A Case of General Paresis. 
MYSOPHOBIAMelancholia 
with Filth Dread. 
By Ira Russell, Winchendon, 
Mass. 
Reprint from 
The Alienist and Neurologist, 
St. Louis, October, 1880. Art, VI.-A Case of General Paresis. 
By Ira Russell, M. D., Wichendon Highlands, Mass. 
A B., aged 59, a man of sanguine, nervous temper- 
-*■ A.* ament, active business habits, who, from small 
beginnings, had accumulated an immense fortune, estimated 
at ten or twelve millions dollars, came under my care 
in July, 1877. He had been under treatment in a 
private asylum the previous fourteen months. From 
physicians whose care he had been under, and from 
Drs. Tyler and Walker, of Boston, and Choate, of New 
York, and from his family, I learned the following partic- 
ulars in regard to his personal habits before the access 
of the disease and after he was taken sick: For years 
he had devoted himself unsparingly to his business, early 
and late-was very irregular about eating and sleeping. 
He engaged actively in politics-run for office-sometimes 
successful, sometimes defeated. Some two or three years 
previous to his coming under my care, his friends noticed 
that he had attacks of unconsciousness, lasting only for 2 
Ira Russell. 
a few seconds, or long enough to interrupt his conversa- 
tion, but would immediately continue what he was saying 
as though nothing had happened. He became irritable in 
his temper imperious in his manner, and fault-finding 
with his associates. His appetite was poor, and he slept but 
little. In the spring of 1876, after engaging in an import- 
ant and long continued business transaction, going without 
sleep and eating but little, he had an attack of acute 
mania and became so violent as to necessitate his removal to 
a private asylum, where he remained fourteen months. 
The acute symptoms soon passed off, leaving him with 
feelings of discontent and great dislike to all restraint. 
Previous to the acute attacks, Dr. Walker had diagnos- 
ticated his disease as general paresis. Having been 
placed under guardianship, he was removed to Wichendon, 
and placed under my care. I employed three intelligent 
gentlemen as attendants, two of whom were with him 
constantly. He was allowed all possible freedom, and, 
as far as possible, all signs of confinement and restraint 
were removed. He played billiards, croquet, bowled, 
went riding, boating, to concerts, fishing and parties, and 
everything was done to make his time pass pleasantly. 
When he first came under my care, although very active, 
walking and running with great agility, he had the hitch 
and shuffle in his gait peculiar to general paresis. His 
appetite was good, his sleep irregular and disturbed. He 
had illusions of sight, saw vermin on his clothes. He 
was easily excited, irritable and passionate, crafty and 
cunning. His memory was defective. He had notions 
of self-importance and his great ability, but not in 
relation to wealth, so common in this disease, and of 
which he possessed so much. He had slight epileptiform 
attacks, after which his speech would be affected and 
his gait less secure. During this time, when his friends 
called upon him, he would appear quite sane and talk 
quite rationally upon matters that happened years before. 
His letters were a medley of sanity, insanity and vulgarity; 
his hand writing was bad. During the first six months A Case of General Paresis. 
3 
he was with me, the change in his symptoms was slight. 
In February his epileptiform attacks were more frequent 
and severe; his gait was more unsteady, frequently falling 
down; his mind was less active, his memory very much im- 
paired. In May he was unable to walk or feed himself; lost 
all control of the sphincters and died July 3d, com- 
pletely demented. July 5th, an autopsy was made by 
Dr. Moses G. Parker, and the morbid appearances were 
carefully noted by myself and Dr. Theo. W. Fisher, of 
Boston. The scalp was rather thick and anaemic. On 
removing the calvarium, the bones were quite thin and 
the marks of vessels were deeply impressed upon the 
inner tables. The diploe congested. Dura-mater not 
very adherent. There was a general and marked 
cloudiness of arachnoid over frontal parietal and temporo- 
sphenoidal lobes. The brain weighed 53 ounces; the 
cerebrum, 46 1-2, the cerebellum and oblongata, 6 1-2. 
Five ounces of bloody cerum flowed from the cranial 
cavities. Sub-arachnoid effusion, moderate; small vessels 
distinctly traced. There was shrinking and flattening 
of the convolutions of the anterior lobes. The effusion 
and opacity were limited to the frontal and parietal lobes. 
The other organs of the body were examined and 
found healthy, except the heart, which was enlarged and 
fatty. 
The brain was put in alcohol and taken to Boston 
by Dr. Fisher, for further examination, who makes the 
following report, together with a report by Dr. S. G. 
Webber: 
* * * In the afternoon of July 5th, it was 
examined superficially with the assistance of Dr. Webber 
The alcohol had somewhat obscured the appearance, 
above described; we found, however, a moderate amount 
of wasting over both frontal and parietal lobes. On the 
right opacity extended backwards to the perpendicular 
fissure, following it downwards and forwards to fissure of 
Sylvius, which it followed to the base of the brain. Opacity, 
greatest over fissure of Sylvius, lower part of fissure of 4 
Ira Hassell. 
Rolando and vertical frontal fissure, over anterior portions 
of first and second frontal convolutions and along the 
medial border of hemisphere. We found on the left, opacity 
a little posterior to that on the right, but rather less 
marked in degree. It was greatest in the before mentioned 
localities, which correspond for the most part to the 
course of the larger vessels as well as sulci. The veins 
were full, but not excessively injected. At the base 
we found opacity marked along the fissure of Sylvius, 
processus zincinatus and gyrus hippocampus at anterior 
extremity; also, along olfactory bulbs and over the first 
and second frontal convolutions. Occipital lobe and 
external portion of temporal lobe free from opacity. No 
marked atrophy at the base. This applies to both sides 
alike. 
We found and located seventeen small extravasations 
(see diagrams) : (i) On the right, at the base for one- 
eighth of an inch on each side of third temporal fissure, 
and extending two inches in length, was a spot of blood 
under the pia-mater. (2) About the middle of the second 
temporal convolution, a spot three-quarters inch in diam- 
eter. (3) In same convolution, a little anterior to last, a 
spot three-quarters by one-quarter inch bordering on 
first temporal fissure. (4) At lower portion of ascending 
frontal, a small spot one-quarter inch in diameter. (5) 
About the center of the second frontal convolutions a 
small stain. (6, 7, 8, 9) At extreme anterior portion of 
the first frontal, four small spots. (10) Posterior to ascend- 
ing parietal at median fissure, a spot three-quarters by one- 
half inch. No spots on left side at base. (11, 12, 13, 
14,) At anterior extremity of frontal lobe, involving first, 
second and third frontal convolutions, a row of four 
small spots. (15) A large spot three-quarters by one 
inch, on both sides the fissure of Rolando at its lower 
part. (16) At anterior part of temporal lobe, bordering 
on the fissure of Sylvius opposite its bifurcation, a small 
spot. (17) On gyrus fornicatus an inch behind the 
corpus callosum, a small spot. EROSIONS. 
a- 
a 
LEFT 
RIGHT 
Posterior 
a Fissure of.Rolando. EXTRAVASATIONS. 
LEFT 
LEFT 
6 
7 
8 
9 
RIGHT 
11 
12 
13 
14* 
RIGHT 
LEFT 
ANT E R I OR. A Case of General Paresis. 
5 
Dr. Webber removed some portions for microscopical 
examination, his report of which is enclosed. The brain 
was then immersed in nitric acid, one part; water, nine 
parts, and allowed to remain four weeks. August 3d, it 
was removed and carefully stripped of its toughened 
membrane, which separated easily, coming out from the 
sulci and leaving a clear yellow surface of the hardness 
of new cheese. At various points could be seen, by 
careful inspection, shallow erosions with ragged edges, 
where a very thin film of the cortex had been removed 
with the membranes. They were all on or near the 
summit of a convolution. Some were so faint as to be doubt- 
ful, but we made out and located twenty-five or twenty-six 
as shown on a sketch of the convolutions, as observed 
in this case. These are quite irregular, and differ much 
from a typical diagram; most of the convolutions can 
be made out however. There were no adhesions at the 
base, nor so low down at the sides as not to be included 
in a single view from above. On the right they follow 
the median fissure along its anterior two-thirds. The 
largest are at the upper part of the ascending parietal 
and frontal convolutions, and along the first frontal to 
its anterior extremity. On the left they follow the fissure 
of Rolando on both sides, a large one being seen at the 
head of the ascending frontal;, another at middle of 
ascending parietal; then in lower parietal lobule; five 
or six lower down in ascending frontal, and one each in 
first and second frontal. 
At the second examination the extravasations had 
disappeared ; but it will be seen that they do not corres- 
pond to'the adhesions, and with the exception of 4, 5 
and 15, are outside the motor region of Ferrier. These 
correspond to Ferrier's numbers, No. 9 and 10, lips and 
tongue; No. 12, lateral motions of head and eyes, eleva- 
tion of eyelids, and dilatation of pupils, and No. 7 and 
8 and A, elevation and depression of angle of mouth 
and emotions of hand and wrist, respectively. 6 
Ira Russell. 
The erosions on the Itft correspond: I, to Ferrier's 
No. 2, 3 and 4, complex motions of arms and legs; 2, 
to No. 6, biceps, i. e., supination and flexion of forearm; 
3, to No. 7 and 8, el. and dep. ang. of mouth ; 4, to 
a, b, c, hand and wrist; 5, to No. 13, the center of vision ; 
6, to No. 12, lat. motion of head and eyes, elev. of 
lids and dil. of pupils. On the right they correspond, 7 
and 8, to No. 2, 3 and 4, arms and legs; 9, to No. 5, 
arm and hand; 10, to No. 12, see above; II, to a, b, 
c, hand and wrist. Ferrier's centers are all accounted 
for except No. I, leg and foot; No. 9, 10 and 11, where 
there was an extravasation; and No. 14, hearing. 
Having thus placed the facts before you, I leave you 
to draw your own inferences. I am in some doubt 
whether the extravasations were not post-mortem, due 
to accidents in removal of brain. There was no gross 
lesion in the interior of brain, to account for death, and 
if, as I hear, there was a fatty heart, death after con- 
vulsions would not be remarkable. 
Very respectfully, 
To Dr. Ira Russell, Thos. W. Fisher. 
Winchendon. 
Boston, August 7th, 1878. 
Dear Dr : 
Dr. Fisher asked me to examine the brain microscopi- 
cally. I found around many of the blood vessels, granular 
blood pigment. I found that many of the nerve cells 
were strongly pigmented, and that many contained fat 
granules without pigment. These changes were rather 
more marked in the anterior portion of the frontal lobes 
than in the motor region. The convolutions about the 
central extremity of the fissure of Rolando contained 
amyloid corpuscles; the large cells in these convolutions 
were strongly pigmented. 
Under the pia-mater, in several spots, especially where 
there was most opacity, were collections of leucocytes. A Case of General Paresis. 
7 
My method was to take small pieces out of various 
regions, or to make slight incisions and take small sections 
out of the cortex ; these were teased apart and the cells 
thus examined. As it was desired to examine the adhe- 
sions, I could not take any portion to harden. 
Yours Truly, 
S. G. Webber. 
Remarks:-I am under great obligations to Dr. Fisher 
for his careful and thorough examination and report of 
the morbid condition of the brain. The lesions observed 
correspond very nearly with those observed by J. Crichton 
Browne in the cases of general paresis, reported by him 
in vol. VI. of "West Riding Lunatic Asylum Medical 
Reports viz.: "The uniformity of inflammation of the 
membranes of the anterior lobes of the brain, and adhe- 
sions of the same in spots to the apices of the convolutions, 
the cortex beneath being more or less affected. Dr. 
Browne and others express the opinion that the lesions 
found and the symptoms manifested during the progress 
of the disease verify the localization of function as taught 
by Ferrier." 
I give the order in which the psychical and motor 
symptoms appeared in the above case : 
Psychical.-First.-The first abnormal symptoms noticed 
by the family of A. B. were general restlessness; intense 
application to business; irritability of temper ; change of 
disposition, and less regard for the proprieties and mor- 
alities of life. 
Second.-Extravagant ideas and desires, with self-exal- 
tation. 
Third.-He had an attack of acute mania after a 
prolonged, harrassing and important business transaction 
-recovering from it. 
Fourth.-He had impairment of memory, especially of 
recent events, and forgetfulness of persons and names. 8 
Ira Russell. 
Fifth-Extreme willfulness and unwillingness to be 
controlled, and general discontent, with occasional attacks 
of maniacal excitement. 
Sixth.-Hallucinations of the senses of sight and 
hearing. 
Seventh.-Good nature, mental weakness, dementia, 
coma and death. 
Motor Symptoms.-First.-An excited manner of walk- 
ing. 
Second.-A pleased expression to the countenance, 
caused by the contraction of the occipito-frontalis muscle, 
Third.-A fibrillar motion of the tongue; irregularity 
in the pupils of the eye; a tremulous movement of 
the chin and lips. 
Foztrth.-Loss of co-ordinating power of the hands 
(as shown by hand-writing), and a hitch or shuffle in his 
gait. 
Fifth.-Alteration in the voice. 
Sixth.-And lastly, a general paralysis of the arms, 
legs and sphincters. [Reprint from Alienist and Neurologist, October, 1880.] 
Art. X. - Mysophobia. Melancholia 
with Filth Dread. - Mania Conlam- 
inationis. 
By Ira Russell, M. D., Winchendon, Mass. 
IN November, 1877, the late lamented Dr. John E. 
Tyler, of Boston, sent me a patient for treatment in 
my family home. From Dr. Tyler, and the friend who 
came with the patient, I learned the following particulars 
of his life, and the manner in which his disease com- 
menced. The patient was a large portly gentleman, 
unmarried, aged forty-seven, of fine personal appearance 
and cultivated manners, a graduate of Harvard College 
and of the Harvard Medical School. Being a man of 
wealth, he never engaged actively in the practice of his 
profession. He visited medical schools and hospitals 
abroad, and traveled - extensively in Europe, Egypt and 
Palestine. He was of a cheerful, happy disposition, 
upright and conscientious; his ready wit, learning, and 2 
Ira Russell. 
intelligent conversation rendering him a great favorite in 
the cultivated circles in which he moved. His father, a 
well-to-do merchant; a brother, an eminent lawyer; and 
a sister committed suicide. A few months prior to his 
coming under my care, a brother had died suddenly in 
his arms, which made a profound impression upon his 
nervous system. He, in consequence, became melan- 
cholic, slept badly, was noted for indecision, imagined 
his hands were dirty, and began constantly washing 
them. When he came under my care, although very 
courteous and gentlemanly in his manners, he was 
much depressed, and complained of a bad feeling in 
his head. He was fearful that everything he touched 
would contaminate and soil his hands; the chair, the 
door-knob, in fact, everything that came in his way he 
carefully avoided touching with his hands. When 
reasoned with in regard to his morbid notions, he 
would admit their unreality, but could not resist the 
impulse to wash his hands whenever they had come 
in contact with anything. I provided him with an 
attendant, a medical student, who is now an assistant 
physician in the N. H. Insane Asylum, who was con- 
stantly with him and carefully watched and noted his 
symptoms. He had a routine which he regularly 
observed and for several weeks did not vary from it. 
Usually he would begin his preparations to retire 
about ten o'clock in the evening, and it would be two 
o'clock in the morning before he would be fairly in 
bed. Before he would begin to undress, his attendant 
must fill the wash bowl with water, as he dared 
not touch tht stop-cock with his hands; then the water 
must be let off, the bowl washed and filled again for 
three times, then he would wash his hands three times, the 
bowl being filled anew each time. Then after the removal 
of each garment he must wash, finally he would wash 
his face, rinse his mouth, each, three times, say his 
prayers and retire, consuming three or four hours, and 
using twenty or more towels. In the morning he went My sophobia-Melancholia with Filth Dread. 
3 
through a similar process, taking two or three hours 
to dress. Before and after each meal he would wash 
three times. During the day he walked or rode with 
his attendant, played billiards, bowled, and frequently 
went to dancing parties in the evening. At such 
places no one would suspect that anything was the 
matter with him. He was fond of music and enjoyed 
playing on the flute, while some one played on the 
piano. On Sunday he went to church. 
After several months he began to improve, and the 
following summer was nearly well. At this time, his 
friends insisted on taking him away, in opposition to 
my judgment, and the opinion of Drs. Hodges and 
Walker, of Boston, who saw him in consultation with 
me, as they feared a return to his home would bring 
on a relapse. Still his friends insisted and took him 
away. In two or three weeks after his return home, 
all his morbid fancies returned very much intensified, 
and with so much mental excitement that his friends 
became alarmed and put him in the insane asylum. 
Not meeting with the improvement his friends expected, 
I was importuned to take him again, which I did, 
and found him much worse than when he first came 
to me. He was unwilling to admit that the ideas of 
filth were groundless. But, after a few weeks of treat- 
ment, he began to improve, and in three months was 
so much improved that he went to New York and 
Washington with his attendant, spending several months. 
But, on his return home, he immediately had a relapse 
and came under my care, and staid with me. until 
he fully recovered. Without stopping at his home, he 
sailed for Europe, and thus far has had no return of 
his disease. 
Treatment.-When he first came under my care, and 
after each relapse, he was very much troubled with 
insomnia, requiring large doses of hipnotics to procure 
sleep. For that purpose I gave him monobromide of 
camphor, bromide potass., chloral hydrate, mecona feet 4 
Ira Russell. 
morphia, belladonna, hyoscyamus, each alone or variously 
combined. I gave him also Esquirol's Red Mixture- 
strychnine, quinine, and syr. of hypophosphites of iron, 
lime and soda. At first it was a question with me 
how much I should restrain, or whether I should 
permit him to gratify his morbid desire to wash. 
After mature deliberation I decided to grant him 
perfect freedom to wash as often and to use as many 
towels as he chose.. At the same time 1 endeavored to 
show him the absurdity of his whims, and appealed to 
him as an educated physician to use his own reason 
and judgment and to consider how he would regard 
similar symptoms in another person. Finally, at first, 
and after each relapse, I persuaded him to make an effort 
to lessen the number of washes each day, and as he 
did so he gradually gained the power of self-control, 
and was much pleased with the results of his efforts. 
While in the asylum he was restricted to a certain 
number of washes and towels a day, but he told me 
that the restriction only aggravated his morbid desire 
to wash and made him almost frantic. 
From the first, I regarded the case as a peculiar 
form of melancholy. 
Like other forms of that disease, the mind had 
fastened upon one thing or subject, while rational upon 
all others. Thus it is with melancholia, some fancy 
that they have committed the unpardonable sin; some 
that they are poor, and refuse to eat; some that they 
have committed a criminal act; and yet, on a great 
variety of subjects, will reason and act rationally. 
The above case, to my mind, teaches this lesson: 
That an insane person may be cured and remain cured, 
provided he is not subjected to the causes or conditions 
that produced the attack, but may have a relapse or 
recurrence of the disease when exposed to the causes 
that produced the first attack. Many insane patients 
are sent to an insane asylum, and, to all appearances, 
are cured. They are discharged and subjected to the Mysophobia-Melancholia with Filth Dread,. 
5 
same moral and physical causes that first produced the 
disease, and a relapse follows, while, under other con- 
ditions and surroundings there would be no return of 
the disease. 
The symptoms of physical defilement, associated 
with melancholia is a less frequent occurrence than that 
of moral defilement. Hammond has applied the term 
mysophobia to a symptomatic expression of disease not 
necessarily associated with insanity. In a paper read 
before the New York Neurological Society, in April, 1879, 
and published in the "Neurological Contributions," of 
that year, he reported two cases, and referred to eight 
others that had come under his observation.