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.

6

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 TUBERCULOSIS AMONG THE INSANE. NEED OF EARLY DETECTION AND ISOLATION IF WE ARE TO LESSEN THE DEATH RATE FROM TUBERCULOSIS. REPORT OF 100 CASES. CONCLUSIONS. 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 II 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.

Tice (11d), at the last meeting of the Illinois State Medical Society, reported 107 cases tested with the Moro ointment. In 31 clinically diagnosed tubercular cases he obtained 23 positive reactions, and in the 76 non-tubercular cases, II positive reactions and 65 negative reactions. He places considerable value on the test and prefers it to the other tests, especially in children.

Patterson (IIe) reports 171 cases tested by this method and at the same time with the von Pirquet. Of the 30 non-tubercular cases only one gave a positive ointment test, while the von Pirquet gave 7 positive tests. The remaining 141 tubercular and suspected tubercular cases gave 98 reactions, the Pirquet giving a slightly larger number of positive reactions.

Thus it will be seen from all sources that this test presents a simple and easy method of diagnosis in tubercular conditions, which compares favorably with any of the other methods of diagnosis. It is simpler than the injection or subcutaneous test, is freed from all the dangers or unpleasant symptoms which may arise from the latter test.

From a limited experience with the von Pirquet test among the insane, the Moro test is easier of application and less confusing in results. The Calamette and Wolff-Eisner tests are not without their dangers and are not to be used with the majority of insane patients, many of whom already have some ocular disease; then there is the additional fact that in nearly all insane cases it is impossible to obtain any history of previous eye disease.

There seems to be one possibility of error in the test, namely, the failure to sufficiently rub the ointment in and hence obtaining a negative reaction. The inconvenience of application, the need of repeating the tests or other drawbacks and complications, have been absolutely nil in the series of cases reported below. In two instances the patients washed off the ointment soon after application. There was, however, in less than 48 hours a distinct eruption of many papules over the site of the application, showing that if the ointment is well applied there is little danger of failure of the test if the patient is tubercular.

I believe that the Moro test offers a valuable aid to the diagnostic work among the insane and a means of lessening the high mortality rate from tuberculosis, since active cases can be early detected,