CHAPTER V

THE HOSPITAL TREATMENT OF MENTAL DISEASES

The responsibility of the hospital for the future of the patient begins with his arrival at the institution and the ultimate outcome of the case often depends entirely upon the developments of the first few weeks of his residence in the wards. A complete understanding of the patient's mental condition, the prospects of an ultimate recovery and the line of treatment to be followed can only be determined by a thorough and accurate examination on admission. This constitutes the basis for all further procedure. If satisfactory results are to be obtained this task should be delegated to a medical officer who has had an extended psychiatric experience. For purposes of completeness, as well as uniformity, a definite plan should be followed. The form used in writing the initial history and in recording the results of the routine mental and physical examinations at the Boston State Hospital are described in full in the "Medical Staff Manual" which is furnished to all assistant physicians entering the service. This has been found to be of great assistance in the training of new men along proper lines and insures a uniformity of hospital records which is indispensable. In a general way the form of examination employed by Meyer and Kirby[31] for some years has been followed. As this scheme is fairly representative of the method of procedure used by hospitals for mental diseases throughout the country it has been thought worth while to reproduce it in full.

HISTORY

_Name of Physician_: _Date_:

_Name of Informant, Address, Relation to Patient_:

It is often desirable to make a note on the intelligence and apparent reliability of the informant.

_Residence and Citizenship of Patient_:

Birthplace? Date of birth? Time in Massachusetts? If foreign born, date of arrival in U. S.? Naturalized or alien?

_Family History_:

It is not sufficient to ask simply the general question: Has any member of the family been insane or nervous? A great many persons will answer in the negative, whereas a detailed inquiry will often bring out a number of instances of nervous or mental troubles.

Specific inquiry must be made concerning the persons of the direct ancestral lines as follows:

(a) Paternal grandparents—nervous or mental disease?

(b) Maternal grandparents—nervous or mental disease?

(c) Father: Age, nervous or mental disease, alcoholism? If dead, age at death and cause of death?

(d) Mother: Age, nervous or mental disease, alcoholism? If dead, age at death and cause of death?

(e) Number of children in family (brothers and sisters of patient). Nervous or mental trouble in any of these besides patient? Psychopathic personality, alcoholism, criminality, etc.?

(f) Collateral branches: mention any known cases of insanity or nervous diseases in uncles, aunts or cousins.

PERSONAL HISTORY OF PATIENT

1. _Early Development_:

Birthplace and age, unusual incidents attending birth, retardation in talking or walking, infantile convulsions, night terrors, fits of temper, etc.—Severe illness or infectious diseases in infancy or childhood—Sequella? Frights, shocks or injuries?

2. _Education, Intellectual and Moral Development_:

Educational opportunities, time spent in school, interest in studies, progress, marks, behavior, truancy, etc.?

As an adult, regarded as bright, intelligent or dullminded? Well informed or ignorant? Reading, memory, judgment?

Moral responsibility, reliability, religious interests? Church affiliations?

Criminal traits, tramp life, police record?

3. _Sexual Life_:

Precocious interests in childhood, masturbation, abnormal practices, assaults or seduction?

Love affairs and disappointments? Age at marriage or reasons for single life. Moderate or excessive sexual desires, irregularities or prostitution.

Miscarriages, number of children, date of birth of youngest? If barren, what explanation; what effect on patient?

Frigidity, loss of power, refusal of partner, infidelity, measures to prevent conception. Treatment of partner, abuse, separation, divorce.

Perversions, abnormal methods of gratification with same or opposite sex.

In women, unusual symptoms at menstrual periods; age at menopause, nervous symptoms accompanying climacterium?

4. _Diseases and Injuries_:

Any previous nervous affection or symptoms, such as headaches, nervous prostration, chorea, epilepsy, hysterical attacks, etc.?

Mention severe infections diseases and sequella, if any. Inquire concerning tuberculosis, rheumatism, heart disease, nephritis, etc.

Venereal disease, _syphilis and gonorrhea_, full account, if possible, of how acquired, age, treatment and after affects.

Severe injuries, particularly head traumata, should be described as regards their immediate and subsequent effects.

5. _Occupation_:

Kinds of work undertaken, ambition, efficiency, wages, etc. Length of time in different positions, reasons for change, etc.

6. _Alcoholism and Other Toxic Influences_:

Intemperate, moderate or total abstainer? If intemperate, age at which drinking began, apparent cause of same, kind of beverage consumed and approximate amounts. Periodic or steady drinker? Usual reaction to alcohol?

Inquire about attacks of neuritis, delirium, hallucinatory episodes, suspicions, ideas of jealousy.

_Other toxic influences_: Drug habits, occupational poisons, lead, arsenic, phosphorus, mercury, etc. Illuminating gas poisoning, nicotine intoxication.

7. _Mental Make-up or Type of Personality_:

Very important because certain of the non-organic psychoses appear to be a further development of mental traits or tendencies early recognized as personal peculiarities or deviations from the normal. In addition to the points already covered under the preceding headings, the following important types should always be borne in mind and appropriate inquiries made:

_Manic make-up_: Lively, active, sociable, pushing, talkative, cheerful, optimistic; may be domineering, irritable and inclined to cruelty; sometimes not very efficient, may be noted as changeable, lacking in persistence, concentration and application. May show transient blue spells or lowering of spirits.

_Depressive make-up_: Gloomy, worrisome, blue natures who feel continuously inhibited or restrained and unable to make decisions; easily discouraged.

_Cyclothymic make-up_: Emotionally unstable, either up or down, have blue spells or are unduly cheerful and care-free.

_Shut-in make-up_: Shy, retiring, self-conscious, bashful, quiet, secretive, seclusive and unsociable. Lack of interest in opposite sex or definite aversion; often prudish and over-particular. Unusual religious interest frequent. Inclined to day-dreaming, show fondness for the abstract and mystical. Odd habits, hobbies or cranky pursuits are common.

_Paranoid make-up_: Mistrustful, suspicious, tend to misunderstand; unduly sensitive, feel discriminated against and have feelings of self-importance. (These traits may be related to shut-in tendencies.)

Other types of make-up include the psychasthenic, neurasthenic and hysterical; also the mentally retarded or undeveloped (feebleminded).

8. _Previous Attacks of Mental Disorder_:

Obtain dates, places where treated, apparent cause, duration of attacks and general character of symptoms.

9. _Precipitating Cause of Present Psychosis_:

Try to determine what occurrence or situation appeared to bring about the mental breakdown. Emotional strains, excitement, quarrels, worries, griefs, disappointments, sexual episodes, separation, deaths, childbirth, etc., financial loss, overwork, physical disease, etc.

10. _Onset and Symptoms of the Psychosis_:

Take as far as possible a spontaneous account beginning with date when first symptoms were noticed in the patient. In this connection particular attention should be given to changes in behavior, in mood, in manner of speech, in attitude towards others and towards work.

Appearance of suspicious, unusual interests, peculiar ideas and delusions?

Hallucinations in various fields and reaction to them?

Obtain as much as possible regarding trend of patient's ideas, topics of conversation and content of hallucinations. What did voices say? What was seen in visions?

Forgetfulness, impairment of memory, loss of orientation and clouding of sensorium.

Always inquire regarding suicidal inclinations or attempts, threats of violence, assaults or homicidal tendencies.

Compare informant's statement with those given in the commitment certificate.

What treatment was given at home? Name of physician in attendance?

Date on which patient was taken to hospital.

PHYSICAL EXAMINATION

I. _GENERAL TYPE, APPEARANCE AND CONDITION_:

1. Weight (with or without clothes).

2. Height and general frame.

3. Malformations (wherever possible state the origin); asymmetries of skull, face, body, spine, thorax; form of palate (low, high, asymmetrical, saddle or V-shaped, longitudinal torus).

Ears (adherent lobules, prominent anthelix, satyr-points, large, angle, asymmetry, length, etc.).

Abnormalities of hands, feet, sexual organs.

4. Color of the skin.

Color and quantity of the hair.

Color of the eyes.

General complexion.

5. General nutrition (panniculus and muscles).

6. Condition of the skin and mucous membranes; anemia, jaundice, dropsy, pallor, flushing and cyanosis; eruptions (describe in detail). Trophic disorders.

7. Scars, bruises and moles (size, location, color and origin).

8. Evidence of syphilis: scars, including those of the penis, back of tongue (patches devoid of villi and fissures) and palate; tibial crests; glands of elbow, groins and neck.

9. Signs of gout and rheumatism, goitre or nodes of the thyroid, etc.

10. Temperature, general, and various parts of the body (both sides if indicated as in hemiplegia).

II. _NERVOUS SYSTEM_:

1. _General and subjective sensations and facial expression_:

General feeling of well-being or exhaustion, general complaints, weakness, etc.

Vertigo: (constant, occasional, or occurring when the patient walks, or in the dark).

Headache: Whole head or limited space; frontal, vertical, occipital, unilateral, bilateral, deep or superficial; constant or periodic, aggravated at night or by some special cause, as with heat, with or without tenderness of head or spine to touch or pressure. Backache (general or localized).

Ovarian, infra-mammary, lumbar and vertex pains (in hysteria).

Neuralgic pains: (fifth nerve, intercostal nerves, sciatic nerve, with pain points, etc.) and muscular pains.

General or wandering pains: Pains in bones (legs) afternoon or night. Girdle pains. Precordial pains (with or without anxiety).

Zones of hyperesthesia: See below.

2. _Eyes_:

Expression: lids: obliquity, mongol type, lagophthalmus, protrusion of eyeballs (with or without the Graefe symptom), ptosis; spasm of palpebral muscles.

Movement of eyes, nystagmus, strabismus (divergent or convergent); position and extent of movement of the eyes; double vision (in what direction does the second object move and incline?).

Weakness of the internal rectus (in close focussing).

Conjunctiva, lachrymal canal. Scars of cornea. Arcus senilis. Reflectory iridoplegia.

Size and form of pupils. Residuals or formation of adhesion of iris. Contraction of iris on exposure to strong light; on accommodation (for near vision) and after shutting the eye.

Imperfect sight (reading print), improved or not by glasses, dimness of sight, limitation of field of vision, scotoma, hemianopsia, loss of color sense; anomalies of refraction. Condition of apparatus (cornea, lens, vitreous body). Ophthalmoscopy where indicated (for choked disc, optic atrophy, lesions of the fundus). Field of vision where indicated and possible (reversal of color fields in hysteria; scotomata).

3. _Ears_:

Discharge, otoscopy. Defect of hearing on one or both sides (use watch and tuning fork).

Conduction through skull. Tinnitus aurium (auscultation for actual sound, over the head).

4. _Taste_:

Test separately the anterior two-thirds of tongue and the posterior third with weak solution of sugar, quinine, acid, salt.

5. _Smell_:

Test each nostril with oil of cloves, bergamot, peppermint, wintergreen and lemon. Note the actual answers.

Parosmia. Put down the actual extent of discrimination and recognition, with explanation of defect (mental, local, or nervous).

6. _Cutaneous Sensibility_:

1. Tactile sensibility (use the finger-tip, feather, or pin). Compare both sides of face, arms, hands, fingers, breasts, inner and outer aspects of thighs and legs. (Never omit the ulnar side and the area outside and above the knee). Sole and dorsum of feet.

2. Localization of touch (time and space) and tickle.

3. Sensibility to pain (cautious pricks with a pin, localization in time and space), with or without the attention of the patient.

4. Sensations of heat and cold (cold water and warm water in a glass tube). (a) Sense of position: See below. (b) Stereognostic sense.

5. Subjective sensations (formication, feeling of needles and pins, numbness).

6. Tenderness of nerve trunks and muscles on pressure and percussion. The distribution to be noted on the drawings of the body surface.

7. Biernacki's sign (analgesia of the ulnar nerve); anesthesia of eyeball; of testicles.

7. _Vasomotor and Trophic Conditions_:

Salivation, seborrhea.

Cyanosis or pallor; scaliness or loss of hair; change of nails.

Blushing, dermatographia. General or localized perspiration. Temperature of paralyzed or anesthetic parts.

8. _Motor Functions_:

Mobility of facial muscles (laugh) (wrinkle the forehead and the nose; move the ears; show the teeth and shut the eyes); tongue; palate.

Muscles of the neck, trunk and extremities; gait.

Functions of the successive segments: In case of paresis or paralysis define the limits of the condition and indicate the results of the following tests: For loss of power: for the coordination of movement (writing, buttoning coat); for muscular sense (discriminating difference in weight; with eyes shut tell the position of the limbs and show with one side the position of the other). Balancing power: (walking along a straight line, stand upright with heels and toes together and eyes closed).

Never forget the test of equality of grip, flexor and extensor strength of elbow, knees and toes. For test of weakness of one lower extremity have both lower extremities raised and hold to fatigue limit. The weaker limb will sink a certain number of seconds before the other.

9. _Reflexes_:

1. Deep reflexes. Masseteric: elbow, wrist, knee-jerk with or without Jendrassic, with clonus, or contralateral adductor reflex, knee-cap reflex; ankle clonus and Achilles tendon reflex. 2. Superficial reflexes: Plantar (with full description as to the Babinski reflex), gluteal, cremasteric, abdominal, epigastric, scapular, corneal, palmar, sneezing.

10. _Condition of the Paralyzed Muscles_:

Firm and of good tone, or flaccid or deficient in tone. Rigid and contracted. Note attitude of limb and the limitation of the motion, active and passive. Atrophy, hypertrophy, electric reaction of nerve and muscle (galvanic and faradic irritability when required).

11. _Fibrillary Twitching_:

Its distribution.

12. _Tremor_:

Of what parts; rhythm, intensity, rapidity. Condition at rest during sleep; when first observed. Condition during motion, how influenced by will.

13. _Organic Reflexes and Their Control_:

Bladder; delay of micturition. Dribbling from empty bladder, from distended bladder. Peculiar sensations on micturition.

Sexual reflexes: Frequent involuntary contraction and evacuation.

Defecation: Is the patient conscious of evacuation?

14. _Convulsions_:

Distribution: Extending over head, trunk, extremities, one side, one member.

Character: Which parts first and most attacked, and how do the waves of the tonic and clonic spasm spread; what movements predominate?

Average duration, frequency, occurring night or day, or early in the morning.

Breathing; pupils; vasomotor condition; froth and bites.

Sphincters: Consciousness totally or partially lost.

Aura.

Equivalents: with or without what automatic movements.

Physical and nervous symptoms before and after attack.

Hysterical attacks.

III. _THORACIC ORGANS_:

Respiratory organs: Is there any difficulty of breathing, permanent or in attacks? Sleep with mouth open? Any pain on deep inspiration? Any cough or expectoration (where from). Nose and larynx. Shape of chest. Frequency of respiration. Respiratory movements. (Compare both sides in deep inspiration and expiration).

Lungs: Percussion. Auscultation. Expansion.

In case of dullness or other abnormalities: Fremitus.

Contents of pleura.

Circulatory organs: Is there any palpitation? In attacks? Due to what? Subjective sensation of arhythmia? Heart: The impulse seen and felt in what area? Relative dullness (right, upper and lateral borders). Sounds and bruits (localized). Pay special attention to muffling of the first sound, to duplication; to change of murmurs in inspiration and by position. Rhythm and accentuation.

Radial pulse: Rate, quality, on lying and sitting and standing. Special attention to variability through position or motion or exertion. If desirable, sphygmogram.

Condition of radial, brachial and temporal arteries.

Arcus senilis.

Sclerosis of veins. Varicosities.

Blood pressure.

IV. _DIGESTIVE AND ABDOMINAL ORGANS_:

Appetite, thirst, anorexia, nausea: Relative to quantity and quality of food. Vomiting (time and form), eructations and brashes; pain (locality, irradiation and time).

Mouth and teeth. Fetor. Fauces and pharynx. Stomach (position, etc.). Digestion. Movement of bowels. Any subjective feeling of obstacle? Form of stools. Flatulence and distensions. Hemorrhoids and fistulas.

Liver and spleen.

If indicated, examination of stomach contents.

V. _URINARY APPARATUS_:

Micturition: Urine, amount in 24 hours, specific gravity, color, reaction, odor, albumen, sugar and indican, etc.

Macroscopic and microscopic examinations of sediment, clouds and threads; casts, epithelia, erythrocytes, leukocytes, bacteria, threads, crystals, amorphous substances.

VI. _GENITAL ORGANS_:

Scars of genital organs. Menstruation: regular; profuse; scanty; accompanying symptoms.

Discharges at intervals; constant; profuse; color.

Internal examination.

In men: Frequency and character of the sexual functions. Frequency of emissions, their occasional exciting causes and correlated symptoms.

Diagnostic summary and indications for further observation and treatment.

MENTAL EXAMINATION

I. _ATTITUDE AND MANNER_:

General appearance of the patient, adaptation to surroundings, patient's general attitude and behavior, attention and cooperation. Note any peculiarities of conduct or demeanor (peculiarity of dress, mannerisms, grimacing, affectations, etc.). Note the manner, gestures, form of intonation, rapidity or slowness of speech, or special peculiarities. Facial and general expression (sadness, anxiety, fear, restlessness, excitement, etc.). Psychomotor retardation or excitement (violence, destructiveness), care of person (whether cleanly or untidy, etc.).

II. _STREAM OF MENTAL ACTIVITY_:

1. _Flow of thought_: Give sample of spontaneous expression or productivity, if possible. If not, give reaction to questioning. Show any disturbance of train of thought (retardation, confusion, incoherence, poverty of ideas, volubility, flight of ideas, distractibility, rhyming, desultoriness, circumstantiality, perseveration, fabrication, coinage of words, verbigeration, echolalia).

2. _Abnormalities in the motor reactions_: Negativism, catalepsy, echopraxia, stereotypy, automatism, mutism, etc. Show loss of initiative, lack of spontaneity or slowness in action, etc.

III. _EMOTIONAL TONE_:

Moods and affects. Show the presence of cheerfulness, laughter, mischievousness, excitement, exaltation, depression, anxiety, fear, perplexity, tendency to be startled, irritability, constraint, confusion, indifference or apathy. Show sensitiveness, seclusiveness, suspicion, emotional instability or suggestibility.

IV. _MENTAL CONTENT_:

1. Hallucinations; hearing, vision, taste, smell, sensation, etc.

2. Delusions; persecution, suspicion, infidelity, poisoning, electricity, hypnotism, mind-reading, self-accusation, grandeur, etc. Show whether permanent or transitory, systematized or unsystematized.

3. Illusions.

4. Obsessions, phobias, etc.

5. Nature of sleep, dreams, etc.

V. _ORIENTATION_:

Time, place and person.

VI. _MEMORY AND MENTAL GRASP_:

1. Recent past.

2. Remote past.

3. Retention of school knowledge.

4. Fund of general information.

5. Data of personal identification.

6. Counting and calculation.

7. Reading and writing.

VII. _INSIGHT AND JUDGMENT_:

The judgment concerning the situation, insight concerning physical and mental health and efficiency, financial status, plans in case of discharge? In discussion of abstract and complicated topics? To what extent is he sensitive to his own errors and to comments?

VIII. _SUMMARY_: Physical and mental.

IX. _DIFFERENTIAL AND PROVISIONAL DIAGNOSIS_.

The question as to what benefit is to be derived by the patient from a residence in a hospital for mental diseases is one which is often raised by relatives and friends. They are quite inclined to feel that if no medicines are being prescribed nothing is being done for the patient and that he could be cared for just as well at home. In considering this question it should be borne in mind that the persons under treatment in a hospital for mental diseases are there, either because they appreciate the need of hospital care themselves, or because, as a result of mental disorders, they are incapable of directing their own affairs, or are, in the eyes of the law, dangerous to themselves or others. Their property and other legal interests must be protected during their period of incompetence. Such persons are liable, if not adequately safeguarded, to enter into improper contracts or make legal conveyances that mean financial ruin to themselves as well as others. Unfortunate sexual irregularities frequently occur. Conduct disorders of various kinds are to be expected and a tendency towards criminal acts is common to several of the psychoses. It is a well-known fact that every mentally unbalanced individual is potentially dangerous, no matter how harmless he may appear. The suicide rate of the country as shown in one hundred of the largest cities has not fallen below fourteen per hundred thousand of the sane population at any time during the last twenty years. The homicide rate in thirty-one of our large cities has not dropped below eight per hundred thousand of the population since 1909. Many of these crimes were undoubtedly committed by persons who should not have been at large and who were not responsible for their acts. The most important benefit derived by the patient in the hospital is the constant personal supervision given him by experts throughout the twenty-four hours of the day, whether he is asleep or awake. He gets the benefit of regular hours of rest and exercise, a properly regulated diet adapted to his needs, a sufficient amount of fresh air, and amusement and entertainments suited to his mental condition. He receives competent medical, dental and nursing care and is provided with opportunities for occupying himself in many different ways. Reading matter is always available for those who care for it. Even religious services are held for his benefit.

The tendency of late years is to dispense with the use of drugs as far as possible and resort to other methods of accomplishing the same results. One of the most important therapeutic procedures in common use in the modern hospital for mental diseases is hydrotherapy. This should be used intelligently if any results are expected. Sending the patient to the hydriatic department where identically the same treatment is applied to all cases whether of excitement, depression, exhaustion, etc., by an attendant who has no knowledge of either medicine, psychiatry or nursing may be referred to as the application of water to the exterior, but it is not hydrotherapy. Hydriatic treatments should be prescribed by a physician who has a thorough familiarity with that particular therapeutic procedure and every patient should receive the form adapted to his individual needs. The treatment should be given by an expert hydrotherapist. The equipment should provide for hot air, electric light, vapor and saline baths, Sitz baths, circular, rain, fan, jet and Scotch douches, dry, hot and cold packs, etc. Much can be accomplished by tonic, stimulating and eliminative therapy. Sedative treatments are much used in hospitals for mental diseases. The hot air bath[32] is given at from 134 to 170 degrees Fahrenheit for from four to ten minutes, preceded by a foot bath at from 104 to 110 degrees. The patient enters the electric light and vapor bath at the room temperature, the baths being continued from four to eight minutes usually. The needle spray is given at a temperature ranging from 96 to 102 degrees, with a pressure of from twenty to thirty pounds, and continued from one to two minutes. The fan douche starts at 90 degrees, is reduced gradually with a pressure of from twenty to twenty-five pounds and is continued for from fifteen to twenty seconds. The jet douche is first used at 90 degrees and gradually reduced, with a pressure of from fifteen to twenty-five pounds, for from ten to twenty seconds. The Scotch douche is used at a temperature of 80 degrees alternating with 110, with from fifteen to thirty pounds pressure. It should be used with extreme care. The same is true of vapor douches. The saline bath contains five pounds of ordinary salt to sixty gallons of water at a temperature of 94 degrees and is continued from ten to thirty minutes. The dry pack is usually continued from twenty to forty-five minutes, although it may be used longer with safety. In the use of the hot blanket pack the inner blanket is wrung out of water at from 140 to 160 degrees and must be applied with great care. Depending on the condition of the patient, etc., the cold wet pack is given with sheets wrung out of water at a temperature ranging from 50 to 60 degrees, although lower temperature may be used. "Neutral" wet sheet packs are often used at a temperature of from 100 to 116 degrees for approximately three-quarters of an hour, as preparatory treatments. These measures should never be attempted by anyone who has not had an extended practical experience. Much can be accomplished by hydrotherapy in the alcoholic and toxic conditions, infective and exhaustive psychoses, manic excitements, involutional melancholia, hysterical and neurasthenic conditions, as well as in occasional cases of dementia praecox. Occupational therapy has been used to great advantage in connection with the hydrotherapeutic treatments.

In the reception service and in the buildings for the noisy and violent cases ample facilities should be at hand for the continuous bath treatments. Pack rooms are also desirable. There is no means at our disposal equal in any way to the efficacy of the continuous bath in controlling excitements. The patient is usually kept in the tub from five to eight hours at a temperature varying from 92 to 97 degrees and averaging 96 degrees. In some hospitals they are kept in the tubs for periods of from two to three weeks. The continuous bath is of no value unless it means what the name implies—the continuous submersion of the body in water. In dealing with very excited cases this necessitates the use of a tub cover and a hammock, although sheet coverings are often used satisfactorily. Not much is to be gained by the tub bath if the patient is to be allowed to get out and in as he pleases and only come into partial contact with the water. The continuous bath is not without drawbacks. There is danger of chilling, scalding and drowning either by accident or with suicidal intent, etc. Too much care cannot be exercised in the supervision of the bath rooms. Every tub room in the Boston State Hospital has the following rules conspicuously displayed:—

THE CONTINUOUS BATH ROOM

1. The nurse on duty in the bath room will be held personally responsible for the safety of the patients and must be thoroughly familiar with these rules. The nurse must never leave the room unless relieved by some other nurse. Eternal vigilance is necessary to prevent the chilling, scalding or drowning of the patient.

2. Patients are to be given continuous baths only on the written order of a physician.

3. Patients going to or from the bath room must wear a nightdress or bathrobe and slippers when not fully clothed.

4. Tubs not in good condition or not properly equipped must not be used.

5. Only patients under treatment are allowed in the room.

6. Toilet each patient just before the bath. Patients may be removed from the tub for toilet purposes when necessary.

7. In preparing for the bath, warm the tubs with hot water and then regulate the temperature so that a small amount of water at 96 degrees will be flowing continually.

8. Adjust the hammock to the tub and place the patient in the bath resting on the hammock. Adjust the cover to the tub, with patient's head through the neck opening unless sheets or other covers are used.

9. The temperature of the water must be taken in each tub at least every half hour. Feel the water in each tub frequently. If it seems too warm or too cold, take the temperature at once. If you find it varying from 96 degrees adjust to that temperature by adding a small amount of hot or cold water. If the temperature cannot be kept between 95 and 97 degrees, let the water out of the tub and remove the patient immediately. The physician in charge and the chief engineer should be notified at once. The bath tub key must be fastened to a special cord worn by the nurse on duty. It must be delivered to the nurse in charge of the ward when the bathroom is closed.

10. If the patient is very noisy, restless or flushed, fasten an ice poultice to the tub cover so that as the patient lies in the water the back of the head or neck will rest upon it. Replace with a fresh one before the ice is entirely melted.

Intensely excited patients may have cold compresses to the neck, changed often, for periods of 20 minutes.

Sponge all faces with cold water once an hour.

11. Patients are to be permitted to drink as much cool water (not iced) as they desire, and must be offered a drink at least once an hour.

12. The nurse must record the following: 1. The water temperature and the patient's pulse rate (temporal or facial) every half hour. 2. The amount of sleep in the bath. 3. Bowel movements. 4. Nourishment. 5. Medicine administered. 6. Hours of each patient in the tub. 7. The name of each nurse and the exact time of going on or off duty.

13. In case the patient shows symptoms of fainting or convulsions, makes any attempt at drowning, shows suicidal tendencies or becomes too violent to remain in the tub with safety, let the water out and remove the patient at once.

14. In the event of any serious accident or injury or sudden illness the patient should be removed from the tub at once and the physician notified.

15. Patients are not to be allowed to feed themselves but must always be fed by the nurse. The inlets to the bath may be closed for twenty minutes while patients are being fed.

16. During the day the warming closet must always contain one sheet and one towel for each patient in preparation for drying. It must also contain washable rugs for patients coming out of the tubs to step upon; also two blankets for emergencies.

At least one hour before the patients are to be removed from the baths the garments they are to wear after the bath must be placed in the closet.

17. The temperature of the room should be kept as nearly as possible at 76 degrees Fahrenheit. If the temperature of the room cannot be kept above 68 degrees discontinue the bathing.

When the care and treatment of mental diseases was first undertaken in our state institutions it was soon found necessary to take advantage in every way of such material assistance as could be offered by the more intelligent class of ablebodied patients in carrying on the routine work of the hospital. There were never employees enough to dispense with their services. In this way it came about that they were employed in the farms and gardens, assisted with the kitchen and housework, shared the tasks of the nurses and attendants in the wards and were busily engaged in almost every department of the hospital activities. It became apparent that occupation, undertaken originally for purely economical purposes, constituted one of the most important therapeutic agents at the disposal of the institution. The next step was the development of industries. Patients were taught by instructors to make clothing, underwear, stockings, shoes, brooms, mats, brushes, mattresses, furniture and many other useful products needed by the hospital. The end products were in every instance utilitarian. These accomplishments led to a still further development—purely occupational in character. Women were encouraged to take up such activities as rug making of all varieties, basketry, weaving, crocheting, embroidery, and needlework of every description. Men usually make towelling on looms, weave rugs, renovate mattresses, do repairing of all sorts and manufacture small articles which interest the masculine mind. Brass work, clay modelling and making jewelry of various kinds have been extensively employed.

All of these forms of employment mean, of course, that the patient must leave the ward and go to some place designed for the purpose. The others, however, have not been overlooked and occupational therapists, who devote their entire time to stimulating the interest of the patients who cannot leave the wards, on account of their mental or physical condition, in some absorbing and diverting occupation, are an important part of the personnel of every institution. No other form of treatment employed in hospitals for mental diseases has been so productive of results. It is interesting to note that the medical officers of all of the forces engaged in the recent war found that occupational therapy was of great value in cases of shell shock and war neuroses.

The highest development perhaps of occupational therapy has been in its application to strictly reeducational work in dementia praecox. This consists in a graduated and systematized reeducation of interests in apparently deteriorated individuals. The success of these efforts depends largely on the fact that very simple lines are followed at first. The patients are interested in marching to music, simple drills, calisthenics, games, basketball and purely physical exercises. Some can be induced to sort out raffia and ultimately take part in basket making. Others cut out pictures or put puzzles together. The women sometimes are willing to do plain sewing or make paper flowers. They progress by easy stages to more advanced and elaborate undertakings leading eventually to occupational work in the wards or possibly in the industrial rooms. Some of the apparently most hopeless cases have, as a result of these reeducational efforts, been able to return to their homes greatly improved. The mental improvement goes hand in hand with a resumption of their interests in their former work or some new occupational venture which may have proved attractive.

Every effort should be made to avoid the possibility of long hours of idleness in the wards. When not actively employed in occupational work, ward games, reading, etc., the patients should be taken out of doors for fresh air and exercise. This, of course, suggests the necessity and importance of attractive surroundings. Nothing can be more depressive or detrimental to the welfare of the patient than a prisonlike appearance either inside of the buildings or on the grounds. The successful operation of a hospital is dependent in no small measure on the amount of attention devoted to the preparation of food. There must be a general dietary for the active ablebodied class, one for the working patients, an entirely different one for the tuberculous and epileptic cases and a special diet for the strictly hospital wards. In an institution of any size this requires the constant supervision of several dietitians.

The advances of recent years in our knowledge as to the etiology and nature of general paresis have led to the introduction of highly specialized therapeutic methods in the treatment of that disease and of cerebro-spinal syphilis. This is an important feature of the work of our hospitals at the present time. The interest recently shown in the study of the endocrine system has already brought about a new line of therapy which is destined to receive much attention in the future.

Even the amusements necessary for the individual are given special attention in the treatment of mental diseases. This refers not only to methods of recreation and diversion in the wards day by day but includes moving picture shows, dances and various other special entertainments. Not the least important consideration is the patient's bodily health. This is often a determining factor in bringing about a restoration of mental integrity. It very often happens that there are diseases of the eye, ear, nose, throat, skin, nervous system, etc., which may require attention. Dental, surgical, gynecological and other special treatments sometimes prevent ordinarily acute and recoverable psychoses from terminating unfavorably.

In a word, the modern hospital treatment of mental diseases may be said to consist of a direct personal supervision of the mental and physical hygiene of the patient, supplemented by such specialized therapeutic procedures as may be indicated in the individual case.