Admission Details for Patient: John Moore (2439)
Gender: Male Age: 30
Marital Status: Married Religion: Not known
Address: Rhydwyn, Anglesey
Date of Admission: April 9, 1875
Date of Death: June 30, 1875
Cause of Death: Epilepsy
Supposed Cause: Drink
When asked anything will not give any answer. If he does it will be a most vacant laugh. His seeing all kinds of imaginary things about the room, and at times gets very savage, in fact dangerous tho he is so weak etc. Communicated by his wife: In the last two years he has been very quiet and morose, would come in from his work and put his head between his hands and sit that way for hours together and then perhaps in an instant without any provocation would fly into the wildest of passions. From Edward, a companion of his: That he tried to kill him with a poker and also with a small table that was in the room.
Approximate duration of present attack: 2 years
Number of Previous Attacks: 0
Number of Previous Admissions: 0
Number of Subsequent Admissions: 0
Total Number of Admissions: 1
Clean Habit: No - watered his bed
Food Refusal: Yes - obliged to be fed previously to coming here
Sleep Habit: Bad
Destructive Habit: No except that he threatened to burn bedclothes
Physical/Mental State at Examination: Lost his eye last summer from a blow from a piece of iron while at work at Valley Foundry. Free from bruises. Middle sized. Lymphatic temperament. Plump and well nourished. Tongue slightly furred. Bowels costive. Appetite good. Pulse strong, heart sounds normal. Has been in Holyhead Workhouse since last Saturday. Brought by the men from Rhydwyn where he resided. Attempted to escape from the workhouse by the windows so that vigilance was necessary to prevent it. Has been gradually getting worse for the last two years becoming taciturn and listless. On admission he was quiet, had a vacant expression of countenance, was quite incoherent and unable to comprehend any questions asked him. Laughing idiotically and saying yes or no to any enquiry. Utterly fatuous.
Current Diagnosis: Delirium (F05.9)
1875 Apr 10 - Today the patient is in the same condition. Walks about in the shed.
Last night he slept well but is of unclean habits having wetted his bed.
Today he was once rather violent and tried to kick a patient.
Has lost his left eye from traumatic corneitis - the result of a blow from a piece of iron.
Eats well but is in a condition of perfect incoherence and mental vacuity.
Apr 13 - This afternoon at 3 o'clock he was seized with a series of epileptiform convulsions notwithstanding that there was no previous history of epilepsy.
They were very violent in their character and have continued with varying intervals throughout the evening.
He is perfectly insensible, breathing stertorously, pupils dilated, the convulsions being limited to the left side, the limbs on which side in the intervals are paralysed. The faeces and urine were discharged involuntarily. The pulse is rapid and feeble and the extremities somewhat cold.
A blister was applied to the nape of the neck.
Apr 14 - The convulsions continued through the night but with far less frequency and violence.
This morning they ceased altogether leaving the patient nearly insensible though he mutters indistinctly when roused.
When raised into the erect posture the left arm and leg showed a considerable return of muscular force.
Apr 16 - Today the convulsions returned with greater violence than ever. He was given a drop of Croton Oil which not being effective was repeated, this having failed to evacuate the bowels. About 10 pm a Turpentine and Castor Oil enema was administered which succeeded.
Apr 17 - This morning he is very much improved.
No convulsions, trying to get out of bed and showing there is no impairment of muscle power. He was found wandering in the corridor.
Completely incoherent and no idea of speech.
During this attack he has been sustained on milk.
Not able to feed himself.
Apr 19 - Continues to improve. Obliged to be fed, has emaciated considerably and when made to walk there was obvious impairment of muscular power, he tottered and had a little tremor.
No control over rectum or bladder.
May 4 - Has improved very much in his bodily condition. No return of epilepsy.
Very restless and mischievous and as speechless and incoherent as ever.
Found him today in bed in the padded room which he had entered and closed upon himself having chanced to find it open.
Eats well, somewhat noisy at night, very dirty in his habits.
May 11 - No return of fits, otherwise no improvement.
June 3 - Has fits occasionally. In bed since last 14 days.
June 30 - The patient got gradually more and more paralysed and had frequent attacks of epileptiform convulsions.
He had long been utterly demented and unable to form a single word. Since last date he has been lying in water bed as bedsores had formed.
To the last he took nourishment freely.
He died this morning.
Medications/Treatments: Blister to nape of neck, Croton Oil, Turpentine and Castor Oil enema