Empathy is the "almost magical" emotion that persons or objects arouse in us as projections of our feelings. Empathy requires passion, more so than does equanimity, so long cherished by physicians. Medical students lose some of their empathy as they learn science and detachment, and hospital residents lose the remainder in the weariness of overwork and in the isolation of the intensive care units that modern hospitals have become. Conversations about experiences, discussions of patients and their human stories, more leisure and unstructured contemplation of the humanities help physicians to cherish empathy and to retain their passion. Physicians need rhetoric as much as knowledge, and they need stories as much as journals if they are to be more empathetic than computers.

In response to the articles in this issue about measuring physician empathy by Hojat and colleagues, Di Lillo and colleagues, and Kataoka and colleagues, this commentary further explores the concept of empathy. It is posited that empathy is an emotion important to medical care, but it is emphasized that it really doesn't matter whether empathy is a thought or an emotion. Retaining or enhancing it in medical care givers is worth doing and may be achieved through (1) the selection of medical students and others who will care for the sick, (2) the training caretakers receive, and more fundamentally even, (3) reconsideration of what doctors do in a world so much changed and so diverse.Empathy is the foundation of patient care, and it should frame the skills of the profession. It may be that empathy can be taught by example, but the minds of students, like soil, must be prepared before they can nourish seeds of knowledge, and in some soils little grows. Physicians must have the time to listen to their patients. Listening can create empathy--if physicians remain open to be moved by the stories they hear. Empathy has always been and will always be among a physician's most essential tools of practice.

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We have reviewed the natural history, reliability of diagnosis, and survivorship of 100 patients with adenocarcinoma of the pancreas, in the context of a thorough review of the literature on survival after therapy for adenocarcinoma of the pancreas. There is 40-62.5% error in the histologic confirmation of the diagnosis of pancreatic cancer. The error by inspection and palpation alone at the time of surgery may be as great as 25%. The absolute 5 year survival rate calculated from 61 clinical studies representing approximately 15,000 patients is 0.4%. The best series in the current literature has only 3% 5 year rate based upon the total population of pancreatic cancer patients. 12.3% of 5 year survivors from the world literature did not have curative surgery. This study shows the necessity for standardization of reporting methods. The same patients and survivors should not be used repeatedly in different reports. Some authors who claim the most effective palliation by pancreatic resection have the highest mortality rates.Cancer 42:2494-2506, 1978.ANCER OF THE PANCREAS, a malignancy C difficult to recognize or treat, has apparently so increased in frequency as to account for 2 1,800 deaths in the United States in 1977' and is now the fourth leading cause of death from cancer among men. The age adjusted mortality rate from pancreatic cancer in the United States has risen from 2.9 per 100,000 in 1920 to 9 per 100,000 in 1970,57,58 an increase of over 300%. In our own state, the Connecticut Tumor Registry has shown an incidence of pancreatic cancer of 6.9 per 100,000 in men in 1935 to 1939,19 9.9 in 1968,20 and 12 Accepted for publication February 3, 1978. dence and any increased survival after therapy. In order to have a base for our clinical impressions, we reviewed the natural history, diagnosis and survivorship of patients with pancreatic cancer in the state of Connecticut. MATERIALS A N D METHODST o establish a convenient data base, we investigated the fate of 100 patients with histologically proven adenocarcinoma of the pancreas, and we selected the years 1960-1971 for our review. The criteria for selection were: 1) histologic proof of the lesion, and 2) operative or autopsy localization of the primary tumor in the pancreas. In some patients with a pancreatic mass, in whom the diagnosis depended upon lymph node or liver biopsy, the site of pancreatic cancer was substantiated at laparotomy or confirmed by autopsy. In order to find 100 records which fulfilled the foregoing criteria, 197 records of patients with a discharge diagnosis of pancreatic cancer had to be scrutinized. The implication of this will be discussed later. Follow-up, ranging from one month to eight years and eleven months, was possible in 97 of the 100 histologically proven cases. The findings in this series were then compared to published results in a thorough literature review.

Plasma pancreatic glucagon concentrations were determined in the basal state and after the infusion of alanine in 10 patients with acute pancreatitis (5 in an initial episode of pancreatitis), in 10 patients with chronic pancreatic insufficiency, and in 21 healthy controls. In acute pancreatitis, basal glucagon levels were nine times normal but were higher during the initial attack than with a history of previous attacks. The glucagon response to alanine was also increased threefold to fourfold in initial attacks. In contrast, after recovery from the initial attack of acute pancreatitis, during acute episodes of pancreatitis in patients with a history of previous attacks, and in patients with pancreatic insufficiency, alanine failed to elicit a consistent rise in plasma glucagon. The data suggest that hyperglucagonemia may contribute to the hyperglycemia of acute pancreatitis, particularly during the initial episode. Loss of alpha cell responsiveness to alanine provides a sensitive index of previous pancreatitis.

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