When I was a house officer I would regularly see a dishevelled street woman who had numerous bizarre complaints. These she attributed to the dirt she had picked up at a flea market, and she would bring along crumpled bits of paper to prove her point. My chief eventually lost all patience and wrote to the general practitioner asking him not to send “this cantankerous woman” again. Two months later she returned jaundiced, her liver massively enlarged from a cancer of the pancreas.
There has always been a tendency to blame the doctors for such delayed diagnoses. Nowadays the public has become even more demanding, its hopes raised by magazines, newspapers, and television programmes. The medical profession has often also contributed to these raised expectations. By contrast, when I was a student our professors taught that diseases needed time to “declare” themselves; and we were often told that no one would be able to survive a complete examination.
More recently I saw a young woman who had had such an examination. She indeed did not survive, because the opposing street gang had fired two bullets into the back of her head. A complete autopsy disclosed a tiny cancer of the ampulla of Vater that might have taken 30 years to declare itself.
As a renal fellow I once saw a boy who had pain in the back after falling off a diving board. A pyelogram showed unsuspected bilateral congenital hydronephroses and he died of uraemia soon afterwards. Six months earlier he had had a normal college entry physical examination—no hypertension, abdominal masses, not even proteinuria. His mother asked if this tragedy could have been prevented. Perhaps by measuring the blood urea, but there was no indication for doing so.
Then there was the middle aged man who underwent renal biopsy for mild proteinuria: the biopsy specimen revealed a tiny focus of renal carcinoma cells. And in a similar case a minute totally unsuspected renal cancer was found on angiography in a woman hoping to donate a kidney to her brother.
No doubt someday doctors will have the means to diagnose such early diseases. But for the time being we (and the public) need to reconcile ourselves to the idea that many diseases still need time to declare themselves.