La escrófula en el siglo XIX / Scrofula in the 19th century

In the 19th century scrofula or scrofulous adenitis was a frequent condition estimated by the finding of swollen cervical lymph nodes or scars, occurring in both sexes at all epochs of life, mainly in children. It was thought that it principally affected people with an inherited phlegmatic constitution that involved a scrofulous disposition or "diathesis". The disease would be triggered by environmental agents, bad habits or excesses in style of life. Besides injuring cervical lymph nodes, in some cases scrofula could compromise other groups of lymph nodes, bones, joints, lungs or other viscera. In some of its clinical presentations the disease could be healed while others were often lethal disorders. The finding of multiorgan compromise, caseation and "tuberculization" of the lesions originated discussion whether scrofula and tuberculosis were one or two different diseases and if they affected subjects with a common diathesis or people with a distinct scrofulous or tuberculous diathesis. Along the 19th century, before the discovery of Koch's bacillus, the notion of contagion as a cause of scrofula and tuberculosis was not predominant in Europe.

En el siglo XIX la escrófula era frecuente, estimada por la percepción de nódulos o cicatrices en el cuello. Paulatinamente se le empezó a denominar adenitis escrofulosa. Podía presentarse en personas de ambos sexos en todas las épocas de la vida; pero era más frecuente en la infancia. Se pensaba que afectaba principalmente a sujetos con una constitución flemática heredada que implicaba una susceptibilidad o diátesis escrofulosa. La enfermedad sería desencadenada por agentes ambientales, hábitos, o excesos en el estilo de vida. Aparte de los ganglios linfáticos cervicales, podía afectar otros grupos ganglionares, huesos, articulaciones, pulmones y otras visceras, atribuyéndosele diversas formas de presentación que variaban entre las potencialmente curables a las frecuentemente mortales. La afectación multiorgánica, la caseificación y la "tuberculización" de las lesiones originaron la discusión sobre si la escrófula y la tuberculosis eran una sola enfermedad o dos diferentes, y si se desencadenaban sobre una diátesis común o cada una sobre una diátesis específica escrofulosa o tuberculosa. En la mayor parte del siglo XIX, antes del descubrimiento del bacilo de Koch, la noción de contagio como causa de la escrófula y de la tuberculosis pulmonar no parecía predominar en países europeos.

El suicidio, conceptos actuales

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Abstract: One current problem in Public Health relates to suicide and the identification of the risk factors needs to be clarified accurately. The bases of suicide involve complex multiple factors. In a high proportion of nations, mainly in industry-developing countries, suicide is placed among the first three causes of death in groups aged from 15 to 34 years. In Mexico, suicide represents the ninth cause of mortality, within a wide scale of age ranging from 15 to 64 years. Some risk factors have been identified. Epidemiological studies show that males commit suicide more frequently than females, in a proportion of 5:1. Consummate suicide occurs in men about 50 years old, mainly by hanging or fire arms. Females between 20 and 29 years old, on the contrary, carry out more frequent unsuccessful attempts in the same proportion, by using pesticides and medical drugs. However, in recent years an increase in the number of suicides among young people from 15 to 24 years old has been observed, commonly in lowincome sectors, in subjects with a previous history of psychiatric disorders, mainly personality disorders, abuse of substances and prior suicidal attempts. The risk of suicide generally increases after 45, and becomes especially serious in older people. The phenomenon of suicide in the elderly deserves special attention, due to the fact that the population over 65 years old is continuously increasing. This group displays fewer attempts than youths, but they achieve their aim more often through a silent suicide, by refusing to eat or to accept and follow medical prescriptions. Some psychiatric disturbances are intimately related to suicide. It is considered that 50% or more of the consummate suicides are performed by people suffering from an affective disorder, mainly depression. In this sense, it is noteworthy that most of these patients had been misdiagnosed and in many cases had not received any proper treatment. In addition, the abuse of or dependence on alcohol is present in about 20% of consummate suicides, and high rates of suicide are also observed in schizophrenia. Another common disturbance associated with suicide is anxiety. The simultaneous presence of anxiety and depression must be considered as a great risk factor, since the depressed patient has a high risk of committing suicide under phases of increased anxiety. All of these observations imply an alert signal for medical care units concerning the importance of detecting signs of the presence of risk factors and suicidal ideation, and of implementing adequate therapeutic management, namely, a supervised pharmacological treatment of depression and anxiety, including hospitalization, if it were the case. The risk factors in potential suicide include isolation, poor health, depression, alcoholism, lowered selfesteem, despair and feelings of social and family refusal. Frequently, the potential suicide directly or indirectly gives behavioral and verbal cues of his or her suicidal intention. Roughly, 60% of the victims of suicide had attended some medical care unit in the month previous to the suicide and had commented something about their desires and feelings about death at some moment, and 30% had clearly revealed their suicidal ideation. For such reason, the evaluation of risk of the potentially suicidal patient should be a common practice in medical care units. Therefore, the early detection of the presence of risk factors of suicide, including the report of self-harm and of a detectable incapacity for solving problems, mainly of social type may provide an invaluable time to permit its prevention. Another current aspect awaiting conclusive evidence is associated with some controversial data regarding the impact that the use of antidepressants could have upon suicide. The Food and Drug Administration office (USA) pointed out that deficiencies in information do not allow to confirm any existing relation between the use of serotonin selective reuptake inhibitors (SS-RIs) and suicide in youths. The suicidal risk after initiating the treatment is similar in the patient receiving tricyclics, or seroton-in selective reuptake inhibitors. The risk of suicide can increase significantly in the first month of antidepressant treatment, especially during the first nine days. Consequently, the observation that patients receiving antidepressants attempt suicide, is due, at least partly, to the fact that for still unknown reasons, antidepres-sants require from three to four weeks of impregnation to attain clear therapeutic effects. Therefore, it is indispensable to carry out further clinical and experimental studies to determine the variables that could be implied in this time lag in the action of antidepressants. However, fluoxetine represents a useful alternative in the management of depressive disorders; albeit as in the case of other antidepressants, it requires a strict follow-up of the patient receiving such treatments to avoid the risk of a fatal complication. In conclusion, the suicide risk, being a serious problem of public health, requires special attention. Recent research indicates that the prevention of suicide includes a series of activities, such as educational programs for children and youths, teachers and educators, and also primary health care units for the early detection of suicide risk factors. And, of course, medical training for the management of the potential suicide. For all of them, some relevant facts must be taken into account: Depression can be present in children and adolescents. Access to means of committing suicide, such as weapons, must be avoided. People from medical care units should be on the alert when any one shows signs and symptoms of despair and impulsiveness. Suicide, anxiety and depression have a biological basis; there-fore it is not a matter of cowardice or an act of defiance. An inadequate and inopportune diagnosis may increase the suicidal risk. Parents and teachers should be instructed to detect any sign of suicidal ideation and despair. Therefore, this revision intends to bring some recent data to bear upon the factors of the risk of suicide that provide the reader with information for a more effective prevention.