S/JAMA-Landmark Article: The Care of the Patient [full text JAMA,. file: ///C: /Documents%20and%20Settings/jpelley/My%20Documents/Iw patient's nervous reactions. The ultimate causes of these disturbances are to be found, not in any gross structural changes in 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 Every one has had experiences that have brought home the way in which emotional reactions affect organic functions. Some 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 have had polyuria before making a speech, and others have felt thumping extrasystoles or a pounding tachycardia before a football game. Some 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 hythm 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 dioxide that the symptoms of tetany ensued. The explanation of the occipital ?9 becomes affected. Thus, I remember an emotional young woman who developed respiratory neurosis with deep and rapid breathing, and expired so much carbon 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 the so-called writers' cramp, in which the ainful muscles of the hand result. not from manual work but from mental work. One might go on 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 maginary 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 timeMS/JAMA - Landmark Article: The Care of the Patient [full text JAMA,... file:///C:/Documents%20and%20Settings/jpelley/My%20Documents/1W... 6 of 11 8/8/2007 10:33 AM patient's nervous reactions. The ultimate causes of these disturbances are to be found, not in any gross structural changes in 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. Every one has had experiences that have brought home the way in which emotional reactions affect organic functions. Some 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 have had polyuria before making a speech, and others have felt thumping extrasystoles or a pounding tachycardia before a football game. Some 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 the so-called writers' cramp, in which the painful muscles of the hand result, not from manual work, but from mental work. One might go on 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