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33, 78, 16, 18, 18, 4, 5, 2, 19, 20, 17, 16, and 25 days or an average of 21 days, and 12 normal periods of 2, 15, 11, 12, 1, 4, 1, 15, II, 4, II, and 21 days, an average of 12 days. In 1903 there were 14 abnormal periods of 20, 20, 14, 18, 19, 23, 24, 15, 26, 16, 25, and 18 days, an average of 17 days, and 14 normal periods of 10, 14, 3, 12, 11, 8, 8, 10, 12, 11, 16, and 13 days, an average of 9 days. In 1904 there were 14 abnormal periods of 22, 13, 23, 15, 18, 16, 13, 16, 12, 15, 23, 10, 17, and 6 days, an average of 15 days, and 14 normal periods of 12, 14, 11, 13, 9, 7, 9, 3, 2, 13, 6, 8, 9, and 15 days, an average of 9 days. In 1905 there were II abnormal periods of 6, 4, 58, 22, 7, 8, 82, 23, 37, 34, and 24 days, an average of 27 days, and ii normal periods of 24, 1, 3, 3, 1, 2, 10, II, 2, 13, and 2 days, an average of 6 days. In 1906 there were 9 abnormal periods of 33, 25, 33, 6, 25, 36, 27, 23, and 47 days, an average of 28 days, and 9 normal periods of 15, 17, 12, 1, 11, 10, 12, 10, and 13 days, an average of 11 days. In 1907 there were 9 abnormal periods of 20, 39, 18, 19, 48, 52, 30, 16, and 34 days, an average of 30 days, and 10 normal periods of 14, 13, 12, 12, II, 15, 12, 11, 12, and 11 days, an average of 12 days. In 1908 the last abnormal period is not included, as besides 25 days of December it extended into February, 1909, so that exclusive of this there were 9 abnormal periods of 13, 22, 4, 33, 17, 35, 55, 21, and 18 days, an average of 27 days, and 9 normal periods of 12, 1, II, 13, 11, 13, 11, 2, and 15 days, an average of 9 days. From the above figures it would appear that there is a tendency for both the abnormal and normal periods to become more uniform in duration.
Case III, it will be remembered, was the only one which was observed in the beginning of the psychosis, and since his discharge he has shown the cyclic character of his psychosis more markedly than while under care here. Chart 3 shows the abnormal and normal periods while in the Sheppard Hospital and there is nothing about it essentially different from charts 1 and 2. I have not charted the abnormal periods since discharge, as there is no record apparently more accurate than the patient's own, and from this we do not know the times when changes in the dates of onset occurred which seems the chief point requiring charting. Neither have I made comparison of the abnormal and normal periods as I have done above, as this case was under observation during the
most irregular part of his psychosis and not of sufficient length of time to give much value to any comparison.
These three cases seem to me to be sufficiently unique to warrant their being grouped by themselves. I have no doubt that others have observed similar cases and like myself have at first grouped them as folie circulaire. I do not believe that they should be so grouped, however, and would reserve that category for cases which show more typically maniacal symptoms and which do not dement. The term cyclic dementia præcox seems to me to well describe this form. It is interesting to speculate on the relationship between the maniacal-depressive group and the dementia præcox
CHART 3.—Showing in black abnormal periods and in white normal periods of Case 1295. A dot indicates no day.
group which is suggested by these two sub-groups of folie circulaire and cyclic dementia præcox but I feel that at present any remarks on the subject would be purely speculative, so that it is best to refrain from making any.
That cases of dementia præcox show a periodical exacerbation of symptoms is well known and has been commented upon by many writers, the same characteristic being shown by cases of maniacal excitement, but this is different, from the changes shown by these three cases where we have a totally different normal and abnormal period. If we turn to Kahlbaum's original description of catatonia we find as follows: Catatonia is a brain disease with cyclic changing course in which the psychic symptoms presented in order are melancholia, mania, stupor, confusion, and finally dementia, of which psychic symptoms one or even more may be absent, and in which besides the psychic symptoms the occurrence of those in the motor nervous system having the general character of cramps appears as an essential symptom.' It can readily be seen that the above cases correspond to the description of Kahlbaum in that they have a periodic course of excitement, confusion, and stupor followed by a remission, but in all of these cases the characteristic motor symptoms were late in appearing, in Case I not until 17 years after onset. It is doubtful also if Kahlbaum had in mind any case similar to these, as it appears most likely that he would have considered them, just as we first did, as belonging in the group of cases described by Falret and Baillarger as folie circulaire.
In conclusion, I would say that I am of the opinion that we are here dealing with a unique form of dementia præcox apparently closely allied to that form of maniacal-depressive insanity known as folie circulaire, and that it seems to point to a middle ground, or connecting link between the maniacal-depressive group and the dementia præcox group.
As a definition I would offer the following: Cyclic dementia præcox is a form of insanity closely resembling folie circulaire in that there are frequently recurring abnormal periods of excitement and stupor, these abnormal periods being succeeded by normal periods, usually of briefer duration. While at first the excitement may seem to resemble that of maniacal-depressive insanity, closer study will show that there is no true flight of ideas, and there is usually evidence of stereotypy. Muscular rigidity, flexibilitas cerea, or hypertonus is also present and motor restlessness may be slight. The stupor does not resemble that of maniacaldepressive insanity and is also characterized by muscular rigidity. In the normal periods the patient may for a long time give little evidence of dementia and merely show the narrow mental horizon of a person who is cut off from active life, but after several years dementia may be apparent, as a rule an emotional dulling being shown before an intellectual one.
• Kahlbaum, Dr. Karl. Klinische Abhandlungen über Psychische Krankheiten. I. Die Katotonie. S. 87. Berlin, 1874, August Hirschwald.
A STUDY OF THE MORO TUBERCULIN OINTMENT TEST, WITH SPECIAL REFERENCE TO ITS
USE IN THE INSANE *
REVIEW OF LITERATURE ON THE TEST. PREVALENCE OF TUBER
CULOSIS AMONG THE INSANE. NEED OF EARLY DETECTION
BY LAURA A. LANE, A. B., M. D., ROCHESTER, Minn. The purpose of this paper is to present the value of the Moro tuberculin ointment test as a simple and reliable method of the diagnosis of tuberculosis, particularly in that class of patients found in insane hospitals and other large institutions.
A brief review of the literature on the Moro test and the method of its application may not be out of place here, since this test has not been brought into such prominence as the Calmette, the WolffEisner or the von Pirquet tests.
In 1908, E. Moro (1a-b), of Munich, brought to the attention of the profession the use of an ointment consisting of five parts of lanolin and six parts of Koch's old tuberculin. He rubbed a small piece of the ointment into the skin of the abdomen, the skin having been previously prepared, and in 24 to 48 hours obtained a papular eruption over the site of the application. Moro divided his reactions into three groups: (1) a slight reaction which appeared within 24 hours, consisting of two to ten discrete papules; (2) a moderately severe reaction, consisting of a hundred or more minute almost pin-point papules; and (3) a marked reaction of large red papules scattered beyond the area where the ointment was applied.
Moro (1a) tried this test in 89 cases, 43 of whom were tubercular or suspected tubercular patients, and he obtained 37 positive reactions. In every case where there was a positive reaction he
* Read before the Blackwell Medical Society of Rochester, N. Y., June, 1909.
Read before Wyoming County Branch of New York State Medical Society at annual meeting, Silver Lake, N. Y., July, 1909.
was able to get a positive test with other methods. Later he reported 722 cases (2) and claimed the reaction to be absolutely harmless, most satisfactory and specific. It is diagnostic of either latent or active foci.
Lejeune (3), Heinemann (4) and Emmerich (5), have reported 442 cases tested by this method, with 212 positive reactions; 201 of all these cases were tubercular or suspects and 241 were nontubercular. Heinemann declares the test harmless and superior to the ocular test.
Kanitz (6) reports 350 tests, with 102 positive reactions; 200 of these cases were non-tubercular and non-suspects and in 22 or only 11 per cent did he get a positive test, while over 64 per cent of the suspected cases reacted and 49 per cent of the distinctly tubercular cases gave positive reactions.
It may be said in passing that many control tests have been tried along with the Moro tests and no reactions obtained. Alderson (7) and Rothschild (8) have reported many interesting controls in tubercular patients where an ointment consisting of lanolin and other agents was tried with negative results, while the tuberculin ointment applied to the same cases gave positive reactions.
Webb and Williams (9) report 155 cases, with 69 positive reactions, and McHammel, Carpenter and Cope (10), in a comparison study of the von Pirquet, Moro and conjunctival tests, report 154 cases in children, with 85 positive reactions. This test compares favorably with the others and they prefer it to the Calamette, which gave some unfavorable eye symptoms.
From the literature (11) to which I have had access and from other sources I have been able to collect up to date 1401 cases tested by this method. Unfortunately it is not possible to give the exact percentage of positive reactions or the number of tubercular and non-tubercular cases, since some authors fail to give these data, but the general average of the complete reports is about 65 per cent positive reactions for all cases.
All authors agree that the test is perfectly harmless, is without temperature reaction, and appears on the average in from 24 to 48 hours. Nearly all writers have given a similar classification to the type of the reactions and nearly all have expressed considerable satisfaction with the reliability and ease of application of the test.