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Paresis would seem to be one of the affections so inevitable in its
course, so positively helpless as regards any medication, and so
hopeless in its absolutely sure termination in idiocy and death, that
nothing can possibly be done for it through the patient's mind, yet it
is probably one of the diseases for which most can be accomplished by
psychotherapy. Mental treatment for it naturally divides itself into
three periods: that of prophylaxis, that of the early stage and that
of the severer stage with remissions. Prophylaxis is much more
important than is usually thought. It is very generally known at
present that paresis is usually a parasyphilitic disease, that is, an
affection not due directly to syphilis, but which develops by
preference and perhaps exclusively in a soil prepared for it by an
attack of syphilis. As a consequence of the diffusion of this
knowledge men who have suffered from syphilis sometimes become
supremely fatalistic as regards the development of locomotor ataxia or
paresis in their cases. Worry is a prominent feature in the causation
of paresis, and it is, therefore, extremely important to neutralize

I have had university graduates tell me their histories and ask
whether I thought they had suffered from syphilis, and when I replied
affirmatively have seen a look of despair come into their faces. One
of them, a graduate of a large eastern university, said, after hearing
my opinion, though it was given with every assurance that my
experience with Fournier in Paris taught me the absolute curability of
the disease, "Well, there are three men of my class who have already
developed paresis, and I suppose I will go the same way." With a
persuasion like this haunting him night and day, exhausting nervous
energy and making his central nervous system less and less resistive,
it would be almost a miracle if paresis did not develop. It is
particularly in those who have had nervously exhaustive
occupations--brokers, speculators, actors, and the like--that paresis
does develop. The strain upon their nervous systems seem to be so
great that the syphilitic virus still remaining in their system has a
peculiarly degenerative effect upon nervous tissue. A man may be in
the least worrisome of occupations, however, and if he is constantly
brooding over the possibility of the coming of the hideous specter of
paresis, he puts himself in the condition most likely to
encourage the development of the pathological changes that underlie
the disease.

Prophylaxis.--As a rule patients who have had syphilis and who dread
the development of paresis should be warned with regard to their
occupations in life. After a patient has had tuberculosis which
developed in particular surroundings, if it is at all possible, we no
longer permit him to go back into the surroundings in which his
disease developed. We are coming, more and more, to apply the
principles of preventive medicine and this is as important in paresis
as in anything else. Even though there may be many monetary or
economic reasons in favor of certain occupations, the danger may
overweigh these. Those who have had syphilis should be warned of the
risk they run if they continue in occupations that require much mental
excitement or the strain of anxiety and the speculative factor of
uncertainty with the inevitable occurrence of disappointments. It is
unjustifiable to permit a patient whose central nervous system is
subjected to the deteriorating influence of the virus of syphilis,
still in his body even after ten years, to submit to the nerve-racking
irritation of occupations which require all the vigor of a healthy,
undisturbed organism to survive their wear and tear.

Sources of Worry.--One of the symptoms which neurotic patients are
sure must be a preliminary sign of paresis is a disturbance of memory.
Patients have heard that paresis causes memory disturbances and
fearing the development of the disease, they disturb themselves very
much by finding real or supposed defects of memory. Most of them have
had only a very vague idea of the sort of memory they possess and
cannot tell whether it is worse than before, but finding a certain
difficulty in recalling things they conclude that it is deteriorating.
Occasionally their supposed defect of memory is founded on nothing
more serious than the fact that they are paying so much attention to
themselves, that they cannot concentrate their attention enough on
what they wish to remember so as really to impress it on their
memories. It is curious how persistent some patients are in making
themselves believe they have serious lacunae in their memory when
there are only certain conventional disturbances of it. The paretic
has defects of memory, but he is, as a rule, quite unconscious of
them. He has to have them pointed out to him. Patients who are
supremely conscious of their supposed defects, by that very fact show
their possession of good intellectual faculties.

Tremor is another symptom that may develop in the midst of the
solicitude of those who dread paresis. The power to hold the limbs in
a given position is due to a very nice balancing of flexor and
extensor muscles. There are many people, especially those a little
awkward in the use of their muscles, who lack this power to some
extent. To stand without swaying is rather a difficult task in one who
is nervous or anxious about himself. Patients who are worrying about
paresis and its possible development will almost surely disturb their
power over their muscles and cause at least a slight tremor or

In other words, in all of these cases a series of dreads, or mental
obsessions which interfere with various functions which may cause
tremor, or some stuttering, or at least some apparent difficulties of
speech and which will surely revive any old-time difficulties of this
kind, may develop in nervous persons and must not be allowed to pass
as signs of developing paresis. The diagnostic tests, of course,
consist in the knee-jerks, the pupillary reactions, the difference in
disposition, the delusions of grandeur, and, in general, the
characteristic symptoms of a physical degeneration running parallel
with a mental deterioration.

Prophylactic Reassurance.--The first point in psychotherapy, then,
is to give just as much reassurance as can be given. Probably not one
out of a thousand of those who have suffered from syphilis afterwards
develops paresis. Nearly always there is something in the history
besides syphilis that seems to be an essential etiological factor. A
great many of the people who develop this disease have some hereditary
taint of mental incapacity at least, if not of actual insanity. Very
often there is a personal or family history that indicates some mental
unevenness or at least some lack of intellectual vigor. When people
are sanely intellectual and have no unfortunate hereditary tendencies
they can be almost completely assured as to the possibility of the
development of paresis, provided they take reasonable care of

Alcohol.--It is still an unsettled question whether alcoholism has
anything to do, even in a subsidiary capacity, with the etiology of
paresis. Probably it helps to predispose nerve tissues to degeneration
by lowering their resistive vitality to the direct pathogenic action
of the virus of syphilis. It seems clear, besides, that men who have
acquired syphilis sometimes take to over-indulgence in alcohol, at
least to a greater degree than would otherwise be the case, because of
the discouraging dread that develops as a result of their worry over
this constitutional taint. A warning in this matter of indulgence in
intoxicants is important because there are many nerve specialists who
insist that alcoholism is probably one of the prime factors in

Unconclusive Diagnosis.--When the first symptoms of paresis have
developed so that the physician is almost certain that the disease is
present--the cumulative experience of recent mistakes on the part of
the most careful experts seems to show that he can never be entirely
certain--then it is important not to announce the worst to the
patient, but to let him learn the reality of his condition gradually,
so that all the awfulness of it does not overwhelm him. What have
seemed typical cases of paresis, so diagnosed by excellent
authorities, have occasionally proved to be something else, or, at
least, to be wayward and very irregular forms of that disease with a
long course and marked remissions. There are forms of paranoia in the
middle-aged which sometimes exhibit symptoms so strongly simulant of

paresis as to deceive even the expert. There are forms of nervous
weakness--neurasthenia--some of which are really cases of mental
exhaustion or incapacity--the modern psychasthenia--which often lead
even experienced physicians to think of and sometimes to diagnose
paresis. There are cases of dementia praecox that only time can

Prognosis.--Seeing the Worst.--There is a tendency in most
physicians to see the worst side of the story rather than the better.
This is not because of any desire to be a harbinger of evil tidings,
nor, as is sometimes said, to show the patient, should he get better,
from what a depth of affliction he has been rescued, but it is rather
due to the very natural tendency existing in most of us to look on the
worst side of things. Besides, we have found by experience that if
patients are to be aroused to the necessity of care for themselves
they must be scared a little, and so we have formed the habit, not of
consciously and deliberately telling the worst, but of stating
the unfavorable possibilities of a group of symptoms, in order that a
patient may take due precautions and that he may realize, if the worst
does happen, that we were not ignorant of it. If he gets better he is
correspondingly grateful for this. If the unfavorable happens and we
had not warned him, he is more or less justifiably resentful.

Consoling Hesitancy of Final Judgment.--Patients suspected of
suffering from paresis can then without any violation of truth be
reassured that their cases may not be incurable until the epileptiform
incidents of the disease bring on that happy obscuration of mentality,
that either takes away all the terror of the disease or lessens so
much its awful significance that the patient is spared the worst.
There are cases of reported cures in the literature even after what
seemed to be characteristic epileptiform attacks had occurred.

We cannot be sure, in any case, of the future course of an affection
exhibiting symptoms resembling paresis. The patient can always be
given the advantage of this doubt then and the awful word incurable or
even the diagnosis paresis need not be mentioned to him. It is
perfectly possible, as a rule, to take other means to prevent
unfortunate incidents from tendencies to violence or serious loss from
foolishness, without overwhelming the patient with an absolutely
unfavorable prognosis, and the diagnosis of paresis, involving as it
does, now that so much more is popularly known of the disease than
before, the dread of inevitable idiocy. In this way much of the
depression that constitutes so large a part of the really sane period
of the early stage of paresis and which inevitably hastens the course
of the disease may be avoided. On the other hand, failure to announce
absolutely the diagnosis of paresis until there can be no particle of
doubt, can do no harm and will do good to the patients themselves, as
well as save their anxious friends from the trial of having to think
of the awful possibilities of the disease. A single sensible member of
the family may be selected as the confidant and the situation saved.

Role of Psychotherapy.--While it is important that someone closely
connected with the patient should know the doctor's suspicions, he
should be bound to absolute secrecy as regards the patient himself and
especially as regards women friends and relatives. The attitude of
mind assumed by women relatives, and especially those nearest and
dearest, is sure to be communicated to the patient, if not directly at
least indirectly and inadvertently, and makes for anything but relief
from the depression that is sure to be his if he has any gleam of
understanding of his condition. Indeed, so much of pain and suffering
is needlessly inflicted on relatives of paretic patients in the early
stages of the disease by a premature announcement of the diagnosis
that it is especially important to insist on care in this matter. The
family will usually clamor to know just what is the matter, but it is
the physician's duty to care for his patient and save the sufferings
of the patient's family, regardless of their unwitting insistence.
Once the disease has developed and the patient's mind becomes affected
it may be thought that psychotherapy is no longer of value. As a
matter of fact, these patients as a rule become more childlike and are
much more affected by suggestion than in their normal states. All this
is worthy of careful attention on the part of the physician who feels
that it is his duty to treat patients and not merely their disease.

The psychic care of the patient is the most important element in any
scheme of therapeutics during the longer remissions of paresis,
which are sometimes so complete that it is difficult to understand
that the patient, who is now as sensible as he ever was, only a few
months before was doing the most foolish things under the influence of
his delusions of grandeur and probably within a few months will be
quite as insane as before and perhaps hopelessly demented. The brevity
of these remissions in most cases seems to depend directly on how much
the patient is persuaded that his disease will return without fail and
run its inevitable course. It is well worth while to lengthen these
remissions by setting the patient's mind just as much at rest as
possible. Instead of the attitude which is so often assumed of
absolute assurance on the part of the physician that the old condition
will inevitably return, it is advisable always to give the opinion
that the previous mental derangement was paranoiac rather than
paretic, or was perhaps only a passing syphilitic condition and that
the ultimate outlook is not as hopeless as might be thought. This
opinion is thoroughly justified by certain surprising results in a
number of recently reported cases. Some patients whose symptoms have
been diagnosed as paresis by excellent diagnosticians, have, after a
time, experienced a cessation of their symptoms which looked very much
like a remission occurring in the midst of the inevitably progressive
paretic degeneration and then to the surprise of their physicians have
not exhibited any further symptoms of the affection. Syphilis of the
nervous system sometimes simulates paresis to such an extent as to
deceive the most expert, and proper antisyphilitic treatment will
sometimes produce results that are little short of marvelous. It is
beyond all question, then, for the good of the patient suspected of
paresis that his physician should give him the benefit of every doubt.

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