Diagnostician

“ When the physician discovers certain signs or symptoms which constitute the diagnosis of any disease, he regards those signs as the effects of a disease already in existence, and treats the patient accordingly. ”

“ Not only in everyday practice in certain lines is a knowledge of this technique necessary for diagnostic purposes, but the true physician should so hold himself toward every problem of diagnosis which presents itself to him, that with every opportunity, he will, through excision, curettage or autopsy, make use of his technical skill to further his knowledge of disease, and to aid his science toward a solution of its great problems. ”

“ In the past seventy-five years medicine has progressed from an art to a science. The doctor today has diagnostic aids which would have seemed fabulous to the physician of a hundred years ago. Exact laboratory tests and the X ray enable the physician to base his treatment on definite knowledge. These are as available to the surgeon and doctor aboard ship as to the man working in the most modern and extensive medical center. ”

“ It is our pride that medicine, from an art, and a pretty black one at that, originally, is becoming a science. And the most powerful factor in this development, its indispensable basis, in fact, has been the invention of instruments of precision—the microscope, the fever thermometer, the stethoscope, the ophthalmoscope, the test-tube, the culture medium, the triumphs of the bacteriologist and of the chemist. Any man who makes a final diagnosis in a serious case without resorting to some or all of these means is regarded—and justly—as careless and derelict in his duty to his patient. ”

“ Much of what is taught to-day in pathology belongs to clinical medicine and surgery, for it is largely special and diagnostic in character. The pathologist is now the servant of the physician and surgeon in completing and rectifying their diagnoses. The pathologist of the future will deal with more general phenomena derived from experimental and comparative data, just as the physiologist has moved onward, or backward if you please, into general and comparative physiology. ”

“ The state of the face, eyes, tongue, voice, hearing, abdomen, sleep, breathing, excretions, posture of the body, and so on, all aided him in diagnosis and prognosis, and to the latter he paid special attention, saying that "the best physician is the one who is able to establish a prognosis, penetrating and exposing first of all, at the bedside, the present, the past, and the future of his patients, and adding what they omit in their statements. He gains their confidence, and being convinced of his superiority of knowledge they do not hesitate to commit themselves entirely into his hands. ”

“ Such a diagnosis would ruin a modern physician. The modern physician tells his patient that he is ill because every drop of his blood is swarming with a million microbes; and the patient believes him abjectly and instantly. ”

“ At a period when pathological research is lending its aid in investigating the appearances of disease in every part of the body, and many nice distinctions in diagnosis are aimed at, which are better calculated for nosological than practical purposes, it seems to me not a little extraordinary, that so few have cultivated that most important branch of medicine, the study of the diseases of children. ”

“ They refer the patient to the skilled surgeon.
The physician is both a curer and preventor of disease. I would advise every one, no mat [90] ter how healthy he may be, to consult a reputable physician once a year, and to be overhauled, so to speak. Most troubles can be obviated if taken in time. A symptom seemingly serious to the one having it may be of little consequence, and yet it may be the forerunner of an incurable disease. If a good physician is consulted in time, he may either obviate the trouble or prevent its rapid increase. No one should attempt to diagnose his own condition. ”

“ But I claim for the modern physician a knowledge and a power far beyond that of alleviating symptoms: viz., a true knowledge of the lesion which causes the symptoms, and the power of conducting the disease to a rapid favourable termination, notwithstanding what appears to the inexperienced or uninformed the most alarming and fatal phenomena. He is enabled to watch with accuracy by means of his stethoscope the removal of the consolidation of the lung, to favour the resolution of the exudation, and to assist the excretion of the absorbed products from the economy. ”

“ Every malady is accompanied by its characteristic indications, some of which are diagnostic, i.e., they particularize the affection and distinguish it from all others.
Medical diagnosis is both a science and an art; a science when the causes and symptoms of a disease are understood, and an art when this knowledge can be applied to determine its location and exact nature. Science presents the general principles of practice; art detects among the characteristic symptoms the differential signs, and applies the remedy. ”

“ So, too, should every respectable physician be trained in methods of biological study. To him every patient should be a field of research. By his own powers of observation he is to find out signs and symptoms of which the patient can not or will not give information. Merely listening to lectures, however entertaining or full of information, is not enough for this class of students. Work in the laboratory is necessary, and, in my opinion, that work had better precede any detailed course of lectures. ”

“ It is not to be denied that the art of making a good diagnosis has been brought to considerable perfection of late; but whether we are more successful than the doctors of former times in curing these well-diagnosed diseases is very doubtful. Now a general hospital, frequented by thousands of “cases,” is to the inquiring physician what an Alpine valley is to the botanist, or a Brazilian forest to an entomologist. It is there that orders, genera, and species are to be found. ”

“ While it is not possible that every medical graduate can enter into the active practice of his profession as an expert pathologist, yet the possession of the technical knowledge necessary to perform an autopsy properly and to select with discrimination the tissue for microscopic examination gives to a physician a distinct practical advantage. This advantage becomes the greater if to the possession of this knowledge there be added also a practical working knowledge of the technique necessary for the microscopic examination and diagnosis. ”

“ The author still advises that a physician be consulted, if it be possible, not only on account of the danger of taking a wrong medicine or too much of a proper one, but because few people are really competent to make a proper diagnosis. ”

“ The final diagnosis is with respect to the nature of the lesion. While the second diagnosis may be said to possess the greater scientific interest, this one must be admitted to possess paramount practical importance, as from it we derive the indications for rational treatment and the data of prognosis. The third diagnosis is to be made by the application of the observer's knowledge of general pathology and etiology; hence it is in this field that the best-trained physician succeeds—where the experienced practitioner may sometimes eclipse the brilliant specialist. ”

“ The object of the American Registry of Pathology, which has grown to include 27 specific specialty registries, as outlined by Major Callender, 3 [3] is to "collect data and specimens from patients, especially those with tumors, with a view to accumulating a sufficient number of instances of each disease to determine its characteristic course, the criteria for diagnosis, and to evaluate methods of treatment * * *. The cases preferred are those living at the time of registration, and that can be followed so that the outcome may be ascertained. ”

“ ADVANTAGES OF SPECIALTIES.
By thorough organization and a perfect system of subdividing the practice of medicine and surgery in this institution, every invalid consulting us is treated by a specialist—one who devotes his undivided attention to the particular class of diseases to which his or her case belongs. The advantage of this arrangement must be obvious. Medical science offers a vast field for investigation, and no physician can, within the limit of a single life-time, achieve the highest degree of success in the treatment of every malady incident to humanity. ”

“ SYMPTOMS AND PROGRESS OF DISEASE—AGE AND CLASS OF PATIENTS TO BE TREATED—OPERATION—AFTER-TREATMENT, ETC. Every medical practitioner must have met with a certain class of cases which has set at defiance every effort at diagnosis, baffled every treatment, and belied every prognosis. ”

“ Troubles which would lead the patient to go to the specialist primarily, without consulting his family physician, should receive little attention.
Two other classes of lesions in such organs as are usually handed over to specialists should receive attention in the undergraduate course—those which are apt to cause remote or reflex disturbances, and those which are definitely symptomatic of central lesions. The first should, in my judgment, be dwelt upon only to such an extent as to enable the student to know causative relation and method of diagnosis. ”

“ Yet there are signs that we are entering on a new phase, and that a realisation of the importance of early diagnosis is slowly permeating through the medical profession. In America we see an increasing insistence on the use of detailed and specialised laboratory methods for exact diagnosis ”

“ Thirty years of active practice had made him familiar with disease in its varied forms, and had led him to reject as useless that which was merely speculative in medicine, while it enabled him to speak with authority of all that was valuable in our science. Thoroughly familiar with medical literature, he had also studied disease in the great book of nature, at the bedside in private practice, and in the wards of hospitals. ”

“ Often a patient is sent a long distance to consult a medical man, and to return to his own physician for treatment based on the diagnosis made. In these instances the doctor consulted is expected to write his views privately to the patient's doctor, and to recommend treatment. ”

“ It is imperative to create an environment or a culture that reduces stress for the physician, to always use differential diagnoses even when the diagnosis seems obvious, and to train humble physicians who are willing to listen to patients and other team members so that they can revisit the evidence when they are questioned about their diagnosis or management of patients. ”

“ Our improved and perfected system of diagnosing, or determining, the exact nature and extent of chronic affections, which, in most cases, we are able to do at a distance, and without a personal examination of the patient, as will be more particularly explained in the appendix, or latter part of this little book, has enabled us to avoid the blunders so often committed by the general practitioner, who not infrequently treats those afflicted with chronic ailments peculiar to women, for long weeks, and perhaps months, without ever discovering their real and true disease, or condition. ”

“ If a patient could once have displayed before him in visible form the immense amount of knowledge, experience, and labor which has gone into the devising and goes into the performing of this test, he would be more content to leave the decision of such questions to his physician than he sometimes is, and would be more alive to its reality and importance. ”

“ Treating of a disease resulting from an assemblage of symptoms, some of which do not appear to have yet engaged the general notice of the profession, particular care is required whilst endeavouring to mark its diagnostic characters. It is sufficient, in general, to point out the characteristic differences which are observable between diseases in some respects resembling each other. But in this case more is required: it is necessary to show that it is a disease [28] which does not accord with any which are marked in the systematic arrangements of nosologists ”

“ We have treated symptoms and even then without intelligence, if it may be said justly that the doctoring of symptoms is done intelligently. We are in need of a physician, a whole staff of physicians, to study, to diagnose, to prescribe treatment and stay with the patient to see that nothing develops which will make the treatment futile. ”

“ He must frequently destroy before he builds up. He approaches the individual case of disease through general laws established through experiment. The physician must begin with his patients and through them reach general formulse governing disease. He studies the patient, whereas the investigator studies the disease.
The investigator should be free to a certain degree to create his material and his problems. The physician must accept his cases as they come to him and he can only exercise the skill of selection. ”

“ In the latter, clinical medicine or medical practise seeks to lay hold of the acquisitions of experimental science and to utilize them in the interpretation of symptoms. The clinical or hospital laboratory approaches medical problems from the professional side and is thus an extension of medical practise into a territory where science and practise meet and shade into one another. Here the future physician should receive most careful training when he begins to direct his studies toward some branch of medicine. ”

“ As there are, in fact, no two human organism exactly alike, so also is there divergence, more or less, in each individual case, in disease; and however apparently similar the symptoms may be, the knowledge and experience of a physician becomes necessary in order to determine correctly what the ailment is and how general principles should be applied in each particular case. ”