Paresis

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 per ods: 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

this.



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

swaying.



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

themselves.





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

paresis.





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

differentiate.





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.