GENERAL PARESIS (known also as general paralysis, softening of the brain, par alytic dementia, general paralysis of the insane, etc.), a disease of the nervous system that usually begins in early adult life, progresses steadily with increasing mental enfeeblement, and leads to ultimate motor paralysis, decay of all of the mental faculties and death within a period averaging from three to five years. From the type indicated in this brief general definition there are numberless variations. It is a disease which, when well advanced, is recog nized with great ease, but in its early stages it may be extremely difficult to know. From the standpoint of the patient's family and friends it is important to be able to recognize the dis ease; for it is in this initial period that the patient often ruins his business, his friends, his family and brings shame and discomfort to all those connected with him. Much of this might be averted if the layman were better informed of this early period of one of the worst scourges of modern times. The disease it probably existed for many centuries, but It is only within comparatively recent times that its true character has been recognized, and in its present extreme forms it seems to be a product of the modern complex social system. It has been aptly termed a disease of civilization and syphilization, an alliteration that contains much truth. Syphilis is the sole cause of general paresis. The disease is a parenchymatous syphilitic disease of the brain, a special trend taken in the development of brain syphilis. (See article on BRAIN SYPHILIS). Before the Tre ponetna pallida, the name given to the minute parasitic organism which is the cause of syphilis, had been found in the brain tissues of paretics, the statistical study of the disease had proved its syphilitic origin for about 90 per cent of the cases, but with the advances made by medi cine in refined methods of diagnosis, the dictum, no syphilis, no general paresis, has come to have universal recognition. There are forms of pseudo-paresis which in their clinical appear ances may resemble paresis, but a study of the blood and of the cerebro-spinal fluid, which should be done in all suspected cases, will establish the correct diagnosis. Among the dis orders which may resemble paresis are brain tumor, poisoning by mercury or lead and by alcohol. Certain senile softenings of arterio sclerotic origin may resemble paresis. Certain maniacal trends in manic depression psychoses often are confused with the early maniacal phases of paresis. Bromide poisoning some times resembles paresis. General paresis is com moner in men than in women, the proportion among different peoples and races, and times, varying from 25-1 to 3-1. Although it is a disease usually beginning in the 30's or 40's, juvenile forms are known, and sometimes the old man is a victim. It seems to be more prevalent in crowded communities, for there the stress of excitement and depression, of gaiety and sadness, of extravagance and destitution, is more pronounced, for both extremes of the mental pendulum must be considered in the esti mation of the strain on a syphilitic brain. The brilliant financier, or the actress who succumbs to this disease may be more in the public eye, and moralists may adorn a tale concerning their supposed profligacy, but the poor, harassed workman, diseased through lack of. knowledge, and drink-sodden to escape the reproofs of his conscience, may also be the victim.
The initial symptoms are usually very insid ious, although occasionally the disease appears in 'full-blown vigor. The previously healthy, neat and careful workman begins to forget things. There is a period of disturbed mental ity. Noises affect him unpleasantly. Undue ir ritability is evidenced by unwonted explosions of anger. This state may be weeks or months in its evolution, and may be confounded with a condition of overwork or overworry. In fact, such a condition is present in many tired people who never develop paresis. Added to this there are vague apprehensions in the patient's own mind of his gradually declining power; -head aches, neuralgias, and vague pants may also be present; and poor sleep may be another symp• tom of the early stage. All of these symptoms
are common to many people who have over• worked, and should not occasion alarm. But when, little by little, one shows increasing care lessness in his personal habits, such as neglect ing to button his trousers, or permitting his food to spill on his clothing, when he shows signs of mental exaltation and dreams of won derful things, then the true disease begins to show itself. From this point on there are countless variations, but in general the typical paretic behavior that leads the person into economic danger, if not disaster, is character ized by an expansive and exaggerated conduct. Buoyancy and elation with great projects and sanguine hopes mark the initial stages of the paretic's mental decay. He becomes restlessly busy, is continually entering into new schemes, is incessantly talking about his affairs with effusive geniality, not only to his friends, but to utter strangers, and he even communicates to others his closest domestic concerns. There is a gradual breaking down of the finest sensi bilities and, closely following this, slight evi. dences of the loss of the most delicate motor adjustments become manifest. It is in this stage that the symptoms become unmistakable. The partial impairment of the motor functions shows itself in an increased lack of control of the finer motions of the tongue, the lips and the hands. There is a fine tremor in the tongue when it is protruded; on showing the teeth, the angles of the mouth betray a fine tremor; and the handwriting is seen to be less firm and even, approaching that of the formative period of the man's youth. The mild grade of in, flammation in the brain causes certain changes in the reflexes of the body. Thus the pupils of the eyes are not apt to act as rapidly as in health; they may be unequal in size; they are sometimes very small and do not open wide in the dark as is usual. With these symptoms the diagnosis -becomes moderately certain, and from this time on the mental degeneration be comes marked. The carelessness becomes slovenliness; the memory goes rapidly; the loss of the finer sensibilities deepens to obscenity, to faithlessness, to utter loss of the moral faculties; the buoyancy becomes foolishness, and big projects are often launched, resulting in financial ruin. Grandiose ideas usually enlarge, and the afflicted one dreams of millions of money, of being a king or president, or Christ, or a god. His personal strength is like that of Samson, his beauty comparable to Apollo's; his voice, his oratory, his writing, his poetry, his actin* are superb— in short, his whole per sonality is puffed up with an amazing exaltation of the ego. Exulting self-confidence dominates all his designs, and a restless, busy, subdued delirium actuates his every thought and move. ment. From this stage, usually termed the grandiose stage, and which may persist for from six months to a year or more, the mental deterioration commences to show itself in a gradually progressive dementia. Mental dilapi dation becomes mental decay. The motor rest lessness goes on to loss of power and a gradual paralysis of the motor functions begins, passing through the stages of progressively increasing incoordination • to complete powerlessness. Tottering, shambling, stumbling incompetence finally advances to absolute motor impotence. This affects all of the muscles of the body, but is appreciated in the speech more readily and earlier than in other motor acts. The loss of ability to repeat the r's and l's, as in "truly rural," "artillery," etc., is an early sign of this speech-defect. Finally the only answer that can be obtained from the patient is that he is "all right." The lack of motor power further manifests itself in the increasingly dimin ished control of handwriting. The paretic is unable to keep to a line. His writing goes up and down, letters and words are omitted, the up strokes are very wavy and the letters be come unequal in size.