Medicine without signs.

Psychiatry is often criticised for not defining the limits of its skill, but its boundaries will remain imprecise until objective diagnostic criteria can be established. Recent studies have broadened its potential scope by showing that the extent of mental disorder ranges far beyond the layman's traditional view of madness.1 One of the more important observations is the frequency with which patients with unrecognised psychiatric morbidity present to medical and surgical specialists. The overlap between psychiatry and other clinical disciplines has become increasingly recognised ; indeed, the leading neurologist Henry Miller2 defined psychiatry as neurology without physical But this is a limited view. A wide variety of medical illnesses may present with mental symptoms and, conversely, psychiatric illness often presents with physical complaints. Indeed, Miller's definition might legitimately be expanded to describe this area of clinical practice as medicine without signs. There are bodily signs of psychiatric illness, but these are subtle and not of the order looked for by the doctor seeking to confirm or refute physical illness. Doctors have long appreciated that many patients consulting them with physical symptoms have no organic but there was little attempt to study the problem systematically until Cabot reported a series of patients from Massachusetts General Hospital in 1907.3 Among 5000 outpatients he found that only 53% had organic disease; the other 47% were said to be suffering from disease, including such diagnoses as uterine misplacements, neurasthenia, apprehension, and gastroptosis. Since then functional disease has been dis? credited as a descriptive term4 and we are now concerned with the positive recognition of psychiatric illness in these patients.