PARESIS 
-BY- 
AMOS J. GIVENS, M. D. 
STAMFORD HARD. 
STAMFORD. CONNECTICUT, 
U. S. A. PARESIS 
Paresis, or general paralysis of the insane, is a disease charac- 
terized by progressive loss of muscular power, a gradual wasting 
of strength, a steady impairment of mind that leads to dementia, 
and by a continuous decay of the whole organism that terminates 
in death, usually within three years from the time its first symp- 
toms are observed. 
Paresis has been variously defined. According to Kraeplin, 
it is a chronic progressive psychosis of middle life, characterized 
clinically by progressive mental deterioration with symptoms of 
excitation of the central nervous-system, leading to absolute 
dementia and paralysis; and, pathologically, by a fairly definite 
series of organic changes in the brain and spinal cord. Clouston 
earlier describes it as "a disease of the cortical part of the brain, 
characterized by progression, by the combined presence of mental 
and motor symptoms, the former always including mental en- 
feeblement and mental facility, and often delusions of grandeur 
and ideas of morbid expansion or self-satisfaction; the motor de- 
ficiencies always including a peculiar defective articulation of 
words and always passing through the stages of fibrillar con- 
vulsions, inco-ordination, paresis and paralysis, the disease process 
spreading to the whole of the nerve tissues in the body, being as 
yet incurable and fatal in a few years." 
Regis says of it: "Paresis is a cerebral disorder, sometimes 
cerebro-spinal (diffuse, chronic, interstitial, meningo-myelo- 
encephalitis), essentially characterized by progressive symptoms 
of dementia and paralysis, with which are frequently associated 
various accessory symptoms, and especially an insanity of the 
maniacal, melancholic or circular type." 
Meynert gives a division of the varieties of paresis which in- 
cludes eight distinct forms of the disease: 
i. Simple progressive dementia, with the usual motor im- 
pairment 'which accompanies it; but, excepting in cases of hypo- 
chrondrical depression, not necessarily exhibiting other mental 
symptoms than dementia. 2. With the expansive delusions and the distinctive motor 
disturbances which appear simultaneously and are progressive, 
constituting the "classic" form of general paralysis. The mental 
state is usually one of self-satisfaction and exaltation, but there 
may be depression. . 
' 3. Of the same type as the last, though failing in its steadily 
progressive character through arrest of the active process. The 
remissions, which seldom last so long as a year, raise hopes ot 
recovery, but still they manifest unmistakable impairment of the 
reasoning faculties. The psychic disturbances are much greater 
than can be accounted for by the atrophy of the brain alone. 
4. Cases in which the characteristic exaltation and grand 
delusions reach such an astounding height that manifest motor 
symptoms are looked for with confidence from day to day and yet 
may not appear for even a year, any slight inco-ordination natur- 
ally being obscured by the general muscular disturbance. Mean- 
while there may be such an improvement that the patient leaves 
the hospital for awhile, once, but rarely twice, on the responsibility 
of his family, returning with marked motor symptoms of in- 
creasing severity. 
5. A very rare form, with alternate symptoms of exaltation 
and depression of the type of circular insanity. 
6. With early furious delirium, painful hallucinations, con- 
fusion, and incoherence somewhat resembling acute delirium. . 
7. Progressive general paralysis, in which the characteristic 
indications appear secondary to other forms of insanity; for in- 
stance, after paranoia or melancholia, first described by Hoester- 
8. The combined form with sclerosis in the whole cerebro- 
spinal tract, the symptoms of tabes or spastic paralysis predom- 
inating, according as the posterior or lateral columns of the spinal 
cord are chiefly involved. The ascending type, in which the cord 
is first affected, is rare. Optic neuritis ending in atrophy and 
paralysis, especially of the ocular muscles, may precede marked 
mental symptoms. 
In about one-half of all the cases that have come under my 
observation during the past seventeen years, a history of syphi is 
has been obtained. Some years ago the theory was advanced that 
all cases of paresis were due to syphilitic poison,_ but this is not 
true. It is well to remember that the' two diseases are quite dis- 
tinct and that paresis is not a late manifestation of syphilitic in- 
fection, and is not in any sense a form of brain syphilis. e 
specific infection may have prepared the soil for later disease by 
rendering the tissues less resistive to circulatory disturbances and 
2 congestion, and more vulnerable to the influence of profoundly 
degenerative processes. 
Brain workers who suffer from overwork, overstrain and 
great anxiety, together with loss of sleep and continued exhaus- 
tion, furnish the most numerous examples of paresis. The clergy, 
the Quakers, the Irish in Ireland, the Scotch in Scotland, and the 
Negroes before the war have at all times been singularly free from 
this disease. Under modern conditions, however, of stress and 
strain in large cities, Scotchmen, Irishmen and Negroes readily 
acquire it. In Egypt, where syphils abounds, there is no reason to 
suppose that paresis ever exists; and in Asia it is almost unknown. 
It occurs most frequently among the active and energetic who 
are fond of the good things of life, among those of the so-called 
sanguine temperament who are good-natured, self-indulgent and 
generous to others. 
There is probably no disease that begins more gradually. Its 
earlier manifestations often pass unnoticed; in fact, in many in- 
stances they are as yet unknown. The prodromal period varies 
within wide limits, but it usually extends over months or even 
years. The mental symptoms vary to such an extent that paresis 
may be mistaken for almost any other form of insanity or for 
simple neurasthenia. While several varieties of paresis have been 
noted, in general there are three distinct types: the exalted, the 
demented, and the depressed. The expansive, jovial paretic of 
some years ago is less frequently seen nowadays; and cases that 
begin as melancholia or show signs of dementia almost from the 
beginning are more and more common. A correct diagnosis may be 
difficult in the early stages. The chances are, however, that the case 
is one of paresis when a man in early middle life shows a recent 
and sudden alteration in his whole character, with great restless- 
ness, marked irritability, forgetfulness, total disregard of the needs 
of others, together with extreme egotism and motility of ideas ; and 
physical symptoms such as pupillary anomalies, alterations in 
the deep reflexes, and unsteadiness of gait. 
The earliest manifestations of paresis that are sufficiently 
marked to attract attention often present a certain likeness to 
those of ordinary neurasthenia. In both there is exhaustion of 
the brain and nerves, inability for steady work or thought, poor 
appetite, general sluggishness and irritability. But in neurasthenia 
the pupils are not contracted to the size of pin-heads nor are they 
unequal; the tremor seen in the fingers and eyelids is fine, not 
jerky; and there are no changes in enunciation or handwriting. 
The neurasthenic patient pays marked attention to his own 
symptoms, which seem to him alarming and of a grave nature. 
3 He deplores his physical weakness and want of will, and earnestly 
desires to get well. The paretic, except iin the beginning and 
before others are impressed by his altered speech or unusual con- 
duct, never considers himself ill; pays no attention to his symptoms 
and thinks it impossible for him to err. He never seeks to excuse 
himself, being unconscious of wrong-doing. Attention is the 
faculty that is impaired earlier than any other; out of this defect 
grows the loss of memory that often results in the unusual actions 
of the paretic, in his lack of courtesy, his poor business manage- 
ment and inability to meet obligation or keep engagements. For- 
getfulness is the cause of this change in conduct. The paretic 
soon loses the memory for dates; and the events of to-day or 
yesterday are somewhat vague and shadowy. What goes on 
around him becomes less and less important as his false ideas 
become more definite. 
The usual habits and the disposition undergo a gradual 
•change. The victim of paresis begins to appropriate various 
articles within easy reach, thinking everything belongs to him, tells 
unnecessary and most palpable falsehoods, fails to appreciate the 
value of money, and commits various indiscretions without method 
or satisfaction. His judgment fails, his honesty departs, he is 
altogether different from his true self. This depressed, abstracted 
and irritable stage may last a few weeks or months, or perhaps 
from two to three years, before the first outbreak of maniacal ex- 
citement. A lively and agreeable man may for a long time conceal 
an undercurrent of anxiety from even his most intimate friends. 
But at last, through the effects of disease, he is unable to hide his 
real feelings. Then he becomes morose, worries more than is 
natural, falls a prey to insomnia and may sink into a profound 
melancholy, which is often concealed by feigned gayety and buoy- 
ancv of spirits. Concealed anxiety forces the patient into frequent 
outbursts of anger. He is now uncertain and easily disturbed, 
ignoring little civilities to those about him because deeply absorbed 
in his own restless and fantastic thoughts. With the loss of self- 
control and the development of an exalted state of mind, friends 
perceive for the first time that the changed man is really ill and 
realize the necessity of seeking medical advice. At this point medi- 
cal observation readily discovers characteristic changes which are 
the chief physical signs of paresis. With certain patients, delusions 
of grandeur or ideas of great personal importance and power are 
observed among the earliest symptoms of the disease. The ex- 
pansive delusions of paresis are characterized by a sense of in- 
creased perfection. The typical paretic may announce that he is 
4 the handsomest man or the best singer in the world; or he is the 
best runner on earth or the writer of the most stirring sermons 
ever put on paper, or is worth fabulous sums of money. The 
delusions may be astonishing and absurd. The deductions drawn 
from them are natural, under the influence of a false belief that is 
characterized by a sense of the patient's own increased importance 
and power. The exalted ideas of the patient are the outcome of an 
unrestrained imagination that is no longer under the control of 
reason. 
As a means of diagnosis the eye symptoms are of great im- 
portance. The pupils may be exceedingly small, in a condition 
of spastic myosis, fixed on exposure to light and not expanding 
when the eye is shaded. One pupil may be larger than the other. 
Even when in rare instances they are equally dilated they fail to 
respond to light. These conditions are seldom present in any form 
of insanity except paresis. The eye itself may be restless and un- 
steady, owing to muscular impairment. In from one-quarter to 
one-third of all cases in the terminal stage, optic changes of an 
atrophic nature are present. 
Alteration in speech is a prominent feature of this disease. 
Heard a few times it is easily recognized. There is marked trem- 
ulousness of the lips and tongue while speaking, similar to that 
of alcoholism or of great excitement in a highly sensitive person. 
This tremulousness is most marked on attempts to speak rapidly 
or to protrude the tongue. There is a slight hesitancy in speech, as 
well as an evident effort to overcome a difficulty of articulation. 
Stammering occurs especially in words containing k, I, m, n, r and 
e. The countenance also undergoes a change. The lines of ex- 
pression are faint or nearly effaced. The skin is sallow, greasy, 
wax-like; and flabby when the patient is stout. 
The tremor of paresis affects all parts of the body, but it is 
most marked in the face and tongue. It is a fine fibrillary tremor 
that becomes jerky when voluntary movements are made, as in 
speech, in smiling, wrinkling the forehead, showing the teeth or 
protruding the tongue. Later, it is found in the small muscles of 
the hands and feet. An indication of the incipient tremor is mani- 
fested in the handwriting, in which alteration first appears in the 
upstroke, making a line like the irregular edge of a saw. 
Knee-jerk is altered in rather more than half the cases, a little 
oftener exaggerated than abolished. All the tendon reflexes may 
be greatly exaggerated. There may be ankle-clonus, quadriceps 
clonus, jerk and clonus of the jaw, together with extreme wrist- 
jerk and elbow jerk. There is unsteadiness of gait, a shambling 
uncertain step that is less unsteady than in locomotor ataxia. It 
5 suggests age rather than disease; and is an impairment of muscular 
power instead of a true paralysis. There are trembling movements 
in the limbs, varying in degree and frequency. In walking the 
feet are not raised in the normal way, the steps are shorter, the 
legs are wider apart than is usual, and turning is accomplished 
with much deliberation. Going up and down stairs is difficult, 
and dancing impossible. There is impairment of all the muscles 
of the body. Ataxia marks the effort to stretch out the hands and 
arms, and to stand with the toes together and the eyes shut. 
A characteristic feature of paresis is the occurence of con- 
gestive attacks. These are variable as regards frequency and 
the stage of the disease at which they appear. In some cases 
they occur every few weeks; in others only a few times during 
the whole course of the disease. These seizures may take place 
at any period; sometimes they are observed in the last stage only. 
In very rare instances they are the first symptoms to be noted. 
These congestive attacks resemble apoplexy; and the patient falls 
suddenly with complete loss of consciousness. An apparent 
paralysis of one side follows, from which he recovers and may 
seem in as good a condition as before. As far as life and 
general movement are concerned these attacks resembling 
apoplexy seem to exercise no particular influence upon the course 
of the disease itself, though death may occur in one of these 
seizures. In three-fifths of all cases, the attacks usher in the 
second stage of the disease. There is often a slight rise of temper- 
ature at all times, even when the patient is quiet and undisturbed, 
varying from one-half degree to two degrees. In the congestive 
attacks the temperature may rise higher, sometimes to 104 degrees 
or more. The attacks that resemble apoplexy differ from it in one 
important particular. In haemorrhagic apoplexy the patient may 
die in the first attack, or in the second or the third. In paresis 
there may be any number of apoplectiform seizures from which 
the patient may recover completely; or else rally with a resulting 
increased weakness that is more or less marked. In the latter 
instance, the paresis in all the muscles will soon become an in- 
creasing paralysis; and the period of complete dementia is not 
distant. 
The diseases from which paresis is to be distinguished are 
neurasthenia, paralysis due to cerebral htemorrhage, embolism, 
tumor of the brain, alcoholic insanity, senile dementia, and 
muscular atrophy. The presence or absence of the convulsive 
tremor in the muscles of articulation at the commencement will 
aid in clearing up the diagnosis. So, also, will the general 
and progressive course of the loss of co-ordination and the 
6 peculiar mental facility and extravagance. While the duration of 
the disease is comparatively brief, about three years on an average, 
there are well authenticated instances where paresis has lasted 
ten or fifteen years. Such examples are extremely rare. 
When paresis has definitely declared itself, treatment consists 
in hygienic care and medical supervision, and usually a complete 
change of environment. It is in the first stage that permanent 
relief can be hoped for, when conditions are most favorable for 
the arrest of the disease; for there is such a thing as an arrested 
paresis, which does not progress for many years, if at all. This 
favorable form is rare, but it does exist. And one thing about it is 
positive: Remissions do not occur in neglected cases or when 
the patient is left to himself. The hope is ever present when a 
new case presents itself that it may prove to be of this nature, 
allowing the patient to return to his home after a period of rest 
and treatment, and resume business for a time as before the in- 
ception of his malady. Voisin, Meynert, and others have ex- 
pressed the belief that paresis may some day in the future be 
cured in its early stage. In the treatment, the patient's surround- 
ings should be as completely changed as the sands of the hour- 
glass that is reversed. The reduction of mental and physical 
work is a necessity. Then comes abstemious living, with 
the avoidance of all stimulants and excesses. Early hours, 
sufficient sleep, a suitable diet, careful attention to the main- 
tenance of regularity in the various functions of the body, 
together with systematic massage, hydrotherapy, and the excellent 
devices of a partial rest-cure, furnish the general outline of a 
rational plan of hygienic treatment. The brain needs to be put in 
splints, as one authority suggests; and that is done by the repose 
and quiet thus outlined, and not through the excitement, hurry 
and possible annoyance of going from place to place, as in travel- 
ing. Dangers from suicide, assault, or the risk of dissipating 
property must ever be borne in mind. Catastrophies cannot 
always be averted when the patient is without the restraining care 
of experienced skill and discrimination. 
In this early stage the diet should be light and consist of 
articles that can be easily digested. Paretic patients as a rule have 
voracious appetites and are seldom satisfied by an ordinary amount 
of food. The regulation and restriction of nourishment suitable 
to their state present difficulties that require tactful management on 
the part of the physician. Meat and all stimulating foods should be 
avoided or restricted in use and amount. Fish, eggs, cereals, 
vegetables and fruit can be freely used. In the later stages care 
7 must be exercised that the patient does not choke or food enter 
the trachea, accidents that sometimes occur on account of more 
or less partial paralysis of the muscles of deglutition. In the first 
stage of paresis, as already stated, the progress of the disease 
may be retarded or the disease arrested in its course. One case of 
fourteen years' duration now under my care illustrates this. For 
twelve years the disease did not progress; and, during that time, 
the patient was interested in financial, political and educational 
matters. He is blind; and during the arrest of his disease and 
the period of active interest in affairs, a companion read aloud 
to him six hours every day. A congestive attack occurred later; 
and degeneration and dementia slowly followed. 
In the treatment of paresis, each patient should be carefully 
individualized. Heroic measures should be avoided, such as bleed- 
ing, the use of murcurials, and depletion by hydrotherapy. The 
treatment of the depressed type is similar to that of neurasthenia. 
There are no specific remedies. In the exalted state the 
remedies indicated in mania are of use. Among these might be 
mentioned belladonna, cannabis indica, opium, veratrum viride 
and ergot. 
Erb recommends for all paretic patients who have a history 
of syphilis anti-syphilitic remedies, and I have used in some cases 
mercurial inunctions and iodide of potassium with marked benefit. 
In the incipient stage such remedies as iodide of arsenic, 
hypophosphites, phosphorous, nux vomica and ferrum might be 
mentioned. 
8 DR GIVENS' SANITARIUM/ 
STAMFORD, CONN., U. S. A.