Part 3

In an era which is so characterized by scientific progress in all directions it would be strange and unfortunate indeed if medical men should lack the instinct for intensive study or for scholarship. Primarily, and in its highest expression, specialization represents the attempt to fulfill an intellectual craving, and as such it is most desirable, both for the tone of the profession itself and for the public which depends on the profession. Such a view of the situation is, however, far from complete, and other motives, of a less disinterested nature it must be confessed explain a considerable part of the tendency of medical men to prefer specialization to general practice. Thus, for example, the life of the specialist sometimes appears to be an easier one than that of the general practitioner, for the latter has less regular hours of work and may be called to his patients at most inconvenient times. If he is successful in his calling it is true that his life can never be called his own. Many doctors whose careers were interrupted by the war said, “I am not going back to continue being at the beck and call of every one by day and night. I’m going to specialize, and do an office practice.” On the other hand, it must be remembered that the life of the specialist is not an easy one. His hours of work can be to a considerable extent regulated, but they are long and exacting, and, if he is worth his salt, he will run up large bills for lighting, since most of his evenings must be devoted to study in a struggle to keep abreast of the advances that are being made in his field throughout the world. Again, the financial rewards of the successful specialist are usually considerably greater than those of the general practitioner, and to some this is unquestionably the determining factor in the choice of a career. Many others, however, are but slightly influenced by either of these considerations in their preference for the limited fields of medicine, and are chiefly affected, not by the new developments in the specialties, but by the fundamentally altered circumstances which at present surround the life of general practice.

Let us approach this question by considering briefly the motives which led men of high grade into the practice of medicine a generation ago or before specialism with all its rewards was widely developed. The motives were, in general, the earning of a livelihood, a specific interest in medical science, and, in the great majority of instances, a very real desire to be of service to one’s fellow men. The chief reward was not the livelihood, which was often extremely meagre, or the satisfaction of scientific interest, but the appreciation, the love, the regard of a community. The physician was the friend and the guide of his patients who turned to him in sickness and in trouble, and he occupied a position among them which was almost unique. His was a life into which any unselfish, high-minded young man might well be drawn, and the reward was all that any man could ask for. Now there is no reason to believe that the type of man who enters the medical profession has altered. A few, of course, take it up purely as a respectable means of getting a living, but the preparation is so long, so expensive, and so laborious, the life itself is commonly known to be so exacting and the financial rewards are usually so moderate in all branches of the profession that the number of men who drift into medicine with no more definite object in view is inconsiderable. A somewhat larger group are drawn to medicine primarily because of a love of science, much as they might be to zoölogy or to chemistry, but this, too, accounts for only a small proportion of medical students. Medical students have a crowded curriculum and work hard during their course of study, but they are not noted for being particularly studious as a class and only a very limited number enter research or teaching, the obvious outlets for those imbued with profound scientific interest. There is evidence for this in the fact that while many excellent opportunities for scientific work have recently been created in teaching and research-institutions the number of applicants qualified for the positions remain seriously low. Interest in science is thus not the compelling factor with most of the men who enter the medical profession and another motive must be sought. To those who, as teachers, watch successive classes of medical students progress in their course of study it is always striking to see how each group responds with enthusiasm when, after a year or two of laboratory study, it reaches the stage where contact with patients begins. This is what they have been working toward and waiting for. Dissecting room, microscope, chemical experiment--these were but means to prepare them for the great end which is the human relationship between the physician and the patient. It is the desire for this human relationship, with its opportunity for sympathetic intimacy and altruistic service, that remains today, as it has been through all the generations, the dominating impulse in drawing men to the study of medicine. The type of man in medicine and his fundamental ideals have not altered. He still retains the instincts that would lead him to general practice and if he does not enter general practice the reason is that he does not believe it is the most effective way to use his life. As he surveys the world about him and the opportunities before him, he finds that the specialist appears to occupy a position in the profession and in the community at large which is more dignified and more respected than that of the general practitioner. Professionally and socially the specialist is often looked up to as on a higher plane, and it is certainly neither unnatural nor discreditable for the young man to desire the career which carries with it the sincere regard of his fellows. It is this factor, rather than the wish for a life of ease or for increased income that so often prompts him to say, “I do not want to be merely a general practitioner.” It is the shift of emphasis on the relative value of the general practitioner and the specialist. Now it is probably true that the medical profession is to some extent responsible for the development of a point of view which exalts the specialist above the general practitioner. Certain trends in medical practice have tended to accentuate it, and many medical teachers and leaders, in their efforts to stimulate research and to promote progress, have laid so much stress on the importance of intensive study that students, often without any particular qualifications, have been directed toward specialized practice. But, granted the truth of this, the brunt of the responsibility for the present-day attitude toward the general practitioner depends upon the general public. It is not the manufacturer who eventually decides the value of his product, nor can any profession determine its own worth to the community. In the last analysis, the price of any article, or the significance of any calling, must depend on its importance to the world at large, and by the same token, the continued existence of the general practitioner will depend on his value to the general public, or, more accurately perhaps, on what the public thinks the general practitioner is worth to it. The supply will depend on the demand.

It may be well, perhaps, to analyze a little more closely this new attitude which the lay public has assumed toward the general practitioner, and which is apparently so potent a factor in directing young physicians away from the general practice of medicine. In thousands of communities and in innumerable individual instances there has been, of course, no change at all in the old relationship between the doctor and his patient, and in the intimate and sympathetic friendship with which the counsel and service of the one are met by the gratitude and respect of the other. Throughout the country, however, and particularly in large cities and the adjacent towns, the bonds of this extremely personal relationship are rapidly breaking down because the public is tending more and more to turn in the first instance to the specialist instead of to the general practitioner. The feeling seems to be that since the specialists know so much and are the ultimate authorities it is foolish to waste time by going elsewhere. Little effort is made to cultivate a relationship with a sound general adviser. “What has happened to the general practitioner?” someone asks, and without waiting for an answer, he runs off to visit a specialist. Whenever there is “anything” the matter, or as soon as one does not immediately recover from his disability, he seeks a specialist, not on the advice of his general practitioner, who might at least know what kind of specialist would be desirable, but on the advice of John or Mary, who had a friend who was cured of what is supposed to have been a similar complaint. In small communities the “City Specialist” wears a particularly brilliant halo, and the country physician must content himself with his lot while his patients seek expensive advice in the metropolis. If this is the situation and if the specialist is regarded with respect well-nigh akin to awe, while the general practitioner is regarded as a useful convenience when one has a cold or has overeaten, is it any wonder that so many of the better medical students wish to prepare themselves for specialism? The public does not seem to want them very seriously as general practitioners.

These are the conditions, therefore, partly inherent in the progress of medical science and partly depending on the attitude of the public which are today determining the rapid increase of medical specialism; and we may now pass on to consider whether this trend toward specialism is really advantageous to the public itself. There can be no question, I take it, that up to a certain point, the development of specialists is not only desirable but necessary if the medical profession is to be thoroughly equipped to prevent the public from becoming sick and to restore them to health when they are suffering. Thus, for instance, in the application of the results of the most modern research in the basic sciences, both to the diagnosis and treatment of disease, it is important that the physician should be thoroughly trained in the principles of the underlying sciences if the patient is to derive the maximum benefit that medicine can confer. It is, therefore, well to have specialists in heart disease who, as students of experimental physiology and pathology, have acquired a knowledge of circulatory disturbances in animals which is subsequently of assistance in treating disease in man; to have specialists in diabetes who are at the same time competent chemists, since their experience in the laboratory is of daily help in regulating the diets of their patients; and to have specialists in infectious diseases who have devoted years to bacteriology because their observations on the course of infections in animals and the effect of sera and vaccines on experimental infections are of practical value at the bedside. There have also been many strictly clinical advances which are the direct outcome of the intensive study of disease in man. Among these may be mentioned the modern highly refined operative procedures. The surgery of the eye, the ear, the nose and throat, or the brain, for example, involves such intricate technical methods and such a high degree of manual dexterity that it is done best by the surgeon with constant experience and practice in the same general type of operation. It is entirely reasonable that all of us prefer to have our tonsils taken out by a laryngologist and not by a general surgeon, and such specialists in medical practice must be available in every community. In another quarter, moreover, and in one which is of vital, although of less immediate concern to the layman, the need of specialists is even greater. This is the field of medical research. Our knowledge of disease has advanced so far that further progress will probably be slow, and little is to be expected except as the result of prolonged and concentrated labor. The nuggets lying on the surface have been picked up and the hidden gold will be found only by him who digs deeply and whose training has taught him where to dig. Here is needed not only the specialist, but the specialist with that unusual gift of vision which belongs to the pioneer and which urges him beyond our present confines.

In these two fields, therefore, in research and in the application to practice of specialized knowledge or complex technical procedures, the expert is absolutely necessary, but the number of men actually needed to satisfy the demands is relatively small and, in the natural course of events, there will always be enough doctors whose intellectual interests direct them to intensive study. The lay public, therefore, need have little anxiety about having sufficient specialists to serve them. The important problem for the public is whether they still have need of encouraging the development of general practitioners. Here is the crux of the situation! Is an attitude which is bound to result in a progressive increase in the number of specialists, at the cost of a progressive decrease both in the number and quality of general practitioners, one which will ultimately be of general benefit? In the light of the development of modern medicine, is the general practitioner an essential factor in preserving and promoting health or is he a makeshift necessary only in communities too small or too poor to support a competent corps of specialists? Can the public get along without the general practitioner? To those who are in a position to see the helpless flounderings of the unfortunates who pass from specialist to specialist the answer is very clear. Never was the sound general practitioner more important than he is today. Never was the public in need of wise, broadly trained advisers so much as it needs them today to guide them through the complicated maze of modern medicine. The extraordinary development of medical science, with its consequent diversity of medical specialism and the increasing limitations in the extent of special fields--the very factors, indeed, which are creating specialists, in themselves create a new demand, not for men who are experts along narrow lines, but for men who are in touch with many lines. The advantages to be derived from advice and treatment by specialists are entirely obvious, but the disadvantages are by no means always so clearly understood. They are inherent in the training, however, for depth is not often combined with breadth, and the enthusiasm which makes one an expert in a limited field is frequently the very factor which prevents him from viewing a situation as a whole. The training of the specialist is in its essence intensive, and he can detect the slightest abnormality in the organ or system which constitutes his field, but man is not merely an aggregation of organs or of systems--he is first of all a human being whose proper care involves an appreciation of his body as a whole, together with the circumstances of his life. Many a sick person, after visiting a series of experts, and being treated for the abnormalities which each discovered in his own sphere, remains an invalid because none of his doctors was accustomed to look at a case as a whole. Many a patient, after going the rounds of the specialists, has found relief in mental healing or New Thought or Christian Science, because he lacked the guidance of a sound general practitioner who understood his physical condition, his nervous temperament and knew the details of his daily life. And many a patient, who on his own initiative has sought out specialists, has had minor defects accentuated so that they assumed a needless importance, and has even undergone operations that might well have been avoided. Those who are particularly blessed with this world’s goods, who want the best regardless of the cost and imagine that they are getting it because they can afford to consult as many renowned specialists as they wish, are often pathetically tragic figures as they veer from one course of treatment to another. Like ships that lack a guiding hand upon the helm, they swing from tack to tack with each new gust of wind, but get no nearer to the Port of Health because there is no pilot to set the general direction of their course.

The latest substitute for the breadth of vision of the general practitioner is that offspring of the American God of Efficiency, the Diagnostic Clinic. What a strong appeal it makes, this apparently ideal combination of a group of specialists so closely affiliated as to afford all the advantages of expert knowledge and at the same time maintain the desirable general supervision! Practically the method seems to work out about like most substitutes--sometimes well and sometimes badly. It all depends upon the men who constitute the group. At its best the patient finds himself in the hands of a wise, broadly trained physician who handles his case personally and refers as occasion demands to intimate and trusted associates who are skilled in special fields. One man has personal supervision over the case and devotes enough time to it to grasp all of its ramifications, so that he can estimate the relative importance of the findings of the specialists on the production of the symptoms in the individual. At its worst, however, the Diagnostic Clinic is a machine, and the patient is automatically passed from one specialist to another and submitted to a series of examinations, so detailed in their nature that it would seem that nothing could be overlooked. The result is a list of so-called “diagnoses”--in reality a list of deviations from the normal, some of which may, and others of which certainly do not have any bearing on the patient’s trouble. The unfortunate thing is that only too often the patient undergoes treatment for some of these unimportant conditions and at the same time, because of the lack of some one man who understands the situation as a whole, the real underlying difficulty is entirely overlooked.

The truth of the matter is that the practice of medicine is intensely personal and no system or machine can be substituted for the personal relationship. The proper interpretation of symptoms involves not only a comprehension of the causes of symptoms but also of the person in whom the symptoms arise. Every experienced physician knows that when one of his patients complains of a pain in the stomach it is probably a very trivial matter and when another makes apparently the same complaint it is probably a very serious matter. It all depends on the type of patient, and the better the physician knows his patient the better will he be able to decide on the proper treatment. Skilled physicians, gifted with peculiar insight into human nature, can often estimate a personality with remarkable accuracy in a few minutes or even seconds, but in general the more a doctor knows of his patient’s background the greater advantage he has in handling the case. That is the great advantage which the general practitioner has always possessed and still possesses. He knows the patient from childhood up--his physical health, the nervous and mental strain to which he has been subjected, the conditions of his social, business and domestic life, and, more even than this, he may have the same detailed knowledge of the patient’s parents and of the circumstances of their lives. Now all this kind of information, which is difficult to obtain except as the result of years of intimacy, has an infinitely important bearing on the question of health and disease. Not to have it is an enormous loss, and the loss falls, of course, primarily on the patient. He is the one who suffers. The only person who can really gather together this fundamental knowledge of his patients is the general practitioner.

In the trend toward specialism the pendulum is swinging too far, and it is the duty of medical educators and leaders to indicate to their students the importance of general practice and the high professional attainments that are necessary for success in it. But this alone will not suffice. In the last analysis it is the attitude of the public which will determine the careers of many of our future medical men. If the public will but realize that it can have no greater asset than a close and continued personal relationship with a wise, sound, general adviser, it may rest assured that there will always be an adequate response to the call for service. In order to get the best type of medical men to turn to general practice, however, it is necessary for the public to understand that the qualifications for general practice are at least as high as those which are requisite for specialism, and to appreciate that the general practitioner is worthy of its respect and confidence.

THE CARE OF THE PATIENT

It is probably fortunate that most systems of education are constantly under the fire of general criticism, for if education were left solely in the hands of teachers the chances are good that it would soon deteriorate. Medical education, however, is less likely to suffer from such stagnation, for whenever the lay public stops criticizing the type of modern doctor, the medical profession itself may be counted on to stir up the stagnant pool and cleanse it of its sedimentary deposit. The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine--or, to put it more bluntly, they are too “scientific” and do not know how to take care of patients.

One is, of course, somewhat tempted to question how completely fitted for his life-work the practitioner of the older generation was when he first entered on it, and how much the haze of time has led him to confuse what he learned in the school of medicine with what he acquired in the harder school of experience. But the indictment is a serious one and it is concurred in by numerous recent graduates, who find that in the actual practice of medicine they encounter many situations which they had not been led to anticipate and which they are not prepared to meet effectively. Where there is so much smoke there is undoubtedly a good deal of fire, and the problem for teachers and for students is to consider what they can do to extinguish whatever is left of this smoldering distrust.

To begin with, the fact must be accepted that one cannot expect to become a skilful practitioner of medicine in the four or five years allotted to the medical curriculum. Medicine is not a trade to be learned but a profession to be entered. It is an ever-widening field that requires continued study and prolonged experience in close contact with the sick. All that the medical school can hope to do is to supply the foundations on which to build. When one considers the amazing progress of science in its relation to medicine during the last thirty years, and the enormous mass of scientific material which must be made available to the modern physician, it is not surprising that the schools have tended to concern themselves more and more with this phase of the educational problem. And while they have been absorbed in the difficult task of digesting and correlating new knowledge, it has been easy to overlook the fact that the application of the principles of science to the diagnosis and treatment of disease is only one limited aspect of medical practice. The practice of medicine in its broadest sense includes the whole relationship of the physician with his patient. It is an art, based to an increasing extent on the medical sciences, but comprising much that still remains outside the realm of any science. The art of medicine and the science of medicine are not antagonistic but supplementary to each other. There is no more contradiction between the science of medicine and the art of medicine than between the science of aeronautics and the art of flying. Good practice presupposes an understanding of the sciences which contribute to the structure of modern medicine, but it is obvious that sound professional training should include a much broader equipment.

The problem that I wish to consider, therefore, is whether this larger view of the profession cannot be approached even under the conditions imposed by the present curriculum of a medical school. Can the practitioner’s art be grafted on the main trunk of the fundamental sciences in such a way that there may arise a symmetrical growth, like an expanding tree, the leaves of which shall be for the “healing of the nations”?

The physician who speaks of the care of patients is naturally thinking about circumstances as they exist in the practice of medicine; but the teacher who is attempting to train medical students is immediately confronted by the fact that, even if he would, he cannot make the conditions under which he has to teach clinical medicine exactly similar to those of actual practice.

The primary difficulty is that instruction has to be carried out largely in the wards and dispensaries of hospitals rather than in the patient’s home and the physician’s office. Now the essence of the practice of medicine is that it is an intensely personal matter, and one of the chief differences between private practice and hospital practice is that the latter always tends to become impersonal. At first sight this may not appear to be a very vital point, but it is, as a matter of fact, the crux of the whole situation. The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal. The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it, and the failure of the young physician to establish this relationship accounts for much of his ineffectiveness in the care of patients.

Hospitals--like other institutions founded with the highest human ideals--are apt to deteriorate into dehumanized machines, and even the physician who has the patient’s welfare most at heart finds that pressure of work forces him to give most of his attention to the critically sick and to those whose diseases are a menace to the public health. In such cases he must first treat the specific disease, and there then remains little time in which to cultivate more than a superficial personal contact with the patients. Moreover, the circumstances under which the physician sees the patient are not wholly favorable to the establishment of the intimate personal relationship that exists in private practice, for one of the outstanding features of hospitalization is that it completely removes the patient from his accustomed environment. This may, of course be entirely desirable, and one of the main reasons for sending a person into the hospital is to get him away from home surroundings, which, be he rich or poor, are often unfavorable to recovery; but at the same time it is equally important for the physician to know the exact character of those surroundings.

Everybody, sick or well, is affected in one way or another, consciously or subconsciously, by the material and spiritual forces that bear on his life, and especially to the sick such forces may act as powerful stimulants or depressants. When the general practitioner goes into the home of a patient, he may know the whole background of the family life from past experience; but even when he comes as a stranger he has every opportunity to find out what manner of man his patient is, and what kind of circumstances makes his life. He gets a hint of financial anxiety or of domestic incompatibility; he may find himself confronted by a querulous, exacting, self-centered patient, or by a gentle invalid overawed by a dominating family; and as he appreciates how these circumstances are reacting on the patient he dispenses sympathy, encouragement, or discipline. What is spoken of as a “clinical picture” is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes, and fears. Now, all of this background of sickness which bears so strongly on the symptomatology is liable to be lost sight of in the hospital: I say “liable to” because it is not by any means always lost sight of, and because I believe that by making a constant and conscious effort one can almost always bring it out into its proper perspective. The difficulty is that in the hospital one gets into the habit of using the oil immersion lens instead of the low power, and focuses too intently on the center of the field.

When a patient enters a hospital, the first thing that commonly happens to him is that he loses his personal identity. He is generally referred to, not as Henry Jones, but as “that case of mitral stenosis in the second bed on the left.” There are plenty of reasons why this is so, and the point is, in itself, relatively unimportant; but the trouble is that it leads, more or less directly, to the patient being treated as a case of mitral stenosis, and not as a sick man. The disease is treated, but Henry Jones, lying awake nights while he worries about his wife and children, represents a problem that is much more complex than the pathologic physiology of mitral stenosis, and he is apt to improve very slowly unless a discerning intern discovers why it is that even large doses of digitalis fail to slow his heart rate. Henry happens to have heart disease, but he is not disturbed so much by dyspnea as he is by anxiety for the future, and a talk with an understanding physician who tries to make the situation clear to him, and then gets the social service worker to find a suitable occupation, does more to straighten him out than a book full of drugs and diets. Henry has an excellent example of a certain type of heart disease, and he is glad that all the staff find him interesting, for it makes him feel that they will do the best they can to cure him; but just because he is an interesting case he does not cease to be a human being with very human hopes and fears. Sickness produces an abnormally sensitive emotional state in almost every one, and in many cases the emotional state repercusses, as it were, on the organic disease. The pneumonia would probably run its course in a week, regardless of treatment, but the experienced physician knows that by quieting the cough, getting the patient to sleep, and giving a bit of encouragement, he can save his patient’s strength and lift him through many distressing hours. The institutional eye tends to become focused on the lung, and it forgets that the lung is only one member of the body.

But if teachers and students are inclined to take a limited point of view even toward interesting cases of organic disease, they fall into much more serious error in their attitude toward a large group of patients who do not show objective, organic, pathologic, conditions, and who are generally spoken of as having “nothing the matter with them.” Up to a certain point, as long as they are regarded as diagnostic problems, they command attention; but as soon as the physician has assured himself that they do not have organic disease, he passes them over lightly.

Take the case of a young woman, for instance, who entered the hospital with a history of nausea and discomfort in the upper part of the abdomen after eating. Mrs. Brown had “suffered many things of many physicians.” Each of them gave her a tonic and limited her diet. She stopped eating everything that any of her physicians advised her to omit, and is now living on a little milk with a few crackers; but her symptoms persist. The history suggests a possible gastric ulcer or gall-stones, and with a proper desire to study the case thoroughly, she is given a test meal, gastric analysis, and duodenal intubation, and roentgen-ray examinations are made of the gastro-intestinal tract and gall-bladder. All of these diagnostic methods give negative results; that is, they do not show evidence of any structural change. The case immediately becomes much less interesting than if it had turned out to be a gastric ulcer with atypical symptoms. The visiting physician walks by and says, “Well there’s nothing the matter with her.” The clinical clerk says, “I did an awful lot of work on that case and it turned out to be nothing at all.” The intern, who wants to clear out the ward to make room for some interesting cases, says, “Mrs. Brown, you can send for your clothes and go home to-morrow. There really is nothing the matter with you, and fortunately you have not got any of the serious troubles we suspected. We have used all the most modern and scientific methods and we find that there is no reason why you should not eat anything you want to. I’ll give you a tonic to take when you go home.” Same story, same colored medicine! Mrs. Brown goes home, somewhat better for her rest in new surroundings, thinking that nurses are kind and physicians are pleasant, but that they do not seem to know much about the sort of medicine that will touch her trouble. She takes up her life and the symptoms return--and then she tries chiropractic, or perhaps Christian Science.

It is rather fashionable to say that the modern physician has become “too scientific.” Now, was it too scientific, with all the stomach tubes and blood counts and roentgen-ray examinations? Not at all. Mrs. Brown’s symptoms might have been due to a gastric ulcer or to gall-stones, and after such a long course it was only proper to use every method that might help to clear the diagnosis. Was it, perhaps, not scientific enough? The popular conception of a scientist as a man who works in a laboratory and who uses instruments of precision is as inaccurate as it is superficial, for a scientist is known, not by his technical processes, but by his intellectual processes; and the essence of the scientific method of thought is that it proceeds in an orderly manner toward the establishment of a truth. Now the chief criticism to be made of the way Mrs. Brown’s case was handled is that the staff was contented with a half-truth. The investigation of the patient was decidedly unscientific in that it stopped short of even an attempt to determine the real cause of the symptoms. As soon as organic disease could be excluded the whole problem was given up, but the symptoms persisted. Speaking candidly, the case was a medical failure in spite of the fact that the patient went home with the assurance that there was “nothing the matter” with her.

A good many “Mrs. Browns,” male and female, come to hospitals, and a great many more go to private physicians. They are all characterized by the presence of symptoms that cannot be accounted for by organic disease, and they are all liable to be told that they have “nothing the matter” with them. Now my own experience as a hospital physician has been rather long and varied, and I have always found that, from my point of view, hospitals are particularly interesting and cheerful places; but I am fairly certain that, except for a few low-grade morons and some poor wretches who want to get in out of the cold, there are not many people who become hospital patients unless there is something the matter with them. And, by the same token, I doubt whether there are many people, except those stupid creatures who would rather go to the physician than go to the theater, who spend their money on visiting private physicians unless there is something the matter with them. In hospital and in private practice, however, one finds this same type of patient, and many physicians whom I have questioned agree in saying that, excluding cases of acute infection, approximately half of their patients complained of symptoms for which an adequate organic cause could not be discovered. Numerically, then, these patients constitute a large group, and their fees go a long way toward spreading butter on the doctor’s bread. Medically speaking, they are not serious cases as regards prospective death, but they are often extremely serious as regards prospective life. Their symptoms will rarely prove fatal, but their lives will be long and miserable, and they may end by nearly exhausting their families and friends. Death is not the worst thing in the world, and to help a man to a happy and useful career may be more of a service than the saving of life.

What is the matter with all these patients? Technically, most of them come under the broad heading of the “psychoneuroses”; but for practical purposes many of them may be regarded as patients whose subjective symptoms are due to disturbances of the physiologic activity of one or more organs or systems. These symptoms may depend on an increase or a decrease of a normal function, on an abnormality of function, or merely on the subjects becoming conscious of a wholly normal function that normally goes on unnoticed; and this last conception indicates that there is a close relation between the appearance of the symptoms and the threshold of the patient’s nervous reactions. The ultimate causes of these disturbances are to be found, not in any gross structural changes of the organs involved, but rather in nervous influences emanating from the emotional or intellectual life, which, directly or indirectly, affect in one way or another organs that are under either voluntary or involuntary control.

All of you have had experiences that have brought home the way in which emotional reactions affect organic functions. Some of you have been nauseated while anxiously waiting for an important examination to begin, and a few may even have vomited; others have been seized by an attack of diarrhea under the same circumstances. Some of you have had polyuria before making a speech, and others have felt thumping extrasystoles or a pounding tachycardia before a football game. Some of you have noticed rapid shallow breathing when listening to a piece of bad news, and others know the type of occipital headache, with pain down the muscles of the back of the neck, that comes from nervous anxiety and fatigue.

These are all simple examples of the way that emotional reactions may upset the normal functioning of an organ. Vomiting and diarrhea are due to abnormalities of the motor function of the gastro-intestinal tract--one to the production of an active reversed peristalsis of the stomach and a relaxation of the cardiac sphincter, the other to hyperperistalsis of the large intestine. The polyuria is caused by vasomotor changes in renal circulation, similar in character to the vasomotor changes that take place in the peripheral vessels in blushing and blanching of the skin, and in addition there are quite possibly associated changes in the rate of blood flow and in blood pressure. Tachycardia and extrasystoles indicate that not only the rate but also the rhythm of the heart is under a nervous control that can be demonstrated in the intact human being as well as in the experimental animal. The ventilatory function of the respiration is extraordinarily subject to nervous influences; so much so, in fact, that the study of the respiration in man is associated with peculiar difficulties. Rate, depth, and rhythm of breathing are easily upset by even minor stimuli, and in extreme cases the disturbance in total ventilation is sometimes so great that gaseous exchange becomes affected. Thus, I remember an emotional young woman who developed a respiratory neurosis with deep and rapid breathing, and expired so much carbon dioxide that the symptoms of tetany ensued. The explanation of the occipital headaches and of so many pains in the muscles of the back is not entirely clear, but they appear to be associated with changes in muscular tone or with prolonged states of contraction. There is certainly a very intimate correlation between mental tenseness and muscular tenseness, and whatever methods are used to produce mental relaxation will usually cause muscular relaxation, together with relief of this type of pain. A similar condition is found in so-called writers’ cramp, in which the painful muscles of the hand result, not from manual work, but from mental work.

One might go much further, but these few illustrations will suffice to recall the infinite number of ways in which physiologic functions may be upset by emotional stimuli, and the manner in which the resulting disturbances of function manifest themselves as symptoms. These symptoms, although obviously not due to anatomic changes, may, nevertheless, be very disturbing and distressing, and there is nothing imaginary about them. Emotional vomiting is just as real as the vomiting due to pyloric obstruction, and so-called “nervous headaches” may be as painful as if they were due to a brain tumor. Moreover, it must be remembered that symptoms based on functional disturbances may be present in a patient who has, at the same time, organic disease, and in such cases the determination of the causes of the different symptoms may be an extremely difficult matter. Every one accepts the relationship between the common functional symptoms and nervous reactions, for convincing evidence is to be found in the fact that under ordinary circumstances the symptoms disappear just as soon as the emotional cause has passed. But what happens if the cause does not pass away? What if, instead of having to face a single three-hour examination, one has to face a life of being constantly on the rack? The emotional stimulus persists, and continues to produce the disturbances of function. As with all nervous reactions the longer the process goes on, or the more frequently it goes on, the easier it is for it to go on. The unusual nervous track becomes an established path. After a time, the symptom and the subjective discomfort that it produces come to occupy the center of the picture, and the causative factors recede into a hazy background. The patient no longer thinks, “I cannot stand this life,” but he says out loud, “I cannot stand this nausea and vomiting. I must go to see a stomach specialist.”

Quite possibly your comment on this will be that the symptoms of such “neurotic” patients are well known, and they ought to go to a neurologist or a psychiatrist and not to an internist or a general practitioner. In an era of internal medicine, however, which takes pride in the fact that it concerns itself with the functional capacity of organs rather than with mere structural changes, and which has developed so many “functional tests” of kidneys, heart, and liver, is it not rather narrow-minded to limit one’s interest to those disturbances of function which are based on anatomic abnormalities? There are other reasons, too, why most of these “functional” cases belong to the field of general medicine. In the first place, the differential diagnosis between organic disease and pure functional disturbance is often extremely difficult, and it needs the broad training in the use of general clinical and laboratory methods which forms the equipment of the internist. Diagnosis is the first step in treatment. In the second place, the patients themselves frequently prefer to go to a medical practitioner rather than to a psychiatrist, and in the long run it is probably better for them to get straightened out without having what they often consider the stigma of having been “nervous” cases. A limited number, it is true, are so refractory or so complex that the aid of the psychiatrist must be sought, but the majority can be helped by the internist without highly specialized psychologic technic, if he will appreciate the significance of functional disturbances and interest himself in their treatment. The physician who does take these cases seriously--one might say scientifically--has the great satisfaction of seeing some of his patients get well, not as the result of drugs or as the result of the disease having run its course, but as the result of his own individual efforts.

Here, then, is a great group of patients in which it is not the disease but the man or the woman who needs to be treated. In general hospital practice physicians are so busy with the critically sick, and in clinical teaching they are so concerned with training students in physical diagnosis and attempting to show them all types of organic disease, that they do not pay as much attention as they should to the functional disorders. Many a student enters upon his career having hardly heard of them except in his course in psychiatry, and without the faintest conception of how large a part they will play in his future practice. At best, his method of treatment is apt to be a cheerful reassurance combined with a placebo. The successful diagnosis and treatment of these patients, however, depends almost wholly on the establishment of that intimate personal contact between physician and patient which forms the basis of private practice. Without this, it is quite impossible for the physician to get an idea of the problems and troubles that lie behind so many functional disorders. If students are to obtain any insight into this field of medicine, they must also be given opportunities to build up the same type of personal relationship with their patients.