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The significance of diagnosis in medicine
Original THE SIGNIFICANCE HAROLD
FISHIER
Articles
OF DIAGNOSIS PIERCE,
M.b.,
NEW
IN MEDICINE YORK,
N. Y.
IAGNOSIS is defined as the determination of the nature of disease. Physical diagnosis employs the methods of inspection, palpation, percussion, and auscultation. Clinical diagnosis bases its findings on the symptoms shown during life, irrespective of the morbid changes producing them. Laboratory diagnosis dekives its results frorn chemical, bacteriologic, electrical, and mechanical procedures applied to the study of biologic material, either living or dead. Finally, the special techniques of the psychiatrist and psychobiologist furnish For diagnosis is built up by deducpertinent details not otherwise obtainable. tion from many observations, and it is the object of the examination to elicit, nil of the data which the case presents. Health is the state of harmonious action of all the functions of the organism. There is a certain feeling of well-being in every healthy individual, and until health is impaired, one is barely conscious of having possessed it. The acme of health is fitness, which Lord Horder has defined as “Health plus Happiness.” Ill health is the discordant action of one or more organs, and its first sign is usually some disagreeable sensation. The patient comes to the doctor because he does not feel well. His trouble may have a physical basis, or it may be wholly imaginary; the essential fact is the patient’s conviction that he is not his usual normal self. To consider the physical illness and pooh-pooh the psychic component is to side-step responsibility and leave the job half-done. The malade imaginaire should be as significant an object of the doctor’s earnest attention as the patient with jaundice or boils. It is the physician’s moral duty to seek the total cause of the indisposition: to study the whole man, and to attempt to return him to health. Diagnosis is based on our observation of signs and symptoms, and our deductions from them. In 1846 John Hutchinson said, in effect : “Future knowledge may prove our deductions erroneous ; but the value of sound observaSound tions, carefully made and properly recorded, can never be questioned.” observations: that is the important point ; for observing is an art, acquired by training, maintained and enhanced by unremitting practice. Someone has said that for every doctor who does not know enough, there are ten who do not set enough : “which have eyes, and they see not.” Since the object of our examination is to discover the cause of the patient’s illness, our primary interest, centers in those findings classed as abnormal. In order to recognize the abnormal, one needs a bhorough knowledge of the normal, and this can be attained only through sound discipline in anatomy and physiology, reinforced by constant study of the human material which comes before one.
D
li.
TXAivfrerl before 1940. at the New
the York
American Academy
AssociiLtion for of Medicine. 169
the
Advancement
of Oral
Diagnosis,
Oct.
170
Harold
Fisher
Pierce
There are such wide variations in the build and functions of normal people that, unless one is cognizant of their significance, a diagnosis of disease may easily be made in a healthy person. For example, the average normal bloodsugar is 97 mg. per 100 ml. of blood, but values ranging from 80 to 120 mg. are frequently found in subjects who are, to all other tests, normal. Hence the impossibility of making a diagnosis on the blood-sugar findings alone, since 120 mg. might represent a normal figure in one individual while in another it might signify hyperglycemia. Diagnosis demands a complete examination, in which the first step is the taking of a comprehensive and adequate history. There is nothing which has ever happened to the patient which may not be important in elucidating the cause of his illness, but everythin, 0 which is relevent to the diagnosis can be included under these four headings : 1. The principal complaint. (“What is your trouble? When did it start’! How did it begin?“) 2. The past history. 3. The family history. 4. The detailed story of the present illness. The history should be taken as far as possible in the patient’s own words and phrases; if converted into the observer’s language the actual fact implied by the patient’s statement may lose its significance. And while the young physician may see little meaning in the patient’s story, the older and more experienced man who reads it later may draw from it facts of prime importance. The doctor should exercise no less care and assiduity in history taking than he displays in the physical examination of the patient, for in many cases a good history carries the observer a long way toward a correct diagnosis. To take an adequate history requires experience, particularly broad expericnce of human nature, not only in one’s own generation, but vicariouslythrough reading-in the past. Paget wrote: “I am sure of this: that as the justly successful members of our profession grow older and presumably wiser, they more and more guide themselves by the study of the patient’s story, learning more of family histories, and detecting constitutional diseases more skillfully in signs which to others seem trivial.” On approaching the physical examination the patient’s general condition should first be noted: his appearance, the tidiness or disarray of his clothing, his gait as he enters the room, his respiration, the color of his face and hands, obvious anatomic defects, and any nervous peculiarity of speech or behavior. If he is in bed one not,es the position he assumes, and any change in his color and respiration in response to such exertions as talking, sitting up, or turning over. By habit one unconsciously sees these things, and as the examination proceeds, gathers one trivial detail after another, which help materially in guiding the examination and forming the examiner’s final opinion. In addition to the signs and symptoms easily observed, t,here is frequently an equally significant set of signs which is found only when specially sought for; to know when to look for them demands enough knowledge of disease for the physician to have in his mind, from the outset of his survey, some tentative idea of the nature it be kept so of the case. Such a working hypothesis is useful, providing nebulous as not to interfere with evidence uncovered as the study proceeds.
Sigrzificance of Diagnosis
in Medicine
171
Physical examination requires a definite, systematic order of procedure. “Top to toe” is a well-tried formula, considering first the hair and scalp, then each succeeding structure in order of descent until the toes are reached. The physician may develop his own system ; but it is essential that he adopt an orderly technique at the outset of his career, and never depart from it except for weighty reasons. Persisted in until it becomes a habit, this method will yield acceptable and useful records even when the examiner is harassed and hurried, overworked, or ill. It is axiomatic in the boxing ring that a pugilist may fight the opening rounds on skill, but that he wins the bout on training. Aristotle said that it is as hard to unlearn as to learn; hence the manifest importance of adopting in the beginning a sound system of observing and recording, and sticking to it. Data from the history, the various examinations, and pertinent laboratory reports are the raw materials from which the diagnosis is drawn. These facts may strengthen one’s working hypothesis or demolish it. They may suggest the need for further study and specific tests to clear a moot point, or send one to works of reference, or call for the opinion of a specialist. Eventually the diagnosis emerges, based on logical interpretation of the findings and the judgment of the physician. Good diagnosis depends most on careful obserration, logical thought, and experience. Experience comes with time, but only if the time has been well spent. Osler said : “The value of experience is not in seeing much, but in seeing wisely. ’ ’ One’s clinical experience comes from seeing, day in and day out, year in and year out, patient after patient in the consulting room or on the hospital wards, studying each as if it were the one important case in the world, recording one’s observations for future reference, comparing one’s experience with those of others through the medium of books and journals, digesting and assimilating this material until it becomes a part of one’s working mind. Equally important to diagnosis is the experience gained through living a full and active life, hearing babes and sages with an open mind, considering high and low, rich and poor with tolerance, sympathy, and kindly understanding, and thinking well on these things. Nature does nothing in vain, and “The daughter of Experience is Wisdom. ” FOURTH
MEDICAL
DIVISION,
BELLET’UE
HOSPITAL.
FISHIER
Articles
OF DIAGNOSIS PIERCE,
M.b.,
NEW
IN MEDICINE YORK,
N. Y.
IAGNOSIS is defined as the determination of the nature of disease. Physical diagnosis employs the methods of inspection, palpation, percussion, and auscultation. Clinical diagnosis bases its findings on the symptoms shown during life, irrespective of the morbid changes producing them. Laboratory diagnosis dekives its results frorn chemical, bacteriologic, electrical, and mechanical procedures applied to the study of biologic material, either living or dead. Finally, the special techniques of the psychiatrist and psychobiologist furnish For diagnosis is built up by deducpertinent details not otherwise obtainable. tion from many observations, and it is the object of the examination to elicit, nil of the data which the case presents. Health is the state of harmonious action of all the functions of the organism. There is a certain feeling of well-being in every healthy individual, and until health is impaired, one is barely conscious of having possessed it. The acme of health is fitness, which Lord Horder has defined as “Health plus Happiness.” Ill health is the discordant action of one or more organs, and its first sign is usually some disagreeable sensation. The patient comes to the doctor because he does not feel well. His trouble may have a physical basis, or it may be wholly imaginary; the essential fact is the patient’s conviction that he is not his usual normal self. To consider the physical illness and pooh-pooh the psychic component is to side-step responsibility and leave the job half-done. The malade imaginaire should be as significant an object of the doctor’s earnest attention as the patient with jaundice or boils. It is the physician’s moral duty to seek the total cause of the indisposition: to study the whole man, and to attempt to return him to health. Diagnosis is based on our observation of signs and symptoms, and our deductions from them. In 1846 John Hutchinson said, in effect : “Future knowledge may prove our deductions erroneous ; but the value of sound observaSound tions, carefully made and properly recorded, can never be questioned.” observations: that is the important point ; for observing is an art, acquired by training, maintained and enhanced by unremitting practice. Someone has said that for every doctor who does not know enough, there are ten who do not set enough : “which have eyes, and they see not.” Since the object of our examination is to discover the cause of the patient’s illness, our primary interest, centers in those findings classed as abnormal. In order to recognize the abnormal, one needs a bhorough knowledge of the normal, and this can be attained only through sound discipline in anatomy and physiology, reinforced by constant study of the human material which comes before one.
D
li.
TXAivfrerl before 1940. at the New
the York
American Academy
AssociiLtion for of Medicine. 169
the
Advancement
of Oral
Diagnosis,
Oct.
170
Harold
Fisher
Pierce
There are such wide variations in the build and functions of normal people that, unless one is cognizant of their significance, a diagnosis of disease may easily be made in a healthy person. For example, the average normal bloodsugar is 97 mg. per 100 ml. of blood, but values ranging from 80 to 120 mg. are frequently found in subjects who are, to all other tests, normal. Hence the impossibility of making a diagnosis on the blood-sugar findings alone, since 120 mg. might represent a normal figure in one individual while in another it might signify hyperglycemia. Diagnosis demands a complete examination, in which the first step is the taking of a comprehensive and adequate history. There is nothing which has ever happened to the patient which may not be important in elucidating the cause of his illness, but everythin, 0 which is relevent to the diagnosis can be included under these four headings : 1. The principal complaint. (“What is your trouble? When did it start’! How did it begin?“) 2. The past history. 3. The family history. 4. The detailed story of the present illness. The history should be taken as far as possible in the patient’s own words and phrases; if converted into the observer’s language the actual fact implied by the patient’s statement may lose its significance. And while the young physician may see little meaning in the patient’s story, the older and more experienced man who reads it later may draw from it facts of prime importance. The doctor should exercise no less care and assiduity in history taking than he displays in the physical examination of the patient, for in many cases a good history carries the observer a long way toward a correct diagnosis. To take an adequate history requires experience, particularly broad expericnce of human nature, not only in one’s own generation, but vicariouslythrough reading-in the past. Paget wrote: “I am sure of this: that as the justly successful members of our profession grow older and presumably wiser, they more and more guide themselves by the study of the patient’s story, learning more of family histories, and detecting constitutional diseases more skillfully in signs which to others seem trivial.” On approaching the physical examination the patient’s general condition should first be noted: his appearance, the tidiness or disarray of his clothing, his gait as he enters the room, his respiration, the color of his face and hands, obvious anatomic defects, and any nervous peculiarity of speech or behavior. If he is in bed one not,es the position he assumes, and any change in his color and respiration in response to such exertions as talking, sitting up, or turning over. By habit one unconsciously sees these things, and as the examination proceeds, gathers one trivial detail after another, which help materially in guiding the examination and forming the examiner’s final opinion. In addition to the signs and symptoms easily observed, t,here is frequently an equally significant set of signs which is found only when specially sought for; to know when to look for them demands enough knowledge of disease for the physician to have in his mind, from the outset of his survey, some tentative idea of the nature it be kept so of the case. Such a working hypothesis is useful, providing nebulous as not to interfere with evidence uncovered as the study proceeds.
Sigrzificance of Diagnosis
in Medicine
171
Physical examination requires a definite, systematic order of procedure. “Top to toe” is a well-tried formula, considering first the hair and scalp, then each succeeding structure in order of descent until the toes are reached. The physician may develop his own system ; but it is essential that he adopt an orderly technique at the outset of his career, and never depart from it except for weighty reasons. Persisted in until it becomes a habit, this method will yield acceptable and useful records even when the examiner is harassed and hurried, overworked, or ill. It is axiomatic in the boxing ring that a pugilist may fight the opening rounds on skill, but that he wins the bout on training. Aristotle said that it is as hard to unlearn as to learn; hence the manifest importance of adopting in the beginning a sound system of observing and recording, and sticking to it. Data from the history, the various examinations, and pertinent laboratory reports are the raw materials from which the diagnosis is drawn. These facts may strengthen one’s working hypothesis or demolish it. They may suggest the need for further study and specific tests to clear a moot point, or send one to works of reference, or call for the opinion of a specialist. Eventually the diagnosis emerges, based on logical interpretation of the findings and the judgment of the physician. Good diagnosis depends most on careful obserration, logical thought, and experience. Experience comes with time, but only if the time has been well spent. Osler said : “The value of experience is not in seeing much, but in seeing wisely. ’ ’ One’s clinical experience comes from seeing, day in and day out, year in and year out, patient after patient in the consulting room or on the hospital wards, studying each as if it were the one important case in the world, recording one’s observations for future reference, comparing one’s experience with those of others through the medium of books and journals, digesting and assimilating this material until it becomes a part of one’s working mind. Equally important to diagnosis is the experience gained through living a full and active life, hearing babes and sages with an open mind, considering high and low, rich and poor with tolerance, sympathy, and kindly understanding, and thinking well on these things. Nature does nothing in vain, and “The daughter of Experience is Wisdom. ” FOURTH
MEDICAL
DIVISION,
BELLET’UE
HOSPITAL.