The Study of Disease.
Selected writings of John M. Scudder.
This is one of the many papers written from time to time by Dr. Scudder indicating methods of study of disease. The mental training he sought to encourage was by no means of minor significance. Besides this the facts acquired by such methods make the physician ready in specific diagnosis and a ready and accurate prescriber.—Ed. Gleaner.
THE STUDY OF DISEASE.—In our last issue we had a brief article "On the Study of the Materia Medica;" this month we propose to think of how we may best study disease. I know very well that there are many who think their days of study are over, at least they do not care to go back to the beginning and bring their studies up afresh; yet there are others who will be glad to do it if a wrong is pointed out, and a sufficient incentive to study given. I have a very firm belief that nothing short of continuous study will insure high attainments in medicine.
There are two methods of study—by synthesis, and by analysis—and each of these will be found valuable mental exercises. It is well known that the diseases we meet with and are called to treat are composed of several elements, each of which may be studied in detail. The first study of disease we make is to take up each of these several elements, see its causes, its progress, its influence over other processes of life, and its entire subsidence. The study of the manifestations of life in health we call physiology; the study of the manifestations of life in disease we call pathology. We study these manifestations of life in health to have a standard of comparison by which we may determine conditions of disease, and we study the diseased manifestations of life in detail that we may be able to determine the value of each when found in combination with others.
Every one, when he commences to think of the elements of disease, will probably commence with the pulse, and with this will think of the capillary and venous circulations. Following this, he will think of the temperature, of the condition of the nervous system, of the processes of waste, of excretion of skin, kidneys, and bowels, of digestion and blood making, of the constituents of the blood, and of certain zymotic processes which may be set up and go on in the body.
It is a most excellent mental exercise (study) for the reader to take a sheet of paper, and pencil, and note down all that he can recall of these elements of disease. What he can recall from observation is of more importance to us than what he can recall from reading, yet both may go together. We ask the questions: What do I know about the wrongs of the circulation, arterial, capillary, venous, and how do I determine these wrongs? What do I know about temperature as an element of disease, increased, diminished, unequal ? What do I know about the wrongs of innervation, pain, unpleasantness, feelings of weight, fullness, dragging, loss of sensation, nervousness, etc? What do I know about the lesions of the processes of waste and retrograde metamorphosis, and how will I recognize them? What do I know about lesions of secretion, from the skin, the kidneys, and the bowels, arrested, scanty, too free, changed in character? What do I know about the lesions of digestion, and of blood making? What do I know about the lesions of the glands associated with the intestinal canal? What do I know of the zymotic causes of disease, and their influence upon the body?
As you read this over, the old injunction, "know thyself," comes out in vivid characters, and has a double meaning. You are estimating your stock of knowledge, and the worth of your brain as an organ of thought, and the majority of us will find that we have overestimated both. Still there is this advantage— we recall things that we had forgotten, and we assure ourselves that if we will but continue this exercise of the mind we can make it extremely useful.
When we have the elements of disease fairly in hand, we may make studies by synthesis, combining them in various proportions to form diseases like we see in ordinary practice. We do not wish to build imaginary diseases, and carry these fictions with us to the sick chamber to replace observation, but we do it as a study to train the brain to mind for its work in the sick chamber. We commence with the most simple elements and combinations, put them together, note the symptoms, estimate the results, and think of the value of drugs in such cases. It is well to build our cases as nearly like the diseases we meet as possible, and we might head our paper with:
Wanted: a Rheumatic Fever. Circulation increased, pulse frequent, (110), hard, surface flushed bright; temperature increased (104°), yet skin is soft and inclined to be moist in parts; urine is scanty, reddish; bowels constipated; complains of wandering pains, but especially of some particular part, which is flushed, slightly swollen and sensitive for a time, then changes its position. Such a case is not uncommon, and as we place the prominent symptoms together we get a better idea of the disease than we could from reading a treatise on rheumatism.
Then continuing the subject, we might think of the disease as it showed a dry, harsh skin; a frequent, small, hard pulse; contracted or pinched features; extreme restlessness; exquisite pain; nausea or vomiting; a broad, white tongue; a tongue red and contracted, etc. I do not think it possible that this synthetic study of medicine can be made without great profit. It brings up all we know of disease; it trains the mind to orderly thought; and it stimulates to close observation and to profitable reading.
The physician complains of want of time to study, especially if he is doing a country business and has long rides. But this is no excuse; every one has abundance of time, and these long rides are the very opportunities that need improving. One can soon attain a habit of thinking whilst making the daily rounds, and these mental processes can go on in the buggy or on horseback as well as in the office. I can testify from personal experience that it lightens the tediousness of daily work.
The process of analysis is just the opposite of that we have been considering. Now we take up some treatise on medicine which describes the diseases of the nosology, and we proceed to divide them into their component parts. In the practice of medicine we give every case a complete analysis, never or rarely prescribing for it as a whole. Every case, therefore, that comes into our hands is a new subject for study, and a visit to one patient furnishes food for thought whilst going to the next. Having the case clearly before us, we separate it into its component parts, and see the wrong of each; then we take these parts and put them together to see that we have made no mistakes. We weigh the value of each part and its relation to the whole, and then estimate the value of drugs to each separate part and to the whole.
We can make somewhat the same kind of classification of disease that we make of remedies, commencing with the more simple and natural divisions. Thus disease is general or local; what will give us general and what local disease? "What functions and structures are common to the entire body?—the blood, its formation, circulation, and depuration; the nervous system and its influence through brain, spinal cord, and sympathetic—here we must find the lesions that give general disease. What are the elements of local disease? Let each one estimate them in the same way—the circulation, the innervation, the nutrition, and the functional activity of the part. Each one will find that he can make his analysis and study better than any other can do it for him.
This, in brief, is about the method I would recommend to every one who wishes to continue the study of medicine. As I have said so often, the practice of medicine requires thought, if it is to be raised above the ordinary routine of empiricism, which is about on a par with patent medicines. This thought is needed from every physician, and should not be restricted to the writer on or teacher of medicine, and the easier and better we think, the easier and better we will find the practice of medicine.—SCUDDER, Eclectic Medical Journal, 1876.