PRECISION IN DIAGNOSIS, 
AN ESSAY 
HEAD BEFORE THE 
IMial Jwietu of i«p lew, 
AT ITS 
ANNUAL MEETING, 
May 25th, 1875. 
BY 
H. R. BALDWIN, *M. D., 
THIRD VICE-PRESIDENT. 
Extracted from the Transactions of the Society. 
NEWARK, N. J.; 
Jennings & Hardham, Steam Printers and Bookbinders. 
153 and 155 Market Street. 
1 875. PRECISION IN DIAGNOSIS. 
AN ESSAY 
BEAD BEFORE THE 
||dM Jwktg of Men* 
AT ITS 
ANNUAL MEETING 
May 25th, 1875. 
BY 
H. R. BALDWIN, M.D., 
THIRD VICE-PRESIDENT. 
Extracted from the Transactions of the Society. 
NEWAEK, N. J.: 
Jennings & Hardiiam, Steam Printers and Bookbinders, 
'153 and 155 Market Street. 
1 875. ESSAY. 
PRECISION IN DIAGNOSIS. 
Gentlemen of the Medical Society of New Jersey: 
Eight years ago I became the recipient of yonr favor in 
making me Treasurer of yonr Society. My thanks are dne 
for this, as well as for the confidence shown in continuing 
to honor me with a re-election during these long years. 
In this official relation it has been my fortune to meet 
many of our profession throughout the State, and it is with 
pleasure that I can testify to their uniform courtesy and 
kindness. There is, however, additional reason for testi- 
fying to your good feeling. Upon my election as Treas- 
urer the idea of accumulating a permanent fund, the inter- 
est of which would enable us to publish our transactions 
without default and without legislative aid, and at the 
same time lay but a slight imposition upon the several 
District Societies, was suggested. This was the goal of my 
ambition. Whatever of success may have attended this 
effort is entirely due to your kind co-operation and that 
of the gentlemen of the Standing Committee. Allow me 
to thank the profession for the noble manner in which they 
have seconded my desire. It is gratifying to know that I 
place in the hands of my successor a sum which is a fair 
nucleus for the future. Raised to my present position 
through your kind courtesy, allow me to tender again my 
hearty thanks for this renewed evidence of your esteem. 4 
As third Vice-President of your Society, it becomes my 
duty to address you upon some theme connected with our 
professional duties. This seems to me a position not 
meant for forensic display, but by a few simple, kind words, 
to emulate each other to renewed diligence in the pursuit 
of our avocation, and perchance awaken a new desire for 
increased accuracy and more comprehensive views of dis- 
ease and diseased action. I propose, then, to call your 
attention to a brief history of Diagnosis, and a few thoughts 
upon Precision in the same department of medicine. 
Although it is highly probable that from the earliest ages 
there were persons who attempted the alleviation of human 
distress and suffering, and devoted themselves specifically 
to the healing art, still the conclusion is drawn more from 
the constitution of the human mind than from any well 
authenticated history. There is evidence that the Egyp- 
tians devoted much attention to medicine, for the knowl- 
edge possessed by the Grecians is acknowledged to have 
been obtained from this source. The centaur Chiron, who 
flourished in the thirteenth century before the Christian 
era, has obtained the credit of first instructing the Grecians 
in the art of medicine. Among his pupils was Aesculapius, 
who became more celebrated than his preceptor, so that 
after his death divine honors were paid to him, bulls and 
goats being offered in sacrifice. 
From this period there seems to have been no material 
progress made in medical knowledge until the time of 
Pythagoras, who, although a philosopher and not a prac- 
titioner of medicine, devoted himself to the study of the 
anatomy and physiology of the human body. This was 
about the sixth century before the Christian era. 
The iEsclepiadse had, in the meantime, continued to per- 
form cures, and were in general the repository of medical 
knowledge. Their practice was, however, almost entirely 5 
empirical and based largely upon tlie superstitions of the 
age. About the middle of the fifth century before the 
Christian era we find the first distinct effort to reduce 
medicine to a scientific basis. 
The great physician of Cos, by a series of careful observa- 
tions and deductions, first elevated the art from its deceits 
and ignorance, and made attempts at Diagnosis. He 
defined diseases as epidemic, endemic and sporadic. He 
also noted the advent, height, decline and termination of 
disorders, and from marked tendencies in diseases to reach 
a climax on certain days deduced the idea of critical days. 
By a careful observation of the seasons, the temperature, 
and the phenomena of disease, he succeeded in opening 
the way to enlarged views and legitimate conclusions. 
There can be no doubt that the high and permanent repu- 
tation of this great man depended most largely upon his 
capacity of diagnosing disease, and the great sagacity of his 
prognosis. The deficiency of anatomical knowledge was, 
however, an insuperable barrier to a correct delineation 
of disease, and it is difficult fojr the practitioner of the 
present day to realize what uncertainties must have 
attended most of the explorations of the ancients. 
About a century after the death of Hippocrates, the 
school of medicine, which had during this period been 
resident in Greece, was, in consequence of the establishment 
of the museum and library at Alexandria, transferred to 
Egypt. Among the disciples of this school were Erasis- 
tratus and Herophilus, who are said to be the first to have 
attained a knowledge of the anatomy of the human body 
by dissection. The bodies of criminals were given over to 
them for this purpose, and they ascertained new and im- 
portant facts concerning the brain and the nerves, and are 
said to have discovered the valves of the heart, Herophilus 
paid particular attention to the pulse, which had heretofore 
received little notice. 6 
About this period the medical world was divided into 
two sects—the dogmatists and the empirics. The dogma- 
tists maintained that before we attempt to cnre disease we 
are to make ourselves acquainted with the structure and 
functions of the body, of the changes which are produced 
in it by various morbid causes, and the influence of reme- 
dies in modifying or counteracting them. The empirics 
affirmed that experience, either derived from personal 
observation or dependent upon reliable testimony, is our 
only sure guide in practice. These latter views were 
earnestly supported by Serapion, of Alexandria, who is 
said to have been a pupil of Herophilus. From our stand- 
point we can easily see that neither were entirely correct, 
but that both reason and experience are to be diligently 
used in the exploration of disease. 
It was nearly a century before iEsclepiades, of Bithynia, 
appears upon the theatre of action, who, although without 
regular medical education, was a man of acute perceptions, 
and established the division of acute and chronic diseases. 
Although many physicians of celebrity followed iEscle- 
piades, none contributed anything to the new develop- 
ment of diagnosis until the time of Galen, of Pergamus, 
who enjoyed advantages of birth and education, which 
enabled him to secure the most advanced ideas of medical 
science at that time. A man of profound convictions, he 
relied much upon his reason, and founded the sect of the 
humoralists. So great was the fame of Galen that for 
thirteen hundred years it was considered in the highest 
degree heterodox to question his views and teachings. 
The advent of Mahomet, the spread of his theology, and 
the consequent wars, for a time absorbed science and 
scholastic pursuits; but about the eighth century of the 
Christian era the Saracens began to pay particular atten- 
tion to medicine, and soon thereafter Phages particularly 7 
studied cutaneous disorders, and his description of small- 
pox is still extant and familiar to many here present. 
From this time forward until the middle of the fifteenth 
century a darkness most profound reigned in the human 
mind; but the discovery of the art of printing at this period 
lent a new impulse to all investigations, and at about the 
middle of the sixteenth century Yesalius, availing him- 
self of the spirit of inquiry which had been awakened, paid 
a stricter attention to anatomy, which had lain somewhat 
dormant since the time of Galen, and added largely to the 
researches in this branch of medicine which are so necessary 
to an investigation of morbid changes in either the fluids or 
solids of the body. 
We cannot at this period fail to recognize the influence 
of the principles laid down by Bacon in the development 
of truth. Although not a physician, he taught us how to 
use the facts already known, and in what manner to draw 
deductions from stated premises. 
The discovery of the circulation of the blood, by William 
Harvey, and his published treatise in the year 1628, cannot 
be forgotten as marking an era in the development of facili- 
ties for diagnosis such as the world were before ignorant 
of. An exactness and certainty were acquired regarding 
all physiological as well as pathological researches, the 
advantages of which cannot be over-estimated. Although 
at this period there was an attempt to introduce mechanics 
as bearing upon medical opinions by a sect of mathe- 
matical physicians, prominent among whom stands Bellini, 
of Florence, yet the opinions were fanciful, and cannot be 
said to have proved serviceable in the research after truth. 
The great Stahl, who was a native of Germany, and an 
independent thinker, and who devoted himself especially 
to chemistry, soon perceived that the changes which the 
fluids undergo in the body were completely unlike what 8 
they would have experienced if placed in ordinary circum- 
stances. As it was well known that substances similar to 
those which constitute the body rapidly tend to dissolution, 
he therefore concluded that when forming a part of the 
organism they must be possessed of some force or principle 
to counteract the effects which would otherwise have been 
produced. This principle he called anima, and believed 
it to possess peculiar qualities distinct from those which 
belong to matter. In fact, it was this that gave to the body 
all those properties which are strictly denominated vital. 
Following Stahl, about the middle of the seventeenth 
century, Hoffman promulgated new views in pathology, 
among which was the assertion that, in many instances, the 
causes of disease may be more easily traced to some 
affection of the solids than to any alteration in the fluids 
of the body. He endeavored to explain this view by intro- 
ducing the operation of what he called spasm or atony, 
according to which the moving fibre is endued with a cer- 
tain action or tone which constitutes its healthy state, 
which may be morbidly increased, causing spasm, or 
diminished, giving rise to atony. He also recognized the 
nervous system as being intimately connected with the 
production of disease. 
From the middle of the eighteenth century, scholastic 
disputation was entirely disregarded, and the exertions 
which were previously directed to the accumulation of learn- 
ing were now bestowed on the acquisition of knowledge. 
Before this period the whole medical world were divided 
into two or three sects, and it was thought to be absolutely 
essential for every one to attach himself to one or the other 
of these schools. But from this time observation and ex- 
periment were diligently pursued, and the mind, casting 
off the influence of the theories of the past and of the 
great names which had supported them, assumed an inde- 9 
pendence and self-reliance which materially aided the pro- 
gress of inquiry. 
Men of genius and sagacity, such as Boerhaave, Cullen, 
Brown, Whyatt and Bichat, each in their respective depart- 
ments contributed much to the advance of medical knowl- 
edge, either by speculations, which awakened interest, or 
by the substantial results of laborious research. 
It will thus be seen how slow and tedious have been the 
developments of knowledge. The labors of centuries and 
the lives of a thousand generations have been necessary to 
clear away the obscurities of ignorance—observations and 
experience recorded and corrected—theoretical teaching 
insisted upon and abandoned. The best thoughts of emi- 
nent medical men not only, but philosophy and philoso- 
phers, have all added much to our present enlarged and 
splendid opportunities for forming correct opinions and 
engaging in successful practice. This, then, is the heir- 
loom of the past. We may now be said to have arrived at 
the golden period in the history of medicine, and it will 
not be improper for us to consider our duty as diagnosti- 
cians, under these circumstances. 
Before attempting to set forth the duty of-the practition- 
er, it will be well for us to remember that early in the 
present century Magendie had, by his brilliant experiments, 
shed a flood of light upon physiology; that Sir Charles 
Bell had explained the operations of the nervous system ; 
that Laennec had made known his views on mediate auscul- 
tation and the use of the stethescope ; that later, Marshal 
Hall had promulgated his views of reflex action ; and that 
Brown Sequard has amplified and perfected our notions 
regarding nervous force. 
These, with the multitudinous facts and facilities which 
have thrust themselves upon the medical public, place the 
practitioner in a position to acquire a degree of accuracy 
which is truly remarkable. It seems, then, with all the 10 
advantages of the experience of the past, and the wonder- 
ful improvements of the present, the physician is inexcusa- 
ble if he fails to make his diagnosis with extreme exactness. 
This duty will perhaps be more evident if we consider what 
precision or exactness of diagnosis comprises. 
It is not only accuracy, but something more. It may be 
accurate to say that a man has plenritis, if upon examina- 
tion of the chest we find the ordinary signs indicative of 
that affection ; but it is precise to be able to follow the case 
further—to search out the cause of the inflammation—to be 
able to define that some toxic influence pervading the blood 
(it may be pus, or urea, or some other agent) so operates 
upon the nerve centres as to cause such aberration of func- 
tion as results in derangement of healthy action. 
By a precision in diagnosis, then, is meant the enuclea- 
tion of the diseased condition, following it up to its hidden 
sources and ascertaining its relation to the whole economy. 
The physician is driven to this position by a number of con- 
siderations. Many of these may be purely selfish—such as 
ease of conscience, sound sleep, pecuniary advantage—but 
there are other reasons as far superior to self as humanity 
is above the individual, as the mental is above the physical. 
The responsibility of life in his hands, the welfare of fami- 
lies, the desire to prevent severance of the dearest ties, and 
the exultant satisfaction of a successful result, all prove 
the absolute necessity of precision in dealing with disease. 
Scarcely less imperative are the demands of his professional 
esprit de corps. No profession can have ultimate respect- 
ability where its votaries disregard those elements which 
are necessary to its future exaltation. It therefore follows 
that all avenues of knowledge must be diligently sought— 
all means available employed—to render our knowledge as 
perfect as is possible for the finite intelligence to accom- 
plish. The haphazard prescription of the charlatan fails to 
secure to himself lasting reputation, from the lack of precise 11 
knowledge. The efforts of painstaking, and industrious 
physicians also sometimes fail, because, even with all his 
acquirements, he is denied precise knowledge, either from 
the recondite nature of the disease or from some other cir- 
cumstance. How is it possible for one to fulfill the condi- 
tions requisite for the removal of morbid action, if the dis- 
eased condition is not fully known to him % The relations 
of the physician to the public also render it proper for him 
to be able to sustain his profession at all times. He must 
not only satisfy his own mind and conscience, but he must 
be ready to give an intelligent explanation of the faith that 
is in him to an inquiring public ; for, let me remark, the 
time for doctors to look wise and shake their heads has 
passed away. The public, a reading and wide-awake pub- 
lic, demand from the profession both a satisfaction of the 
intellect and a conviction of the judgment. The humanity 
of the profession also cries loudly to us for exactness in 
our knowledge. Is there an aroma in the parable of the 
good Samaritan, as related by our Divine Master, the fra- 
grance of which the lapse of time has only served to render 
more lasting \ Is there anything ennobling in the allevia- 
tion of suffering, in the extension of joy, in the oblitera- 
tion of woe, in the promotion of that cementing bond 
of brotherhood, which is, or should be, felt wherever the 
foot of man has found its way % Then is it proper that our 
profession should not be wanting in that exactness in our 
dealings with men which will secure these ends. The 
necessity of our cultivation of exactness will further appear 
from the want of it. 
Now far be it from me to arraign a noble profession, (and 
one to which we have all shown our fealty by the devotion 
of our lives,) by detracting from its merits ; but, as a mat- 
ter of fact, the highest kindness is sometimes to probe the 
wound most deeply. Do we not find too often a lamentable 
want of exact knowledge in our general practice? It is 12 
true that tins sometimes occurs from tlie very desire to do 
good most quickly—to assuage pain before the causes are 
sufficiently elucidated ; but I am afraid we must admit 
that sometimes carelessness can be laid at the door of the 
practitioner. A certain vagueness of expression, such as 
“it is a cold,” or “a little nervous,” ‘‘biliousness,” or 
“the liver is touched;” or the requisition of the diminu- 
tives, as “a little fever,” “a little pneumonia,” or, again, a 
grave assertion that “the patient has come near having 
typhoid fever.” Now all such expressions indicate the 
want of that exact knowledge which it is the duty of the 
prescriber to possess before he enters upon the responsible 
duty of writing a prescription, upon which may hang the 
life of - a fellow being. I have seen a man laboring under 
acute nephritis, with urine loaded with albumen, and the 
stomach rejecting whatever was put into it, treated with 
the hypodermic syringe to quiet these warnings of nature, 
without even an attempt made to inquire into the source 
of these evidences of disordered nerve force. How com- 
mon is it for the doctor, upon the application of the patient 
for relief from a dizzy head and a furred tongue, to give a 
dose of mercurial cathartic, when a day’s abstinence and 
rest would rectify the unpleasant symptoms. 
We have already insisted upon exactitude in diagnosis, 
as the imperative duty of the practitioner. Let us now 
look for a moment at some of the factors necessary for 
acquiring this desirable end. They reside, first, in himself; 
and, secondly, in his surroundings. Of those resident in 
self, industry is all-important, and is the only sure road to 
knowledge ; for, without persistent and pains-taking labor, 
recondite processes will never be discovered; the relation 
of certain parts of the organism to other parts will never 
be disclosed ; the relative connection of healthy and mor- 
bid action will not be appreciated. As there is no royal 
road to fortune, so there is no permanent advance in 13 
science, except by the entire absorption of self in mastering 
its intricacies. Independence is also a necessary adjunct 
to the searcher after truth. ' There must be no bias by the 
theories of the past; no undue truckling to authority; no 
pinning of the faith to the garments of another; but a fear- 
less and exhausting search into all the facts which may be 
presented to the mind. Honesty to the patient and hon- 
esty to self, even to self-abnegation, are indispensable. 
The patient must have credit for all reliable statements. 
His case must be faithfully examined, and due weight 
given to all the subjective symptoms. The honesty to self 
must be such that any prejudicQ must be set aside ; any 
preconceived notions, any mawkish sentimentality and 
desire to hide or cover up; hasty expressions given as 
snap judgment; any sensitiveness as to professional posi- 
tion ; any or all of these must be sacrificed to thorough 
and searching deference to truth. The judgment, too, 
must be accurate, sifting the symptoms, giving their rela- 
tive weight to each, and shutting out from view the fancies 
of the patient regarding his own condition, as he is in no 
position to form an unbiased opinion. 
It happened to the writer once to find a patient suffering 
from cancer of the rectum, who insisted that he was per- 
fectly well, and only needed a good dose of cathartic medi- 
cine, and who desired to go on a long journey to his ordi- 
nary avocation; when, upon inquiry, it was found that so 
great constipation existed that he could only walk with a 
straddling gait, and, upon further exploration, it was found 
that the contractions of the intestine were so forcible as 
to be visible through the external parietes. A skilled 
consultor christened the affection cirrhosis, but the autopsy 
revealed cancer of the rectum. 
The knowledge necessary for a correct diagnostician em- 
braces a variety of subjects. First, he must know human 
nature—the peculiar idiosyncracies which modify symp- 14 
Toms, give cast to character, and mould all the processes 
of thought, must be thoroughly understood. How fre- 
quently does the victim of hysteria palm off on the unsus- 
pecting doctor a malady which exists only in a disordered 
innervation. An acquaintance with histories of diseases, 
climate, topography of country, malarial tendencies, modi- 
fying circumstances attending; situation, as well as thor- 
ough knowledge of anatomy and physiological processes ; 
the relation of the respiration to the circulation, of the 
digestion to the assimilative processes, and all again to the 
all-pervading governor, the nervous system. The means 
of attaining excellence or precision in diagnosis must be 
reached through this same avenue of knowledge also. 
The physical sciences come largely to our assistance in 
discriminating disease. Physical signs, through ausculta- 
tion and percussion, are within the reach of every practi- 
tioner, and give such exact knowledge that mistake seems 
almost impossible. Thus an enlarged heart may be accu- 
rately measured; a cavity in the lung positively marked 
out; the gradual increase or diminution of pleuritic effu- 
sion detailed. Thus tumors, solid or fluid, may be defined, 
and by auscultatory percussion still more definite data 
obtained. 
The scientific world, through the invention of instru- 
ments, have added largely to our facilities for diagnosis. 
It was only a few days since that being called to see a little 
patient, suffering with severe symptoms of enteric disease, 
I found valuable aid in this direction. The abdominal 
symptoms were relieved by treatment, the pulse fell in 
frequency, the temperature diminished to a healthy stand- 
ard, but suddenly, without pain or dyspnoea or other 
symptom, save a slight hacking cough scarcely noticeable, 
the temperature rises to 103°—suspicion is awakened— 
the new lesion must be sought and found—and in twenty- 
four hours physical exploration reveals pneumonia. 15 
I chanced to find within a brief period a young lady 
suffering with an imperfect vision ; together with this symp- 
tom was associated severe pain in the,head and what might 
be termed a variety of neuralgic manifestations. A careful 
examination with the opthalmoscope reveals neuro-retinitis, 
with atrophy of the optic disc. This, with the progress 
of disease and a partial paralysis of one side, enabled the 
accurate diagnosis of an intracranial tumor, which im- 
pinged upon the capacity of the optic nerve. The autopsy 
demonstrated the presence of a tumor as large as a pullet’s 
egg, resting upon the medulla and cerebellum, and press- 
ing forward upon the optic commissure. 
Again, a patient being seized with severe vomiting, with- 
out derangement of the sensorial faculties, and with but 
few, if any, symptoms pointing toward cerebral lesion, ex- 
cept diplopia, is shown by the opthalmascope to be suffer- 
ing from inordinate brain pressure. The post mortem 
shows a tumor lodged upon the petrous portion of the 
temporal bone, and finding its way up through the tento- 
rium cerebelli. 
Time would fail to enumerate the instances in which the 
microscope is of immense value. To say nothing of the 
advantages which obtain from its use in the investigation 
of renal, vesical, and gastric diseases, let me instance a 
case of convenience to the physician. The patient is taken 
with symptoms of abortion; hemorrhage and pain mark its 
progress. The doctor is pestered to death with questions : 
“Is she quite through?” “Has everything come away?” 
How frequently is an evasive reply necessary; but a sus- 
pected substance is placed under your glass ; the villosities 
of the chorion are seen. The patient is assured of her con- 
dition, and the doctor is restored to his self-respect. 
Your patience would be exhausted by an enumeration 
of similar advantages which accrue from the comparatively 
recent introduction of scientific instruments By the laryn- 16 
goscope we can define diseases of tlie larynx; the endo- 
scope inspects tlie inner wall of the bladder; onr sphyg- 
mograph writes the action of the heart; onr dynamometer 
measures decreased muscular contraction and inferentially 
defective innervation; the sesthesiometer measures sensi- 
bility. Tims we see the immense resources at onr com- 
mand to give ns exact knowledge. The physician of the 
present day has powers of which his predecessors could 
scarcely dream. The advances in medicine have been far 
greater than in the other learned professions, and its prac- 
tice is being rapidly reduced to the condition of an exact 
science. Now the results of these acquirements must be 
immense upon the observer. They are manifested first 
upon himself, giving him confidence, assurance, almost 
certainty, in his hand-to-hand conflict with disease. It 
enables him to define positively, to act boldly, to prescribe 
fearlessly; or again to prognosticate with certainty the 
futile nature of all his efforts. Nor is the influence felt 
only by himself. Those with whom he is brought in con- 
tact feel the impulse, confidence, reliance, as it were, in a 
being of superior power, and intelligence springs up in 
their hearts, and his coming is looked for as if an angel’s 
visit were at hand. 
I have thus, in this brief resume, endeavored, though 
feebly, to show the advantages of precise knowledge in 
medicine, and the benefits which result therefrom. Nor is 
this true only of medicine. In all departments of study, 
the value of exact knowledge cannot be over-estimated. It 
gives such force that men meet and overcome obstacles, 
which, to the careless, would be insurmountable. It gives 
that power which removes mountains, and it rapidly brings 
ns to that state of perfection which raises humanity to a 
loftier standard, and reveals that for which the world has 
for centuries been stirving—nntrammeled truth.