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in a similar way, percuss each axilla. Definite impairment of resonance, no matter how slight, over any localized area, where a normal note should be present, when elicited after comparing same with a symmetrical area on the other side of the chest, is quite suggestive of a tubercular process.
Auscultation. The most important method. Go over the chest systematically, as outlined under “Percussion.” First listen to spoken voice, while patient says “ninety-nine or “one, two, three," then listen to the whispered voice. An increase or decrease of the vocal fremitus has the same significance as the tactile fremitus.
Listen to the breathing. Observe the following:
( a) Character of breathing, vesicul , vesiculo-bronchial, broncho-vesicular, bronchial, etc. Note whether the breathing is smooth, even, or interrupted and jerky, whether clear or distant.
(b) Pay special attention to the ratio of time between inspiration and expiration. Normally, expiration, as heard, is very short, and occupies one-third of the time of inspiration. When expiration equals inspiration, in point of time, it is pathological.
(c) Listen to the breathing while patient breathes quietly or what is normal to him. You may fail to hear any breathing at all at some areas, while at others it may be rough and loud as compared with the breathing over the rest of the chest. Continuing the auscultation in the same methodical manner, ask the patient to breathe deeply, first slowly and then faster. At times it is desirable to ask the patient to breathe with his mouth open. Some patients are naturally poor breathers, and their breathing must be varied in order to elicit signs present. Localized areas of abnormal breathing are strongly indicative of tuberculosis.
(d) Listen very carefully for râles, paying special attention to any area or areas where abnormal signs were elicited by any of the above-mentioned methods. Râles are quite often not elicited upon ordinary, and even deep, breathing, but that does not exclude their presence.
Ask the patient to give a light cough at the end of expiration, following it at once with a deep inspiration, when râles will quite often be elicited when otherwise absent.
Râles, be they dry, crackling, crepitant, sub-crepitant, etc., when present over localized areas in one or both lungs while the rest of lung tissue is free from them, are almost, by themselves, pathognomonic of pulmonary tuberculosis. When elicited over an established tubercular area, they often indicate the degree of activity of the process.
(e) Pleural friction, elicited with or without cough, unaccompanied by pain, while, by itself, suggesting an old pleural condition, should not be disregarded for reasons mentioned above, and, also, because it often obscures other signs present, such as rough breathing, râles, etc. Such cases should be looked upon as actively tubercular, unless after a more or less prolonged observation of the patient, with repeated physical and laboratory examinations, no other lesions are found, and the patient is free from any suggestive or objective symptoms.
CONCLUSIONS. The proper management of the tubercular department, as outlined above, together with the coöperation of the entire medical staff, would reduce the danger from the spread of this disease, and the occurrence of new cases, to a minimum, and would effect cures, or apparent cures, in many cases that otherwise progress to a hopeless stage entirely unobserved.
REFERENCES. 1. White, Wm. A.: Mechanisms of Character Formation. Macmillan Co. 2. Ochsner, R. L.: Relative Value of Five Diagnostic Procedures in 400
Consecutive Cases Investigated by Group-Study Method for Pulmonary Tuberculosis. Medicine & Surgery, H. Louis, November,
1917, p. 975. 3. Silk, S. A.: The Psychical Changes Observed in Pulmonary Tuberculosis
and Its Relation to Insanity. Medical Record, New York, Decem
ber 8, 1917. 4. Ibid: A Plea for the Early Diagnosis of Pulmonary Tuberculosis.
New York Med. Journal, September 8, 1917.
THE PSYCHOLOGIC TREATMENT OF RETARDED
DEPRESSIONS.* By L. PIERCE CLARK, M. D., New YORK CITY. It is unfortunate that practically during the last decade only has any consistent or methodical effort been made to treat the benign psychoses on the basis of their psychogenesis. Even now I fear these mental disorders are in the vast majority of instances treated by physiotherapy of baths, exercise and occupations, leaving the large domain of mental therapy per se to the chance attention of friends or sympathetic attendants and nurses. It is not that a somatic approach to these psychoses is to be deprecated, but no one will deny that the individual as a whole is not properly considered until a mental therapy in a more specific manner is also instituted. One may contend that in the last analysis the benign psychoses are organic; nevertheless another may retort that the mental symptoms themselves are as truly organic and treatment of them is as surely a somato-therapeutic approach to the problem as considering the infections and disturbances of metabolism that may be found therein. However this may be, as psychiatrists we should hold that nothing less than the most inclusive therapy for handling the benign psychoses should be our united aim in this special field. In view of the fact that our treatment of the retarded depressions, especially in private practice, has had such a laisserfaire attitude attached to it, for several years I have given special attention to some cases of this type, first, to see if we may not make the recovery from individual attacks sounder, and secondly, to discover a possible manner of preventing recurrences of such episodes in these cyclothymic individuals. Inasmuch as I have already reported fully upon a series of cases of retarded depressions treated by mental analysis, a brief summary digest of the results in some of these cases at this time may be given. A complete detailed report of the same will be published elsewhere. In addition to the usual approved physiotherapy of baths, diet, occupation, recreation and the like, I employed a modified psychoanalytic reconstruction therapy.
* Read at the seventy-fourth annual meeting of the American MedicoPsychological Association, Chicago, June 4-7, 1918.
Case I. The first case handled by this method was that of a married woman who had passed the climacteric and who had two periodic depressive attacks yearly since her twenty-fourth year. The attacks were those of simple retarded depressions. Intensive treatment for several months was undertaken. In spite of the incompleteness of the analysis and the age of the patient, she has had no subsequent attacks for a period of over eight years. Furthermore she has been unusually free from any of the interval symptoms.
Case II was that of a middle-aged widow who also had passed the climacteric. She had had several recurrent periodic retarded depressions. She had short periods of depression every five or six months for 15 years. Since a brief and incomplete course of treatment she has had no more depressionsma period of over five years' freedom from any attacks.
Case III was that of an unmarried man in the middle thirties who had had several attacks of retarded depressions in a space of 13 years. He has been entirely well for over five years. In the usual order of his psychosis a subsequent attack might have been expected within two years.
Case IV was that of a married woman who had passed the climacteric. She had her first attack of retarded depression at 22 years of age at the death of her first child. The attack lasted a year. Since that time she had had recurrent attacks nearly every year lasting several months each time. The analytic treatment was given for the greater part of a year. For the past three years she has had but slight vestigial symptoms but has had no actual retarded depressions.
Case V, a married woman now in the late twenties, had her first attack at 17 years. There were but slight symptoms of depression without retardation for a few months at that time. It followed an unfortunate love affair. Her first pronounced manic attack followed her first childbirth. She has had several severe manic-depressive attacks with scarcely a stable or free interval between complete attacks. She often had to be restrained and twice attempted suicide. Following a short but intense manic attack she was removed from a sanatorium and given a six months' course of analytic treatment during the depressive phase of her disorder. The results in this case have been extremely satisfactory; she has remained entirely free from attacks or even the slight though unmistakable vestigial symptoms for two years. She has passed through her second childbirth naturally. After a most intensive scrutiny of her mental life, all agree that she has not been so normal as she is at present for 10 years or since she began her pronounced manic-depressive career.
Case VI is that of an unmarried woman of late middle life who had had a circular type of disorder for 10 or 15 years. For a few years before she was given a six months' course of treatment, the regular alternation of excitement and depression had been sharp and of the classic type. The treatment was given at the end of a depression and through an entire excitement period. The patient was mildly hypomanic throughout the treatment. It is interesting to note in this case that a distinct paranoid trend was soon analyzed away and has not returned. The patient remains mildly hypomanic with clear insight and with excellent power and capacity
for work. She has now successfully passed two periods of depressions and is at this report practically without vestigial symptoms. There has been a long series of other and similar cases treated, but too short a period has passed to make one certain of the real or superadded advantages of analysis over older and more common methods in vogue for the care of such cases. For instance, a man of 43 years, in his second marriage finds he is a really married ” for the first time, in that his present wife fulfills the longed-for attentions of his mother who died several years ago. He came with a history of many recurrent retarded depressions followed by mild elations since his first “marriage of convenience." It was really the death of his mother and his present wife's serious illness at the same time that brought on his last retarded depression. It was obvious from his symptoms and dreams at the beginning of the analytic treatment that the retarded depression was already lifting. This analysis made the rate of recovery about twice as rapid as that experienced in previous attacks. After several treatments he became quite free from his depression and was mildly elated, as is usual following his depressions. Unfortunately, as is common, he then saw no reason for further treatment. As soon as the depression disappeared, it was interesting to note the great improvement which the marked cardiorenal disease underwent. He had this latter physical disorder for years. Another case was that of a young unmarried man of 29, who had a depressive make-up. There were several in the family of the same type. An uncle of this young man in his seventh retarded depression was relieved in a few weeks following a short course of analysis, and he insisted that his nephew should follow the same treatment. It was obvious from clinical symptoms that the young man had nearly reached the end of his depression; however, after a preliminary analysis he was released almost immediately of his remaining symptoms. He promised faithfully to return for complete analysis but, again, as is usual under such circumstances, he never did.
From my experience in treating a score of cases by intensive mental analysis I would say that the ideal type of case for this method of therapy is an individual who is young and who has suffered from as few attacks as possible. Inasmuch as the analysis is often very painful to such retarded depressants, the strictly analytic treatment must be for short periods, often for half an hour only. The analysis of the conscious and foreconscious life had best be considered first, then should follow a complete dream analysis. If there has been an actual manic excitement in the cyclothymic, the spontaneous productions obtained during the elation furnish an almost ideal material for consideration, as these may be considered, at least for practical purposes, as direct emanations from the unconscious. The depressive ideas themselves may be analyzed, but these are often so confused and distorted that