The term ‘extreme states’ indicates a certain infrequency of occurrence for a given observer. A volcano for an inhabitant of Hawaii will not be an extreme condition, for a New Yorker or Zuricher, it will be. Hence, what is sick or extreme for one culture will not be for another. By using terms like ‘extreme states’ and ‘process work,’ we have the chance of developing a transcultural psychiatry which deals with relative deviations from the norm and which is independent of the specific cultural definitions of illness.The western world differentiates its extreme states according to the way people in these states do or do not communicate. About one half of the people in our mental hospitals are said to suffer from what is diagnosed as schizophrenia, the rest are a mixture of severely depressed or suicidal people, the aged and senile, people in manic states, chronic alcoholics, heroin addicts, people with organic brain damage, the so-called criminally insane, those laboring under subnormal intelligence, and a large category entitled ‘mixed psychoses,’ those with a mixture of the above, or the ‘generally handicapped.’ These categories vary from one hospital and community to the next.*12\227\8*

The usual clinical features of community-acquired pneumonia are very familiar. Symptoms include fever, cough (usually productive of purulent sputum), shortness of breath, and chest pain (often described as pleuritic). Symptoms are typically rapid in onset, with most patients presenting within the first few days of symptoms. Patients may experience chills or rigors. Nonspecific symptoms are also common, such as headache, fatigue, myalgias, and occasionally abdominal pain.Clinical signs of pneumonia include fever, tachycardia, tachypnea, and abnormal breath sounds. Focal crackles, egophony, increased tactile fremitus, and wheezes are the most common physical examination findings associated with pneumonia.Although these signs and symptoms are identified in most patients, atypical presentations occur, especially in elderly or immunosuppressed patients. Among these patients, pneumonia may occur without signs or symptoms localizing to the chest and without fever. Elderly patients may be found with mental status changes, failure to thrive, abdominal Pain, or exacerbation of underlying chronic diseases. Tachypnea (respiratory rate exceeding 26 breaths/minute) may suggest pneumonia in the elderly patient without other obvious clinical features of pneumonia, and this may be the only clinical clue to the diagnosis.*40/348/5*

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