S/JAMA-Landmark Article: The Care of the Patient [full text JAMA,. file: ///C: /Documents%20and%20Settings/pelley/My%20Documents/IW MSJ丿AMA ONLINE HOME [ARTICLES [RESOURCESSEARCH[ FEEDBACK [PAST ISSUES web eXtras JAMA vo88,pp.877-882,Mar.19,1927 The Care of the patient* Francis W. Peabody, MD Boston See the related 1984 commentary on this article It is probably fortunate that 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 skillful 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 sciend
MS/JAMA - Landmark Article: The Care of the Patient [full text JAMA,... file:///C:/Documents%20and%20Settings/jpelley/My%20Documents/1W... 1 of 11 8/8/2007 10:33 AM Vol. 88, pp. 877-882, Mar. 19, 1927 The Care of the Patient* Francis W. Peabody, MD Boston See the related 1984 commentary on this article It is probably fortunate that 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 skillful 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
S/JAMA-Landmark Article: The Care of the Patient [full text JAMA,. file: ///C: /Documents%20and%20Settings/jpelley/My%20Documents/Iw 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 to the diagnosis and treatment of disease is only one limited aspect of medical practice. The practice of his patient. It is an art, based to an increasing extent on the medical sciences, bur medicine in its broadest sense includes the whole relationship of the physician w 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 the medical school. Can the practitioner's art be grafted on the main trunk of the fundamental sciences in such a way that there shall arise a symmetrical growth, like an expanding tree, the leaves of which may be for the"healing of the nations"? One 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 could, 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 al ways 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 INSTRUCTION IN TREATMENT OF DISEASE 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 elfare 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
MS/JAMA - Landmark Article: The Care of the Patient [full text JAMA,... file:///C:/Documents%20and%20Settings/jpelley/My%20Documents/1W... 2 of 11 8/8/2007 10:33 AM 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 the medical school. Can the practitioner's art be grafted on the main trunk of the fundamental sciences in such a way that there shall arise a symmetrical growth, like an expanding tree, the leaves of which may be for the "healing of the nations"? One 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 could, 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. INSTRUCTION IN TREATMENT OF DISEASE 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
S/JAMA-Landmark Article: The Care of the Patient [full text JAMA,. file: ///C: /Documents%20and%20Settings/pelley/My%20Documents/IW 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 make 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 al ways ost sight of, and because I believe that by making a constant and conscious effort one can almost al ways 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, one of the first things 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 lying awake nights while he worries about his wife and children, represents a s, of mitral stenosis, and not as a sick man. The disease is treated, but Henry Jone 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 happens to discover 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 nry 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
MS/JAMA - Landmark Article: The Care of the Patient [full text JAMA,... file:///C:/Documents%20and%20Settings/jpelley/My%20Documents/1W... 3 of 11 8/8/2007 10:33 AM 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 make 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, one of the first things 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 happens to discover 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
S/JAMA-Landmark Article: The Care of the Patient [full text JAMA,. file: ///C: /Documents%20and%20Settings/jpelley/My%20Documents/Iw 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 PATIENTS WHO HAVE NOTHING THE MATTER WITH THEM But if teachers and students are liable 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 a 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 physician advised her to omit, and is now living on a little milk and a few crackers; but her symptoms persist. The history suggests a possible gastric ulcer or gallstones, 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 gallbladder. All of these diagnostic methods give negative results, that is, they do not show evidence of any structural change. The case is mmediately 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 so as to make room for some interesting cases, says"Mrs Brown, you can send for your clothes and go home tomorrow. 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 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 it is 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 gallstones, and after such a long It 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
MS/JAMA - Landmark Article: The Care of the Patient [full text JAMA,... file:///C:/Documents%20and%20Settings/jpelley/My%20Documents/1W... 4 of 11 8/8/2007 10:33 AM 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. PATIENTS WHO HAVE "NOTHING THE MATTER WITH THEM" But if teachers and students are liable 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 a 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 and a few crackers; but her symptoms persist. The history suggests a possible gastric ulcer or gallstones, 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 gallbladder. All of these diagnostic methods give negative results, that is, they do not show evidence of any structural change. The case is immediately 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 so as to make room for some interesting cases, says "Mrs. Brown, you can send for your clothes and go home tomorrow. 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 it is 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 gallstones, 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
S/JAMA-Landmark Article: The Care of the Patient [full text JAMA,. file: ///C: /Documents%20and%20Settings/jpelley/My%20Documents/Iw 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 hospital physician has been rather long and varied, and I have al ways 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 for 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 physicians 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 PHYSIOLOGIC DISTURBANCES FROM EMOTIONAL REACTIONS 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
MS/JAMA - Landmark Article: The Care of the Patient [full text JAMA,... file:///C:/Documents%20and%20Settings/jpelley/My%20Documents/1W... 5 of 11 8/8/2007 10:33 AM 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 for 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 physician'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. PHYSIOLOGIC DISTURBANCES FROM EMOTIONAL REACTIONS 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