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help to establish the diagnosis is the test of specific treatment, as was well shown by our case of cerebral syphilis in which the original diagnosis was general paresis in the last stage; in that case treatment by means of intragluteal injections of salicylate of mercury was instituted, not with the hope of obtaining a cure, but with the object of observing the effect of such treatment upon the Wassermann reaction and the butyric acid reaction in general paresis. Our case surprised us by making a recovery within eight weeks, and owing to this fact the diagnosis was changed to cerebral syphilis.
Turning now to Table III we are struck by the almost complete lack of correspondence between positive or negative histories of syphilis and positive or negative results, respectively given by the reactions. In the case of general paresis this is not discomfiting as it is now almost universally acceded that syphilitic infection is a constant precedent of that disease; so that when we find a positive Wassermann reaction or a positive butyric acid reaction and get in the clinical history a denial of specific infection, we simply assume the history to be unreliable.
It may be pointed out that a positive history of syphilis is of higher value than a negative one; in other words, a positive history is more to be relied upon in establishing the fact of actual infection than a negative one in excluding it-for reasons that are sufficiently obvious—although it must be borne in mind that even in the case of positive histories there are still possibilities of error due to mistaken diagnosis of venereal sores, various skin lesions, etc.
Thus it may appear strange that of those cases of psychoses, other than general paresis or cerebral syphilis, which gave a positive history of syphilis practically no higher percentage gave a positive Wassermann reaction or butyric acid reaction than those in which negative histories were obtained.
An individual study of our cases revealed the fact that, outside of general paresis, positive reactions were obtained chiefly in cases with a history of recent syphilitic infection, that is where there was any history at all, while in many cases of arteriosclerotic brain disease, involutional psychoses, etc., negative reactions were regularly obtained in spite of a positive history of old syphilitic infection.
It is to be regretted that, owing to special difficulties encountered
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 spiroch@ta 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 sequelæ 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 spirochæta 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
BY ALLEN B. KANAVEL, M. D., Assistant Professor of Surgery, Northwestern University Medical School,
LEWIS J. POLLOCK, M, D.,
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 fin port 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.
A 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