The History of the Physical Exam and Diagnostic Techniques

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The History of the Physical Exam and Diagnostic
Techniques

• Hughes Evans, MD, PhD

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Humoral Medicine

• Importance of the history
• Physical exam less important
• Highly individualized
• Stressed regimen, diet, climate, inheritance

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Diagnosis before 19th century

• Importance of the history
• Gathered information about the body
• Feeling the pulse
• Examining the stool and urine
• Assess external manifestations of illness
• Internal workings not accessible and not
  interesting

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Pulse taking, ancient China
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Persian Medicine
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Pulse taking, Renaissance
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Dr. William Clysson, 1780
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Development of Phys. Exam

• Percussion
• Auscultation
• Temperature
• Blood Pressure
• How did these reflect new ways of thinking about
  disease?
• What was the impact on the dr/pt relationship?

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Percussion

• Leopold Auenbrugger
• Inventum Novum, 1761
• Wine cask
• Localized disease
• Neglected throughout 18th century

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Percussion

• Pros
• Accuracy Precision
• Identified alterations in internal organs, esp
  the chest
• Objective evidence of disease
• Related structural internal change to external
  symptoms

• Cons
• Went against humoral theory which held that
  disease was lack of balance, not local process
• Manual process

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Auscultation

• Rene-Theophile-Hyacinthe Laennec
• Paris Clinical School
• On Mediate Auscultation, 1819
• stethoscope

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Immediate Auscultation

• Immediate or direct auscultation
• Problematic in obese and female patients

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Mediate Auscultation

• Mediate or indirect
• Use of stethoscope to augment sound
• Stethoscope means chest and observe
• A window in the breast through which we can see
  the precise state of things within.

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Impact of Stethoscope

• Correlation of sounds with pathology
• Localize disease to an organ and tissue
• Correlate symptoms with autopsy findings
• New way of conceptualizing disease
• Anatomy in a living patient
• Understanding how disease evolves

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Philosophical shift

• Increased role of physical exam relative to
  history
• Gave disease increased autonomy
• Importance of localizing disease

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Monaural and binaural models
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Laennecs portable stethoscope
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Thermometer

• Carl Wunderlich
• Germany
• On the Temperature in Diseases, 1868
• Based on 25,000 hospitalized patients

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Impact of Thermometer vs Stethoscope

• Quantitative information
• More precise
• Showed trends
• Could be graphed and show change over time
• Fever curves assisted in diagnosis, treatment,
  and prognosis

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Wunderlichs fever curve
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Reception of the Thermometer

• Focus on disease instead of patient
  idiosyncracies
• Reinforced notion of disease as process
• Replace physicians sense of touch
• Technical difficulties
• Easily broken, not portable
• Hard to calibrate
• Expensive

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Physicians sense of touch

• Pros
• Portable
• Convenient
• Mysterious
• Art of Medicine
• Symbol of laying on of hands
• Status and professionalism

• Cons
• Qualitative
• Less accurate
• Difficult to communicate
• Manual

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Sphygmomanometer
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Pulse diagnosis and BP

• Revered part of medicine since ancient times
• German physiologists in 1840s
• Reduce bodily processes to laws of physics and
  chemistry
• Use technology to measure these processes
• The Graphic Method
• Adapted physiological instruments for clinical use

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Kymograph

• Carl Ludwig
• 1840
• Apply physics to medicine
• Change over time

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Sphygmograph, 1880s
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Sphygmomanometer
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Sphygmomanometer

• Measures BP by occluding the pulse and recording
  pressure at which pulse returns
• Many designs
• Modern design based on Scipione Riva-Roccis
  device

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Sphygmomanometer

• Scipione Riva-Rocci
• 1896
• Italy
• Means pulse and measure
• Adapted by Harvey Cushing
• Uses in surgery first, then at bedside

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Uses of BP technology

• Monitor VS in surgery and at bedside
• Objectify teaching
• Consultation
• Diagnosis and Treatment
• Ancillary staff instructions
• First used to identify shock later for
  hypertension

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Cushings ether curves
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Helmholtz Ophthalmoscope, 1850
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Electrocardiograph

• 1901, Einthoven
• String galvanometer
• Bulky, delicate, expensive
• Initially used to study rhythm
• Later discovered changes assocd w/ myocardial
  infarction

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Electrocardiograph
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X-rays

• Wilhelm Roentgen
• Professor of physics in Bavaria
• 1895
• Could show internal anatomy
• Immediately accepted

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Xrays
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Benefits of PE technology

• Instruments more reliable than patients
• Information from the disease itself
• independent of the caprice or ignorance of the
  patient
• Delegation of tasks
• National Importance of Instruments of Precision
• Artistry yielding to machinery
• Useful in research

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Medical Research
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Concerns about PE technology

• Patients wary
• Doctors concerned that instruments made them
  appear less intellectual. Thinkers not tinkers
• Fear of being duped by technology

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Concerns about Med. Technology

• Difficulty of adapting technology to medical
  practice
• Convenience, durability, size, reliability,
  calibration
• Price
• House-calls

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Concerns about medical technology

• Increased cost of medicine

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Concerns about medical technology

• Dr/ Patient encounter became less personal

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Impact on Medicine

• Changed communication and learning
• Emphasized accuracy
• Stressed quantification
• Increased autonomy of disease

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Impact on education

• Osler, inspection

• Osler, palpation

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Impact on education

• Osler, percussion

• Osler, auscultation

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Impact on Medicine

• Fueled move to hospital-based medicine
• Fueled specialization
• Changed doctors image

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Image of the Doctor
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Doctors as Body Mechanics
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Larry Weeds SOAP note