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April 27, 1964


JAMA. 1964;188(4):387. doi:10.1001/jama.1964.03060300049014

The art of skillful physical diagnosis is based on careful observation: Osler spoke of the necessity "to make perfect that most difficult of all arts, the art of observation." For centuries careful practitioners have observed and recorded, and certain signs have become associated with disease entities. Ask any medical student what clubbed fingers denote, and he will reply, "Pulmonary sepsis or malignancy—and splinter hemorrhages mean bacterial endocarditis."

The clinician knows what the student has not had opportunity to learn: relationships are seldom so definite and unequivocal when one turns from the textbook to the patient. In a recent report, Just-Viera1 states that "clubbing is a frequently observed, often misdiagnosed, and inadequately explained phenomenon recognized since antiquity." Clubbing is often associated with pulmonary disease, but it is also found in conjunction with a wide variety of other disorders, as a hereditary variety or as an idiopathic type with no known

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