336 T U B E R C L E December 1953

nervous irritability rather than 'the elastic recoil of the lungs' which 'varies considerably from person to person' and which explains why certain types of p a t i e n t s - n o t certain age groups-deve lop this exaggerated pleuro-pul- monary reflex reaction, i.e. pulmonary spasm, and others do not. I t is quite true, as Dr Jackson observes, that 'the c o n d i t i o n . . , occurs most frequently follmving lengthy adhesion sections'. But not because these 'lead inevitably" to an excess of air in the pleural cavity". Rather, because the long 'fiddling abo~at' in the chest naturally puts a heavier strain on the patient, and more so on the nervous patient who, in spite of the usual premeditation, might be under high tension. Clearly the same standard dose of Omnopon and Scopolamine (or Atro- pine) will have a different effect on different p a t i e n t s - n o t according to their body weight but according to the state and response of their nervous system, particularly their autonomous nervous system. These important psychosomatic and neuro-vegetative reactions tend to be neglected in surgical circles.

Overfilling with air during the operation has nothing to do with the development of atelectasis - a s a result of pulmonary spasm. Any surplus air is usually removed by repeated deep breathing with the eanula hole closed during inspiration and opened during expiration before the wound is closed. The negative air pressure is building up with the retraction (collapse) of the lung or lobe. Air aspirations do not as a rule help to re-expand the collapsed lung, even if a high negative pressure is hereby created. It seems to me more in line with physiological facts thaf what varies individually is the muscular tone and not the elastic recoil. This is what I tried to illustrate in Table I of my paper (p. 236) by showing the 'scale' reaching from complete atelectasis to emphysema. How the elastic recoil of the lung can reduce its size far below its normal size as seen on the p.m. table is beyond my imagination. No passive 'elastic recoil'., but only active spastic contraction can, to my mind, account for the shrivelling of the lung to tangerine size. May I remind Dr Jackson on the unreliability of surgical inter- ference with tim sympathetic-vagal system in diseases d u e to dysfunction of the autonomous N.S.? As these operations are gradually falling in disrepute, not too great reliance should be placed on antispasmodic drags which are sometimes very he lpfuland sometimes no good at all.

Finally I should like to suggest that the presence of a drainage tube is in no way com- parable to the experience of a lengthy operation with all its paraphernalia.

Summing up, I find it strange that even most knowledgeable doctors refuse to acknowledge the same physiological and pathological mecha- nisms they readily accept with any other atttonomous hollow o r g a n - whether blood vessels, the intestinal canal, the gall-bladder or the u r e t e r - w h e n it comes to recognize the action of the smooth musculature of the bronchial tree, particularly its more contractile peripheral elements which are free from carti- lage rings.

I must leave it to your readers whether they prefer to accept Dr Jackson's new theory of individually varying elastic recoil of the lung or my attempt to put lung pathology on a common basis with other known facts of patho-physiology (functional pathology).

Yours faithfully, E. G. W. HOrFSTAEDT.

British Tuberculosis Association

There will be a meeting of the Association on February x9, I954, at Manson House, when the Radiolo~, of the Chest in Infants and Children will be discusscd by Dr B. C. H. '~Vard of High 1,Vood Hospital and the Children's Hospital, Hackney, and Dr Stefan Grybowski of High V~rood Hospital.

The Annual Conference will be held at Oxford from Wednesday, July 7, to Saturday, July 1o. Members will be staying at St. John's College.

Members should note the alterations here announced.

Review ASPECTS OF T H E PSYCHOLOGY OF

T H E T U B E R C U L O U S . - B y Gordon F. Derner, PU.D. Publishers: Paul B. Hoeber, Inc., Medical Book Department of Harper & Bros.

The author of~this monograph is Associate Professor of Psychology and Director of the Clinical Psycholo~, Training Prcgramme of the Adelphi College, New York.

Written ahnost exclusively from the point of view of clinical psychology, it is neither psychi- atrically nor medically orientated. The author's claim that it will prove of interest to the phthisiologist, tuberculosis social worker, tuber- culosis nurse, rehabilitation worker, psychologisi: and workers in the field of psyehosomatics in general, does not therefore seem well founded.

The author feels that much of the literature on tim psychology of tuberculous patients is an

December 1953 T U B E R C k E 337

expression of opinion, rather than tile result of carefully controlled research study. He makes it clear that this work does not at tempt to give either a psychosomatic portrait of tuberculous patients, or to describe psychodynamic factors which m a y have a bearing on the disease. He claims to describe and measure the general attitude, feelings and personality traits found among hospitalized tuberculous patients, and he bases his study on a careful investigation of consciously motivated and discernible behaviour. He attempts to discover the extent, frequency and nature of the patient's feelings about his disease and Iris emotional reaction to life in a sanatorium. He wished to find out to what /:xtent tuberculous patients showed personality deviations. He hoped to discover indications for the guidance and education of such patients and for workers in the field of phthisiology.

3 2 patients, aged from I8 to 4 o, hospitalized for not more than two years, during their first admission for tuberculosis, form the sample population for the study. Another criterion in selection was that no patient had been on the hospital 'Seriously Ill ' List. 9 of the patients were nurses or nursing students, a n d 3 were physicians. The intellectual level of all the patients, as measured by an adult reading test, was well above average for tile normal popu- lation.

Eight tests were nsed, consisting of an intro- ductory interview, a controlled interview based on forty-two questions, an adult reading test used as a gauge of intelligence, a spes-phthisica questionnaire, a happiness scale, the Minnesota multiphasic personality inventory, the Rors- chach ink-blot test and a specially designed 'psychosomatic attitude' test, based on the well-known thematic apperception test.

'~Vith the standard tests, normal populations were used as an indirect control. For the psychosomatic attitude pictures, a direct con- trol was used and on tests which were specific to a tuberculous population no controls were used.

I t emerges from these investigations that most of the patients thought about going home. Only two considered that emotional factors had played any par t in causing their disease, but the author rightly points out that unconscious factors, in its genesis, would not be elicited by interview or questionnaire.

Only I7 of the patients admit ted emotional difficulties before the illness and these seemed to be of the t}q3e frequent in normal population. Those most frequently found, after diagnosis, were apprehension and depression, and the patient's emotional reaction to a diagnosis of

tuberculosis was related to his perception of its true meaning.

The most frequent reaction to early symp- toms, unless very severe, was to ignore them. This is not specific to tuberculosis, occmjng equally in other serious illnesses, notably early malignant disease. Answers to tile question as to how they were told of their disease, and by whom, indicated that further research on physician-patient communication might be useful to American practitioners and that emotional t rauma consequent on the knowledge should be handled psychotherapeutically.

I t seems to your reviewer that the possibility of emotional t rauma consequent on a diagnosis of tuberculosis is recognized by most phthisiolo- gists and that they handle it with humanity. This, after all, is the essence of the physician- patient relationship about which the author 's conclusions seem somewhat naive.

I t seems rash to conclude as a result of a questionnaire to 3 2 patients, none of whom was seriously ill, that spes-phthisica does not exist. I t is presumptuous to conclude that a belief in it has arisen as a result of hasty ward rounds and faulty observations on the part of physicians. Clearly the author 's conception of what consti- tutes spes-phthisica differs markedly from that of European clinicians.

Some of the implications which the author draws from his intensive study may prove to be of importance in the treatment of tile disease. He suggests that the approach to both diagnosis and t rea tment should be psychotherapeutic and that the basic anxiety which he finds typical of tuberculous patients may require either indi- vidual or group psychotherapy. As the neurotic patterns are frequently reactive to the disease, he advocates, for most cases, brief rather than intensive psychotherapy.

Annual Reports I P S W I C H AND EAST S U F F O L K C H E S T

SERVICE. Repor t of Physician in Charge of the Chest Clinic, C . J . Stewart, for the Year 195 I. Chest Clinic, Foxhall Road, Ipswich. February i953. 7 mimeographed pp.

The attendance at the clinics increased con- siderably during the year, from 6,837 in I95o at the Ipswich clinic to 18,956 in I95t , and from 5o7 in the sub-clinics to 3,oo9. The attendance is expected to grow to 3 ° to 35,ooo. Even today no patient has to wait more than a few days for an appointment. One disturbing factor is the increase in the cases seen of pulmonary" carci-