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THREE CLINICAL CASES
C. K. Clarke
Am J Psychiatry 1892;48:499-507.
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March 13th, 1884. W. inclined to be very gloomy and melancholy; making umo improvement.

April 8th, 1884. In au unsatisfactory condition, refuses to. speak, and is not nearly as well as when admitted.

April 15th, 1884. No improveimment. Is very melancholy.

May 12th, 1884. No change.

June 9th, 1884. Melancholia still persists. Patient appears to be losing flesh.

September 19th, 1884. Quiet and stupid.

October 9th, 1884. Has been working in the fields of late. About this time a change took place in the patient's general condition. He began to take an interest in his surroundings; was brighter generally, although at times was in deep melancholina. He persistently refused to speak.

April 9th, 1885. Does not yet speak, but by means of nods and signs tells us that he is getting better; wishes us to under-stand that he is not able to talk, but, would like to go home.

During 1885 lie appeared to be at a standstil mentally; at times bright—then again depressed.

February 2d, 1886. Appears to be in fair bodily health, but will not speak to any one. Has a more cheerful expression when spoken to.

In 1886 he brightened up a greal deal, and by 1887 had become as useful as an attendant in the wards, and ordinarily was bright and cheerful, but occasionally had periods of depression. Undoubtedly had hallucinations and delusions, and, as a result of these, did not wish to go out of the house. He would not say what these were, and still refuse to speak, but eventually it was necessary to use force to get him out of the asylum for exercise. When outside he made no further resistance, and always went out after this without trouble.

February 14th, 1888. Still refuses to speak, and is about as usual.

May 24th, 1888. In a letter written to his wife a day or two ago, he revealed the fact that he is suffering from hallucinations. He wrote as if something came into his room at night. This he can see distinctly, but manages to drive away. This "something " is written about in an indefinite mainner; but without doubt he has hallucinations of sight.

March, 1889. W. will not speak yet, although he is wonderfully bright and cheerful. The periods of depression are gradually diappearing, and the patient is better, although he has marked delusions and hallucinations as shown by his letters. He is man of great intelligence, and in certain directions has marked ability. Is fond of working mathematical problems and puzzles, and it is said in the ward that if W. cannot get a puzzles right no one else need attempt it. Has a habit of walking about and laughing to himself a great deal, and at night is to be heard laughing in his room.

When walking will frequently strike strange attitndes, and clasp his hands above his head. When aroused is passionate, and, although of gentle temperament, becomes white with passion at times. Whatever he does he does well; and is entiusiastic. Has learned to weave rag carpets; and although he dislikes going to the loom-room, on account of a patient who uses very bad language, still he goes as mutter of duty, thinking that it pleases me. The rag carpet made by him is excellent.

October, 1890, There is decided improvement in this patient. He has written me a letter to the effect that he is gradually recovering, and is certain that he will be able to speak before long and explain his conditions. The letter is couched in the most polite language, and the fact is apparent that a marked change for the better is taking place. No time is set for the breaking of silence.

December 10th, 1890, Owing to an oubreak if diphtheria in my family, we have been forced to move to the City of Kingston. When I went home from the asylum yesterday Mrs. Clarke remarked to me, "What a bright and intelligent patient that was who has been helping us to put down carpets to-day" I asked her to give me the patient's name, and she described W. She said hue had been talking to her all day. I thought she must be mistaken in regard to the patient, especial as W. had not spoken when he returned to the asyplum.

December 11th, 1890. Refused to speak to Mrs. Clarke when at the house to-day, but one of the children, who seemed interested in the fact that he would not talk, finally induced him to carry on a conversation.

December 13th, 1890. Was wife came to see him to-day, and he spoke to her; in fact talked quite freely. He did not seem to be able to explain why he had spoken, or to tell why he had not spoken sooner. Appears to be quite rational.

December 14th, 1890. I had a long conversation with W. to-day, and his condition is remarkable, in view of the fact that he has been so clearly insane for seven years. He is not only rational, and apparently sane, but gives a clear and concise account of his mental trouble. Of course I am sceptical in regard to the permanency of the present condition, but there is no disguising the fact that, for the time being, W. is well mentally. He says that about a year before he entered the asylum he received an injury on the back of the head, and dated his trouble from this time. A few months later he hmeard voices telling him that if he spoke he would be killed. He felt that something like an immense cloud was hanging over him, and if he spoke this would fall and instantly destroy him. At night too he saw dark forms that looked like snakes. He tried to fight against them, but became bewildered and confused, and eventually gave up the struggle and obeyed the voices. Time voices were in whispers, and said nothing else beyond the statement that he would be killed if he spoke Gradually the voices faded away, and he did not hear them for nearly a year before he spoke. The snakes were not seen for about six months before lie talked. Complains that his throatt feels sore, as the result of using his voice.

December 14th, 1890. I am not altogether sure of my ground in this case, although it is impossible to detect the slightest evidence of mental defect in the patient. I hope that the recovery is real, and certainly we seem justified in allowing the patient to return to his home on probation.

December l5th, 1890. Has to-day been given two months probation.

February 21st, 1891. Has been written off our books as discharged recovered. W. has remained quite well, both physically and mentally, and there is no doubt the recovery is real.

March, 1892. W. has now been home for fifteen months, and his friends state that he has never been us competent mentally as at present. He is managing his business affairs and doing well.

This is a satisfactory ending to a remarkable case.

The possibility of organic lesion, as a result of the blow on the head, has suggested itself as the cause of the trouble, although the method of removal, and reason for improvemnent are not altogether clear. If this case was really time result of organic lesion, and the history had been clear, what an opportunity for a cure by surgical interference would have been presented.

The lessons taught by this instructive case are self evident.

CASE II.—Cases of puerperal mania occurring in connection with eclampsia are comparatively rare.

Dr. Blumer, of Utica, has, I believe, complied some statistics regarding this complication.

The following case is of interest:

M. A. H., aged thirty-eight. Was first seen in her own home, where I went with Dr. Anglin, who had asked me to see the patient with him. On the way to the house, the doctor said that the patient, who had been confined the day before, was maniacal, and in a critical condition. The condition was, as the doctor said, critical, and when we arrived the woman was unconscious. The temperature was slightly over 104, pulse 140, and of wretched quality. The arms and legs were twitching, and the general appearance suggested uræmia. Although there had been no history that would lead one to suspect albuminuria, the urine was at once examined, and found almost solid with albumen. The patient had many convulsions, and, when not unconscious, was wildly excited, but the condition suggested delirium rather than mania.

Dr. Anglin was positive though that the mania was quite evident before the uræmic convulsions were present. For several days the temperature remained elevated, and the excitement continued, but the albumen rapidly disappeared from the urine. When this had happened the mania made itself apparent in a marked manner, and asylum treatment became necessary.

Mrs. H. was admitted to the Kingston Asylum on December 1st, 1891, her history showed neurotic tendencies on the part of the members of the family. One brother was insane for a short time, but made a good recovery. When admitted was quiet, and when examined was found to have elevated temperature, 103° F. and quick pulse, 120. Sue had been taking, large doses of chloral. Became extremely restless in a short time, and was frequently sponged. Took her nourishment very well, and it was found advisable to give stimulants freely. Tongue was coated and dry. The mania was of peculiar type. For hours the patient would be able to converse freely regarding herself, and would explain that she dreaded the approach of the attacks, when she knew that she would lose control of herself.

When these attacks occurred, as they did every day, the unfortunate woman was in the wildest delirium, full of delusions, and appearenly unable to control herself in any way.

On December 5th, her temperature was 101 4-5° F., and her pulse 140, and, as there was refusal to take nourishment, artificial feeding had to be resported to. Sulpimonal was given regularly, but little rest was secured.

On December 6th, was quieter, and a little better, although temperature had gone up to 102 3-5.

December 7th. Was again excited.

December 8th. Excited.

Decenmber 9th. Excited, and seemed to be doing so badly that it was determined to try baths at 105°F., with cold to the head.

Time first bath was given on December 10th, and continued for twenty minutes. The result was satisfactory, and the patient rested quietly and slpet for several hours.

December 11th. Both repeated and continued twenty minutes. Patient perspired freely afterwards, and, although she did not quiet down at once, eventually obtained a few hours' sleep. Temperature 100; pulse 120.

December 12th. Restless all day; did not have a hot bath.

December 13th. Two hot baths given to-day with the most satisfactory results. Temperature 100; pulse 94.

December 14th. Restless all day. Bath given in evening. Slept afterwards.

December 15th. Decidely better. Sleeping and eating well. Temperature 99 3-5 F.: palse 99. Hot both thirty minutes.

Improvement continued from this time, and on the 20th the last hot bath was given. On December 21st, the temperature was normal—pulse 74, and patient quite rational. she was very anxious to sleep a great deal, and was permitted to indulge her desire.

On January 11th, 1892, was discharged on probation, quite recovered.

Case III.—In a recent issue of the Journal Of Insanity, I published an account of a Case of Lethargy. Dr. Wesley Mills, of McGill University, has placed at my disposal notes by Dr. Robinson, of Annapolis, on a patient who hibernates in an extraordinary manner. Many points of similarity between my Case of Lathergy and this man are to be found, such as neurotic family history, sub-normal temperature, &c. It is a pity that more extended notes are not to be had, as the case is unique.

Notes by Augustus Robinson, of Annapolis' N. S., on a remarkable Case of Lethargy.

John T., son of a pensioner, is now about sity-two years old. When he was twenty-eight years of age his father committed suicide by cutting his throat in a fit of insanity. Before his father's death, John had shown symptoms of melancholia. He would sit by the hour over his father's bench (cobber's) laughing and talking to himself, and working himself into a frenzy, fighting imaginary foes, and going into immoderate fits of laughter.

I cannot ascertain, after much enquiry, how long this condition of things lasted before he lapsed into his present state; but this much is certain, for the last thirty years or more, about the end of September every year he falls into a sleep or stupor, and, as his present conditions is a fair sample of the manner in which his winter have been passed since he was first attacked, I will describe him as I found him on Monday, December 10th, 1888, and repeat what I was told by his friends regarding his attack this autumn:

About August 31st, Jack went to bed after eating his evening meal as usual, without exhibiting anything out of the common in his manner or otherwise, or giving any reason for the supposition that he was out of sorts in any way. On the following morning he did not get up, nor has be shown any more vitality than any sleeping man up to this time. His sleep is very quiet without any stertor, indeed it is calm as that of a child. Twice in every twenty-four hours he is taken up, a person supporting him on each side, holding a vessel for his convenience. He knows enough to voluntarily empty his bladder. The urine is high in color and scant in quantity. About eleven O'clock every night he seems to show rater more life than at any other time, and advantage is taken of this to pour a little thin oatmeal gruel, beef-tea or soup down his throat, he opening his lips to allow them to do so, and slowly swallowing it. He only takes a very little each time, and, if urged to take more, simly keeps his mouth shut. About once in every thirty days, not exactly at regular intervals, during the evening generally, the family will hear a peculiar chattering noise. They never take any notice of it, for they know it is Jack going down to the out-house to empty his bowels. He then returns to his bed and sleeps. He knows enough to throw a quilt over his shoulders at such times.

At the time of my visit I found his temperature 96° F. pulse 60, regular, though not strong; respirations 14, easy and quiet, skin cool. A pin stuck into his arm caused no apparent change, and he migiht be pinched until black and blue without its causing him the slightest uneasiness.

My first visit to Jack was about twenty years ago, when I first came to live and practice in this vicinity, and it came about in this way. Of course there was a talk about the new doctor and what he could do, so I was called to sed this qucer case. I got all the particulars from the friends and neighbors, and what means had been tried by other doctors, and then I promised to try whiat I could do. On the following day I went again, accompanied by my brother, also a physician. We took with us a good galvanic battery. One of the handles was placed in each hand and bound closely to the fingers with wet bandages. We then put on the full power of the instrument. Poor old Jack was out of bed in one instant, and I shall never forget his look of astonishment and horror as he yelled out "Damnation, what's that?" I can also well remember my own feelings of satisfaction and complacency when the natives congratulated me on my success in this, my first case. I walked off as if saying to myself, "I knew I could do it." Well, Jack remained awake about three days and then I got a message that my patient was off again. I went up and tried the battery a second time, with only the effect, however, of making him open his eyes and grunt out "Eh," in a querulous manner, and, after looking about him for a half-hour or so, he lapsed into his former condition. Next day I again tried the battery, but without the slightest effect, so I gave it up as a hard case.

This is all I hmave to say about this singular object, except that, of course, he becomes very thin and haggard before he rouses flnally in the spring, and he does not fairly waken until the end of May or first of June. During the summer months Jack does exactly the work he is told to do, but he must be told over again every day; for example, if desired to bring the cows from pasture, he will do so, but will not milk them until told to, nor will he turn them afield again without being desired. He does not seem to know what to do next, even though the same routine is carried out every day. An exception, however, must be made in one respect. He does not uequire to be told when dinner or tea-time arrives, and is blessed with an excellent appetite. Jack is always ready for his hash, and is not particular about quality, so that quantity is there. He will talk quite rationally on any subject when spoken to, and recollects distinctly most of the incidents of his childimood. He will hold auimated confab with the cows, dogs, trees, wheelbarrow, or any other object which happens to be in his way, and may be noticed sometimes lecturimig a tree for some time, breaking out occasionally into uproarious fits of laughter.

Asylum for Insane, Kingston, Ontario

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