care of the insane gradually evolved the method of taking patients for work about the hospital and institution. First the ordinary ward duties and then gradually extending the work outside of the walls, until in Iowa each institution has built up a large farm which is taken care of in a great measure by the patients. Tɔ my mind this is all occupational therapy, maybe not in the minutest detail as spoken of in the paper, but the occupation is there and the therapy is there.

The public was prejudiced when Pinel struck off the fetters and the public is as prejudiced today when we give the insane dangerous weapons to work with, such as axes, sledges, etc. But we have all come to understand the insane better. We know today that most of them are amenable to be treated as normals. They have the same reactions, the same emotions, but do not control them as well and may be excused.

Occupational therapy has been evolved to take care of the mind that is really beginning to be demented. I cannot agree with the one quoted-I think it was Pollock-that it will close up the hospitals for insane, because it will not.

My own experience with occupational therapy is limited, but it was begun at Cherokee before the war. We began first on the back wards, my thought being that if we could teach new habits to demented patients, we could get less of untidiness and save in our clothing bills. It has been quite satisfactory. It has not made the patients any better, the dementia praecox cases are not any better, but their habits are better.

This work was carried on by Dr. Wm. A. Bryan, my second assistant, one of the brightest men I have met in the hospitals. of Iowa. He is now superintendent of a hospital at Worchester, Mass. He evolved a scheme of exercises and gymnastics for those who were moderately demented-weaving and basketry, and the making of various things out of hammock cord for those a little better.

After a short while at that with chronic patients he asked permission to take some patients from the acute service, those in the admission wards. Whether it was because he went away and took the spirit with him our work in the admission wards. has not been as satisfactory to us as it has been on the chronic

service. We have read and kept in touch with almost all of the literature on work in the acute service.

I was in the government hospitals during the war, but have not personally seen any of the United States hospitals since the war. But my belief is that you do less with the acute cases than you do with the chronic. To me the best place I have visited for occupational therapy is the Michigan City Hospital for criminal insane. They have developed it there to a remarkble degree. I think they have a population somewhat larger than at Anamosa. but have a large one, over 300 and over 80 per cent of their men are doing something-either making articles of service to the institution and other institutions, or doing some of the simpler things we do on the back wards.

There is no question at all but that occupational therapy ought to be in the hospitals for the insane and we should all do as much of it as we possibly can. And I am willing to have my mind opened about the recent cases, but at Cherokee I do not think we have had as good success as the literature referred to would make us believe.

Superintendent Witte: It is nearly time to adjourn but this is a subject on which I want to say a few words. I want to say that we have occupational therapy in its modern acceptation of the word at Clarinda but we have been selecting out those patients who were most promising and from the beginning would offer most hope of being benefitted by the various kinds of work. In the last three weeks, I have been at a hospital in southeastern Missouri at Farmington, an admirably conducted place which occupies advanced ground in bringing occupational therapy to the front.

Take for instance a ward such as ordinarily in our institution is known as a "back ward;" they take the entire ward out to the place where they are to be occupied, not leaving one behind unless bedfast, and occupy the attention of each patient. In the first place it gets them away from the ward. And out of the group there are those who will show themselves particularly responsive to this manual activity, and even though some do not do something to keep busy and while not permanently benefitted they are temporarily benefitted by the change of scene.

One case of a young man, evidently an old catatonic, sat with his eyes closed and his face away from the table, building a large brush with his hands not guided by his sight and he was doing pretty well. Another man was working with a block of wood, rubbing it smooth-do not know how long he had been working at it, nevertheless it was giving him something to do and he was benefitted to that extent. As has been said by Dr. Donohoe, we have had occupational therapy for many years.

One statement quoted in the paper, has been made in the past and has been discussed on the floor of this conference. When we argued I took occasion at that time to oppose it, and I still oppose it and that is: that in selecting occupation for the insane individual, it must be different kind than he is accustomed to. I did not believe it then and I do not believe it now. Must get the patient interested in something and focus that interest until the mind has been rehabilitated to such an extent as is possible. During excitement and active brain disturbance, patient does not require stimulation but on the contrary, quieting, rest and sleep for the restoration and regulation of disordered functions. With modification this is true also in depression. This also explains Dr. Donohoe's experience with acute cases. In these we have not had much success by diversion in the way of occupational therapy, and the disorder is unrelieved. But after the "brainstorm" has subsided a state of chaos remains behind, and if the patient is allowed to sit quietly, he will deteriorate, get into mischief, become destructive and disorderly, and generally unable to care for himself. If you do not divert his mind from the chaotic confused state and bring in some interest, something healthy, whether weaving a rug, hoeing in the garden, or some other health generating influence, he is liable to drift into permanent mental enfeeblement and vacity, metaphorically speaking, we should endeavor to aid him by the growing of fruit and flowers in the place where weeds were grown.

It is a real re-education and we must employ the same methods as for the normal mind. Dr. Donohoe is right in saying that the insane does not differ from the normal individual-is not different in kind. So we employ the same methods for the rehabilitation and re-education of the insane that the educator

does in the normal, developing personality. Froebel, Montessori, and other kindergarten teachers-these workers try to bring into service the psychometer system-that part of the brain which underlies our will-directed movements, and controls our harmonious and purposeful activity by messages going out from the brain.

In these directed coordinated movements, whether work or play, an interest must be there first and stimulated and fostered. By this, not only the psychomotor, but other brain fields also are set into orderly activity.

Member Strief (Presiding): Chairman McColl, you have made a notation here about the purchasing of supplies, did you wish to say something about that?

Chairman McColl: The author of the paper is not familiar with our method of purchasing supplies, so I think maybe the thought was inspired by someone else who does know and has a grievance.

The duty of the board of control is to conform strictly with the laws. It is not always possible to do these things, but we must be practical. I know of cases where employes were allowed to select goods-silks, yarns, etc, but to allow everyone to run to the merchant to select everything they want, it is entirely out of harmony with the law and should not be allowed.

Member Strief: If there is no further discussion of the paper, we will stand adjourned unto two o'clock.

The conference reconvened in the afternoon after intermission and proceeded with Member Butler in the chair.

PNEUMONIA SIMULATING APPENDICITIS IN
CHILDREN.

Member Butler (Presiding): The first paper this afternoon is on the subject, "Pneumonia Simulating Appendicitis in Children," by Paul A. White, M. D., associated physician at the Soldiers' Orphans' Home, Davenport, Iowa.

Dr. White: I might preface this paper with a little sketch of our work at Davenport. We think we have a very fine institution, and we have a very nice little hospital with about fifty beds available. We have a most excellent nurse in charge, and very intelligent cooperation from our superintendent.

As we get into some of these intense problems of diagnosis. in determining the proper method of procedure, at times we have felt a little handicapped in lacking some of the laboratory facilities we might have close at hand. We have been forced to resort to Iowa City and other hospital equipment. In emergency cases where laboratory results were necessary in a hurry, we are forced to depend upon ourselves. We feel that lives are saved by that procedure, and that no measure is toc extreme to be taken where it is a matter of life and death with these little youngsters.

It seems to us it is but a common sense principle and that it would help us sometimes to avoid the initiation of epidemics, if we had a cottage or some means for reception of our children when they first arrive at the institution, where they could be observed for three to six weeks, allowing an opportunity for development of any acute diseases they might have been exposed to. It would allow for complete examination; allow for immunization which has become definitely established and commonplace among progressive men-to diphtheria, small pox, typhoid fever, and for observation if there has been exposure for development of diseases, thus protecting the other children in the Home. It is a very simple common sense proposition.

Under the direction of the board at Iowa City, we have carried out extensive immunization for diphtheria. We had a very severe epidemic two years ago and following immunization, we have had practically no diphtheria. Most of the cases have been in children who have come into the institution from the outside, and have either acquired it from carriers in the institution or brought it with them. We have thought that there should be a wall of defense built between the incoming children and those already present, through the means of a reception cottage.

The details of the efforts to establish diagnosis of cases reported here will show some of the means to which we resort in making a diagnosis. We are today in rather a transitional stage, between conception on the part of the public and some members of the profession themselves, as to what constitutes the necessary means of diagnosis and treatment. Less than six months ago at a meeting in Davenport an acrimonious debate took place concern