S/JAMA-Landmark Article: The Care of the Patient [full text JAMA,. file: ///C: /Documents%20and%20Settings/jpelley/My%20Documents/Iw becomes necessary to consider whether the symptomatology may be due to a good deal about the personal life of your patient by this time, but perhaps there /s Q functional disorder which is caused by nervous or emotional influences. You know nothing that stands out as an obvious etiologic factor and it becomes nec down for a long intimate talk with him to discover what has remained hidden Sometimes it is well to explain to the patient, by obvious examples, how it is that emotional states may bring about symptoms similar to his own, so that he will understand what you are driving at and will cooperate with you. Often the best way is to go back to the very beginning and try to find out the circumstances of the patient's life at the time the symptoms first began. The association between symptoms and cause may have been simpler and more direct at the onset, at least in the patient' s mind, for as time goes on, and the symptoms become more pronounced and distressing, there is a natural tendency for the symptoms to occupy so much of the foreground of the picture that the background is completely obliterated. Sorrow, disappointment, anxiety, self-distrust, thwarted ideals or ambitions in social business or personal life, and particularly what are called maladaptations to these conditions-these are among the commonest and simplest factors that initiate and perpetuate the functional disturbances. Perhaps you will find that the digestive disturbances began at the time the patient was in serious financial difficulties and they have recurred whenever he is worried about money matters. Or you may find that ten years ago a physician told the patient he had heart disease, cautioning him not to worry about it For ten years the patient has never mentioned the subject, but he has avoided every exertion, and has lived with the idea that sudden death was in store for him. You will find that physicians, by wrong diagnoses and ill considered statements, are responsible for many a wrecked life, and you will discover that it is much easier to make a wrong diagnosis than it is to unmake it Or, again, you may find that the pain in this womans back made its appearance when she first felt her domestic unhappiness, and that this man s headaches have been associated, not with long hours of work, but with a constant depression due to unfulfilled ambitions. The causes are manifold and the manifestations protean Sometimes the mechanism of cause and effect is obvious: sometimes it becomes apparent only after a very tangled skein has been unraveled If the establishment of an intimate personal relationship is necessary in the diagnosis of functional disturbances, it becomes doubly necessary in their treatment. Unless there is complete confidence in the sympathetic understanding of the physician well as in his professional skill, very little can be accomplished; but granted that you have been able to get close enough to the patient to discover the cause of the trouble you will find that a general hospital is not at all an impossible place for the treatment of functional disturbances. The hospital has, indeed, the advantage that the entire reputation of the institution, and all that it represents in the way of facilities for diagnosis and treatment, go to enhance the confidence which the patient has in the individual physician who represents it. This gives the very young physician a hold on his patients that he could scarcely hope to have without its support. Another advantage is that hospital patients are removed from their usual environment, for the treatment of functional disturbances is often easier when patients are away fron friends, relatives, home, work and, indeed, everything that is associated with their daily life. It is true that in a public ward one cannot obtain complete isolation in the sense that this is a part of the Weir Mitchell treatment, but the main object isMS/JAMA - Landmark Article: The Care of the Patient [full text JAMA,... file:///C:/Documents%20and%20Settings/jpelley/My%20Documents/1W... 10 of 11 8/8/2007 10:33 AM becomes necessary to consider whether the symptomatology may be due to a functional disorder which is caused by nervous or emotional influences. You know a good deal about the personal life of your patient by this time, but perhaps there is nothing that stands out as an obvious etiologic factor, and it becomes necessary to sit down for a long intimate talk with him to discover what has remained hidden. Sometimes it is well to explain to the patient, by obvious examples, how it is that emotional states may bring about symptoms similar to his own, so that he will understand what you are driving at and will cooperate with you. Often the best way is to go back to the very beginning and try to find out the circumstances of the patient's life at the time the symptoms first began. The association between symptoms and cause may have been simpler and more direct at the onset, at least in the patient's mind, for as time goes on, and the symptoms become more pronounced and distressing, there is a natural tendency for the symptoms to occupy so much of the foreground of the picture that the background is completely obliterated. Sorrow, disappointment, anxiety, self-distrust, thwarted ideals or ambitions in social, business or personal life, and particularly what are called maladaptations to these conditions—these are among the commonest and simplest factors that initiate and perpetuate the functional disturbances. Perhaps you will find that the digestive disturbances began at the time the patient was in serious financial difficulties, and they have recurred whenever he is worried about money matters. Or you may find that ten years ago a physician told the patient he had heart disease, cautioning him "not to worry about it." For ten years the patient has never mentioned the subject, but he has avoided every exertion, and has lived with the idea that sudden death was in store for him. You will find that physicians, by wrong diagnoses and ill considered statements, are responsible for many a wrecked life, and you will discover that it is much easier to make a wrong diagnosis than it is to unmake it. Or, again, you may find that the pain in this woman's back made its appearance when she first felt her domestic unhappiness, and that this man's headaches have been associated, not with long hours of work, but with a constant depression due to unfulfilled ambitions. The causes are manifold and the manifestations protean. Sometimes the mechanism of cause and effect is obvious; sometimes it becomes apparent only after a very tangled skein has been unraveled. If the establishment of an intimate personal relationship is necessary in the diagnosis of functional disturbances, it becomes doubly necessary in their treatment. Unless there is complete confidence in the sympathetic understanding of the physician as well as in his professional skill, very little can be accomplished; but granted that you have been able to get close enough to the patient to discover the cause of the trouble, you will find that a general hospital is not at all an impossible place for the treatment of functional disturbances. The hospital has, indeed, the advantage that the entire reputation of the institution, and all that it represents in the way of facilities for diagnosis and treatment, go to enhance the confidence which the patient has in the individual physician who represents it. This gives the very young physician a hold on his patients that he could scarcely hope to have without its support. Another advantage is that hospital patients are removed from their usual environment, for the treatment of functional disturbances is often easier when patients are away from friends, relatives, home, work and, indeed, everything that is associated with their daily life. It is true that in a public ward one cannot obtain complete isolation in the sense that this is a part of the Weir Mitchell treatment, but the main object is