must diligently make effort to substitute useful and invigorating emotions for those which are depressing, pure and ennobling thoughts for those which are unwholesome and debasing, and direct the activity into channels of helpfulness, usefulness and industry. This is a task which calls for the full use of all the powers of mind, sympathies of heart and skill of hand which a nurse has to offer.

The observation of symptoms in mental disease presents many difficulties, because of the not infrequent lack of cooperation and inability of the patient to accurately express them. Physical symptoms must not be overlooked, for very often an exacerbation of the mental symptoms is traceable to some disordered physical function, and some forms of mental illness result directly from imperfect or deranged function of some other part of the body. Because of a dulling of sensation some physical condition which would cause great suffering to the sane person apparently produces no discomfort, while on the other hand slight and trivial conditions are so exaggerated that they seem to produce almost unbearable pain and wretchedness. The nurse must learn therefore to discover symptoms and conditions of which the patient never complains, and to discriminate between symptoms which are real and those which are feigned or imagined. The temperature is subject to many variations. Inasmuch as a good deal of the heat of the body is produced in the muscles, overactivity will cause an increase in the body temperature, while a state of sadness and inactivity tends to lower the temperature below normal. A very high temperature, not associated with infection or exhaustion, may be produced by intestinal intoxication, and is quite promptly reduced by enemata. A continued elevation, even of one degree, must not be disregarded, for many mental patients develop tuberculosis; and typhoid fever, diphtheria and other infectious diseases are not uncommon occurrences in mental hospitals. Unless the patient has been proven to be perfectly trustworthy the temperature must not be taken by mouth, for the thermometer is easily

broken and the pieces of glass may be swallowed, or the thermometer may be pushed down the throat and cause choking, or swallowed without being broken. When the temperature is being taken per rectum the thermometer must always be held in position by the nurse, and under no circumstances should the patient be left alone with it.

The pulse also shows many variations. A sudden emotional disturbance, fear, surprise or joy may hasten it, and sudden anger or agitation may make it irregular as well as rapid. In depressed states the pulse is usually slow. In some functional diseases the heart action may be greatly increased and the pulse rate may range from 100 to 150 without a corresponding elevation of temperature. This condition is shown in hyperthyroidism. A continued elevation of temperature and a persistently high pulse rate together with rapid respirations may be the indication of exhaustion or other serious condition, and the patient must be kept under careful observation.

The respirations are less reliable, for many nervous patients breathe as rapidly as sixty times a minute or the rate may be very much decreased. Frequent sighing respirations are quite common in neurotic individuals. However, dyspnoea upon slight exertion, when lying down or when associated with pain must always be regarded as an important symptom and promptly reported to the physician. Cheyne-Stokes respirations frequently occur in disorders of the central nervous system, and must be looked for and reported.

Nausea, vomiting and headache are significant symptoms and should be carefully observed. The character of the vomiting should be noted, whether it is accompanied by nausea or occurs independently of it, whether it is of the projectile type and when it occurs, whether at irregular intervals or immediately following meals. The character of the headache should also be noted, whether it is dull, throbbing or painful, and where in the cranium it is most

acute.

Loss of appetite when one has been eating well, languor

when one has been active, loss of weight and anæmia always are important indications of a lowering in the general condition. Each patient must be thoughtfully observed and peculiarities of conduct, attitude and appearance noted, for owing to the derangement of mental function these patients are more unlike than a group of physically ill patients would be.

It is, therefore, in the observation of mental symptoms that nurses who have the care of patients suffering from nervous and mental disorders must be especially proficient, and therefore must prepare themselves studiously, in order to recognize and understand them, for mental symptoms are more obscure and less tangible than physical symptoms, and many which are of great importance may be overlooked by a nurse who is not familiar with mental patients and their characteristics. Some symptoms are transitory and some others change, and some are cleverly masked and suppressed when the physician is present, so that it devolves upon the nurse who sees the patient in many situations and under various conditions to furnish as full and accurate a report as possible. In recording or reporting symptoms the nurse should state exactly what is said and done by the patient rather than the condition she thinks the symptoms indicate. If the patient stands for a long time gazing into space, listening, smiling and muttering, he is undoubtedly having hallucinations of hearing; but it is of much more real assistance to the physician to describe what the patient does and says, if the conversation can be heard, than to state that the patient has auditory hallucinations. Then, too, although the nurse may carefully make her observations, she may not always interpret the symptoms correctly and this might be misleading. If a patient seems worried and anxious, perplexed or apprehensive, find out if possible what is operating to disturb the peace of mind, and record this rather than the mere statement that the patient appears anxious, etc. Not infrequently does it happen that the nurse is able by tactful questioning and kindly, sympathetic

ministrations to ascertain what the disquieting ideas and feelings may be, even though the patient has persistently denied their presence or refused to reveal them. This is of great importance, for when the causes of mental conflicts are known, the physician is able to discuss them freely with the patient, to explain their origin, nature and import, to give suggestions how to correct them and to make the necessary readjustments, which afford great relief and many times mark the beginning of permanent improvement.

In the course of mental disease all the functions of the mind, thinking, feeling and acting, may be changed, impaired or lost, and in the following pages the disorders are arranged and defined under the headings which are most conveniently used in observing and describing symptoms.

I. DISORDERS OF BEHAVIOR OR CONDUCT

Inasmuch as the physical organism is the instrument of the mind and the body becomes the expression of the mind, any derangement of the mental functions is soon manifested in the behavior. Observers of the mentally ill agree that the intellectual defect is not the first abnormal symptom in mental disease, for the memory may show no impairment, the patient may be able to converse brilliantly, to argue convincingly on many questions, give no sign of hallucinations or delusions, and yet there is evidence that he is changed because the behavior is different from what it formerly was. These changes may be shown in all sorts of ways and nurses and those who have the care of the mentally ill must ever keep in mind that one whose language has been refined and whose conduct has been exemplary, may, when the mind is deranged, become vulgar, obscene and profane, and never should character be judged by its manifestations during mental illness.

The psychomotor activity may be increased or diminished in mental disease. Increased activity is shown by restlessness, constant moving about or acting in an excited, destruc

tive or violent manner. These activities which are the responses to the increased mental activity may be accompanied by talking, shouting, whistling, singing, scolding or threatening. When the activity is diminished there is much difficulty and slowness in executing movements, and in extreme cases the motor activity may be suspended. The speech is very slow, and may be monosyllabic or suppressed and the patient remains mute.

Impulsiveness is shown by sudden acts which are the responses to uncontrollable thoughts or feelings. These responses are in no way premeditated, for the idea barely comes into consciousness and is immediately transformed into action without thought of the consequences. Unprovoked attacks upon other patients and upon the nurses are frequently of this nature, as also are the hazardous and dangerous activities to which the patient is impelled frequently by hallucinations.

Suggestibility is a condition in which the activity is determined by impressions or suggestions received from others. There are three types: Echolalia, the tendency to repeat the exact words of another; echopraxia, the tendency to repeat or imitate the movements of another; and catalepsy, the tendency to hold or maintain by muscular rigidity a given position. If the arms are extended over the head, they will be held in that position for a very long time, it may be all day, unless some one changes them. Some patients who show this tendency can be molded or fashioned into almost any attitude and the positions are maintained indefinitely (Cerea flexibilitas). There is believed to be a form of muscular anesthesia present and the position of the various parts of the body is apparently unknown and unfelt.

Negativism is the tendency to respond to a stimulus in a way which is the reverse of the usual reaction. If a patient is told to put his tongue out, he does the exact opposite, shuts his lips tightly to keep his tongue in his mouth. Negativism may also be shown by resisting baths and treatment,