at the table and taking one plate in each hand distribute them, as fast as the nurse fills the plates, to the group of 32 patients, thus each patient makes eight trips. The two patients then place their own plates at their places at the table and resume their seats and eat their dinner at the same time with the other patients. This operation of serving the meat and vegetable courses occupies five or six minutes. Without any further signals the nurse then goes to the bread tables, which are ranged in the broad center aisle, and distributes six plates of bread, usually with ten slices on each plate, to her group of 32 patients. She then takes a tray from the butter rack and distributes the butter chips, which, as I have already indicated, have had the butter distributed on them some time before the meal begins by the regular employees, who are occupied in the serving room. The nurse then pours into the glasses water from pitchers which are on hand on the sideboard and then leaves two filled pitchers on each table, in order that the patients may further help themselves. Tea is sometimes served at the dinner hour. The nurse in that case passes around, filling the cups from a pitcher. There is always sufficient food, so that in case patients wish for a second helping they can have it.

Up to this point 25 minutes have been consumed from the time the signal was given for the entering of the patients, and it is now 11.40. At this time another signal is played and upon this the attendants and nurses, with the exception of four supervisors and six attendants, go to their own tables in order to eat their dinners. Four tables at the present time are reserved at the end of the dining room nearest the main serving room for employees. The time which these nurses and attendants have for their dinner is 25 minutes and during all this time the supervisors and those nurses and attendants who have been left on the floor are overseeing the patients and attending to their wants.

If a hot dessert is to be served the employees in the main serving room, assisted by certain patients, will have begun at 11.30 to distribute this dessert into the dessert saucers, the dessert saucers being then placed in the dessert rack, above described. All these dessert racks, having been placed upon the food cars, are taken to the dining-room at 11.55 and two racks are placed on the slate sideboard at the end of each group of 32 people. At

12 o'clock a signal sounds and the two patients from each unit of 32, who in the first instance assisted the nurse in distributing the main course, go to the sideboard, each taking one rack and distributing 16 saucers from it to 16 places at the table. This latter process of distributing the saucers occupies usually less than a minute and a half. At 12.15 the signal which sounds is the call for the nurses and attendants, who have been eating their dinners, to return to their places at the patients' tables. As soon as they have all reached their places, the orchestra having ceased playing, another signal is sounded which is the signal for the collecting of the silver. The orchestra during this process begins again playing appropriate music. In the picking up of the silver the patients are trained to place their knives, forks and spoons at their right hand and the attendants are instructed to pick up from the right hand of each patient the same number of utensils which were originally given out. In this way, knives, forks, and spoons are checked up. If anything is found missing the fact is reported at once to the supervisor, who takes the necessary steps to find the missing articles. At 12.20 a signal is played which is the signal for the patients to leave the hall. Each table is dismissed by a supervisor in order and the patients file out in the same manner in which they entered. I should have stated that the patients, in entering and leaving the hall, do not file out in close or in any regular marching order.

I will say a word here about the character and quality of the music which is rendered during the meal. While the patients are entering and leaving the hall it is customary to play marches, during the distribution and collecting of the silver the music is of a lively and forte character. During the remainder of the meal the instructions to the orchestra are that compositions without marked time shall be played and as the meal progresses the instructions are that the music shall gradually become more quiet. The reason for this is that as a meal progresses the sounds which arise from the handling of the plates and the use of the knives and forks by patients gradually diminish. It is desirable at all times not to have the music of an obtrusive character, but that it shall furnish rather the effect of a quiet undertone of musical sounds. I think it is this effect that should be striven for. If music of a lively nature or of a marked time is being played,

I have observed that patients are apt to beat time to the music with their feet or with their knives or forks, while subdued music seems to me to have a tranquilizing effect upon the patients. Usually at the latter portion of our meals, we will say after the desserts have been given out, the hall will be perfectly quiet, as far as any sound occasioned by patients is concerned.

To those who have an acquaintance with musical compositions the following sample program will indicate the sort of music which I think should be rendered during a meal.

PROGRAM FOR THURSDAY NOON-MAY 22, 1913.

1. March, "Prince of India"....

2. Distribution of Silver, "Silver Bell".

3. Selection from "Lohengrin”.

.Farrand.

..Wenrich

Wagner

....Chopin

. Rubinstein. Wenrich

.Hall.

In regard to the orchestra, I think that care should be taken that this is not too large. From four to six pieces, aside from the piano, are sufficient.

In regard to the furnishing of entertainments during or immediately after meals, I will say that I have frequently been able to obtain professional singers to sing from the stage during the meal and I have had our hospital choir, consisting of thirty voices, render Christmas carols and music appropriate to other holiday seasons of the year. After a meal has been finished I have on occasions had an entertainment lasting for an hour's time given from the stage. The patients in that case who were seated back to the stage turning their seats toward it. On such an occasion patients who do not eat regularly in the dining-room, as for instance some of the more feeble and certain disturbed patients, are brought to the dining-hall and seated in the broad aisle, and in this way we can furnish entertainment for 1000 or more of our patients at one time.

By the method of serving which I have described efficiency, order and precision are arrived at; the food reaches the patient steaming hot and one hour is given to the dinner meal.

If I have made this description clear I think it will be seen that it is immaterial how many units of patients we have, pro

vided we have the proper arrangement for the care of each unit. In regard to the size of the unit, I would say that this can be 20-24-28 or 32 within practical limits. If smaller or larger units should be used a disadvantage would arise. In my opinion a group should not be less than 20 because the food will be distributed in too small amounts to retain its heat and the smaller the unit the larger number of units which you will have to have. If the units are larger than 32, the amount of food for the units becomes too bulky to handle properly.

I wish to contrast this picture with one in which the patients enter a hall without surroundings which have been made attractive, where the food has been placed on the tables before the patients enter the dining-hall. In this last instance you will observe for one thing that the patient who is the first to seat himself has finished his meal before the last patient has reached his place.

If you go into most of our hospitals for the insane you will find that the small ward dining-rooms have been rendered attractive by the furnishings and decorations and flowers, but oftentimes, where congregate dining-rooms have been established, I think it has been the case that the asthetic side has been strangely forgotten. I think that the greater part of the mistakes which have been made in conducting large congregate dining-rooms rise through improper methods of serving food.

I think that attention given to the propositions which I have set forth, namely: the making of the large congregate diningroom a therapeutic measure and the adoption of methods of efficiency in the serving of food, will make all the difference between condemnation and approval of the congregate dining-room, on the part of officials, employees and the patients themselves.

SOME SUGGESTIONS REGARDING THE IMPROVEMENT OF THE MEDICAL SERVICE AND THE CARE AND TREATMENT OF THE INSANE.

BY WALTER G. RYON, M. D.,

Medical Inspector for the State Hospital Commission, Albany, N. Y. Prior to the advent of the newer psychiatry in this country the medical work, in the large number of our public institutions, was more or less of a stereotyped character; the histories were meager in outline, and the scientific work at a low ebb. The hospitals were, in other words, institutions more for custodial care than for scientific purposes.

In the past decade the medical work has made more rapid advances. In a few states psychiatric institutes have been established, affording governing centers for the scientific work of the institutions under their direction. Such institutes should be established in all states. It is only by having such central institutes as these that the medical work can be at all systematized and the most uniform and best scientific results obtained. Here the various physicians of the public hospitals and also of the private sanitaria can be instructed in clinical psychiatry and neuro-pathology and returning to their respective institutions, instruct their colleagues on the staff, thereby increasing the efficiency of all. It would be most fortunate if all the new men entering the medical service of our hospitals could have their first service at such institutes, thereby fitting themselves at once for thorough and scientific work.

The establishment of courses in clinical psychiatry and neuropathology, the holding of inter-hospital conferences, the conduction of daily staff meetings and the organization of local psychiatrical societies and clinics, have all given an impetus to the work which had not heretofore been attained.

Notwithstanding this, it is still true that, upon the part of some, there exists a tendency to perform the required work in a more or less mechanical and superficial way, with a laxity of purpose that should be corrected.