The power of bedside diagnosis
There is a growing inclination to rely upon the evidence of laboratory investigations in diagnosis, and no doubt that tendency is increasing.
Looking back, I have no doubt that the clinician of 25 or 30 years ago was from necessity more skilful than the clinician of to-day: I mean the power of bedside diagnosis was greater 25 years ago than it is to-day. Of that I am certain, from what I note in the course of ordinary consultation work.
This is the outcome of the tendency of us all to rely too exclusively on laboratory work in diagnosis. It is a common experience, in a consultation in these days, to find an expression of opinion given up to a certain point as to the diagnosis, the final decision being postponed until a blood test or bacteriological examinations have been made. Now, this reliance upon the laboratory as a last resource checks, as does the exploratory operation, the impetus to real clinical work, at least so it seems to me, and many a case has been wrongly diagnosed, and therefore treated wrongly, because the diagnosis has practically depended upon the verdict of the laboratory.
Do not misunderstand me in this: I do not wish it to be thought that I depreciate laboratory work in any way, because I think that it is one of the most valuable assets of modern times; but, if full value is to be obtained from the laboratory references, there must be a consultation between the bacteriologist or pathological expert, as the case may be, on the one hand, and the people in touch with the case, on the other; moreover, if the evidence of the laboratory is not considered very closely in conjunction with the clinical factors of the case, we are as likely to be misled as to be helped in our diagnosis.
A case history
It is very easy to give examples to illustrate this point. I remember, for instance, a case in which not only was a man's health concerned, but his career in life endangered by reliance upon the pathological laboratory as a means of settling the diagnosis.
The patient was a man of 30 years of age. He had been in foreign parts for a considerable period, and came on leave suffering from a disease of both knees. He also had an affection of a wrist and of one of his elbows. He was seen by several practitioners, and various investigations were made. At first he came into medical hands, because of his general condition and other things. Very little progress had been made with his case, and, finally, a bacteriological examination of his urine was made, and it was found to contain gonococci.
Here was an apparently clear case, a man with multiple arthritis, the urine containing gonococci. He was a straightforward man, and had no recollection of specific disease for some years. On the strength of gonococci being found in the urine, the case was considered to be one of gonococcal arthritis. It was treated accordingly, but without success, and a report was on the point of being sent to the effect that he was the subject of this condition, which would have marred his career.
He happened, however, at the instigation of a wise physician, to be brought into contact with a surgeon, because the condition of one of his knees became rather threatening, whilst, coincidently, the lesions of the elbow and wrist began to disappear, until he was left with the disease for the most part concentrated in one knee. When the knee was examined, it was found to contain a certain amount of fluid, and it crepitated freely, obviously because there was a large number of vegetations in it.
In a man of 30 years of age, the subject of gonococcal arthritis, vegetations are distinctly rare. But, at the same time of life, the common characteristic of osteo-arthritis (so-called), especially in the knee, is the existence of vegetations. As a matter of fact, in patients of about 30 years of age, with osteo-arthritis, one of the commonest characteristics is the formation of vegetations in the joints concerned, especially when, after multiple arthritis, the disease has concentrated itself in one articulation and remains there. This man, locally, had all the indications of a knee full of vegetations, such as those met with in osteo-arthritis occurring at his time of life. He had none of the signs commonly met with in the other form of arthritis, and, as a matter of act, the existence of the gonococcus in the water was a mere coincidence, and had nothing to do with the condition of his knee at this time.
Had those, who originally saw this patient, approached the case from the local aspect of the joints, it is probable that a bacteriological examination would hardly have been required to complete the diagnosis. As it was, the chance which led to his coming in contact with someone, who happened to look at the case from the local point of view, saved the position. Indeed, the joint was subsequently opened and a considerable mass of vegetation removed, after which the knee resumed for practical purposes its normal function.
This case also shows very clearly how very long the specific evidences of disease, such as gonorrhoea, syphilis, enteric fever, etc., may remain in an individual and be demonstrable, after all influence for evil has disappeared, and it is a distinct warning against attaching too much importance to the mere existence of evidences of this kind.