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 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, {531} 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 {532} 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 {533} 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.

RÔle 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 {534} 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.