in attempts to obtain personal histories among the insane, in the great majority of cases the facts concerning venereal infection cannot be ascertained. Our study pertaining to this question, therefore, rests on the basis of but a small number of cases. But even these scant data lead us to suspect that neither the Wassermann reaction nor the butyric acid reaction is to be looked for in cases with a well established history of old syphilitic infection unless the disease still exists in an active form, or, if we may use the expression, at least in a potentially active form; and that such conditions as arteriosclerotic brain disease, cerebral apoplexy or softening, and the like, when depending upon syphilis, are to be regarded merely as syphilitic sequelæ. Inversely, the same considerations suggest that general paresis, in which the Wassermann reaction and the butyric acid reaction are found as regularly as in syphilis itself, is to be regarded as a manifestation of active syphilis, that is to say, as being due, like other syphilitic lesions, to the activity of the spirocheta pallida.” However, in spite of all the evidence that we possess in favor of this view, it cannot be considered as established until the essential link in the chain of evidence is supplied, namely, the finding in the tissues of the organism in question. Until such time we shall have to continue to speak of "parasyphilitic affections "-whatever that may mean. §3.-CONCLUSIONS. On the basis of our results the relationship existing between syphilis and insanity may be summarized in the form of the following tentative conclusions. (1) The regular absence of lymphocytosis, of the Wassermann reaction, and of the butyric acid reaction in psychoses with a basis of arteriosclerotic disease known to be the result of old syphilitic infection indicates that these conditions are to be regarded as sequelae of syphilis, and that the syphilitic process itself is in cases of these conditions already extinct. (2) In general paresis either the Wassermann reaction or Noguchi's butyric acid reaction is invariably found-and most fre "The same view has been expressed by others (Plaut and Fischer, Browning and McKenzie), but on the basis of evidence of a different nature. quently together; any doubt of the essential dependence of general paresis upon syphilitic infection can no longer be entertained. (3) Inasmuch as the Wassermann reaction and the butyric acid reaction seem to indicate syphilis only when it exists in an active or potentially active form their regular occurrence in general paresis would tend to prove that that disease is a manifestation of active syphilis, of activity of the spirochata pallida; while the evidence for this view is not as yet complete, it is sufficient to justify its being used as a basis of therapeutic essay. (4) In no other common psychosis does either the Wassermann reaction or the butyric acid reaction occur with any regularity or even with special frequency; the relation of syphilis to these psychoses is that of a complication by accidental coincidence. (5) From the standpoint of diagnosis cytological examination of the cerebro-spinal fluid is an indispensable aid in the practice of psychiatry; with the further aid of the Wassermann reaction and of Noguchi's butyric acid reaction the diagnosis of general paresis can be either established or excluded with practical certainty. ACKNOWLEDGMENTS. In carrying out this investigation we received a great deal of assistance from several sources. Dr. Hideyo Noguchi, of the Rockefeller Institute for Medical Research, has prepared for us all the antigen and amboceptor test papers that we used. He also spent about two weeks at our laboratory and helped us materially by making many of the tests. We feel that our greatest debt of gratitude we owe to him. Drs. John R. Ross, John V. Reilly, Edward P. Powers, Percy L. Dodge, and Nell W. Bartram, also Mr. Edward Martin, of Tufts Medical College, and Miss Jennie A. Dean, of Cornell University, have assisted us by collecting many blood specimens and performing lumbar punctures. Finally, we wish to express our thanks to Dr. William Austin Macy, the superintendent of this hospital, without whose interest and cooperation this work could not have been undertaken and carried out to its completion. PARTIAL THYROIDECTOMY FOR CATATONIC DEMENTIA PRÆCOX. A FINAL REPORT CONCERNING INVESTIGATIONS INTO THIS SUBJECT. BY ALLEN B. KANAVEL, M. D., Assistant Professor of Surgery, Northwestern University Medical School, AND LEWIS J. POLLOCK, M. D., Senior Physician, Cook County Institutions, Dunning, Illinois. At the last meeting of the Illinois State Medical Society, held at Quincy, we presented a preliminary report upon this procedure, introduced by Berkley and reported' in the AMERICAN JOURNAL OF INSANITY in January 1909. In that report we stated that the procedure had been absolutely without avail in old cases and that as yet sufficient time had not elapsed to make a final report concerning those cases operated upon within a short time. after the onset of the disease. Although somewhat skeptical at that time as to the favorable outcome even in recent cases, we felt that the greatest conservatism should be exercised since if this procedure offered the slightest grounds for hope in this otherwise hopeless group of cases the research should be prosecuted to the final conclusion. We, therefore, prefaced our report with the following statement: Before beginning a discussion of this subject we wish to emphasize that the present contribution is but a preliminary report upon which we feel an ultimate decision cannot be based. It is but a report of work in progress. We wish to be neither ultra-conservative nor over-enthusiastic, but desire to maintain a strictly scientific attitude of investigation and wish not to be betrayed into either advising or condemning the procedure. 1A Preliminary Report upon the Advisability of Thyroidectomy in Catatonic Dementia Præcox. By Allen B. Kanavel, M. D., in association with Lewis J. Pollock, M. D. and Arthur B. Eustace, M. D. Illinois Medical Journal, September, 1909. 'An Investigation into the Merits of Thyroidectomy and Thyrolecithin in the Treatment of Catatonia. By Henry J. Berkley and Richard H. Follis, the AMERICAN JOURNAL OF INSANITY, January, 1909. A basis for some encouragement was found in the fact that Berkley had subjected eight cases to operative interference and five of these had shown an apparently perfect recovery. Moreover, there seemed to be some theoretical and experimental support to the proposition. The disease often arises at puberty when the ovaries and the thyroid, in common with other organs, take on a change of function. The inter-relation of these glands and the fluctuation of the thyroid at various phases of ovarian activity is well known. Again, Hunt in developing the acetonitril test, found that the ovaries, testicles, mammary glands, and prostate contained a substance acting feebly like thyroid. Berkley had seemed to demonstrate that dessicated thyroid gland and iodine aggravated the symptoms of catatonic dementia præcox, and finally there was the chance similarity between the symptoms and signs of this disease and thyro-toxicosis; for instance the increased reflexes, hyperidrosis, tremor, skin changes and loss of weight. Moreover, in view of the reversions which Wilson and Marine and Williams have shown to occur in exophthalmic goitre, it may be said that the pathological condition of the glands while not distinctly favoring the assumption of an etiological relationship is not incompatible with it as will be seen by examining the pathological reports herein attached. At the time of making our preliminary report there had been a complete lack of result in the patients who had suffered from the disease over one year; of two cases under that time one had just been operated upon and hence could not be used in making our deductions while the other case operated upon four months previous had apparently recovered and his parole was contemplated. Since the preliminary report was made, however, the patient who had apparently recovered has gradually relapsed into his previous state and the other case operated upon, remains absolutely unimproved to all intents and purposes. The case mentioned in the preliminary report as having apparently recovered after having had a considerable tumor of the thyroid removed has now returned with a complete relapse after an absence of eight months in which he remained practically well. A summary of our personal cases which includes one not here recorded, therefore allows only a report adverse to the procedure. The list of cases which should have recovered was very small, therefore, one of us (A. B. K.) wrote to Professor Berkley stating our unfavorable results in late cases and the lack of distinct pathological support as shown by our old cases; and we here append a part of his letter which bears directly upon the subject: Your letter of the 16th inst. reached me this morning. You are only obtaining the results two other surgeons have done (in three cases operated on by them), and for reasons unknown to me, possibly because the cases were not pure catatonia or possibly because they did not do the same operation Dr. Follis has done. All I can now add to the article in the January number of the JOURNAL OF INSANITY is that we partly thyroidectomized three additional cases and that they all recovered perfectly, and have remained in perfct mental health since their recovery from the operation. Dr. Follis and I have proceeded with the utmost caution in selecting our cases and have oft times rejected as many as twenty successive cases before coming to one that we concluded was suitable for operation from the mental and blood examination standpoints. Now that we know more about these cases than we did two years ago, we are turning down more and more cases in proportion to the number accepted and have no idea of its becoming a panacea for catatonia. All we now look for is to obtain good results in a very limited number of well-selected examples of this malady. The suggestions of Berkley here, and in his article, in reference to the non-improvement of certain cases, that the duration may have been too long, the cases not properly selected, and that a sufficient amount of thyroid gland may not have been removed suggest certain pertinent remarks. It seems to us that the choice of cases based upon the duration of the illness is not an entirely scientific one, inasmuch as the rapidity of the course cannot be ascertained and the determination of where brain changes supersede the perverted thyroid gland function, cannot be made. Again, from the standpoint of the symptomatology it is entirely possible to meet with a psychosis presenting in its early stages the catatonia which later may be found not to belong to the adolescent group. We have demonstrated conclusively that the pathological appearance of the gland is of no importance from a diagnostic or prognostic standpoint. The mere examination of the blood by ordinary methods does not help in choosing the cases. In other words, if the procedure is of any value there is no satisfactory method of selecting favorable cases. Finally, there must also be considered the occurrence of remissions which are present from a few hours to a few days in almost all cases; and in almost 20 per cent of the cases, the occurrence of a relapse within the |