9 - Bench and Bedside

Summary

How did physicians who were not laboratory researchers use the lab? This question does not admit of a full answer. Original case records for the medical wards do not exist except for the physician Edwin Bramwell.There is an almost full set of his patient records for the period 1919–1935. In addition a complete register of all of Bramwell's in-patients exists, so it is usually possible to know the names, diagnoses, admission, and discharge (or death) dates of those few patients whose notes are missing. Further, in surgery, there is virtually a complete set of case notes from 1925–1946 of Professor John Fraser.There are various problems in using the records of Bramwell.The major one is that they are frequently written up long after admission and for the most part contain virtually no progress notes or discharge summaries.The records are often in duplicate or even triplicate and are occasionally contradictory, seemingly having been written up by student clerks. Temperature charts, presumably kept by the nurses, sometimes with daily entries and comments have often proved vital sources of information. It is frequently difficult, often impossible, to work out who is using the lab and for what purpose. Even when this is clear the clinical reasoning behind lab usage is rarely recorded.

If there are general conclusions they are two very cautious ones. First, the lab was not a major resource for Bramwell and by extrapolation from the figures of lab usage this holds true for many other clinicians at the Infirmary. In the light of the overwhelming centrality of laboratory testing to modern medicine this is an extremely difficult chapter to write without seeming critical of Bramwell and other clinicians who might have availed themselves of the lab's facilities more frequently.They were, however, devoted to preserving their clinical skills and, in a way that might make the best teachers of medicine today jealous, they sought to show how valid conclusions might be arrived at without recourse to laboratory data. Perhaps too, they were, as they saw it, perpetuating a great clinical tradition tuned to the production of general practitioners who would not have easy access to laboratory tests. Further, although this is more difficult to reconstruct from case notes, clinicians such as Bramwell were assessing their patients’ sickness through the subjective data of symptoms rather than the objective data of the lab.