Mental diseases: a public health problem. James Vance May
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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