brief accounts o f m odern m ethods o f investigation are therefore given th roughou t the n ine teen th edition of the book; these are not in tended to be com plete but, ra ther , to give som e idea both of the principles underly ing them , and of the indications for the ir use.

Earlier editions o f this book excluded surgical, gynaecological and obstetric problem s but this now seems inappropria te . Indeed , o ther aspects of medical practice, especially the assessment of the sexually-transm itted diseases, have h itherto suffered unnecessary neglect, yet fall na tu ra l ly into place in the context of the clinical m ethods used in their diagnosis, investigation and m an ag em en t . T hese m atte rs now receive p roper a tten tion . Despite these changes it is hoped tha t faithful, older readers will continue to recognise in Clinical Methods an old friend; a friend offering some new inform ation, together with m uch tha t is well-tried, and that ought to be as well-known to new genera tions of s tuden ts as it was to their teachers when they were s tudents . G ood clinical m e thod . Robert H utch ison said, is still the root of the m atter .

D r A. S tu a r t M ason has now retired from T h e London H ospita l and from his long association w ith Clinical Methods. His influence on the book has been profound, p a r t icu la r ly in ensuring its relevance to clinical practice, to the acquis it ion o f clinical skills, and to the fundam en ta l im portance of p lann ing a p p ro p r ia te investiga tion and m anagem en t. W ith this n ineteen th edition of

ix

x Preface

Clinical Methods several new con tr ibu to rs have jo in ed the book. Som e have con tr ibu ted entirely new chap ters a n d others have modified the w ork o f their predecessors. T h u s Hutchison’s Clinical Methods is not the work o f any ind iv idual but is the result o f close collaboration betw een clinical colleagues in their practise at T h e London H ospita l. T h e ed ito r bo th con tr ibu tes to the book an d carefully m oulds and modifies the individual con tr ibu tions so as to in tegra te them into a single text. T h ro u g h o u t the book an a t te m p t has been m a d e to indicate particu larly im p o r tan t m atte rs , and to suggest the d iagnostic re le­vance of certa in findings. T h e book m ay therefore be used not on l\ as a text o f clinical m ethods bu t as a supp lem en t to textbooks o f medicine, su rgery a n d the specialties. It m ay be read from cover to cover or ap p ro a c h e d piecem eal, as seems appropria te . C onstruc tive criticisms are , as always, welcom ed.

Michael Swash The London Hospital London E l