The Social Component in Medical Care: A Study of One Hundred Cases from the Presbyterian Hospital in the City of New York 9780231897372

Citation preview

T H E SOCIAL C O M P O N E N T IN M E D I C A L C A R E

THE SOCIAL COMPONENT IN MEDICAL CARE A STUDY OF ONE HUNDRED CASES FROM T H E PRESBYTERIAN IN T H E CITY OF N E W

HOSPITAL YORK

BY JANET THORNTON DIRECTOR, SOCIAL SERVICE

DEPARTMENT

IN C O L L A B O R A T I O N W I T H

MARJORIE STRAUSS KNAUTH ASSISTANT P H Y S I C I A N , D E P A R T M E N T OF MEDICINE

N E W YORK : MORNINGSIDE H E I G H T S

COLUMBIA UNIVERSITY PRESS 1937

Copyright

1937

COLUMBIA UNIVERSITY PRESS Published

1937

Foreign Agents OXFORD UNIVERSITY PRESS Humphrey Milford, Amen House London, E. C. 4, England K W A N G HSUEH PUBLISHING HOUSE 140 Peking Road Shanghai, China MARUZEN COMPANY, LTD. 6 Nihonbashi, Tori-Nichome Tokyo, Japan OXFORD UNIVERSITY PRESS B. I. Building, Nicol Road Bombay, India

Printed in the United States of America

FOREWORD Thirty years ago, under the stimulus of Dr. Richard C. Cabot, medical social service started at the Massachusetts General Hospital in Boston. The movement has spread until now many of the larger hospitals have active, well organized social service departments. Also, training for this field is available in several schools. The physicians who work in teaching hospitals have come to look upon the social service worker as one of the personnel necessary for the best type of medical care of patients. I have had the opportunity to witness the growth of the Social Service Department at the Presbyterian Hospital in New York City during the last twenty years. Starting in 1904 with one worker attached to the School of Nursing to train their students for home visiting, the service has now grown to have a staff of thirty workers most of whom are graduates of schools of social work. Miss Thornton has been the director of the service for the past twelve years and it is due to her vision and wise management that the department has raised its standards and reached a high degree of efficiency. She has had the hearty support of the Board of Managers and the cordial cooperation of the professional staff in the development of her excellent service. The question may well be asked: Is there need for social service in the hospital from a purely medical standpoint? Furthermore, is the expense of maintaining such a staff warranted? The answers to these questions, most decidedly in the affirmative, are to be found in the following pages. An honest, stock-taking report on any activity is always welcome and refreshing. Miss Thornton and Dr. Knauth, in this report, present a most conscientious and thoroughgoing evaluation of the activities of the social worker in the Pres-

vi

FOREWORD

byterian Hospital. A study of the case reports impresses one with the amount of information gathered which has a pertinent bearing on the medical problems of the patients studied. T h e many important details of the social component obtained in certain of the cases is eloquent testimony to the skill and discretion on the part of the well trained social worker. Such material frequently is of the greatest value to the busy attending physician in planning a reasonably adequate treatment. Often it is required for a complete diagnosis. Moreover, accurate knowledge of the home conditions may enable the doctor, with the aid of the social worker, to modify the situation so as to prevent relapses or even disease itself. A f t e r reading these case reports there can be little doubt of the great need for a department of social service in hospitals; nor can the expense be questioned. When the facts that the daily cost per patient ranges over six dollars and that the average stay per patient is three weeks are considered, the small additional expense of maintaining the social service work, which strikingly enhances the effectiveness of the professional efforts, is more than justified. Medicine may take a well deserved pride in the progress of past years. Diseases formerly considered incurable are now controllable; methods of diagnosis have been improved so that operations "just to find out what the trouble i s " are less frequent; and specific therapeutic remedies have been increased in number. This very progress in medicine, however, has brought increased responsibilities and h e a v y burdens on the practitioners with the inevitable development of specialization and a tendency more and more to institutional and office practice. T h e busy physician,

though

better equipped professionally, has less time to know and consider the home life of his patients than did the doctor in times past who visited his patients in their homes. In the large teaching hospitals there is grave danger of overlook-

vii

FOREWORD

ing the fact that the ward patient is a human being after all, with particular difficulties in the struggle with his environment. T h e attending physician, under the pressure of many patients, some of whom are acutely and seriously ill, has scant time to explore the social component of the individual. T h a t another specialty, medical social service, is needed is vividly portrayed in the analysis of the cases presented by Miss Thornton and D r . Knauth. T h e book is an admirable textbook for students of social service;

it

should be read b y all physicians, teachers of medical school, hospital attendings, and general practitioners, for the many helpful suggestions it contains for the discovery and management of unfavorable factors; and finally, it should serve as a much-needed basis for instruction of medical students in that part of medical practice so essential to complete success with the patient. WALTER

W.

PALMER

Bard Professor oj Medicine, Columbia Director, Medical Service, Presbyterian

University Hospital

AUTHOR'S

PREFACE

Social service, as an organized division of the hospital for which trustees and managers have judged it proper to spend the institution's funds, has existed here and there in the United States for some thirty years. Many hospitals still have no organized service, and in some of those that have, the number of persons employed increases and diminishes as the sponsoring groups secure funds, rather than as the need for the service is made manifest. In fact, no adequate criteria for determining the need have ever been formulated. Yet many who have worked in the clinics and wards of hospitals have become convinced that much careful work of medical staffs has achieved less than it might have if it had been possible to offer more protection and guidance to patients before serious loss of health occurred and during periods of disability following loss. What waste of the community's medical resources this may represent can only be surmised. The writer believes this waste to be great and believes also that it can be obviated, since it is caused largely by failure to recognize and deal with the social-economic disturbances and unadjustments from which an important proportion, perhaps half, of hospital patients suffer. When, therefore, in 1930 the Vanderbilt Clinic Auxiliary made a grant of $10,000 to the Presbyterian Hospital to be used "not for current expenses but for some undertaking to improve the work of the social service department," it seemed that a long-awaited opportunity was afforded to attempt determination, as discriminating and accurate as we could make it, of the part played by social-economic factors in causing loss of health and in hindering recovery from illness. From such determination we hoped that the kind and amount of service needed for dealing with social factors

χ

AUTHOR'S

PREFACE

important for medical care might b e indicated. Effort to develop needed service could then be directed by knowledge rather than b y surmise. T h e present undertaking has been a collaboration of persons interested to make this determination. It was the full and generous collaboration of the medical department that in the first place made it possible to secure the medical direction essential. Without the constant encouragement, the guidance, and the constructive criticism of the director, D r . Palmer, neither the study itself nor the report of the study would ever h a v e been made. Miss

Harriett

M.

Bartlett,

borrowed

from

the social

service department of the Massachusetts General Hospital, and M i s s Dorothea Gilbert, of our own department, did the social work on the cases in this study. It is primarily due to their sympathetic and intelligent handling of the delicate relationships with the patients that so much intimate personal revelation could be brought to the doctors for interpretation, and could serve as a basis for more adequate care. Their reports and the medical interpretation constitute the basic material for the study. Miss

Mercedes

Geyer

and

other

social workers

con-

tributed, in continuing collaboration with the doctors, additional material of great value from their observation and care of certain of these patients in the years following the original collection of data. T h e doctors who interpreted the social factors in the case of each patient and advised regarding the treatment of such factors as were judged relevant to medical care were Drs. D a n a W . A t c h l e y , M a r t i n H . D a w s o n , Franklin M . Hangar, Jr., Arthur E. Neergaard, Martin de Forest Smith, and Randolph West, attending physicians of the Medical West Service under the leadership of D r . Albert R . L a m b ; D r s . Walter P . Anderton and A l v i n Coburn, other attending physicians of the department of medicine; and D r s . Agnes Conrad,

AUTHOR'S

zi

PREFACE

George E . Daniels, Robert S. Grinnell, Charles L . Janssen, Camella Losada, William B a r c l a y Parsons, F o r d y c e B . St. John, Rudolph N . Schullinger, Lawrence W . Sloan, J. Bentley Squier, and Allen O . Whipple, doctors of the surgical and psychiatric departments to whose care sixteen of the one hundred patients were transferred. B y arrangement with the department of medicine

Dr.

M a r j o r i e Strauss K n a u t h was appointed to supervise the study. In frequent conferences between D r . K n a u t h and the social workers the effect of the social factors on the medical problem was kept constantly in the foreground and constantly under critical consideration. From information and opinion developed in these conferences and from a critical review of the medical and social records, D r . K n a u t h prepared the abstracts of cases presented in Appendix 1. On these cases the report which follows is based. In addition, D r . K n a u t h drafted the outline of the report and wrote parts of it. Such order and coherence as the report now exhibits is due to the c l a r i f y i n g thought of Miss M a r y K . T a y l o r of our social service department, w h o revised and unified the several parts. Both for faith in our endeavor and for financial support we would express gratitude to M r s . Y a l e Kneeland, Chairman of the Vanderbilt Clinic A u x i l i a r y , and to the members of her committee, who thus made possible the report which w e now present to them. It is the hope of those w h o have collaborated in this undertaking that the results m a y contribute not only to the improvement of the social service department of our own hospital but to a wider understanding of the social component in medical care, and that it m a y thus promote the development of social service in all hospitals. New York City December i, 1936

JANET

THORNTON

CONTENTS FOREWORD

ν

AUTHOR'S PREFACE

¡x

I. PURPOSE AND METHOD OF THE STUDY

. . .

II. GENERAL INFORMATION CONCERNING PATIENTS UNDER STUDY

3

THE

13

III. DEMONSTRATION OF CASES: ACUTE AND RECURRENT

21

IV. DEMONSTRATION OF CASES: CHRONIC

54

. . .

V. DESCRIPTION OF ADVERSE SOCIAL FACTORS ASSOCIATED WITH INDIVIDUAL PROBLEMS OF ILL-HEALTH INTRODUCTION

114 114

ADVERSE SOCIAL FACTORS AFFECTING SUBSISTENCE

.

119

INADEQUATE PHYSICAL PROTECTION UNFAVORABLE HABITAT AND LOCALITY

120 .

.

.

.

120

INADEQUATE SHELTER AND CLOTHING

123

INSUFFICIENT FOOD SUPPLY LACK OF PERSONAL SERVICE

128 131

INADEQUATE ECONOMIC PROTECTION UNDUE EFFORT TO SECURE SUBSISTENCE .

.

.

133 133

.

INADEQUACY OF MEANS TO SECURE SUBSISTENCE . . FAULTY PERSONAL HABITS INFLUENCING PROTECTION OF HEALTH HABITS INTERFERING W I T H

151 166

T H E CARRYING OUT OF

MEDICAL RECOMMENDATIONS HABITS UNFAVORABLE TO MAINTAINING HEALTH

.

166 17S

HABITS MAKING DIFFICULT T H E ENDURANCE OF DISABILITY

182

VI. DESCRIPTION OF ADVERSE SOCIAL FACTORS ASSOCIATED WITH INDIVIDUAL PROBLEMS OF ILL-HEALTH (CONTINUED)

187

ADVERSE SOCIAL FACTORS AFFECTING SATISFACTION

187

.

DISSATISFACTIONS CONNECTED W I T H FAMILY OR OTHER GROUP RELATIONSHIPS

188

riv

CONTENTS LACK OF FAMILY GROUP INCOMPATIBILITY AND FRICTION WITH ASSOCIATES . LACK OF SATISFYING SOCIAL STATUS

188 191 198

DISSATISFACTIONS CONNECTED WITH RESTRICTED OUTLETS LACK OF SATISFYING WORK LACK OF SATISFYING RECREATION LACK OF SATISFYING SOCIABLE LIFE RECAPITULATION

203 206 208 209 211

VII. D E S C R I P T I O N REMEDY

OF MEASURES UNDERTAKEN

UNFAVORABLE

TO

SOCIAL FACTORS

.

INTRODUCTION

220

MEASURES DESIGNED TO CONTROL ENVIRONMENT SUPPLYING DEFICIENCIES IN ENVIRONMENT.

.

225

.

.

HELPING PATIENT UTILIZE AVAILABLE RESOURCES .

226 229

REMOVING OBSTACLES TO CARE

232

REMOVING PATIENT TO MORE FAVORABLE ENVIRONMENT

236

VIII. D E S C R I P T I O N REMEDY

OF

MEASURES

UNFAVORABLE

UNDERTAKEN SOCIAL

TO

FACTORS

(CONTINUED)

240

MEASURES DESIGNED TO INFLUENCE CONDUCT . . . IMPARTING INFORMATION REGARDING PROBLEMS OF

240

SUBSISTENCE AND SATISFACTION EXPLAINING ELUCIDATING DEMONSTRATING

242 242 247 250

INFLUENCING CHOICE REGARDING PROBLEMS OF SUBSISTENCE AND SATISFACTION

252

FOSTERINC HABITS

262

STANDING BY

269

RECAPITULATION IX. CONCLUDING

276

OBSERVATIONS

278

APPENDIX

1. A B S T R A C T S O F O N E H U N D R E D

APPENDIX

2. T H E

INDEX

220

CATHARINE

ΜΟΝΑΗΑΝ

CASES

CASE

.

.

285

.

346 403

THE SOCIAL COMPONENT IN MEDICAL CARE

I P U R P O S E AND M E T H O D OF T H E

STUDY

Purpose.—So manifold are the influences that seem to affect the health of human beings that any real human interest can with considerable plausibility be set forth as matter important to the art of healing. Generations of medical practitioners have differed in estimating the effect on health of various influences and especially in estimating the responsibility to be undertaken by the practitioner for controlling social relationships which affect his patients. The tendency at the present time to treat "the diseased individual" rather than particular manifestations of disease has again called to attention the social influences surrounding every sick person. This has led to renewed interest in situations and habits predisposing to disease and affecting the readjustment of the sick person. It is being recognized too that, compared with laboratory and clinical procedures for studying and treating disease, the procedures for discovering and controlling social influences are not well developed, and that if they are to be seriously dealt with in medicine, more reliable procedures must be devised.* From our attempt these points have emerged and seem to warrant further endeavor to establish their validity: (1) Persons are disabled not only as a result of impairment of function by organic disease but also as a * It is even possible that certain studies now under way in research laboratories, dealing with human fatigue and emotion, may some day yield objective tests by the use of which physicians can acquire more reliable information than is now obtainable from the patient's representations or his overt behavior. Cf. Walter B. Cannon, M.D., S.D., Bodily Changes in Pain, Hunger, Fear and Rage (1929); Edmund Jacobson, M.D., Progressive Relaxation (1929); Elton Mayo, The Human Problems oj an Industrial Civilization (1933).

4

PURPOSE A N D METHOD

result of impairment of function by physical deprivations and strains, and by feelings of dissatisfaction. (2) It is possible (even without objective physiological tests) to secure fairly accurate information about states of dissatisfaction, as well as about states of physical deprivation and strain, and the conditions producing them. (3) Measures which relieve these states are known and can be applied, thus reducing the disability they cause. (4) Disability from these states frequently complicates disability from organic disease, and measures suitable for relieving both forms of disability must be applied in order to restore some patients to the best health possible for them. Our purpose in this study has been to discover and describe the social disorders of a certain number of patients, and to determine whether the patients' reactions to such disorders were unfavorable to health. It has been our purpose further to display the method employed to determine the character of the patients' reactions and their effect on health. Incidentally, also, we have considered what, if any, responsibility devolves upon the medical practitioner to control social influences which he concludes are unfavorable to health. As corollary to the main purposes expressed above we have kept in mind this question: Can a service adjunct to medical practice, such as a social service department in a hospital, contribute to more adequate medical care by discovering and controlling social-economic influences which may be relevant and important to this care? The idea that social influences are significant for medical care is not new. Physicians have long recognized that some of these influences play a part in the etiology of certain diseases; for example, overcrowding of human beings and faulty habits frequently are associated factors in the etiology

PURPOSE A N D METHOD

5

of tuberculosis, and emotional disturbance is held by many to be a factor in the etiology of peptic ulcer and of thyroid disease. In connection with therapy, the idea that social factors are important and must to some extent be controlled by the physician is even more readily accepted. Therapy is directed towards removing the causes of disease where possible, lessening disability, and adjusting the patient to disability which cannot be lessened, all of which usually involve dealing with the patient's attitudes and abilities and with persons and conditions in his environment. In prognosis, too, physicians habitually utilize observation, reports, and inferences regarding social make-up. The special formulation of expectancy in each case must be based in part on knowledge of such factors as the adequacy of the protection obtainable for the patient, and his willingness and ability to play his part in the necessary treatment. This general recognition by physicians that social factors are of importance in medical practice has not, however, led to the formulation of procedures to make as thorough exploration of the social make-up as is made of the organic make-up. It was with these facts in mind that we undertook to study a series of cases to determine what part influences in the patient's social situation and his manner of reacting to them played in the development of ill health, in the defeat of curative measures, and in the adjustment to chronic disease. Collection of data.—The wards of the Presbyterian Hospital Medical West Service (containing forty beds for adult male and female patients) were chosen as the source of the material since nearly all manifestations of disease and specialties of medical treatment are exemplified there in any series of one hundred cases. One hundred cases were made the subject of this special study. In these is described the care given alternate patients

6

PURPOSE AND METHOD

admitted between October 1, 1930, and May 12, 1931. Two interruptions occurred when pressure of work for patients already taken had become too great. Nine cases were omitted because death took place before social history could be secured. The patients whose cases form the basis of this report were cared for in the usual way by members of the professional staff of the hospital, assisted by the customary technical and adjunct services. Two workers were added to the social service staff to assemble the social data and to carry out the social treatment for these patients. The social work for the other patients under care was carried on as usual by the two regular members of the social service staff assigned to the West Service. For this special undertaking the social workers' inquiry was somewhat more detailed than usual, but in no important way different. In addition, the information gathered was more fully recorded, and favorable as well as unfavorable conditions were noted. Social information secured previously concerning patients included for study who had been in the hospital before was added to the material assembled at the time of the study. The special workers were protected from undue pressure of routine duties and were able to concentrate attention on the one hundred cases, securing as reliable information as possible, and discussing it point by point with the physicians. Method.—The procedures used for obtaining information concerning social factors were: interviewing of patient, relatives, and others, to get as accurate a picture as possible of the patient's circumstances and way of life (past and present); direct observation of physical surroundings and conduct in the home and elsewhere; securing of testimony from records and other sources. Concerning each patient the social worker determined as accurately as she could the adequacy of his physical protection; the amount of effort he had expended to secure

PURPOSE AND

METHOD

7

subsistence, with some estimate of the responsibilities and fears involved; his habits and attitudes; and his satisfaction with his place and part in life. Knowledge was sought not only as means for throwing light on certain phases of the medical problem, but also as basis for arranging suitable protection and for undertaking other curative or preventive treatment. Criteria.—All social factors which would tend to produce depletion or disturbance of energy—to produce, that is, malnutrition, overfatigue, or excessive emotional tension—were considered relevant. Had it been possible for the physician, by direct physical examination of the patient, to detect the presence and degree of fatigue or emotional tension, as malnutrition can be measured, we should have been able to eliminate from social exploration cases where fatigue and tension were not present. Since this sort of detection was not possible, it became necessary to search each patient's experiences for social * strains, and to estimate whether or not they had produced disturbance of energy sufficient to be harmful to health. When the patient's experiences appeared to be of the kind that are generally found to result in fatigue and tension, and he exhibited reactions characteristic of such states, it was assumed by us that they existed. Such reactions were irritability and restlessness, excitement in recalling some experience, repeated mention of some experience described as painful, studied avoidance of a topic, etc. When similar reactions were observed to recur each time similar situations were met by patients, e.g., asthmatic or * The meaning of the word social throughout this report includes the idea of association with fellow men and also the idea of personal reaction which such association induces. For example, social in the phrase social strains means the personal reaction of the patient to strains which human association imposed as well as the association itself. This condensation in the interest of brevity seems permissible.

8

P U R P O S E A N D METHOD

cardiac attack following emotional upset, the fact of recurrence added corroborating evidence for the assumption that such situations were part of the medical problem and its solution. Furthermore, observations of this sort accumulated in the past by the investigators themselves from their own work and from that of others formed part of the knowledge which they constantly used in this inquiry to explain problems and guide remedial measures. The basis for judgment was the patient's own report of his feelings, the testimony of associates, and the observations and inferences of physicians and social workers. Where disturbed bodily and social states existed simultaneously, endeavor was made to determine whether they merely coincided in time or whether there were connections between them, such as a mutual influencing, or a cause-andeffect relationship. Such connection was considered probable in instances, let us say, where after onset of illness, patients had lacked personal service and been compelled to exert themselves, when rest was needed; where after years of heavy labor, multiple responsibilities, and habitual worrying, premature organic deterioration was observed, especially if there were no clear signs of injury from infection or poisoning; where failure to follow medical advice as to habits of eating, resting, working, etc., was associated with a rebellious disposition, or concern for reputation, economic security, etc. If these connections could be demonstrated, the disturbed social state was considered a probable component of the health problem. For relief of the collateral or unrelated social problems the aid of nonmedical welfare agencies was sought and responsibility was left with them. But for social problems thought to be component parts of the health problem, the hospital undertook remedial measures and the effects of such measures were studied for further substantiating or

PURPOSE AND METHOD

9

qualifying evidence regarding the significance of the social factors in question.* Constant evaluation of the significance of the social factors was attempted throughout the period of care. One physician made abstracts of all cases and each abstract was reviewed and approved by the physician responsible for the case. The whole report is the joint endeavor of the group by whom the enterprise was undertaken. The director of the Medical Service, Dr. W. W. Palmer, gave counsel to the group throughout the course of its work and finally reviewed and amended the manuscript of the report. Plan of presentation.—In the one hundred unselected cases there are presented such a variety of situations and so few examples of each that attempts to classify and tabulate them for statistical interpretation do not yield satisfactory results. A few enumerations which have helped us to comprehend the incidence of certain findings will be given as we proceed. Interpretation by analysis and demonstration of complete cases with some contrasting of cases have seemed to us to yield more meaning than a quantitative analysis. In Chapters I I I and IV we are therefore demonstrating seventeen typical cases identified by pseudonyms, illustrating the interrelatedness thought to exist between social factors and ill health. In Chapters V and VI we itemize particular social factors found and give a rough measure of the incidence of each. Through illustrations from our material we here attempt to demonstrate the significance of separate factors, as distinguished from the significance of factors in combinations. In Chapters VII and VIII we item* In the five years that have elapsed since the termination of the official time for collecting material, many of the patients continued under medical care, and additional data concerning them has been available. Feeling that inclusion of relevant material served the best interests of the study, we have not hesitated to make use of it.

10

PURPOSE AND METHOD

ize and demonstrate in the same manner the measures used in the treatment of social factors. Full records of the care of all the patients in the study are in the files of the Presbyterian Hospital. Abstracts, identified by numbers, appear in the Appendix (pp. 285-345). A complete case record, "Catharine Monahan" (pseudonym), is also given in the Appendix (pp. 346-400). Limitations of the method of study.—Certain limitations of the method followed in the study must be noted at this point. Inability to set up a control group.—Had it not been for the resources supplied by the hospital and by the community, unfavorable social conditions affecting the sickness and recovery of these patients would have been added; for example, each of these patients was removed, during the critical period of his illness, from situations where in most instances adequate care would have been unobtainable, and placed in the protective environment of the hospital ward. Again, several of these patients were already under the care of community social agencies at the time this study was begun, and certain unfavorable social conditions were prevented or mitigated. Then too, social factors that might have contributed to failure to regain health we did not permit to function in this way. Because we were dealing with human "material" it was not permissible for us to set up a control group of sick persons in whose lives harmful social factors were discovered and allowed to operate without interference. Limited amount of material.—While one hundred cases were considered sufficient for our purpose, they do not yield evidence necessary to confirm probabilities and must be considered demonstrations affording clues for further studies. Lack of precedent for this type of study.—Because of lack of precedent, we were obliged to develop our method as we went along, with considerable fumbling at first. On the

PURPOSE AND METHOD

11

one hand, the general feeling of familiarity with the subject and the commonplace nature of many of the situations involved proved an obstacle to critical and serious study. On the other hand, when analysis revealed the complexity of the phenomena of social make-up, in many instances we found ourselves bewildered and doubtful of our ability to decipher the meanings or to develop the power and skill to make use of them. Inadequacy of the method employed to gain knowledge of the inner life of the patients studied.—In this inquiry the method of psychological measurement was not employed, so that exact knowledge of the intelligence and aptitudes of the patients was not secured. Neither was psychiatric study of emotional patterns made. The interviewing method employed, while it revealed hints regarding the inner life of many patients, did not afford full comprehension of basic motives controlling conduct. The patients' own reticence, as well as the investigators', and, more important still, the patients' unawareness and confusion about the controlling or conflicting motives in their lives seemed to obscure recognition of deep-seated attitudes. Especially was this true of the intimate religious and love life. Judgment could not be made regarding these matters. Since they are probably always important either as baneful or as beneficent influences, a more penetrating inquiry must be made before we can know their importance for medical care. General limitations.—We must recognize certain general limitations to any study made under such conditions. Accuracy must at times be sacrificed in the interest of proper medical care, since it is often not suitable to press for full information from an ill person because of the need of protecting him from strain, or because of the danger of increasing disability by directing his attention to it. Again, understanding of this sort of material is subject to personal bias and error, since it is based to so large a degree on im-

12

PURPOSE AND

METHOD

pressions; the data can never be duplicated for experiment and thus rechecked for accuracy. In spite of inadequacies, we are presenting this report of our study in the hope that it will stimulate critical attention to the subject. The patterns in which the material is displayed do, we believe, make clearer the nature of the problems to be solved and of the methods now available for solving them.

II GENERAL INFORMATION CONCERNING THE PATIENTS UNDER STUDY The one hundred patients under study comprised 56 male and 44 female patients, of whom 86 were white and 14 Negroes. They represented for the most part a group of young and middle-aged persons; 54 were under 40 years of age, and 70 were under 50. The majority were Englishspeaking American citizens, 89 being citizens, of whom 56 were native-born. As indicated in the following table 69 were born in English-speaking countries. TABLE I BIRTHPLACE OF PATIENTS A N D PATIENTS'

Birthplace United States of America Great Britain Central Europe Germany Russia Italy Puerto Rico France Norway Turkey Costa Rica British West Indies Greece Finland Belgium TOTAL

No. of Patients 56 12 7 8 5 3 3 2" 1 1 1 1 0 0 100

FATHERS

No. of Patients' 33 21 11 10 7 8 3 0 1 1 1 1 1 1 1

Fathers

100

• Neither patient French.

Marital state.—Of these patients 56 were married, 12 widowed, 3 separated, and 29 single.

14

GENERAL

INFORMATION

Household.—Only 19 of the patients lived alone. Seventyeight were living with family or kin, or cooperatively with friends. Three were resident employees. More than half lived in households of from three to five members, and about the same number in apartments of from three to five rooms. The families of 66 patients occupied apartments, twothirds of them paying from $40 to $60 rent, rates moderate for the locality. Twelve paid $40. Seven were owners or part owners of their homes. Schooling.—Of the 67 patients for whom we have complete data concerning schooling, 49 (about 73%) had schooling through grammar grades or higher; 26 (about 40%) had more than grammar-school education. TABLE II SCHOOLING R E C E I V E D BY 67 P A T I E N T S Education N o schooling Grammar school—incomplete Grammar school—graduate High school—incomplete High school—graduate Business training College Bachelor of Arts Master of Arts Law degree Information lacking * TOTAL

No. of

Patients 2 16 23 S 10 7 2 1 1 33 100

• These patients belonged mostly in the immigrant group whose early schooling was slight and difficult to classify.

Religion.—Religious preferences expressed by the patients were as follows: Protestant, 47; Catholic, 38; Hebrew, 14; Christian Science, one. Economic and employment status.—Listing the income of these patients at the time they were admitted does not give a reliable picture of their economic status unless many

GENERAL

15

INFORMATION

variable factors, such as description of the nature and duration of disability, size of family, number of wage earners, unemployment, debts, savings, and contributions from others, are displayed. Our data, however, indicate that for the most part the patients belonged to the group for whom the resources of the hospital were designed—persons of small means unable to pay the full cost of medical care. At the time they were accepted for hospital care, $45 was the largest weekly wage earned by any patient. This amount was received by 3 persons; each had three or more dependents. Of the single patients listed as "self-maintaining," the largest weekly wage was $25 and maintenance (received by one patient); one received $30; the smallest wage was "maintenance only," received by 2 patients. Only 9 patients were members of family groups whose incomes were below that estimated as adequate for subsistence.* Except 2 young persons who had never worked, all had been independent wage-earners, business men, or housewives. After illness developed nearly half of them had become dependent by reason of this illness. The tables which follow give a rough index of the economic and employment status of the group prior to illness. TABLE I I I E M P L O Y M E N T STATUS OF PATIENTS PRIOR TO

Employment Status Chief breadwinners of families Housewives Not employed outside home Employed outside home Single self-maintaining Not contributing to families Contributing to families Dependents TOTAL

ILLNESS

No. of Patients 34 28 16 12 31 15 16 7 100

* For fuller discussion see "Inadequacy of Means to Secure Subsistence," pp. 151-166.

GENERAL INFORMATION

16

TABLE I V USUAL OCCUPATION OF PATIENTS P R I O R TO ILLNESS

Usual Occupation Housewives Self-employed (proprietors) Wage-earners White collar Domestic and personal service Labor operating with machines Labor operating without machines Young persons who had never been employed

No. of Patients 28 13 56 23 11 14 8 3

TOTAL

100

Medical diagnosis and prognosis.—For convenience of handling, we have grouped our cases according to major diagnosis and a rough scheme of prognosis. Acute.—Characterized by sudden onset of illness in persons previously well, resulting in death or apparent return to normal health without symptoms. Recurrent.—Characterized by recovery from present illness and recession of symptoms (with or without damage) but with liability for repetition of the same symptoms and of periods of illness. Chronic.—Characterized by permanent impairment of the organism with some degree of permanent disability and continuing symptoms. Chronic-terminal.—Chronic cases characterized by brief life-expectancy. Without organic disease.—Characterized by failure of physical findings to explain the symptoms, and an abnormal type of psyche.

Where the neurotic tendencies were merely complicating factors in cases of physical disease, we have classified the cases under the major medical pathology only. The one hundred cases fall into the following groups: TABLE V CASES G R O U P E D BY PROGNOSIS A N D

Prognosis Acute

Diagnosis Respiratory (6) Bronchitis Bronchopneumonia Lobar Pneumonia Bronchopneumonia; ? Tuberculosis Potential Tuberculosis

DIAGNOSIS

No. of

Patients 1 1 2 1 1

GENERAL Prognosis

INFORMATION

Diagnosis Myositis Tonsillitis Pharyngitis Hemorrhage (2) Intestinal Bleeding Oral Bleeding Lupus Erythematosis Catarrhal Jaundice .. Fever

17 No. of Pa ients

TOTAL

Recurrent

Exophthalmic Goiter Toxic Adenoma Cholecystitis Cholecystitis; ? Psychoneurosis Duodenal Ulcer Diagnosis not made Diagnosis not made; ? Colitis Rheumatic Fever Pernicious Anemia Hookworm; Tonsillitis; Malnutrition Serofibrinous Pleurisy Lupus Erythema Colitis; ? Dementia Precox Malaria Salpingitis TOTAL

Chronic

Cardiovascular (26) Angina ; Insufficiency Aortitis Insufficiency; Fibrillation Angina Hypertension Fibrillation; Manic Depressive Psychosis Coronary Thrombosis Mitral Disease Fibrillation; Aphasia Arteriosclerosis; Bronchitis Arteriosclerosis Rheumatic Pancarditis Coronary Disease Fibrillation Endocarditis Insufficiency; Arteriosclerosis Cerebral Hemorrhage t Sclerosis of Arteries, Legs, etc

2

18

GENERAL

Prognosis

INFORMATION

Diagnosis Arthritis (6) Multiple Arthritis Arthritis Deformans Sacroiliac Nephritis (2) Uremia Asthma (3) Bronchiectasis Bronchial Ulcer and Tabes Ulcer; Schizophrenia Adenoma of Thyroid Adenoma ; Fibrillation Lues; Arsphenamine Poisoning Dyspnoea Nephritis and Pleurisy; Tuberculosis Diabetes; ? Syphilis Hodgkin's Disease Aplastic Anemia Hypopituitarism Cirrhosis; Syphilis

No. of

4 1 1 2 1 2 1 1 1 1 1 1 1 1 1 1 1 1

TOTAL

49

ChronicCarcinoma, Stomach Terminal Carcinoma, Primary Source Undetermined Carcinoma, Lung, Bronchus Carcinoma, Colon Carcinoma, Kidney Carcinoma, Lung Carcinoma, Prostate Leukemia

Without organic disease

Patients

1 1 X X I X I I

TOTAL

8

Psychoneurosis Psychosis

4 1

TOTAL

S

SUMMARY Prognosis Acute Recurrent Chronic Chronic-Terminal Without organic disease TOTAL

No. of

Patients 14 24 49 8 S 100

GENERAL

INFORMATION

19

Adverse social factors.—In this group of one hundred patients, no adverse social factors were discovered in the lives of 20. For 9 more no adverse social factors were discovered which could not be handled unaided by patient or family. For 65 it appeared probable that one or more of these factors (and often they were found in combinations, several interacting to produce adverse influences) affected the health problem unfavorably. For 3 it was doubtful whether or not strains to which they had been subjected affected them unfavorably. Concerning 3 more we were unable to obtain enough information to make a decision. While generalization on the basis of such small numbers is not sound, it is perhaps pertinent to note that unfavorable social factors were more frequently relevant to the health problem in the groups of recurrent and chronic cases than in the acute. Experience confirms this higher correlation. The explanation is not difficult. First, of course, is the fact that it is for patients in acute stages of disease that the resources of this hospital are especially designed, and for this group of patients care in the hospital forestalls social problems in the home or prevents them from complicating the problem of care for the sick person. In such cases the rapidity of onset and termination of the disease and the return to normal functioning within a short time lessens the liability that adverse social factors will play a large part in the prevention of recovery. Recurrent and chronic cases, on the other hand, are characterized by more prolonged disability * and by need of a greater degree of adjustment requiring the patient's participation, and thus, as one would expect, adverse influences from the patient's personality and his social environment become more significant in the medical problem. The social factors are analyzed in detail later in this report (Chapters V and VI). As preparation for better understand* For fuller discussion of disability, see Chapter V, "Introduction."

GENERAL

20

INFORMATION

ing of the demonstrations which follow, however, we may say briefly here that these social factors are described as of two general kinds : those affecting the patient's subsistence or survival, and those affecting his satisfaction with his place and part in life. On behalf of 54 of the 65 patients whose health problems seemed probably in some degree to have been unfavorably affected by social factors, measures to abate their effect were undertaken. Such measures are discussed in Chapters V I I and V I I I . They fall under two general headings: controlling the patient's environment, and influencing the patient's conduct.

III D E M O N S T R A T I O N OF CASES: AND RECURRENT

ACUTE

Our object in demonstrating a number of cases prior to discussion of particular social factors and remedial measures has been twofold: to familiarize the reader with the nature of the material gathered; and to illustrate the interrelatedness of the factors as they occur in the life of a given person, a characteristic which the method of analysis obscures. Appreciating the reader's natural inclination to become absorbed in the dramatic interest of any life history and thus to lose sight of the questions to be raised and debated, we have condensed the records and portrayed only events and reactions which in our opinion are necessary for debating the questions raised. In addition, we have summarized at the beginning of each demonstration our opinion of the relevancy of such events and reactions, with the hope that evidence and argument will be critically appraised. In the fourteen acute cases studied, the patient's situations were found to be favorable in all but three instances. We select for illustration one of these three. DEMONSTRATION

NO.

1:

JAMES

ROBERTS

Unfavorable social factors found in this case were: marital difficulties, litigation over nonsupport of child, and dependency. They did not appear to disturb the patient nor deprive him of the essentials of subsistence and were therefore not considered important in the medical problem and social treatment was not undertaken by the hospital.

James Roberts (Abstract 80), twenty-four years old, was admitted suffering from catarrhal jaundice and acute follicular tonsillitis. He also showed chronic arsenic poisoning from arsphenamine treatment of syphilis a year and a

22

DEMONSTRATION OF CASES

half before. It was decided that he had no symptoms at time of admission from either arsenic or syphilis. The jaundice cleared in three weeks; he went home to complete convalescence there and returned in a few weeks for removal of tonsils, at which time he was found to have recovered his usual health. He proved unable to bring himself to have the tonsil operation. The syphilis and chronic infection of the tonsils remained as probable hazards to his future. Speculation regarding his capacity for protecting himself against these hazards would not be out of place here, but we decided arbitrarily to limit our analysis to the episode of acute illness described as catarrhal jaundice and tonsillitis, for which this hospital assumed responsibility. This man was a Southern Negro who went through only the lower grades of grammar school, and left school by choice at the age of fifteen to engage in unskilled work as bootblack, porter, etc. Three years before coming to the hospital he had married; he and his wife had separated, she charging him in Family Court with nonsupport. He had been ordered to support their child but had defaulted in payments, and before he entered the hospital a warrant for his arrest had been issued. At the time we knew him he was penniless and dependent on an old grandmother who was willing to have him in her home, though it was never determined how she kept a roof over their heads. He claimed that he and his wife were still on friendly terms, in spite of her appeal to the court and her forcing him to take the child off her hands when he failed to contribute to his support. When relating these facts he exhibited no grief, resentment, or anger. Our opinion is that since this person was not disturbed by the derangements and precariousness of his situation, and since there was no evidence of damage from lack of food or of other bodily necessities, neither his state of mind nor the state of his affairs influenced his sickness or his

ACUTE AND

RECURRENT

23

recovery. We therefore made no effort to influence the social factors, and action was limited to explanation to the Family Court of the patient's sickness and temporary inability to work. We next select illustrations from the twenty-four cases classified as recurrent. While social factors commonly regarded as unfavorable are noted in a number of these, it proved more difficult to determine whether health was in any way affected by the unfavorable factors than it was in the acute or chronic cases. In the illustrations which follow we attempt to set forth the unfavorable situations to which certain patients were forced to adapt themselves, and to suggest reasons for and against regarding these situations as significant to the medical problem. DEMONSTRATION

No.

2:

ELSIE

DUFF

Malnutrition and chronic fatigue from heavy physical labor, multiple home duties, and faulty habits of working, resting, and eating were believed to be contributing factors in the development of illness in this patient. Recovery and defense against recurrence of illness were sought chiefly by providing service in the home and instruction in health habits.

Elsie Duff (Abstract 29), a woman of twenty-nine, entered the hospital a month after the appearance of a rash, photophobia, and fever. She was markedly underweight. She was found to have lupus erythematosis, corneal ulcers, incipient pulmonary tuberculosis, and pansinusitis. Tuberculosis seemed to explain all lesions. She had suffered great physical strain and some anxiety due to economic derangement of her life, immediately preceding the onset of her symptoms. We shall briefly review here the elements of strain discovered in her life, which seem to have caused the great physical depletion and fatigue from which she suffered when first known to us, and which

24

DEMONSTRATION OF CASES

we propose were factors influencing the development of disease. This patient was born and grew up in rural Scotland, married at the age of twenty-three, bore two children, and came to this country two years before the onset of illness, to join her husband who had, he believed, established himself in a secure position. We have no evidence of excessive strain in her life up to this time. She was, however, unprepared to meet the complexities of metropolitan living, especially the unaccustomed confinement of an apartment house and the lack of convenient play spaces for the children. Within a year the husband lost his job, was unemployed for three months, and then found a position at half his former wage. Savings were adequate to cover their needs during unemployment, but the experience was accompanied by some anxiety. In attempting to economize, she provided a diet consisting largely of high carbohydrates, with inadequate milk, fresh fruits, and vegetables. In addition to managing the household and caring for two young children, she supplemented the income by undertaking heavy janitress duties. She was so fatigued after a day's work that she seldom left the house except for hurried marketing excursions in the immediate neighborhood. Excessive fatigue, deprivation of sunlight, and improper diet should, we believe, be considered as factors in the development of her illness. At the time of her admission to the hospital her attending physician summed up the medical situation as follows: "She has suffered from a chronic infection of the lungs (particularly involving bronchi) which has been suggestive of but not proven acid-fast. (Note: She had had a chronic cough since childhood.) There is also a concomitant pansinusitis and there have been corneal ulcers and keratitis which was thought to be acid-fast in origin. The whole picture could be explained on acid-fast or nonacid-fast basis.

ACUTE A N D R E C U R R E N T

25

In any case the care and treatment of the patient is essentially the same. She is a potential chronic bronchiectasis candidate. . . ." In this case the actual period in the hospital constituted only a small part of the treatment of the condition. Had provision for the fulfilling of treatment outside our walls not been made, the patient would have profited little by the brief period of bed care. Instruction to her and to those who must be relied on outside the hospital to create a situation in which care could be adequately provided constituted a major part of therapy. The hospital had to assume considerable responsibility in order to assure adequate care for the patient. She herself had little drive or initiative, tended to minimize the importance of her condition, and did not relate it to the increasing lassitude she had experienced over a period of six months or more. Lack of knowledge and slowness of comprehension required that detailed explanation of the plan of treatment and the reasons therefor be given her. We undertook further to teach her the rudiments of planning meals and other household management, child caring, and personal hygiene. Instruction was given directly to the patient, with the assistance of others who already had her confidence and knew how to present ideas to her (her husband and her pastor), or who possessed specialized knowledge (physicians in tuberculosis and children's clinics, dietitian). Even with increased knowledge and insight the responsibilities of the home proved too great to be met by her in her debilitated condition; care in the country for a month was provided for both her and the children, and later she was helped to secure the assistance of a competent woman to do the janitress work and assist with the household tasks. The physician decided that the strain of pregnancy at this time should be avoided, and she was given instruction in methods of contraception.

26

DEMONSTRATION

OF

CASES

On first examination the children were found undernourished, the younger one also rachitic. Their fretfulness, which before illness had broken her rest, disappeared as their general health improved under treatment. A regimen was prescribed, including cod-liver oil, regular nourishing meals, daily rest periods, daily walks in an adjacent park, ultraviolet light treatment, and occasional sinus irrigations. This was followed carefully for one year. Three months after she left the hospital she had gained twenty pounds. She continued to hold this weight. At the end of the year she was allowed to resume full responsibility for her home duties. Once this patient and her husband understood that tuberculosis might develop, they became overzealous in their efforts to prevent it. Reassurance, repeated reinterpretation, and some urging were necessary to persuade her to resume responsibilities as her health improved. Hospital supervision was needed to avoid the dangers of underdoing as well as overdoing. The hospital helped this patient to reorganize her life so that she could avoid excessive strains and could maintain adequate nutrition. She was helped also to use wisely the strength she had. This was accomplished through the education of the patient and her family and by utilizing resources in her social group. DEMONSTRATION N o . 3 :

FLORENCE DANIELS

Inconveniences of housing and inefficiency of home management were thought to be of some importance in this case because they produced a moderate degree of fatigue in the patient. Social treatment was directed to improving environment and influencing habits of work.

Florence Daniels (Abstract 12), age thirty-two, was admitted for treatment for a thyrotoxic condition. Her social situation seemed on the whole fairly favorable. She had not suffered the shock of catastrophe nor endured the siege of

ACUTE AND R E C U R R E N T

27

long adversities. There were no eccentricities of character to complicate her relationships with others. She had adapted herself quietly and contentedly to circumstances as they arose. At an early age she lost both parents, and she was brought up by an aunt who was "like a mother to her." At eighteen she went to work as salesgirl; at twenty she married a man about her own age, of the same religious faith (Catholic), whose social and economic status was satisfactory to her. In the next ten years she became pregnant four times, at intervals of about two years, and bore four living children who appeared normal, healthy, and attractive. T h e husband was a large, vigorous man. He was the more dominant character and the patient seemed to derive a feeling of security from his strength and self-confidence. She gladly allowed him to play the role of head of the family. They were on friendly terms with their relatives; his lived in the same community, and hers, the aunt and younger brother, lived in near-by communities. With neighbors, also, the relationship seemed friendly. T h e husband had steady work as a skilled mechanic and earned enough to meet their ordinary needs. The physical environment was not entirely satisfactory. The main line of a railroad ran past the house and the noise of the trains was disturbing. Three steep flights of stairs led to the apartment; the rooms were small, and not well arranged for the needs of the family. There was no suitable yard or place for the children to play, and Mrs. Daniels' deafness made her anxious about them if they were out of sight. She frequently interrupted her housework to keep guard over them, running up and down the steep stairs as often as ten times a day. T h e management of this home was on the whole somewhat better than average. Nevertheless, the necessary work gave her a full program. T h e husband showed genuine appreciation and affection for his wife and children, but he

28

D E M O N S T R A T I O N OF CASES

did not help with the housework and the children were too small to depend on. Had our patient been a woman of robust physique and in good health, the duties of mother and wife in this family would not have been unduly fatiguing. She had, however, always been frail and at the time she was examined here she was found to be suffering from several organic defects besides the exophthalmos: cystocele and chronic endocervicitis, dating from her confinement two years before; varicose veins; diseased teeth and gums; deafness for three months; and tertiary syphilis (without recognized symptoms). For a person so handicapped, the duties of this household proved very exhausting. Six months before she came to us a physician had told her of exophthalmos and ordered rest. But since no one relieved her of the work, she continued to do it, growing more nervous and irritable and sleepless. Fainting attacks occurred, with unconsciousness lasting from five to twenty minutes. A neighbor finally called the husband's attention to her condition and persuaded her to consult our hospital. Her basal metabolism rate was plus 45, pulse 112. Thyroidectomy was performed, and her basal metabolism dropped to minus 17. In less than four weeks after the operation, she was able to take up her old duties and she performed them satisfactorily during the two succeeding years. During this time, treatment of syphilis, pelvic, and ear diseases was also carried out, further relieving her discomforts and probably improving her general health. Four months after the patient's operation the family moved from the inconvenient apartment to an apartment on the ground floor where a yard and porch afforded play place for the children. By this means and by better planning of her daily schedule of work, the strain of maintaining the home was somewhat lessened. A two weeks' vacation, six months after operation, was provided for the patient as

ACUTE

AND

RECURRENT

29

another measure of relief from strain. B u t these measures hardly compensated for the extra strain entailed in planning and carrying out the clinic visits required for the many treatments given her. Our conclusion, therefore, is that after relief of the thyroid disturbance the patient was able to resume without further difficulty the activities of a full life which for about six months had resulted in exhaustion. Since ability to resume these activities occurred within a month after thyroidectomy and before other medical relief or relief of social strain had been attempted, it seems reasonable to ascribe her renewal of strength to the relief of the thyroid disturbance. Furthermore, since there has been no recurrence of disturbance under virtually the same social strains, it seems unlikely that these social strains played any part in developing the thyroid or other diseases from which she suffered. T h e y did, we feel sure, contribute to her total disability in that they constituted, together with disease, causes of fatigue and resulting frustration. With functional balance restored by surgical relief of hyperthyroidism the social factors shift in the main to the credit side of the reckoning. Her interest centered in her family and their well-being. T o be able again to fulfill competently her role in the life of her family created feelings of satisfaction, whereas, before, inability to fulfill her role had created feelings of frustration. In other words, social factors ceased to add their quota to the strains which disabled her, as soon as she had sufficient store of energy to permit her to cope successfully with them. In the social situation and in the patient's reaction to this, we found no risks, but rather strength, for the future. DEMONSTRATION

NO.

4:

HILDA

POGANY

In this case a v e r y serious derangement of the social situation is found to occur at the same time as a third exacerbation of thyroid disease. Operation corrected the thyroid disturbance. Social strains

30

D E M O N S T R A T I O N OF C A S E S

were not corrected and the patient continued to feel ill in spite of the relief from hyperthyroidism. We raise the question whether her continued disability may not have been caused largely by the social strains.

In November, 1930, Hilda Pogany (Abstract 46), when forty-two years old, applied for medical care, complaining of dyspnoea, palpitation, exophthalmos, and tremor of a year's duration. She had had similar symptoms on two previous occasions, the first in 1918 following a miscarriage at two and a half months, the second before the birth of her daughter in 1920. Each attack was associated by the patient with severe shock. The first was associated with the explosion of a powder factory which she witnessed; she was in bed six months following this experience. The second attack occurred in 1919, when she was three months pregnant (fourth pregnancy), after she had received word of the death of her brother, but she had then "pulled herself together for the child's sake." At this time she lost about sixty pounds. She noticed symptoms, including great loss of weight, again in 1930, a month after her husband, a construction engineer, was thrown out of work when the firm employing him failed. Other misfortunes followed in quick succession. Savings were lost in the business derangements of 1929-30. The husband's fruitless efforts to secure employment, the state of demoralization which this produced in him, debts contracted and insurance policies sold to meet living expenses, moving to a less expensive apartment, renouncing college education for their son—all these changes, regarded by the patient as major misfortunes, disturbed her profoundly. It is our purpose to consider whether these disturbing influences in the social situation, which made the patient extremely anxious and discouraged, affected to an important extent either the development of sickness or recovery or her continuing discomfort even after relief from thyroid disturbance had been obtained.

ACUTE AND R E C U R R E N T

31

In order to appreciate the meaning of these influences to the person in question, we add to the account of sicknesses and misfortune reported above a brief summary of her past life. She was the eighth child born in a family of eleven children. Her parents were Jews, belonging to the professional class in the Hungarian city where they lived. She was given the best educational opportunities available to girls of her class. At the age of twenty-three she came to New York City to meet her fiancé, who had left Hungary one year earlier and established himself here in business. They were at once married. The husband was also of Hungarian Jewish parentage; his family belonged to the professional class in their community, and he had graduated from college. He succeeded in business here, earning at one time $10,000 a year (in salary and commissions). They had two children and were able to afford an attractive apartment, an automobile, and the services of a maid, as well as to indulge their love of beautiful objects by building up a valuable collection of porcelains. Before adversity came to them in 1929, they felt themselves to be in a more secure and more favorable situation than most of their relatives and acquaintances and expected to help others rather than to ask help for themselves. In the autumn of 1929 their son, a tall, alert boy of seventeen, entered college. Between November, 1929, and November, 1930, when the mother came to our hospital, the family experienced the reverses of fortune described, which threatened to take from them forever the success and security they had labored to establish. After remaining a week in the hospital, the patient decided to return home, so great was her anxiety over her husband's discouragement and the precarious state of her home. (By remaining away she felt she was deserting her family in their hour of greatest need.) The husband, upon learning the importance of medical treatment for the patient, for both present relief and future health, persuaded her to

32

D E M O N S T R A T I O N OF CASES

remain. After making this decision she became quieter and more amenable to treatment. Ten days more of bed rest and iodine prepared her for operation. Partial thyroidectomy was successfully performed. On the ninth day after operation her basal metabolism rate was plus 8, her pulse 80-100, and she was allowed to go home. A month later her condition was pronounced "very satisfactory; pulse 88; she is doing all her own housework, though it fatigues her and she feels nervous." Five months later her pulse was rapid (120); "she is worrying over economic difficulties." Eleven months later the thyroid disorder was believed to be completely relieved. Pulse rate 80, basal metabolism rate plus 13. During these months of convalescence the strain upon her from social and economic problems in no sense diminished. Offer of the meager financial relief which social agencies could then supply was refused by the family. The son left college and found occasional low-paying jobs. The collection of porcelains was sold, the husband peddling it from door to door. Then he took other articles on commission and peddled them. In addition to doing the housework, our patient assisted her husband with the peddling. Her labors were much greater than before her operation or ever before in her life. Nevertheless, her general health improved and she became less anxious and fretful. During the second year after operation the family continued in the same precarious financial state. N o one had regular employment. The weekly earnings from peddling are said to have averaged about $12.00; that is, a group of four persons subsisted on an amount less than the minimum assumed to be necessary for one adult. Some weeks they earned nothing, other weeks enough to pay off part of their accumulated indebtedness to grocer and landlord. Always their accounts were in arrears, payments for rent being usually six months in arrears. Thus

ACUTE A N D

RECURRENT

33

they suffered not only from insufficient income but also from insecure income. The patient's improvement in health under these conditions is the more noteworthy because of her great concern for social prestige. She had grieved over the loss of their household treasures and the abandoning of their comfortable home and automobile, because to her they were symbols of a successful life. To have her son leave college and engage in common, unskilled labor was for her a tragic experience, again because it meant lowered standards, a loss of "face." When, after operation, discharge from the hospital was being planned, the usual period of convalescence free from excessive physical and emotional strain was recommended. Having learned of the family's financial state from husband and son, as well as from the patient, we advised that the patient spend a few weeks in a convalescent institution before returning to the burdens that awaited her at home. We also urged the husband to seek such economic security as social agencies were then able to provide. The patient and her husband could not bring themselves to ask for "charity" other than free hospital care, which they finally accepted after months passed and they were unable to make payments on the bill for ward care or even to meet the nominal clinic charges. The patient also refused care in the convalescent institution, insisting that she preferred to be at home. Explanation for this and for some of her extreme agitation during her first week in the hospital ward was revealed later to have been a fear that her husband would commit suicide. The haggard, depleted appearance of the husband made her fear seem to us not unreasonable. Whether the danger was real or not, her apprehension was real and it constituted a factor in the great strain to which she was exposed both during the year when sickness developed and during the period when recovery from hyper-

34

DEMONSTRATION OF CASES

thyroidism took place. T h e calamities which befell this woman in the year following the third exacerbation of her thyroid disease may seem, when considered apart from previous illnesses, sufficiently overwhelming to account for her inability to regain equilibrium. When, however, we find that two previous attacks were not associated with reverses of fortune, and when we find that she recovered satisfactorily from the thyroid disease while misfortunes continued unabated, then all the external influences whether of prosperity or of adversity may be judged to have been of relatively small importance compared to the internal influences disturbing the organism proper. Paradoxical as it may at first sound, it is our belief that her struggle to meet adversity was at first a force favorable to recovery. Combativeness was aroused; energy dissipated in worrying was directed to achieving results of momentous importance to her. Realization of ability to engage in the struggle and of achievement brought satisfaction and renewal of strength. Before her physical condition was relieved, she had not been able to control her energies sufficiently to direct them and therefore had experienced constant frustration, which increased tension and thereby perhaps disability. Effort directed toward a purpose relieved the turmoil of undirected energy which had constituted much of her sickness. Even though the occasion for effort against adversity aroused feelings of fear and humiliation, the combat itself brought relief. For this reason adversity, if it had any significant influence, may at this period have been favorable rather than unfavorable. Yet it is not correct to say that this patient had regained health in the sense of feeling fit. Objective tests repeatedly established the fact that the thyroid gland was no longer causing disturbance. During the five years that her doctor has kept her under supervision, her basal metabolism rate has remained normal. During those years, however, at no

ACUTE AND

RECURRENT

35

time has she felt comfortable and really well. After the operation, rapid gain in weight took place. She soon reached her usual weight, around 200 pounds, but continued to gain. At one time she weighed 240 pounds. Much of her discomfort was ascribed to this obese condition. She did not force herself to follow rigidly the reducing diet of 1,000 calories prescribed, claiming that it weakened her and rendered her unfit to do the heavy work she had to do to care for her home and to assist in earning the family's livelihood. She claimed, too, that she could not afford either the energy or the money to purchase and prepare for herself foods different from those she served to her family and therefore she did not follow the diet. Even when we allow that these excuses were hardly adequate, it is not difficult to understand this woman's failure in self-control. When driven to exert herself in ways to which she was unaccustomed and when engrossed in concerns of great importance to her, the eating of this or that probably seemed inconsequential or at any rate but another annoyance added to burdens already too great. Awareness of discomfort in some part of the body became more or less constant. Her eyes became inflamed. Discomfort from the lacerations which she had suffered when her first child was born, nineteen years before, seemed less bearable. Relief from these causes of discomfort was in time obtained but the feeling of well-being has never come. Besides such bodily discomforts and the continuing strain due to poverty and loss of status, other causes for anxiety arose. Her twelve-year-old daughter grew to be so disfigured by obesity that she withdrew from playmates and usual activities, becoming morose and unmanageable. The son, as the family's misfortune continued through the years, came to resent being forced to give up cherished plans for his own career in order to help meet family needs. The husband continued depressed and irritable because of his failure to provide. Following the regaining of strength during the first

36

DEMONSTRATION

OF

CASES

months after recovery from the thyroid disturbance, the patient herself became dispirited. She appeared disillusioned and unhappy like the husband. Shortly after her operation for pelvic repair and a year and a half after the thyroid operation, the family's ineffectual efforts at self-maintenance failed completely. The patient sought help from a relief agency, first a loan to establish a small business, and later, when this failed, an allowance for maintenance. But financial aid has been a threat rather than a help to this family. I t has never been acceptable; it has been instead a source of great emotional tension, even though it has been given with special consideration for restoring in the members of the family feelings of adequacy and capacity. Two years after partial thyroidectomy the patient seemed to be relieved of her physical discomforts but she had lost ground in her ability to cope with the problems in life. She appeared as one defeated by life and unable to accept this with resignation. During the following three years she has become more reconciled to her situation, less unhappy, and better able to cope with her daily problems. The small but regular relief allowance received during these latter years may have been an important factor in producing this change. DEMONSTRATION NO. 5 : SELMA SWENSEN This case illustrates the difficulty of determining the actual effect of influences in the environment which seem to be of the kind one would expect to undermine health and obstruct curative measures. Unfavorable as the circumstances were for the patient in question, it is impossible to say that she might not have been equally sick in a favorable situation, because of the nature of the disease from which she suffered. In so far, however, as alleviation of the unfavorable circumstances influenced the patient to use the specific remedy for overcoming the disease, this alleviation of the unfavorable circumstances must be regarded as significant. Lessening of fatigue and anxiety and improvement in nutrition may also have resulted from the supplying of funds, so that the patient no longer had the same pressure upon her to labor excessively, and could move to less depressing living quarters. It is

ACUTE AND

RECURRENT

37

unlikely, though, that any improvement would have resulted without the specific liver and thyroid therapies. The main significance of the social factors, therefore, would seem to have come from their hindering or facilitating utilization of these therapies.

Selma Swensen (Abstract 84), a Norwegian woman of thirty-eight, applied for medical care when she felt too weak to do her work. We learned from her that she had been born on a farm, the youngest of seven children. She did not remember ever being sick in early life, but in general she remembered little of her early life in Norway except the hard farm labor. At eighteen she came alone to the United States; she found employment as maid of all work and remained with the same mistress seven years. At twenty-four she married a young Norwegian carpenter just before he went with the American Army to France. She continued at gainful employment until his return. They then established a home of their own, and two years later, when she was twenty-nine, a son was born. Four years later, when the patient was thirty-three, her hair turned gray, and she began to notice weakness and other vague symptoms of ill-health which persisted. About this time also she undertook to supplement the family income by working as janitress. The husband, a union carpenter earning high wages when employed, was often out of work. For three years before the patient came to us, the family had been living in the damp, sunless basement of an apartment house where she gave janitress service. This meant stoking the furnace, disposing of garbage and trash, and scrubbing the hallways and stairs of a five-story house on hands and knees. In addition, she did her own housework, maintaining a high standard of cleanliness. Care of her child also added considerably to her labors and caused her much concern. He was rated of borderline intelligence (I.Q. 70), was in an ungraded class in school, and was somewhat difficult to manage. He was, however, the source of most of his mother's happiness.

38

D E M O N S T R A T I O N OF CASES

In spite of failing health during these years, she had the satisfaction of improving the family's economic condition. Investments were made in insurance policies, aiming at the protection of the child, and in furnishings for the home. By 1930, however, the husband ceased to have employment, and the family were maintained almost entirely from our patient's earnings, which provided the basement shelter described and $12 a month in cash. In the autumn of 1930 Selma Swensen applied to our hospital for relief of ailments of which she had been aware but which she had disregarded during the three preceding years. She was thirty-eight years old, but her sunken cheeks, gray hair, and yellowish skin made her appear many years older. She had lost twenty pounds in weight. For a month she had had numbness in arms and legs. In addition she was suffering from sore tongue, swollen ankles, headaches, weakness, and palpitation on exertion. In spite of feeling less able to work, she had driven herself relentlessly until finally the point of exhaustion was reached. Yet there was nothing to indicate that the hardships experienced had made her unhappy. She had friends among Norwegian people, and had enjoyed their social gatherings. Her church had meant much to her. She had enjoyed keeping her own home and caring for her child and even the hard work for others. Throughout our dealings with this patient it was difficult to protect her. Her devotion to and solicitude for her eightyear-old son so completely engrossed her attention that her own discomfort seemed of little importance to her. She was singularly lacking in self-interest. Even the change in her appearance and the loss of capacity to do things skillfully did not embarrass her. Her loss of capacity was important to her chiefly because this made her less able to protect her son. During the first two months she refused bed care in the hospital because she was unwilling to entrust the child to any other person. When forced by great exhaustion to enter

ACUTE AND

RECURRENT

39

the hospital for relief of a condition which from the first was believed to be pernicious anemia, though some symptoms found were not characteristic, she remained only a week and then returned home to the same drudgery. When she was in the hospital, treatment was under control, but disturbances in the home situation beset her. Financial aid was haphazard because relief policies in the early days of the depression were unsettled. The husband searched unceasingly for work and sometimes forgot that the boy needed care after school hours. Crises arose which disturbed the patient in spite of the watchfulness of the social worker. She worried for days because her insurance was unpaid, before the cause of her anxiety was discovered and the necessary money could be raised. When she returned to her home and could more adequately meet home problems, she neglected to follow medical advice. All she was asked to do was to take regularly the liver extract prescribed. But she forgot to take the liver; she used too small a spoon and thus took too little; she postponed coming to the hospital for new supplies, although they were given without charge. Through a social agency a small weekly allowance was provided, the janitress work was given up, and the family moved to an apartment aboveground. But even when necessities were provided, the patient persisted in her routine of drudgery and anxiety. The son must each day put on clean underwear and a clean shirt; her rooms must be spotless. She added to her domestic toil by going from house to house to secure scrubbing jobs in order to pay her insurance. Two fears obsessed her: (1) that she would die and her boy would be left unprotected and unprovided-for; (2) that unless her insurance were paid, she would not have decent burial. Her solicitude for her husband was not very different from that for her child. She it was, however ill she felt, who assumed the major responsibility for providing. When with-

40

D E M O N S T R A T I O N OF CASES

drawn from his skilled carpentry, the husband showed no ingenuity in finding other ways of earning. He tramped the streets, returning empty-handed. For months before we knew of their condition, Selma Swensen herself had managed, even when hardly able to walk, to earn food and shelter. To be sure, the diet consisted mainly of cereal foods. Hence inadequate nourishment as well as drudgery and anxiety may have increased the disability which disease had been causing during preceding years. Yet supplying foodstuffs alone did not assure nourishment. The patient had the sore tongue and distaste for food usual in pernicious anemia. Supplying the necessary liver extract did not insure that the right amount would be taken. She complained little and continued her dull, plodding concern to provide maintenance for the family as though driven by some force beyond her control to act thus, regardless of consequences to herself. After five months no improvement was noted, and she again reluctantly entered the hospital for further study. There continued to be a question as to whether the patient's anemia was primary. A subacute combined sclerosis was found as well as deep chronic fatigue and undernourishment. The efforts of doctor and social worker to persuade her to take liver regularly in sufficient quantity continued. Some interest was awakened by telling her that the liver extract was a "blood medicine." She began to respond to the ceaseless explaining and persuading by following directions more faithfully, and finally formed the habit of taking the liver fairly regularly. Slow improvement resulted. For a year she did well. Then, following a period of three months when she was to have eaten liver meat instead of taking the extract and failed to do so, she was again incapacitated. She entered the hospital much run-down, and weak and unsteady on her feet. In this hospitalization thyroid deficiency was detected and thyroid extract administered. Rapid improvement began immediately and continued; her gait im-

ACUTE A N D

RECURRENT

41

proved, and her weight and strength increased. Since then she has continued treatment, with only infrequent lapses. She seems at last to have realized the grave threat of complete incapacity unless she does have treatment. The husband found no employment other than that provided by the Welfare Department at Work Relief, for which he was paid $44.80 a month. The patient continued to utilize every opportunity to supplement their meager income. In this way she continued to fatigue herself as she had throughout the time of illness. Nevertheless her health improved steadily. It seems reasonable, therefore, to conclude that the deprivations suffered by this patient were little if any more depleting to her than they would have been to a person in ordinary health. If these deprivations had any special significance for the medical problem, this was because they forced her to occupy herself in ways that interrupted treatment. So absorbed was she in providing subsistence for her family that she could give little heed to anything else. Had she not been relieved of the necessity to provide for them and had the hospital not drawn her attention continuously to the importance of taking the prescribed medication, it is unlikely that treatment could have been accomplished. Except for this fact the economic derangement had probably no important effect in disabling the patient. Acceptance of relief was not humiliating to her, as it was to other patients whom we describe in this report. She had always been selfmaintaining and expected somehow always to remain so. It had not occurred to her to ask for aid. When it was given, she accepted it as simply as she did air and sunlight. But even if economic difficulties had not occurred or if community resources had permitted more adequate relief, this patient would not readily have been induced to carry through any medical plan that required changing habitual behavior. Her dull intellect adapted very slowly to new de-

42

DEMONSTRATION

OF

CASES

mands of any kind. Up to the time of illness she had lived contentedly within the folk patterns of her people. Her singular lack of concern about herself, her unawareness of or inattention to danger signals, her preoccupation with her son's care and welfare were all hindrances to forming any new habit. It was probably, then, of no small importance for the successful treatment of this woman, disabled by a serious disease, that the assets and liabilities in her character and in her situation were discovered and that pains were taken to rectify inadequacies in both. The habits necessary for fulfilling her part in medical treatment having once been formed, their continuance seems insured by the very traits of character that had made instituting these habits difficult. DEMONSTRATION N o . 6 : T H E R E S A

FLEMING

Development of illness resulting in great disability is shown in this case as the result mainly of emotional tension induced by a distressing situation. A fair adjustment was reached by removal of the patient to a more tranquil environment where satisfying experiences diverted her attention from her insoluble difficulties.

Theresa Fleming (Abstract 39), fifty-four years old, was referred to this hospital by a private physician who had taken care of her, and also of her husband, for several years. Two years before, he had treated the wife for symptoms identical with those now presented, and had been on the point of referring her for hospital care, when the symptoms subsided. He had been in a true sense the family physician to this couple, knowing their home life and surroundings, the economic reverses that had befallen them, and their anxiety. He had also assisted in reestablishing the husband in work he was able to do. The husband had first come to him for treatment and had remained his primary concern. This man in the preceding six years had experienced two prolonged illnesses. The first had occurred when he was

ACUTE A N D R E C U R R E N T

43

fifty-five years old. He had suffered a paralytic stroke while at work and had fallen and sustained serious injuries. He then spent four months in a hospital. Three years later he went again to a hospital to have one kidney and several stones removed. After the operation his condition was believed hopeless, but he improved and in three months was able to return home. Following the last illness he had periods of paranoia, became violent, and had delusions of persecution. His wife, our patient, cared for him during convalescence after both illnesses. She became ill and had symptoms like those she now complained of six months after his operation for kidney disease. The present attack came on shortly after the husband returned from a five months' absence, when his son, our patient's stepson, had taken him to his home in the country to convalesce from his mental disorder. When admitted to the hospital, this woman appeared sallow, thin and pale, and chronically ill. She was fifty-four years old, but looked many years older. She complained of soreness and burning in epigastrium and spells of dizziness, faintness, and shortness of breath. In the preceding six weeks, she had, she said, lost 17 pounds. She weighed but 91 pounds, some 25 below the weight proportionate for her age and height. Her symptoms and general appearance suggested either a malignant growth, ulcer of stomach, or cholelithiasis, although none of these diagnoses was confirmed by laboratory findings. Loss of weight and asthenia suggested so strongly a malignancy that an exploratory operation was done; it revealed no growth, but mild inflammation of liver and peritoneum, enlarged peritoneal nodes, and a slightly diseased appendix. The gall bladder and appendix were removed and after five weeks the patient left the hospital to convalesce. These findings were regarded as insufficient to account for the severity of her symptoms. Investigation of this woman's social situation revealed dis-

44

D E M O N S T R A T I O N OF CASES

turbances and dissatisfaction believed important for understanding and treating her condition. She was one of a large family, all of whom, with the exception of herself, had married in early maturity and left the parental home. She continued to live with her parents, both of whom became chronic invalids, and nursed them for several years preceding their death. Following this, she had made her home with a married sister in whose home an invalid great-aunt and the sister's mentally deranged husband also lived. The sister's husband was at times so violent that our patient tells of having to wrest knives from him. This man was finally committed to a hospital for mental disease and the sister supported the home by running a millinery shop. Our patient helped in managing the home and rearing the sister's four children and enjoyed the attachment that developed between herself and these children. But when they grew up and left the home, she was no longer needed and she began to feel a burden to her sister. She had never been robust and in middle life had had several illnesses. At the age of thirty-one, she had typhoid fever and was very ill for seven weeks. She believes that following this she never recovered her former strength. Seven years before we knew her, at the age of forty-seven, she had influenza and pleurisy followed by what she described as a "nervous breakdown" for which she was treated for several months in a hospital. Although the financial resources of her group had always been limited, there is no indication that she had at any time suffered physical privation from lack of necessities. Nor is there report that she had worried over money matters while living with her own kinspeople. Social relationships with kinspeople and friends had been congenial and satisfying. Another important source of happiness in her life was religion. She was an active member of a small Protestant sect at whose meetings testimony regarding per-

ACUTE AND RECURRENT

45

sonai religious experience was encouraged and conversions were acknowledged publicly. She was forty-eight years old when she realized that her sister no longer needed her help. For the first time it seemed seriously to trouble her that she had no home of her own, no gainful employment on which to rely, and no one able to support and care for her in case of sickness. Up to this time all that was learned from her or others testified to a life of fair contentment in spite of not a little ill-health and of almost constant association with the ill-health and suffering of others. When she was about forty-nine years old and seemingly a confirmed spinster, the opportunity to marry a widower seven years older than herself was offered and accepted. This man also held lost his home, when his son and daughter married, and he too felt alone in the world. He was a skilled mechanic, earning as foreman $100 a week at employment that seemed stable. In marriage she sought companionship, a home of her own, economic security, and an object to be mothered. She found the sexual relationship unpleasant and after the first few months refused to live with her husband and returned to her sister's home. The husband's work kept him in New York. They remained on friendly terms, however, and on week ends he visited her. One year after their marriage he sustained the serious injuries previously noted. She came to New York then to care for him and they lived together in a single room. She earned livelihood for them both by managing a "furnished rooming" apartment house, work which she found very exhausting. The husband's mental state grew worse, he feared that his life was threatened, and he had attacks in which he turned against his wife, became physically violent, and in obscene language accused her of infidelity. His violent outbursts finally compelled her to give up the apartment-house venture. They moved again into a single room, where she devoted herself to caring for him.

46

DEMONSTRATION

OF C A S E S

His jealousy increased to such a degree that he would not allow her to leave the room unaccompanied. Shame prevented her from seeking aid of kin or friends. She was advised by a psychiatrist to have her husband committed to a mental hospital, but this she refused to do. It is reported that his episodes of violence occurred once to three times a week and proved so exhausting to our patient that she fainted as often as three or four times in the course of one of them. On these occasions she had what she described as intense cramplike pains around her stomach "which felt as if something were tearing." She also stated that she found his irrational violence easier to bear than his repentance and expression of affection after a seizure. In the spring, six months before coming to us, she finally revealed her situation to relatives and to her husband's employer. Custody of the husband was for about five months assumed by his son, to whose home he was taken. He improved gradually and returned to New York, where his employer, advised by their physician, arranged for him to have work which he was able to do, though at wages less than a quarter of the amount previously earned. He still had occasional attacks and still refused to allow his wife to go out alone. Her social contacts were very limited. The room was small, bare, and unattractive. She had practically no outdoor exercise and no interesting occupation. Her sleep was broken by her husband's restlessness. She ate irregularly; she had no appetite and food made her feel sick. The income, though sufficient to cover their needs, was insecure; their savings had been spent and they were in debt. The couple had been living together in this fashion for three months when she came to us. It is important for this study to evaluate the effect of emotional strains such as these in the development of illhealth and in the processes of recovery. Our material in this case is particularly reliable and full. Testimony was obtained

ACUTE A N D R E C U R R E N T

47

from the patient, the husband, the husband's daughter, the patient's sister, and the private physician who had known the couple several years. In addition, the independent observation of two social workers added substantiating evidence regarding this woman's distressing situation. Since the illness could not be explained as due to organic disease, it was assumed that the emotional state, due to the social situation, was of major importance and treatment was directed toward altering that situation. The patient believed that the operation had removed the cause of her most severe symptoms. It was made clear to her and to those around her (the stepdaughter, the husband, and the sister) that if she were again allowed to become weakened by lack of proper food and rest and by excessive physical exertion her symptoms might return. She was encouraged also to give expression to her feelings, for we believed that reticence regarding the relationship with her husband had allowed great inner tension to develop. Her long association with a religious group who practiced public avowal of intimate personal religion and the comfort this association had apparently yielded suggested that some lessening of reticence might prove beneficial. During the early postoperative period, recovery of strength and weight was slow but steady. She was surrounded and supported by sympathy, consideration, and solicitude. She was given nourishing food at regular intervals and was freed from responsibility. Her appetite returned. For the first few weeks following her discharge the husband had no paranoid attacks. As soon as her strength permitted, she visited her sister in her old home; here during six weeks she gained strength. She had left the hospital weighing 84 pounds; three months later she weighed 101 pounds. Then she returned to New York and in less than two months new symptoms began. She complained of palpitation, suffocation, pressure at the pit of her stomach and

48

DEMONSTRATION

OF

CASES

around her throat, and pain in her back and shoulders. These seemed to be associated with the husband's attacks. She was persuaded once more to visit her sisters and with them she remained symptom-free all summer. Following her return to New York in the autumn she became absorbed in helping her stepdaughter, who was seriously ill and having much trouble in caring for her home and children. Our patient undertook considerable labor and responsibility in the care of the stepdaughter's home, with actual improvement in health. A year after leaving the hospital she weighed 114 pounds, a total gain of 20 pounds. This was 4 pounds more than her best weight and 12 more than her average weight. About this time it became possible for the couple to move back to their old community, where she was once more in daily touch with kin, friends, and her church. They remodeled and furnished a home of their own and our patient was able to do all the housework without excessive fatigue and with great pleasure and pride in the accomplishment. She had no serious recurrence of symptoms in the following year. The prognosis for this woman remains guarded. She seems constitutionally unequal to great strain. Narrowness of financial margin, the husband's emotional instability, or an eventual return to New York City may precipitate symptoms. On the other hand, there has been some progress in making her aware of her constitutional limitations, and should she be subjected to unavoidable strain in the future, it is believed that she will recognize the danger and will seek aid. [ L A T E R NOTE.—Two years after her operation and a year after establishing her home once more in her native village, this patient again moved to New York City because her husband found work here. Within a month she was asking treatment at this hospital for symptoms hardly less alarming than those she had first presented. The question

ACUTE AND

RECURRENT

49

of malignancy was again raised because of her appearance, weakness, loss of weight, etc. After reinvestigation and three months' observation it was again concluded that no disabling organic disease was present and that "if she were contented and happy, she would have no indigestion." Once more she was advised to leave the city and return to the familiar and tranquil surroundings where she had been able to live more successfully.] DEMONSTRATION N o .

7:

CHARLES

LEFKOWITZ

For our purpose of understanding more clearly the effect of adverse social factors on health, it is of special interest to note in the following case that it was not the experience of external calamities which disordered bodily functioning, but the feeling of personal inadequacy to meet creditably the ordinary requirements of adult life. The patient herein described was cured of chronic colitis when enabled to recognize the kinds of encounters in life which caused him to suffer emotional perturbation and brought on symptoms of illness, and to learn by practice how to approach these encounters with less diffidence and finally with pleasure and assurance.

Charles Lefkowitz (Abstract 50), a twenty-year-old Jewish immigrant, sought the aid of this hospital because he had noted, over the course of two years, that his bowel movements had increased in frequency to four or five a day and that recently rather severe rectal pain had occurred on defecation. Until shortly before coming to us he had not been alarmed by his condition. On first noting symptoms he had believed that they were due to certain foods and had experimented with his diet. When he failed to gain relief he had consulted two private doctors. He had had brief periods of relief when he restricted his diet to bland foods, but symptoms recurred in spite of careful adherence to the prescribed diet. Shortly before coming to the hospital he had heard of a case similar to his own in which cure had been effected only by removal of "part of the stomach." Not until then had he felt alarmed about his condition. Physical examination and laboratory findings failed to ex-

SO

D E M O N S T R A T I O N OF C A S E S

plain the symptoms. Neither infection nor parasites were found. Abdominal X ray suggested the presence of calcified tubercular mesenteric nodes but there was no evidence of an active tubercular process. The patient was born in Warsaw, Poland; although he was one of dizygotic twins, birth had been easy, and he had grown to be a robust and healthy child. He was four when the World War broke out. Throughout the war the family suffered severe deprivation. For a time they lived in one room. Food was poor and inadequate. The household consisted at that time of the boy's parents, their four children, and two small cousins. Both of the cousins died of tuberculosis within the year after leaving this household but none of our patient's immediate family developed recognized symptoms of this disease. When our patient was eight he had typhus fever, as did six other members of the family group. He had measles at two and again at fourteen, and at thirteen he had a vague illness, the chief symptom being severe pain in the head, relieved by leeches. The only evidence of a neurotic tendency was a feeling of faintness and occasional loss of consciousness at the sight of any bleeding injury. The patient's father expressed the belief that the deprivations of the years of war had permanently affected the whole family, making them "nervous." Shortly after the war the father emigrated to New York and became owner of a small delicatessen shop, and in the course of the next five years earned enough money to bring his family to America. The patient and his twin brother were the last members to be sent for. He was then fourteen. He had completed the equivalent of two years of high school. His chief interest had, however, not been in school but in an active, outdoor life. He had been accepted as a leader in a group of boys his own age, and had enjoyed the association and such experiences as

ACUTE AND

RECURRENT

51

going with them on long jaunts into the country. In spite of the hardships of war, the ever-present fear of pogroms, and separation from his family, he now looks back upon his childhood in Poland as happy. From the first he had disliked New York City, saying that here he had always felt "small and submissive." He disliked especially the crowds; in the subway he became nauseated and occasionally vomited. He found his family established in a comfortable, clean, and well-managed apartment. The father's business, though small, provided adequate maintenance. The oldest brother was already apprenticed to a pocketbook maker and the family as a whole were intent on learning English and adapting themselves to their new environment. Even the mother was attending night school. Charles enrolled in school, learned rapidly, and two years later graduated from the eighth grade. He made friends easily, joined a boys' club, made week-end excursions into the country, and availed himself of a neighborhood gymnasium and swimming pool. The home life was congenial and our patient was in accord with the other members of the group. At the age of sixteen he and his twin brother were apprenticed to a pocketbook maker. This trade was selected not because of any interest on his part but merely because of his older brother's affiliations. From the start he had little liking for the work. The odors of leather and glue nauseated him, as did the subway, and crowds in a closed place. Once started, however, he continued in the trade because of family precedent, and because he did not feel that he could afford to take time to learn another trade. He completed his apprenticeship at nineteen. The family at that time began to experience the effect of the general economic depression. The three brothers were engaged in a seasonal trade, which still paid fairly well when work could be found, but periods of employment were short. The father's business

52

D E M O N S T R A T I O N OF CASES

was threatened with failure. The family as a whole became apprehensive about its economic future. At the time the patient came to us the father was so distracted by his fear of business failure that it was difficult to hold his attention on any other subject. The adverse social factors discovered in this patient's background and present situation were: physical deprivation in early childhood, exposure to children dying of tuberculosis, association with persons terrorized by war and race persecution; broken home during adolescence, entailing separation from both parents ; radical change in environment at the age of fourteen, requiring that difficult adjustments be made ; dissatisfaction with chosen vocation in preparation for which three years had been spent; great economic insecurity at present for the whole family. On discharge from the hospital the patient spent a month in the country at a convalescent home. There bowel movements decreased to one or two a day, but new, vague symptoms, also unexplained by organic pathology, developed. Psychiatric study and treatment were then undertaken, in the course of which it became clear that none of the social and economic adversities experienced were of primary importance in creating the state of anxiety which was believed the cause of illness. His present symptoms had started at the time when he had discovered that he was expected to meet and "go out" with young girls. He felt awkward and inadequate in their presence. Even the suggestion that he "make a date" had brought on acute diarrhea. The connection here was so clear that it could be pointed out to the patient. He was assured that no organic disease had been found. The physiological processes causing his symptoms were elucidated. He was told that to be free and easy with girls had to be learned little by little and could be learned only through experience. His attention was turned from symptoms that annoyed

ACUTE AND

RECURRENT

53

him and increased his anxiety to the conditions that caused the symptoms. He had previously avoided "dates" because they had seemed to make him sicker. To his great satisfaction he discovered that he was socially acceptable. Now he forced himself to seek the company of girls. He himself observed that as his bashfulness lessened with experience, his symptoms also subsided. When his symptoms changed— "migrated"—and he suffered from palpitation, he was again able to see the connection between cause and effect and to bend his energies to master the cause without undue concern over the effect. The analytic process, continuing through fourteen visits of about an hour each distributed over the spring months, had helped him to understand and resolve the feeling of personal inadequacy which for about two years had made him unhappy and ill. Six months after termination of treatment he returned to the clinic to express appreciation of the help given him. He said that he felt like a different person. Symptoms had entirely disappeared. It was observed that his whole bearing had changed from one of anxious dejection to one of competence and self-reliance. In this time his father's business had failed. Our patient and his brothers had found no work in their trade and only occasional odd jobs at unskilled labor like dishwashing. The economic condition was the worst they had ever known. Amidst these vicissitudes the patient had remained well and in good spirits.

IV D E M O N S T R A T I O N OF CASES:

CHRONIC

The cases of three patients elaborate the idea that disability for the kind of life and labor one desires and is accustomed to results not only from disease which by damaging tissues and organs disturbs functioning, but also from the reaction of the patient to his circumstances and to his disease and the limitations therefrom. We further suggest that such interaction is of special importance when no specific remedy for the disease is known and the patient must himself be responsible for carrying out the therapies prescribed to protect already damaged parts. DEMONSTRATION

NO.

8:

PASQUALE

DI

LORENZO

During the five and one-half years this patient was under the care of our hospital, the major medical recommendation, that fatigue from overactivity and excitement should be avoided, was at no time carried out. Social factors are described which explain in large measure his resistance to prohibitions intended to control his habitual overdoing.

Pasquale Di Lorenzo (Abstract 70), having been admitted to our hospital nine times in the course of five and one-half years, died in the hospital at the age of nineteen. His diagnosis was rheumatic heart disease. The story of the steady progression of cardiac damage is given in the following summary written in his medical chart at the time of his last admission: "Past History: Tonsillectomy at 4, which relieved him of frequent sore throats. Rheumatic fever at 5 with cardiac involvement. "Scarlet fever at 12 followed by dyspnoea and palpitation. "His first admission here $y 2 years ago (age 13) was for acute rheumatic joints at which time he had a double

CHRONIC

55

mitral lesion, normal electrocardiograms. The question of aortic involvement was raised. Tonsillectomy was again done. "Three years ago at his second entry (age 16) aortic involvement was certain and X rays showed a 'mitral heart.' His acute polyarthritis subsided on salicylates. "Two and a half years ago (age 17) he was admitted for recurrence of joint pains and for precordial pain of 6 days' duration. Two electrocardiograms showed progressive myocardial damage and X rays an enlarged heart. He developed pericardial and left pleural effusions. The question of mediastinitis was raised but not settled. "Recurring polyarthritis and cardiac symptoms (precordial pain, tachycardia, dyspnoea) led to admissions IV to VI (age 16 to 17). During this time there was evidence of increasing cardiac damage (electrocardiogram) and of hypertrophy. "Fourteen months ago (admission VII, age 18) his symptoms were wholly cardiac and electrocardiograms showed premature beats of ventricular origin (digitalis given). "On his next admission (VIII) two months ago he had developed a lung infarct (left lower lobe) and auricular fibrillation. He did well on maintenance doses of 0/3 gms. digitalis O. D. (This admission was necessitated by his failure to push digitalis at home.) "On his last admission (IX, age 19) he had active pancarditis, symptoms suggestive of adherent pericardium and also of a mesenteric thrombosis. The latter was not found on exploratory operation." It is perhaps worth noting that on only one occasion (that of the seventh admission) did an upper respiratory infection precede the acute illness which brought him to the hospital. This boy was born and reared in New York City. Both his father and mother came from Northern Italy. The

56

D E M O N S T R A T I O N OF CASES

father's family considered themselves aristocrats. The father himself, whom our patient resembled, was reported to have been irresponsible. He drank heavily, was discharged from the police force after twelve years of service because of a scandal, and was unsuccessful in ensuing business ventures. He finally deserted his family when our patient was ten, and in spite of court action, did not contribute after that to their support. The mother came from a family with less pretension to rank, and was herself capable, dominating, ambitious, and emotional. Our patient, the only child of this marriage, was a sickly baby, and was always regarded by his mother as frail. There is evidence that from infancy on he was indulged and pampered. The home atmosphere until the time of the father's desertion was tense with the friction between the parents, and there may have been more than a little rivalry for the affections of the child since in later years the boy expressed more affection and admiration for the father than the mother led us to believe he possessed. The physical conditions and the standards of living maintained in the home seem to have been wholly favorable and throughout his life there is no suggestion of physical deprivation of any sort. After the first recognized appearance of rheumatic fever when the patient was five years old, he was cared for at home and was not allowed to enter school until he was seven and a half. He is said to have been facile and quick and to have accomplished the requisite school work without difficulty but with little enthusiasm. His interests seem to have centered in athletic activities in which he was ambitious to excel, and in which his prowess won him easy recognition from younger classmates. After the desertion of the father, the mother went to work and earned an excellent salary. Both maternal and paternal kin were sympathetic with her and joined her in solicitous

CHRONIC

57

indulgence of the child. The mother was proud that she could keep him better dressed and give him more than his associates had. She succeeded in emulating the standards of his father's well-to-do relatives. Aside from the satisfactions of ostentation and of lavish affection, she had little to offer him. Limited in education, she was not equipped to stimulate his interests and she watched with apprehension, and attempted to curb in him, traits of self-reliance which presaged maturity and independence. His satisfaction in personal accomplishment was won chiefly through athletics which he enjoyed the more because he was cautioned against them. We have grounds for believing that the activities he engaged in, from seven and a half to thirteen years of age, were excessive for an already damaged rheumatic heart. When he first came to us at thirteen, the social worker recorded the following observation of him and of his mother : "He is childish and morose if he does not get his own way. Expects a great deal of his mother, is inconsiderate of her. He is not easy to manage and is decidedly spoiled. He is not embarrassed by the demonstrative attitude of his mother on the ward. Seems to take fondling and exaggerated display of affection pretty much for granted." Of the mother she noted, "Uses little discretion in talking before him. Praises him in an exaggerated way, seems to be absorbed in what she can do for him regardless of her own interests, and of the ordinary hospital routine. It is hard for her to realize that she should deny him anything and he knows it." There were many factors both in the patient's personality and in the social situation which, properly directed, might have been assets in the management of his condition, but which had been so misdirected that they had become obstacles rather than assets. The boy was intelligent, quick, enthusiastic, and self-willed. The mother and relatives were intelligent, responsible, and deeply interested in the child's welfare. They had means to carry through any plan we

58

D E M O N S T R A T I O N OF CASES

might have suggested. The home was well situated and comfortable. Yet it became evident to those who were planning the management of his condition that these apparently favorable factors interfered with the carrying out of the medical regimen, which was largely control of activity. They also presaged one of two reactions on his part in the future—either abject acceptance of the role of invalid, or open rebellion and flouting of restraints—either of which would increase his suffering and prevent enjoyment of life. At this point it was recognized that the influencing of this situation was an integral part of treatment of the case and therefore we accepted it as a rightful function of the hospital. Explanation of the medical condition was given to the mother and the need for restricted activity was explained to her and to the patient. An attempt was made to provide supervision in a home and school for cardiac children so that the boy might learn a disciplined routine of life and learn to enjoy activities within his energy capacity. The boy remained in the school only a few days. The mother removed him, saying that the physical conditions were "not good enough" for her son, and on her own responsibility she sent him to an expensive resort. An attempt was then made to enlist the interest of a priest of magnetic personality, in the hope that he might win the admiration of the boy and the confidence of the mother. It was hoped that he might discover less harmful interests for the patient and help the mother to realize that her program of overindulgence and lack of discipline was harmful to him. Explanation of the boy's illness and of the need of controlling his activity was made to the parochial school. They eliminated for him much stair-climbing and restricted his playground privileges. Explanation was also given to the master of his Boy Scout troop who further restricted his activity. All these attempts to control activity and develop

CHRONIC

59

suitable interests failed. The child did not participate in the plan and his letters in the next few years show resentment of the restriction. The mother attempted to compensate him for his disappointments by dressing him in expensive clothes and giving him spending money. It is interesting to note that the patient's next three admissions to the hospital, one in 1927 and two in 1928, occurred not in the winter and early spring months when rheumatic recurrence is expected, but in the supposedly beneficent summer months. Moreover, none of these admissions was preceded by upper respiratory infections and all were preceded by distressing cardiac symptoms. We interpret this as meaning that this boy needed the discipline and the artificial control of activity that school attendance enforced. Left to his own devices (his mother being either unwilling or unable to control him) he overdid. He had never learned self-control. He had no interests other than sports to fill his time or hold his attention. Prohibitions aroused his resentment and challenged him to test his endurance. Fatigue followed overexertion, and influenced these recurrent cardiac attacks. In 1928 when he was sixteen he had completed his education (graduated from grammar school and from a oneyear course in accountancy). His father died. He was observed to express impatience with his mother's demonstrativeness on the ward, and his mother admitted that she could no longer control him. He was a tall, slender, handsome youth, mature in appearance, fastidiously and expensively dressed. The following excerpts taken from the medical chart indicate his reaction to his disability: "Patient says he was very short of breath last night so that he could not lie down. Nurses said he slept practically all night. I saw him at 9:00 A.M. He was crying hysterically

60

D E M O N S T R A T I O N OF C A S E S

and taking deep gulps of air. Dyspnoea was not increased when he lay down for examination. No change in physical signs. Temperature at 102 degrees for two days. I think, however, that 9 0 % of this upset was mental. He quieted down after reassurance." Again, "Subjectively he is a difficult case to handle. Marked emotional instability and quite panicky." On this admission (his third) he left the hospital against advice, was taken ill a few days later, and was readmitted. "Patient is cooperating not at all as his pulse shows. He will not keep quiet." He again insisted on leaving the hospital against advice. "Patient strongly advised against going home. The situation explained to him and his mother. In view of the repeated lack of cooperation shown by him and the hopelessness of doing anything for him under the circumstances I believe he should not be readmitted to the hospital." He was, however, to have five more admissions to our hospital. Perhaps part of our failure to influence this patient resulted from our lack of contact with him when he was out of the wards. After the first brief attempts outlined above, control was taken out of the hands of the hospital and placed with a local doctor with whom we had no communication. Looking back over the patient's course, two factors, both of which might have been remedied, seem to stand out as contributing to the failure. One was this lack of coordination of medical control and supervision. The other was the failure to appeal to the patient. I t seems probable that he would have responded had he been made to feel that he alone—not his mother, his school, his doctor—was responsible for his regimen. From the age of sixteen to the time of his death three years later he was in a state of war against his restrictions. T h e formal routine of school had been left behind and he had nothing but the pursuit of pleasure to fill his time. He

CHRONIC

61

was not without ambition and he was equipped for sedentary work. His mother would not permit him to accept suitable positions which were offered to him, fearing, she said, that the strain would be too great. H e traveled around visiting kin during the day, and found for himself friends of whom his mother did not approve, and with whom he spent the evenings away from home, keeping late hours, occasionally staying out all night. T h e mother watched with panic the growth in him of traits resembling those of his father. Her tearful reproaches and appeals failed to evoke his tenderness; the gift of an expensive automobile and the rental and furnishing of a more fashionable apartment failed to keep him at home. Of the next five admissions, four occurred in the winter and early spring months ( M a r c h , April, November, J a n u a r y ) and the fifth in September immediately following three and a half months spent at a mountain resort where he indulged in strenuous sports: tennis and hiking. H e neglected to take even simple medication (salicylates to relieve joint pains, digitalis to regulate heart action), and one of his admissions to the hospital is directly attributed to this neglect to follow medical instructions. If this boy at the age of sixteen had been given suitable work, for which he had already been trained, as an antidote to fear and discomfort, and as an outlet for his energies, it could not have involved greater strain than the type of " r e s t " in which he indulged. It may be argued that he was already doomed and that he should have been allowed a short life and a merry one. This attitude would perhaps be justifiable if he had really enjoyed his life, but he was observed to be unhappy and restless. He manifested deep discouragement when discussing his own problems and the futility and purposelessness of his life, and expressed active resentment against his sickness, of which he said, " I t keeps me from doing anything."

62

D E M O N S T R A T I O N OF C A S E S DEMONSTRATION N O . 9 :

EMMA

KOVACS

Disfigurement as well as disability for school and the usual pastimes of a young girl created in this patient petulant rebellion succeeded by despair. The provision of part-time employment suited to her limitations developed her capacities, increased her happiness, and apparently checked the development of invalidism.

The picture presented by Emma Kovacs (Abstract 72) in April, 1931, when seventeen years old, was that of a girl very young in appearance and immature in development. She was five feet tall and weighed sixty-fi ve pounds. The spine was stiff, particularly in the cervical region, and there was conspicuous deformity of the hands, wrists, elbows, and shoulders. In addition to this, her body from head to feet was covered by scaling red patches which over most of the body were confluent. The scalp was entirely covered by a crust, fitting her head like a skullcap. The diagnoses made were chronic multiple arthritis (Still's disease) and psoriasis. She had not been well since the age of eight, when she had fallen and injured the back of her neck. For several months she was unable to attend school. Before she recovered from this accident she began to complain of precordial pain. Her condition became worse during the next year and a half. She was then admitted to a cardiac clinic. No joint changes had as yet occurred. The diagnosis made was subacute rheumatic fever. Some heart damage had occurred. This girl was born in New York City of immigrant Hungarian parents. We know little about the father. It was reported that he had been a laborer who worked steadily and earned enough to support his family, and that he had died of influenza when our patient was seven. The mother, about whom we came to know a good deal, was thirty-seven years old and although twenty-five years had passed since she was transplanted from a peasant community in Hungary, she still retained Hungarian customs in her home here in

CHRONIC

63

one of the most congested tenement districts of New York City. High standards of order and cleanliness were upheld. She regarded cooking as an art and provided a rich diet for her family. Wine or diluted whisky was always served with meals. For things American she had a deep distrust and dislike. After the death of the father, the mother became the breadwinner as well as the homemaker. She quickly acquired skill as a factory worker and earned enough to maintain a comfortable home for herself and her two children, and leave a slight margin for savings. There was not, however, sufficient income to meet the expenses of the various medical treatments for our patient which the distracted mother felt she must have. Numerous private physicians were tried in addition to patent medicines and faith healers. Thus financial strain was added to her other cares. Then, too, work necessitated her absence from home during the day, and when away from the child she worried. Her apprehensiveness and emotional outbursts made the atmosphere of the home tense. She centered her attention on the sick child, indulged and pampered her. We have testimony, from those outside the immediate family who knew her from the age of ten, that this child was self-centered, demanding, stubborn, "food-fussy," and petulant. These attitudes, which later were to prove serious obstacles to the management of her illness, could not perhaps have been avoided under the circumstances. In the first years of her sickness there was no consistent medical program, and had there been a program it could hardly have been carried out effectively with the mother away at work all day. Yet unfortunate as her pampering was from the standpoint of character development, as were also the loss of her father, her mother's absence at work, and the confinement of the tenement rooms, the home was not without compensatory features for a child who was to become progressively

64

DEMONSTRATION OF CASES

crippled. The family was closely united by affection, esteem, and loyalties. In the home this child felt secure, for she realized that she was wanted and loved. Up to the age of ten our patient, in spite of increasing discomfort, continued the pursuits of a normal child. She attended school and played with other children. No disfiguring deformity had as yet appeared. Between the ages of ten and eleven her joint pains became much worse and she was placed in an institution for cardiac children where she remained fifteen months. Her treatment and activities there were most carefully managed. But during this period she was unhappy and homesick. She believed that she had been cast off and signed away by her mother. During the last three months of her stay she was kept in bed; joint deformity became manifest and subcutaneous nodules appeared on both hands. In spite of rest, physiotherapy, and special diet, she lost weight rapidly. The mother was thoroughly alarmed; she lost confidence in the medical care and took the child home. There she was fed and tended with the most solicitous care of which the untrained mother was capable and she slowly began to gain in weight, her color improved, and her pain subsided. It is in the nature of this disease process thus to advance and subside, but the coincidence of gain in general health with the return to her home raises the question as to whether the child's emotional disturbance might not have counteracted to an appreciable degree the effects of the good care given in the institution. It was obvious that she was unhappy, but the degree of tension and restlessness which the child's own statements now lead us to believe then existed was not appreciated. Had this been appreciated, a plan of care at home better suited to her temperament and the family's ability could probably have been carried out, and the cost to the community would have been little higher than that for institutional care. At the time, however, no adequate

CHRONIC

65

appraisal of social factors was made, and ways of assisting the mother to solve her problems other than by removal of the sick child from her home were not considered. The child's condition was now diagnosed as Still's disease or child's arthritis. She continued under the supervision of the same hospital she had attended before going to the cardiac institution, but was transferred to the arthritis clinic. For the next three years experimental vaccine treatments were given. During the first year joint changes progressed rapidly. Her fingers, wrists, and elbows became stiff, swollen, and deformed. Then for the ensuing three years the condition became almost static and she had little or no pain. During this time four to six hours' daily rest in bed was prescribed. As this made it impossible to attend public school, a teacher was sent to the home for two hours three days a week and the child completed grammar-school training and began that of high school. From the age of twelve to seventeen her life was conducted almost entirely within the rather cramped quarters of the home. Deprivation of sunlight may have been an adverse factor and there may have been some dietary deficiency, due not to failure on the mother's part to provide the foods advised but to the girl's dislike of milk and fresh fruits, and her indulgence in breads and pastries. She accepted the care of the home as her responsibility. She did the marketing, the cleaning, and some of the cooking. Neighbors were friendly and, left to her own devices during the day, she now admits that she was up and around most of the time, instead of remaining in bed as advised. The brother, three years her senior, was developing into a capable, intelligent person with recognized artistic talents. He enjoyed reading and he had many friends. He brought his enthusiasms, his books, and his friends home. Their little apartment became the gathering place of a group of

66

D E M O N S T R A T I O N OF CASES

young boys and girls. The mother proved adroit in making them feel welcome and less restrained than they did in their own homes. In spite of her youth, our patient, who was pretty, alert, and appealing, was made to feel welcome by this group. She showed, however, a deep resentment against her illness and a growing sensitiveness about her deformities. The efforts to aid her made by an agency for crippled children she met with stubborn, sullen resistance and she would fly into tempers when her mother wept over her or expressed pity. Although she enjoyed the company of people she knew, she shunned strangers and dreaded crowds. In 1929, following the onset of the industrial depression, the mother's earnings decreased and the brother gave up school and went to work; the family felt that in doing so he was sacrificing his ambitions and our patient became conscious of being a burden. She was then sixteen years old and felt she must prepare herself to earn a livelihood. She undertook training which would, she believed, equip her soon for gainful employment. Through the visiting teacher service she now attempted to learn shorthand and typing at home. Great discouragement and bitterness accompanied the realization that her hands were too crippled for this kind of work. She abandoned it, and resisted all further attempts to bring to her educational opportunities. This was another unhappy experience, probably detrimental to health, from which she could have been protected had social factors been recognized as important in her medical care and suitable measures for their control been employed. If the teacher had fully comprehended the permanence and progressive nature of her disability, the girl might have been spared the discouragement of this failure, and training more suited to her capacity might have meant much in maintaining her morale, preparing her possibly for gainful employment and certainly for the satisfying use of leisure time.

CHRONIC

67

She was a mentally alert person, appreciative of beauty, receptive to ideas; but after this disappointment, boredom, petulance, and bursts of temper, associated with considerable self-reproach, manifested themselves increasingly. The solicitude and indulgence through which the mother expressed affection were distasteful to her; they emphasized her uselessness and her dependency when her desire was for normal independence. She became unapproachable andjtense, and the only emotion she would permit herself to display was anger. She met her mother's tears with a hostile and somewhat scornful calm. In November of 1930 psoriasis began to appear and spread steadily. Her joints again became painful. A period of six weeks' hospital care brought no relief. At home again, pain in her feet and knees made it impossible for her to be up. The mother prepared a cold lunch for her and she was left alone all day in the apartment, locked against intruders. As months passed and the extremely disfiguring psoriasis spread, she seemed to abandon herself to despair until the mother, fearing that she would commit suicide, gave up work to stay at home and watch over her. At the time of her second admission to our hospital, in March, 1931,* her condition seemed so hopeless that the physicians in charge of her case advised securing permanent care in a chronic hospital. Both the mother and the brother felt that it was impossible to care for her longer at home and accepted this suggestion. The patient herself who, since the episode of the cardiac school, had resisted any suggestion that she leave her home, consented to "try staying in a hospital for several months." Pending admission to an institution for the care of chronic patients, a research hospital near her home consented to accept her temporarily for study. Here she had daily complete exposure to sun* Her ease then became one of those prepared for this study and the social data here presented was assembled.

68

D E M O N S T R A T I O N OF CASES

light, natural or by violet-ray lamp; effort was made to improve nutrition not only by giving cod-liver oil but by tempting her appetite with dishes cooked and seasoned like her mother's and occupation was provided to divert attention from suffering and discouragement. Here also she was permitted, as she had not been at the cardiac institution, to have frequent visits from her family. The psoriasis began to abate and the pain subsided. At the end of six weeks, when a bed was available for her in the chronic institution, its acceptance was postponed because of her improvement. During the next three months the same regimen of sunlight, feeding, and mental stimulation was continued, and the psoriasis completely disappeared. Her weight rose from 6 0 ^ to 7 5 p o u n d s and she was able to walk and to use her arms and hands without discomfort. She became more alert and contented. She took pleasure in regaining some use of her hands and enjoyed the work and instruction given her by the occupational therapist which was designed to exercise her hands (dressing dolls and stuffing toy animals). She became interested and eager to win approval. The sympathetic and intelligent manner in which she was treated in this hospital seems to have played a large part in the emotional readjustment which began at this time. It is our belief that this wise handling saved this child from the deep invalidism into which she was sinking. When after four months she was well enough to return home, a program by which to conduct her daily life was given her. She was to continue the sunlight treatment (by Alpine lamp) judged to have been probably the most important factor in her recovery, to continue the cod-liver oil and an ample diet, to be up five hours a day, and to keep regular rest periods. Also as part of the prescribed program she was to have some occupation which would engage her interest and develop her powers. The doctor's closing note is as follows: "The patient is naturally apt to be depressed.

CHRONIC

69

It seems almost a necessity that she be given some occupation to keep her mind off her own troubles." In conferences with her mother and brother, plans were made to help the patient accept and live according to this program. The point especially stressed, and the one that required most discussing with them from time to time, was that of treating the patient as an adult person, allowing her to make choices and direct her own activities. The mother's solicitousness for the patient and her habit of worrying were only slowly relieved but regular financial aid from a welfare agency served to reduce markedly the anxious state of every member of the family. The patient herself expressed a desire to do office work. Funds were raised to provide her a quarter-time position as errand girl in one of our hospital offices. In this position her assets—intelligence, reliability, accuracy—were used, while at the same time she was guarded from the strain of competition and from tasks unsuited to her handicap. The satisfaction she displayed at home over her position and her small earnings confirmed our belief that she needed this outlet for her energy and abilities. At the office she never alluded in any way to her handicap. In the ensuing year she missed work only three days from sickness, though a less interested and courageous person would many a time have made discomfort an excuse for staying away. She was permitted after six months to double her working time so that she could spend six mornings a week in the office. The tasks assigned were chosen so that this work gave her an opportunity to prove to herself her powers. She became more mature, and formed friendships with several girls in the office, even taking part in their outside recreations. In contributing to the family income, she developed a new attitude of responsibility. The damage to structure by disease remains unchanged but her personal attitudes and behavior are now those of

70

DEMONSTRATION

OF

CASES

health, not of disease. Her functioning is now limited only by structural damage whereas previously it was limited both by structural damage and by feelings of dissatisfaction, especially resentment. DEMONSTRATION NO. 10: JAMES DARROW Physical strains incident to earning livelihood probably influenced breakdown in health of this patient. Assistance in learning to restrict activity and utilize wisely the limited opportunities available in his situation resulted in good adjustment to great disability.

James Darrow (Abstract 19) became a patient of this hospital at the age of twenty-two. For five months he had been ill at home, having night sweats, nausea, vomiting; his heart was decompensated, and he was considered dangerously ill. Complete bed rest in the hospital and digitalis restored compensation after four weeks, and after three further weeks of convalescence the patient again felt well and compelled to put his restored energy to use. So great was the heart damage, however, that his physician advised that he never again engage in any regular work, but continue as nearly as possible the sedentary, quiet activities of convalescence. This young man, like most others, lacked aptitude or preparation for such a life of inactivity. Since the age of fifteen when he completed grammar school he had, until the present illness, been almost constantly at work on jobs which were interesting to him and which he performed competently: (1) telegraph messenger for one year (a lively and exciting experience) ; (2) plumber's helper a year and a half (heavy work, which called into play more abilities and taught him the use of tools); (3) assistant to his father in his grocery store over a year (learning to deal with customers and handle money) ; (4) for the next two years driver of a truck, loading and unloading heavy ice-cream containers, and earning as much

CHRONIC

71

as $45 per week; (5) again for a year assistant in his father's grocery store. His school experience was interrupted once for the period of a year because of cardiac disease. Except during this absence, he carried full work and took part in sports and all the usual activities of boyhood (ran in track meets, played in basketball games, etc.). At the age of six he is said to have had rheumatic fever for three months. Then for two years he had chorea. At nine his tonsils were removed. From the age of twelve to the age of fifteen he was under the medical direction and supervision of a children's cardiac clinic, and it was in this time that the interruption of school for one year occurred and he was twice sent to convalescent institutions. The diagnosis was mitral stenosis. On his return to school no restriction of activity was advised and after graduation the clinic discharged the patient. There was no understanding by him or his parents that he might not engage in any kind of work. Being untrained for a special vocation, he could secure only the heavier, unskilled kinds of work. Such work he performed successfully for seven years without cardiac symptoms that he recognized, until about six months before admission to our hospital. After he had recovered from that acute illness, he was pronounced by his physician to be totally and permanently disabled for work and unlikely to live more than five years. The surroundings of this young man may best be described as neutral rather than either favorable or unfavorable. He lived with his parents, as he had always; he had a small bedroom of his own and shared the living room where a radio and some books diverted him during convalescence. His mother had given up work as chambermaid in a hotel to care for him when he became ill. She was not a good nurse nor a wise counselor for him. His father was

72

D E M O N S T R A T I O N OF C A S E S

absorbed in the task of earning a meager and uncertain income from his small grocery store. His younger brother had left the home to be married, against his parents' wishes, and had thus withdrawn a substantial contribution to the family's income. The atmosphere of the home was anxious and somewhat gloomy. Nevertheless it was a home where our patient's essential physical needs and comforts were met and a fair measure of protection was provided. How to fill the empty days that must stretch into years was the problem he faced, and in solving this problem we felt little help could be counted on from the family. During the months preceding his breakdown they had not observed his failing health, and during sickness had not known how to care for him. The problem in this case was not the recurrence of rheumatic attacks and increasing damage therefrom. The attack in early childhood is the only one reported. Development of disease thereafter must be attributed to strain on the damaged heart and we have ample evidence of much strain during the years of heavy labor, especially from truck driving and lifting fifty-pound ice-cream cans. In a preceding case, that of Pasquale Di Lorenzo (Demonstration 8), we have an example of overemphasis on restrictions ; in this one we have an example of underemphasis. The testimony of the patient and his parents convinced us that they had no understanding of risk for the patient in heavy labor. No plan for the boy's future occupation and means of livelihood had been considered necessary by either clinic or school. He had been inconspicuous because he was well-behaved and was a regular member of the group, and his individual needs had been overlooked. He went his own way cheerfully conforming to what he had observed to be customary and acceptable for boys with whom he associated. In the patient's character we found assets which have proved sufficient to enable him to adjust his way of life to

CHRONIC

73

great disability amid surroundings that are not significantly favorable. He appeared shy and reserved, yet always interested in life and ready to take part. Sickness he accepted as a natural event and not as a personal indignity or injustice. He did not fret nor appear gloomy and apprehensive. Nor did he defy medical advice and attempt foolhardy activity. He accepted the prescribed rest program and patiently adhered to it for a time. Being a person of action, an imitator and follower of others, and not contemplative or inventive himself, reading detective stories, listening to the radio, and viewing motion pictures became tedious. Furthermore, the idea that a man of twenty-two should give up entirely and allow his aged father to support him was not acceptable to him. The effort to "rest" became fatiguing. He sought medical sanction for the experiment of assisting his father in the shop during morning hours and overcame the reluctance of both his physician and his father to his trying this. Contentment returned when he found himself even partially able to fill a man's place again and for more than a year and a half now he has continued at work and has been in better condition than was believed ever again possible for him. The adjustment thus reached leads us to believe that a tractable person like James Darrow, even though he lacked intellectual capacity, could in early youth have been taught to live within his energy limits without provoking rebelliousness or overcaution. We next consider the different capacities for adjusting to great organic impairment that were observed in three patients who, previous to illness, had achieved a fair degree of success and satisfaction in life. DEMONSTRATION N o . 11: ISAAC KLEIN Social factors considered significant to the medical problem in this case are: the patient's failure in business and inability thereafter to find any satisfying occupation; further decrease of satisfactions through

74

D E M O N S T R A T I O N OF CASES

alienation of associates by irritability and inconsiderateness ; increase of discomfort by concentration on symptoms; some relief of discomfort by removal from scenes associated with his failure and unhappiness to the protection and discipline of a chronic hospital.

Examination of Isaac Klein (Abstract 34) four and a half years after his first illness showed a well-developed but poorly nourished man, looking chronically ill; heart greatly enlarged, liver enlarged, fluid in chest, retention of urine. The diagnosis made was: thrombosis of coronary arteries, cardiac insufficiency and hypertrophy, emphysema. He was then fifty-seven years old. The physical surroundings of this patient were found to be in every way adequate. The son, age twenty-six, lived with his parents and supplied funds to maintain a comfortable home. The wife, though in poor health, had always been able to attend to household duties and care for the patient. The daughter had lived in the parental home and been a wage earner until her marriage and then had established her own home near by, so that she continued to help her parents. The private physician who had known the patient for twenty-five years and who continued to care for his wife gave assurance that the family had at no time been in want. Nor did the patient's expression of discontent indicate fear of want or even of insecurity, but rather depression and resentment over the loss some years previously of his place in life as a prosperous manufacturer, disappointment that his son showed only mediocre ability in business, and regret that this son must defer marriage and the establishment of his own home to support his parents. He did not blame others for his failure. Fictitious excuses were not indulged in. He had expanded the business beyond his capacity for management and he blamed his own poor judgment for the result. The private physician referred to who had long known him had noted no intellectual deterioration. Although his heart

CHRONIC

75

was greatly damaged he still had much energy, and somehow this energy must be spent. Lacking the imagination and ingenuity to find pleasurable and useful activities, destructive ones had been utilized. He had found fault, fretted himself into angry outbursts, accused his wife of neglect, and watched for symptoms and exaggerated them. Friends became alienated and ceased to visit him. The wife's tolerance for this twenty-four-hour day of ill-humor diminished as the years passed and her health failed (she suffered from arteriosclerosis and arthritis). She and the patient both entreated us to provide for him away from home until they should regain somewhat their strength and equanimity. This was done and there was temporary relief for both. The task of helping the patient to understand that his irascibility and self-centeredness might increase his discomfort and to plan a schedule of daily activities into which his energies could be directed for at least mildly satisfying ends was never attempted. Perhaps this patient could not have been helped. During our brief contact with him we recognized his resistance to the suggestion that he modify his behavior in any way. He was "too busy and worried" to keep regular sleeping and eating habits, to take the digitalis prescribed; he would not consider occupying any of the empty hours of his life with handicrafts. Yet when we review his past eager and enterprising life, it seems unlikely that he lacked entirely the ability and courage to adapt to a change of fortune. That his interests were mainly acquisitive and that his cardiac damage limited his power to satisfy these interests made adaptation more difficult than it would have been for a person of diversified interests. But medical experience predicts continuance of life in terms of years, not weeks or months, for one thus stricken at the age of fifty-two. To look into those years, to choose desirable ends

76

D E M O N S T R A T I O N OF CASES

towards which one's failing powers shall be directed, and to persist wisely in the endeavor to achieve these ends challenges ability and courage as do few other occasions in life. For this person knowledge of serious impairment produced disorganization of the whole being, although probably degenerative and compensatory processes had proceeded for years without inducing enough discomfort to attract attention while the adventure and rewards of living yielded satisfaction. Business failure meant humiliation, not merely money loss. It must also have meant, prior to final abandonment of the enterprise, anxiety and fatigue, these possibly being influences accelerating degeneration, and certainly influences producing tension. A state of chronic dissatisfaction developed which was expressed as irascibility and appeared to have an adverse effect on the functioning of the whole organism. Measures to improve the functioning of his heart were thereby rendered less effective. Indeed there is reason to doubt that such measures were ever properly carried through except when the patient was under hospital control. A person in the emotional condition of this man may be quite unable to rest—and rest, limited activity, and digitalis were the measures prescribed. He himself confessed that he had not taken the digitalis regularly during the two months between leaving our hospital and entering the chronic hospital. He was "too busy and worried" or, more accurately expressed, too busy worrying. If our presentation is correct, this case yields its own argument for relating the factors of social make-up to the problem of medical care. Could any one of the many physicians who endeavored to help this man in his very great need have used his authority and influence to reveal to him the nature of his moods and their effect and to direct his energies toward satisfying objectives, the results in ability to function would, we believe, have been different. If the private doctor who had charge of him in his

77

CHRONIC

first illness had had under his control opportunities for suitable employment which he might have prescribed in appropriate amounts, as he did drugs and rest, the dissatisfaction of this patient might have been somewhat lessened without any adverse effect upon his physical condition. DEMONSTRATION N o .

1 2 : HARKY

SANTOS

Of special interest in the following case is t h e use of social m e a s u r e s to relieve anxiety and hopelessness developed during seven years of invalidism. Previous to incapacitating illness, t h e physical strain of earning a livelihood m a y have caused sufficient fatigue in this p a t i e n t to have contributed to t h e development of his disability. T h e r e a f t e r the tension produced by his restless idleness is accounted injurious. Social factors that played a p a r t in his rehabilitation were t h e insuring of a d e q u a t e support for the family and the devising of suitable occupations for the patient in order to interest him and divert a t t e n t i o n f r o m his illness.

Up to the age of twenty-four there is no evidence of excessive strain in the life of Harry Santos (Abstract 83). He was born in Puerto Rico of native Spanish stock, his parents being moderately prosperous middle-class residents of San Juan. He completed elementary-school education and four years' training in an industrial school. There he learned the trade of typesetting. On graduation he obtained a position in a government office in San Juan at $46 a week, a superior wage in that community. He derived great pride and enjoyment from his skill. At twenty-one he married, with the approval of his family, a very attractive girl three years his junior. The marriage from the start seems to have been unusually happy. He and his wife were devoted, congenial, and proud of each other. They wished to have children and to create a home. The first child was born in Puerto Rico two years after their marriage. The following year, 1908, they came to New York at the urging of relatives who had already established themselves here. In doing this our patient hoped to improve his position and to give his children bet-

78

D E M O N S T R A T I O N OF C A S E S

ter opportunity for education. Up to this time his general health had been excellent. On coming to New York he met his first real anxieties. The only work he, a foreigner, could find here in his trade paid only $9 a week. After several months of trial he decided to attempt different work and obtained a position as a streetcar motorman. Within a short time he developed severe "rheumatism." This illness he thought was caused by exposure at work and again he decided to try a different occupation. Change from a mild, warm climate, strain of adaptation to new surroundings, anxiety over economic insecurity all appear as possible factors in undermining resistance to infection at this time. His family was growing. Two more children were born, the second the year after their arrival in New York, the third three years later. Following his "recovery" from rheumatism, he found work as a house painter, became a member of the trade union, and earned as much as $12 a day. The fumes of the paint troubled him, however, and he suffered from a chronic cough. He was treated for this in a tuberculosis clinic, and although no active tubercular process was found was kept under observation for several years. In 1920 the tuberculosis clinic referred him to this hospital, and his advanced cardiac damage was discovered. For several years he had noticed shortness of breath on climbing stairs and sensations of dizziness which made him timid about working on scaffoldings, so that he had given up house painting and become a floor polisher. Two and a half months before coming to us he had been alarmed because his heart felt "as if it were coming up out of my mouth," and at night he felt it beating "hard and quick." He also had had occasional attacks of sternal and precordial pain. The diagnosis was chronic cardiac valvular disease, mitral and aortic insufficiency, and aortic stenosis. Whatever

CHRONIC

79

the etiology of this condition,* it was realized that we were dealing with a man who was now permanently disabled for any work involving heavy physical exertion, who was liable to distressing symptoms at all times, and whose physical impairment would probably increase over a period of years. It was not realized how great was his terror at learning the seriousness of his disease nor how demoralizing his conviction that his career and usefulness to his family were ended. He was then thirty-five years old and had four dependents. In the eleven years since he had left Puerto Rico he had experienced vicissitudes resulting in large measure from illhealth, but had always succeeded in finding a way out. He had been ambitious, self-reliant, and capable, displaying more than average intelligence and manual skill. On two previous occasions he had adjusted to different occupations in order to protect his health. Though he had never fully realized the ambitions he had held for himself and his family, he had nevertheless achieved position in the community as a good citizen and a competent workman. And despite much ill-health he had managed always to provide adequately for his family. In retrospect we can see now that such a person needed only moderate cautioning to restrict his activity. He was already aware of his physical limitations and had endeavored to protect himself. He did need guidance and encouragement to use cautiously yet fully the powers of mind and body that he still possessed and to avoid provoking or aggravating symptoms by dwelling on them. Discovering the resourcelessness of this man and his family, the hospital referred them to a welfare agency which promptly provided support for them. Though on several occasions, in the ten years of treatment in our clinics, he * T h e etiology throughout t h e eleven years we knew h i m remained obscure. I t was believed to b e chiefly rheumatic but findings also suggested luetic complications.

80

D E M O N S T R A T I O N OF CASES

had had dealing with the hospital's social workers to secure free medicine or a period of convalescent care, no one of them had ever thought to search thoroughly his situation and mode of living for influences that might be disabling. Yet there were indications that should have aroused suspicion. In 1921, a year after his first examination and the shock of learning his condition, his wife reported that he had been "scared to death after his last visit." Examination always found his heart steady and regular. At no time in these years was there a real break in compensation and not for six years was there evidence of advancing myocardial damage. Indeed after that he survived four years and accomplished a good deal of useful work. Other indications which should have suggested that some of his disability might derive from social influences were his great humiliation over accepting financial assistance and his frequent expressions of regret over the failure of his life and over being a burden to his wife and children. Our medical record contains no statement of what was actually told this man about his condition but the record of the welfare agency which we have been permitted to read indicates clearly enough what he understood. Continued cautioning, continued prohibitions, repeated examinations, and his own surreptitious reading of his chart induced a state of terror. The following excerpts from their record (and there are many more of similar nature) describe his emotional state: "January, 1921: The wife is worried because he seems melancholy. She is afraid to let him go on the roof alone for fear, in a fit of despondency, he will jump off. "March, 1922: Man is extremely irritable. Wife has become all unnerved owing to this. He does not even wish her to leave him to go to the market. "August, 1922: He had two or three serious heart attacks and because one doctor in the clinic told him there is not

CHRONIC

81

much chance of recovery he has become quite despondent. "September, 1922: He is depressed and at times loses complete control of himself and weeps. The doctor at the hospital has told him that if he does not stop smoking he will not live very long; he has also told him that his condition is very bad. This has preyed on his mind and seems to have set him back a good deal. "October, 1922: The man's condition is not favorable. He is moody most of the time; feels keenly the fact that he is dependent. "September, 1923: Seems to have mind on self all the time. Wife states he almost makes life unbearable. He refused to go to the country without his wife because he 'wanted her near when he died.' "October, 1923: The slightest thing upsets him and he becomes so excited that an attack comes on." Early in their relationship with the patient the welfare agency began to doubt the wisdom of prohibiting all work, but they accepted the verdict of the hospital that he was permanently disabled and attempted to counteract his discouragement over his dependency and inactivity. Their worker notes after her first visit to the family, when she found that they had no money, owed a month's rent, and had sold most of their furniture for food, "the man was distressed about having to accept assistance and broke down completely when ten dollars was given for food." Throughout the time that relief was given (over three years) he never overcame his feeling of shame, although persistent effort was made to help him do so; instruction and persuasion were necessary because the family attempted to save the agency's money by living on less than the amount calculated to cover the essentials for them. At the time the agency first knew the family it was their impression that the wife had been indulged by our patient and demanded much of him. The children were attractive

82

DEMONSTRATION OF CASES

and well-mannered, but not in good physical condition. The wife lacked knowledge and training to fit her for good domestic management. Lessons in cooking and budget-planning were given in the home. The wife proved an enthusiastic and apt pupil and the patient an interested onlooker. T h e family were moved from their top-floor tenement apartment to a pleasant house with porches and a yard, situated near a park. B y joint planning with the family in whatever was done for their welfare, the agency subordinated the giving of money, and personal interest gave a feeling of security that financial aid alone could not have given. ( I t speaks well for this relationship that after it was no longer necessary for money to be given the social worker was frequently consulted by the family when critical situations arose, and that the family took the initiative in maintaining the relationship with her.) At first the primary concern of those caring for the patient had been the improvement of his physical condition, but it became increasingly evident that his morale also must be considered. More direct efforts were made to change his thoughts and relieve his gloom. A benevolently minded woman took him books and papers and theater tickets. The wife was helped to plan activities for him; she persuaded him to accompany her to church, to visit friends, and to go for walks. T h e relationship between him and his children seems to have been always close and congenial. H e began to help them with their school work and to teach them the use of tools; under his tutelage the daughter learned to operate a telegraph key. But these expedients were insufficient to fill satisfactorily the waking hours of a man, still young and ambitious, craving purposive work. T h e first recorded activity from which he derived any real pleasure or relief was placed in his hands unwittingly and about a year and a half after the first con-

CHRONIC

83

tact. The agency, noting the absence of furniture, purchased some battered second-hand pieces for the family. He seized the opportunity eagerly, saying he could "make them like new." He made good his boast. He showed so much pride and enthusiasm that the agency's visitor decided to find more opportunities of this kind even though the hospital had said he must not work. She gave him a key to her apartment and told him that, when he felt able, he might go there and work on her furniture. She commented two weeks later, "He has worked almost every day for about two hours. He does his work well and seems more contented than he has for some time. He says that just the idea of having some place to go every day helps him. He states that it has meant a great deal to him to have something to do when he felt like doing it, and it is evident that he does not want the job to come to an end." It was with difficulty that he was persuaded to accept payment for this work, and to purchase something that he wanted with the money. He bought materials for a radio and constructed what is described as a "splendid set." Looking back over these three years of invalidism, it seems now probable that much of the anxiety and fretting which constituted this patient's "rest at home" could have been avoided, had even one phase of his social make-up been studied, viz., his work history and interests. He had had unusual training in manual skills, had keen interest in them, and had demonstrated some versatility. Had a limited period of complete rest and a change from the heavy labor of floor polishing or house painting to some sedentary handicraft been advised, thus holding out to him hope of independence and continuing work association with other men, there seems reason to believe that he could have accommodated to all necessary restrictions. But once the image of a man doing only heavy labor had been formed, this remained associated with the other image of a heart unable

84

D E M O N S T R A T I O N OF C A S E S

to cope with such labor. Had his doctor known the work history and not reckoned solely with the great exertions required for the occupations in which he had been employed, viz., motorman, house painter, floor polisher, experiment might have been allowed with work in some more sedentary, less hurried occupation, say radio assembling, and the strain of anxiety and fretting associated with his "rest at home" might have been avoided. Until the spring of 1923 the agency accepted literally the pronouncements of the hospital that the man was unable to work. But now experience had convinced them that the quietude advised was possible for him only when he was occupied. They consulted their bureau for the placement of handicapped persons. When placement is made through such a bureau the physical conditions and limitations are known to the placement secretary and interpreted by him to the employer. What was believed a suitable place was thus found and offered to him. His reaction is recorded: "The man is more than anxious for work but is in such a nervous state that he feels that he is going to die away from home, so refused a good position that was offered to him. He made all arrangements to go to work the following morning and then did not have courage to start out." To combat this demoralization from fear the agency used a statement issued by the hospital two years before: "The man's condition will undoubtedly improve if he does not climb stairs and lives in the country." Bolstered by this assurance, he was persuaded to accept a position as "man about the premises" in a boys' camp. Within the month he wrote the agency enthusiastically, saying that he was "in splendid condition" and that the air was so pure "it would bring a dead body to life." The wife visited him and reported that he looked like a different person. He was occupied for the next four months picking up papers, doing a little carpentering, and doing other odd jobs. He was well-liked and

CHRONIC

85

he enjoyed the boys. In the middle of the summer the family was sent up to be with him. On the whole he seemed better, though he overdid when helping with the closing of the camp and had two or three attacks of pain on his return to the city. The wife hoped they could go back the next summer "if he is alive." These attacks frightened him and the hospital again warned him against working. For a month he was idle and extremely fretful. I t was then that the record stated, "he becomes so excited that an attack comes on." T h e success of their experiments had convinced the agency that the man must have occupation. But to carry through their plan they realized that the cooperation of the hospital was essential. The worker, feeling that, in the past, letters and telephone conversations had been inadequate, requested a personal conference and laid the situation before the physician. Their view was fully accepted and a medical policy of reassurance was entered upon. The patient was told by the doctor that he was better and could work in the city. He was incredulous, but he tried it. Opportunity was offered in a toy shop for the handicapped. He worked there daily for a year, earning a few dollars a week. It is interesting that he displayed the same immediate reaction to his release from invalidism and dependency as did Emma Kovacs (Demonstration 9). He was domineering at home and when things did not please him he would "threaten to go and live in a furnished room like the old men at the shop." This phase passed as his confidence in himself increased. The following year (the fall of 1924) he found himself a job through his union and announced that the family could get along without further financial aid. He held the job for three months, overdid, had attacks, and went back to the toy shop for a few months. This venture may be regarded as a trial flight in which he learned through experimentation the limits of his tolerance without really

86

DEMONSTRATION

OF

CASES

disastrous results. He practiced greater moderation the next time and was able to work successfully for three years. He continued at work until three months before his first admission to the ward in 1927. At that time pain had increased in severity. There was an almost constant sharp steady pain around the heart with sensations of gastric distress after eating. At the time of entering the hospital he was having as many as four anginal attacks in one night, and he was said to be worse than he had been six months previously although there were "no real breaks in compensation yet." From this time on he accepted the fact that he was too ill to engage in a regular gainful employment. The children were working and the wife secured a job as presser in a shop near their home. She remembered the effect on him of having no occupation and they reached an agreement that if she became the wage earner he must become the housekeeper. From then on he did the shopping, tidied the house, prepared the meals. He took pride in his proficiency as a cook, and by doing these useful and necessary tasks he felt throughout the remaining four years of his life that he was a contributing member of the family. Although his pain increased he suffered no break necessitating hospital care until June, 1930. At that time he was having as many as ten anginal attacks a night and his heart was fibrillating. In November, 1930, he was readmitted; his case became one of those in the group which constitute the basis of this study and the social data given above was obtained. Bacterial endocarditis had set in and he died three months later, never leaving the hospital. His fortitude and consideration of others during those last months won the admiration of the ward. DEMONSTRATION N o .

1 3 : RITA LARSON

Carefully regulated working conditions and a protecting family group proved aids in preventing the invalidism of a woman suffering many years from a progressively disabling disease.

CHRONIC

87

Rita Larson (Abstract 54), a woman of forty-nine, had been suffering from recognized chronic nephritis for twelve years. Associated with the nephritis were hypertension and cardiac hypertrophy and insufficiency. She had been under the care of this hospital for ten years and during the last four the progress of her disease had been evident not only to the physicians but to herself. When she was first admitted in 1921, it was noted in the medical record: "This patient gives one the picture of rather advanced nephritis with both oedema and nitrogen retention." She appeared, however, to recover from this illness and for several years had no symptoms. Her blood pressure was found normal and her urine free of albumin. In 1923 a note in her record reads: "feels in better health than during past twelve years." By 1926 she was sleeping poorly and suffering from severe headaches and shortness of breath on exertion. By 1928 to these symptoms had been added nausea and vomiting. The following year her vision began to blur, she had a cerebral hemorrhage, and her left side was paralyzed. This illness kept her in bed for five months, but again she rallied and returned to her work. By 1930 she was having frequent clouding of vision lasting fifteen to twenty minutes, and also increased dyspnoea and dizziness. Headaches also increased in severity and frequency. In January of 1931 she had a second stroke, and in April she died. Until this last illness, however, she had remained a selfsupporting member of society. Her mental capacity seems to have been no more than adequate for the rather simple, routine, monotonous, clerical work from the performance of which she had derived satisfaction for twenty-two years. She had been "nervous" since adolescence, and it is probable that she had inherited a poor constitution. In her immediate family, we learned, four of the six other members had died before the age of forty, of heart disease, tuberculosis, cancer, and cholelithiasis. A fifth member was in a

88

D E M O N S T R A T I O N OF CASES

state hospital for the insane. The patient herself had never been robust; she had had severe menstrual pain and other distressing gynaecological symptoms since childhood. She had suffered a miscarriage in her brief and unhappy marriage. At two, she had had a fracture of the right thigh; at nineteen, fractures of the scapula and both legs and an injury to the back for which she was treated by a chiropractor for many years; at forty-four, a colles fracture of the wrist. Her interests seem to have been as limited as her mentality and her physique. She was not reflective and cared little for intellectual pursuits; her only source of solitary enjoyment was sewing. This she was unable to pursue for the last three years of her life because of failing eyesight. She was dependent upon association with others but seemed to be satisfied if she could win approbation and protection. We found no evidence of the close personal give-and-take that marks adult friendship. But her willingness to depend on others for protection and guidance, and her social setting, fashioned to demand no more of her than her limited capacities enabled her to give, were in our opinion the chief factors which made possible an excellent adjustment to great incapacity. Indeed, it may even have been that because she had known pain and sickness during most of her life they did not demoralize her as they may a person who experiences them for the first time later in life. Our patient was the youngest in a family of five children. Her parents had died when she was small and a sister twenty years her senior, capable, protective, and devoted, had stood in loco parentis. Aside from a six months' episode of unhappy married life which terminated with the death of her husband, her life was spent under her sister's protection. Her conduct seemed controlled largely by the rigid and circumscribed conventional code of her sister's social group

CHRONIC

89

which she accepted and made her own without question. The acceptance of this code, which clearly defined for her right and wrong, good and evil, relieved her of the responsibility and strain of personal choice. Social life and interests centered around their church. She derived enjoyment from active participation in its organized activities. She cherished the esteem and protective interest of the pastor. From her work also she derived great satisfaction and she was able to perform it with a sense of competence. Her business associates respected her honesty and showed appreciation for her conscientious fulfillment of the simple routine. She was proud and happy to be a contributing unit in one of the largest and best-managed banking firms of the world. When we first knew this woman, ten years before her death, she was already handicapped, and doomed to progressive, incurable illness. Rest was needed and was advised, and this might have led to her being dropped from employment or to her abandoning effort to continue at work. If at that time she had been withdrawn from the routine which supported her and sustained her interest and self-esteem, it is likely that, with her limited capacities and paucity of inner resources, she would have sunk into invalidism. This did not occur, however, because her physician at the hospital and the personnel physician at the bank from time to time conferred about her condition and were able to explain her needs and limitations and thus make it possible for the bank, in recognition of her long and faithful service, to continue to employ her. She was moved from one job to another as her powers failed. Until shortly before her death she was successfully doing simple filing under no pressure to hurry, protected from irritations by having an office of her own and permitted to rest whenever she felt tired. The only strain that might be considered a tax on her much-

90

DEMONSTRATION

OF

CASES

limited energies was the trip from her home to work, requiring an hour, in transit, three changes of conveyance, crowded subway, and several flights of stairs. This employment relationship, together with the protection of her sister's home, enabled her to maintain through these years both emotional and economic equilibrium. We next select for discussion two cases in which the patient's illness and limitations were similar but in which the acceptance of limitations presents contrasting aspects. DEMONSTRATION

NO.

14:

JEROME

EDWARDS

Of special interest in this case is the patient's control of his own conduct following his recognition that he could to a considerable extent ward off anginal attacks by cultivating new interests and adhering to the routines of life that were developed after experiment.

Jerome Edwards (Abstract 24), a man of fifty-two, was referred to us by his private physician for diagnostic study and treatment. For three months he had been incapacitated by attacks of the acute discomfort typical of angina pectoris, occurring six or eight times a day. For three years before this he had been short of breath on exertion, and for a year and a half he had had attacks of "indigestion." The former he attributed to age, the latter to business worries. He had not been concerned about them and they had not interfered with his usual activities. He was studied in the out-patient department for one month and then admitted to our wards for more thorough study. The attending physician made the following note: "A typical story of coronary disease with no definite physical signs." He remained in the hospital fourteen weeks, and received alcohol injections. The frequency of his attacks in this period dropped to about one a day. In the discharge note he was described as a person "with unstable vasomotor apparatus and heart pain controlled by a mixture of nitro-

CHRONIC

91

glycerine, theocalcine, and encouragement." He was advised by our physicians to apply for his permanent total disability insurance and the requisite forms were sent to the insurance company by the hospital. This man had had on the whole an unusually successful and satisfying life prior to the onset of his first symptoms. He had had no more than high-school training, but by persistent and directed study he had become well-informed and interested in many and diverse fields. He had held responsible positions in real estate, insurance, and newspaper work. His marriage had been congenial. He had established his home in a suburban community and purchased a house. He was an active member of the church and elected to the Presbytery. He was also a member of a fraternal organization and had a large group of friends and many social interests. By temperament he was active, outgoing. He enjoyed the excitement of much social activity as well as the quieter recreations of gardening and doing odd jobs around the house. He was proud of his respected social position, of his business career, of the comfort and economic security of his home, of his son, who had grown up and married, and of his infant grandson. At what proved to be the end of the boom period he had invested heavily in a real-estate project. With the market collapse and the general economic depression which followed, this business failed. Salvaging what he could, he attempted to establish an insurance office. Before passing on to a discussion of the process of this patient's adjustment, which is the chief interest of this case for us, we call attention to the fact that for three years before he came to us he had suffered increasing anxiety, had worked long hours, and in general had driven himself to great exhaustion. Throughout this period he suffered from shortness of breath and from "nervous indigestion." His insurance venture proved unsuccessful and at the time when

92

D E M O N S T R A T I O N OF CASES

cardiac pain developed he was casting about for some more remunerative occupation. The severity and frequency of attacks of angina confined him to his home from then on. At that time the household consisted of his wife, who suffered from gastric ulcers; the patient's aged and invalid mother-in-law; his son, the son's wife, and their child. The son was employed and able to contribute enough to cover the running expenses of the home. They had always lived simply; the wife was an excellent manager, thrifty and resourceful, and so they had been able to "get by" without any apparent reduction in their standards of living. There was no income from investments and we were later to learn that in order to meet hospital expenses insurance policies had been sold. The case of this patient bears a resemblance to certain others where we have noted that, while in all probability degenerative processes had been going on for years unrecognized, severe incapacity developed only after some adversity such as business failure had occurred. As this man had unusual self-control, it was often difficult to gauge how much disturbed he was. But we are quite sure that he was gravely disturbed by the derangement of his career and the loss of financial reserves, and it seems reasonable to think the business failure played some part in breaking down his health. He himself made the observation that attacks were less frequent when his attention was diverted from his illness and his troubles. The first few weeks he was in the hospital were for him a period of uncertainty and suspense. He knew that we considered his condition grave. But he could make no plans for his future until we were in a position to tell him how much he could safely do and how much his pain could be relieved. At first he read constantly, "to keep his mind off his worries." He was a "good patient," cooperative, always appearing calm and cheerful, joking about and minimizing his

CHRONIC

93

illness, even while he was having as many as ten attacks of severe pain a day. H e admitted that the unaccustomed confinement and inactivity of bed care were hard for him to endure, and that only by concentration could he keep his mind on his reading. Life in the hospital interested him as a new experience. Within a few days he was on a friendly footing with the other patients and the staff. He watched with considerable amusement the interplay of personalities and the various procedures of medical care. He was quick and adept in acquiring a mass of detailed information about medicine. A naturally participating, creative, and social person, he could not long be content with the passive role of reader. He began writing humorous verses about the ward. Because these were simple, timely, and often witty, they attracted attention and praise. Facility increased with practice and he became amazingly prolific. After a month, interest in this pastime began to wane and the idea of a ward newspaper took his fancy. H e appointed himself editor in chief, and recruited his staff from the other ward patients. He brought out three issues, the first hand-printed, the others mimeographed by the hospital. When he left at the end of fourteen weeks, he was planning to enlarge the project to include the whole of the men's medical service. We were sorry to see him leave for he had improved the morale of the whole ward. A less articulate, less personally resourceful patient might pass an equivalent length of time in the hospital and remain unaware and uninformed of his condition. From the start this man participated in his own treatment. When it became apparent that neither medication nor restricted activity could give him much relief, it was suggested that alcohol injections might help. The risks, the discomfort, and the slightness of the chance of alleviation were explained to him, discussed in joint conference between the medical staff, the patient,

94

D E M O N S T R A T I O N OF CASES

and his family, and accepted with full understanding by the patient. When he left the hospital both he and his family were told that all fatigue, sudden exertion, and emotional stress must be avoided. There are perhaps few persons controlled and flexible enough to accept calmly and resourcefully such a verdict, which means the complete reorganization of life habits and life goals. Yet before he left the hospital it was evident he had faced the problem squarely and determined on his course of action. With the small regular income from his insurance and a reasonable charge for "board and room" to his son's family, living expenses and taxes could be met. He was determined to make a success of the business of being an invalid, of which he said, "It is the hardest job I have ever tackled." He worked out with his wife and son a rigid daily schedule which included, aside from regular hours of rising, resting, sleeping, such recreational activities as tending his three-year-old grandson, writing, watering the garden, reading, motoring (with his son), repairing things around the house, and keeping for the hospital a requested record of the frequency of attacks, with comments on possible precipitating factors. Then he experimented with his schedule, increasing or decreasing the duration and range of activities, until he believed he had established the point of his physical tolerance. He was pleased to find after a time that he could do increasingly more. Visits from friends tired him less and they were encouraged to come, and he and his wife began to accept invitations. He undertook the editing and revising of a handbook for the church. He experimented with driving the car, attending lodge meetings, going to the movies, taking week-end excursions into the country. Occasionally increase in frequency or severity of attacks warned him that he was attempting too much and he eliminated this or that activity, but on the whole, tolerance seemed to increase pretty steadily. A year after leaving the hospital he went

CHRONIC

95

as a delegate to a church conference in Colorado. The trip was made by automobile and he himself did a large part of the driving. He found the altitude of Denver exhilarating and took the trip up Pikes Peak (altitude 14,108 feet) without discomfort. He believed that his comparative freedom from attacks during this period was due to the fact that his attention was held by interests outside himself. He experimented with this assumption, and in November, 1932, he wrote in his report to the clinic describing frequency of attacks, "I believe that the fact that one stops thinking about his condition is a great help. Have kept my mind off the trouble and been occupied with other matters during that period since September 27th." To a large extent this patient proved capable of managing his own treatment. The only important function the hospital was called on to perform, after treatment plan had been decided upon, was the explanation of the condition to the patient and his family. We could rest assured that the plan would be fulfilled. With the presence of so many group resources (private physician, kin, lodge, church, friends) it was only necessary that the hospital stand by, ready to help in case of crisis, physical, economic, or social. The patient had confidence in us and his realization that we could be counted on to advise and aid helped, we believe, to stabilize the situation for him. DEMONSTRATION N o .

1 5 : A L L I E BACH

This patient's unwillingness to accept illness and dependency led her to conceal the unprotected state of her social situation until too late to prevent damage f r o m overexertion. Social treatment could therefore be directed only to providing f o r her support in institutions and to helping her to make the most of the invalid role she must play.

When Allie Bach (Abstract 2) first came to this hospital in the fall of 1929, a diagnosis of cardiac insufficiency, coronary sclerosis, and hypertension was made. Much or-

96

D E M O N S T R A T I O N OF CASES

ganic deterioration had occurred and she was thought able to do only light work, although her condition at that time was not sufficiently grave to warrant permanent institutional care. Her recovery on the ward, under a regimen of strict bed care, digitalis, and Magendie's solution, was described as "dramatic." She was a single woman of fifty-one, born and reared in Germany. She had worked as a lady's maid from the age of eighteen until the time of her admission to the hospital. Socially she was an isolated individual. Her only relative in this country was a sister, married, poor, living in the Middle West, whom she had not seen for thirty years. Because of her work her life had been migratory and she had no close friends or associates. Her relatives in Germany, never wellto-do, had been impoverished since the war and she had sent part of her earnings to them. In recent years she had held no position long enough to have established a feeling of responsibility for her on the part of any employer. She belonged to no fraternal group and had no insurance. Her only assets were savings sufficient to pay essential living expenses for two or three months, and a reputation with her employment agency of being a capable, honest, and pleasing employee. On her first admission to the hospital, her activities, as she described them, were not strenuous and it seemed to us that by a little self-direction and moderation she should be capable of self-maintenance. During the first year and a half she was under our care she did not confide in us her personal difficulties. Her years of training as a personal domestic had taught her to be self-effacing and reticent about discussing her affairs. Because she was reserved and quiet and appeared capable and calm, the hospital assumed that she would control her situation and would seek our aid if she was unable to do so. On leaving the hospital she was advised to guard against strains that fatigued her. She did

CHRONIC

97

permit us to refer her to an employment agency for the placement of handicapped persons, but they failed to find work for her and she secured a position through her regular employment agency. This woman had always been independent and selfsufficient, never accepting what she felt she had not earned, and dependency in any form was repugnant to her. She had never been strong and throughout her life she had been accustomed to ignore physical comforts. She had had sick headaches since childhood and had for fifteen years noted increasing fatigue, faintness, and what were probably slight cardiac attacks. She was quick and active. She had developed no satisfying interests or activities other than those connected with her work. We had no comprehension of how far she could drive herself before admitting defeat. Her rapid recovery on bed rest and restricted activity should, however, have led us to suspect that she had been subjected to some excessive strain, either physical or emotional. In the interval of about six months, while she was out of the hospital between her first and second admissions, she was seen only a few times in the follow-up clinic before her work took her out of the city. Her letters in that period indicate that she understood our instructions to her and attempted to comply with them. She took digitalis regularly and the physical conditions in her employer's home conformed to our recommendations (no stairs, a room of her own, etc.). This employer was kind and considerate and our patient enjoyed working for her. She did not, however, realize that the patient was a handicapped person, and the patient did not easily ask for favors. She feared that if it was discovered that she was not strong she might be dismissed, and when she realized that heart attacks were increasing in frequency she did not slacken but increased her efforts, fearing that she might lose her position and have

98

D E M O N S T R A T I O N OF CASES

insufficient funds to tide her over a period of sickness. Even when she contracted a severe cold she continued to work. In our later contact with this employer we were convinced that had she understood the patient's condition she would have been willing to make allowances, to help her organize a routine which would have been within her capacity in order to retain an unusually skillful and pleasing servant. As it was, the patient drove herself until she collapsed completely at the end of five months and had to leave. Even then she did not come to us. She had saved all her wages, over $300, and she came to New York, where she shared a cheap room in a noisy apartment, prepared her own meals, and tried to build herself up again. But she was too disturbed and worried to take advantage of such opportunity for rest as she had. In the next five months she tried to work several times but always collapsed and after a few days returned to her room. By her repeated failures, she was acquiring with the employment agency the reputation of being an unemployable person whom they could no longer recommend. When she finally dragged herself back to the hospital she had had no work for two months and her heart was badly decompensated. On her admission, the doctor notes: "She is rather nervous and worried—she will probably need nearly constant hospital care from now on, due to progressive failure of cardiac reserves." Again she made a dramatic recovery and when time for discharge came, after six weeks in bed, she decided that she would accept no more than two weeks' care in a convalescent home and at the end of that time would seek another job. Further suggestions of aid in the adjustment of either her living or working conditions she rejected, saying that she had enough money to keep her until she could find a suitable position. On her return from the convalescent home a medical note reads: "Patient has been doing nicely. Has been doing no

CHRONIC

99

work. Patient only in fair condition. A few weeks of work will cause decompensation again." The following month it is noted: "Doing light work. Advised to take things a bit easier." A month later her heart was badly decompensated and she was again admitted to the hospital until chronic care could be arranged. It was the opinion of the physician at that time that her heart could never become fully compensated again. The first of a list of fourteen medical findings was "Anxiety and apprehension. . . . " A further note reads: "Crying quietly. There are dark circles under her eyes, the rims of eyelids are reddened from constant crying; her face is lined—anxiety." From careful questioning of the patient, her employment agency, and some of her previous employers, we secured then our first real insight into the nature of her social problems and of her reaction to them. We discovered that the "light work" last described by her had been in the home of the director of the employment agency, after she had spent a month pleading for a chance to work. It consisted in doing all the housework, caring for a neurotic, heavy, bedridden invalid, in a crowded apartment on the sixth floor of a non-elevator house. She had slept on a cot in the living room, going to bed late, rising early, having no opportunity for rest or privacy during the day. She had come to the hospital only when the employer, alarmed by the severity of the attacks, refused to keep her longer. Up to this time we had accepted this patient's statements that she could look after herself. We had never looked beyond the superficial information she was willing to give us nor attempted to analyze the forces at work in her life, which kept her from asking aid before the point of collapse was reached. We had offered to secure aid for her should she need it, without realizing that she would never voluntarily request it.

100

D E M O N S T R A T I O N OF CASES

Even when it was recognized that for her best physical protection the care of a chronic hospital was desirable and she rejected our suggestion, we did not attempt to persuade her to accept this care to which she was strongly opposed. Our opinion at that time was that it was for her greater happiness to let her work out her own problems. The courage with which she faced these problems alone commands respect even though from the standpoint of medicine it was foolhardly in the extreme. If, when we had first known her, we had assumed not the role of adviser but one of more active direction, we have reason to believe that this person, trained to accept orders under supervision, might have been spared much of the strain which further disabled her. At the time of her third admission to the hospital, when thorough study of the social situation was first made, she had spent her savings. In spite of repeated assurance that we would accept no money from her for hospital care, she felt obligated to repay us, and each day repeated her request to be allowed up so that she could get back to work. Even when her chart showed a great pulse deficit and fever, she would assure us that she felt quite strong again, and that if we would only let her go she could work. The suggestion that this time she must count her sickness in terms not of days but of weeks would bring on an emotional upset ending in a heart attack. It became evident that such fierce determination to live above illness was in her case a destructive factor and perhaps the most important phase of her illness to understand and control. In this she presented the antithesis of the problem often faced with chronic invalids—that of an almost grateful withdrawal into illness as a protection against the responsibilities of life. From now on, the hospital attempted more active direction. We secured her compliance by insisting that only

CHRONIC

101

through following our orders could she repay us for the care we had given her. Gradually, thereafter, she came to regard her doctor and the hospital as she had an employer—someone to whom she was responsible for the fulfillment of duties. This relationship was to become for her a close personal one, and one from which she derived not a little satisfaction. The playing of the role of invalid in as good form as possible, she accepted as her job. It was decided that the best protection that could be secured for her would be in an institution where she would be with a congenial and sympathetic group and under the eyes of a trained nurse. She was sent to a well-run convalescent home and she remained for six months. Here she learned to moderate her activity, and to make some satisfying use of leisure time. Her letters in this period were filled with assurance that she was "much better," although the reports received from the nurse were less encouraging. The following excerpts indicate the tenor of her letters: "I wish you could see me. I think you would be satisfied as well as Dr. H. would be. Of course, I will stay as long as Miss F. [the director of the home] thinks I should. She is the kindest, nicest, motherly lady in the world." Two months later, "Would you or could you help me find out if Dr. H. would allow me to work as I really must." Then a month later, "No doubt you will be pleased to know that I am progressing very well. I would like to do some work, so I ask you whether there are ladies or institutions where I could apply by mail stating my case. If I could do some work before the hot weather comes I may hold out during the summer perhaps. I am taking the digitalis faithfully but I am out of sleeping tablets (though I do not take more than necessary) as the nights are not so good at times. Otherwise Dr. H. I am sure would be satisfied with the way I am progressing." Then later, "I will do as you advise, of course, and

102

D E M O N S T R A T I O N OF CASES

stay here until the end of May but if there is work for me to do I am willing to start in at any time you say so. I know I am lots of trouble to you but I cannot help myself much at present so I hope you will keep me in mind and let me know of anything suitable, please." The report from the convalescent home on her discharge gives the following opinion: "Miss Bach is decidedly better, only one or two bad heart attacks in as many months and always the result of imprudence. She could hold a part-time job which is a sitting one, such as in an office answering questions, telephone calls, and receiving messages. A doctor's building where there is a general waiting-room would be ideal." When she was seen in the follow-up clinic upon her return, the physician noted, "Patient has been resting a great deal and is now reaping the benefits, as she is moderately well-compensated though still orthopnoeic." It was felt that she had now reached the maximum physical reserve of which her damaged organism was capable. With many patients so prolonged a period of concentration on illness would have caused invalidism. In this case it seems to have restored emotional equilibrium. There was less panic, a clearer understanding of her incapacity, and belief in the controllability of her condition by her own regulation of activity. She expressed a feeling of relief at being able to confide in the social worker and to depend upon the hospital. We hoped that it might be possible to find for her some gainful employment that would at least create the illusion of economic self-sufficiency, even though it was a time of widespread unemployment. In spite of effort, over a period of six months, on the part of the hospital and a cooperating social agency, no suitable place was found. She was, however, supported by the cooperating agency in a residence club for business women. Here she had physical protection, a

CHRONIC

103

room of her own, some companionship. She was assigned small routine tasks for the club, such as caring for the canaries, mending, etc. She remodeled her own clothes. She was given a course in the making of Braille books for the blind. She learned to use the public library, and there set herself to learn the history of her native land. She became increasingly devout, attending Mass daily and finding new spiritual consolation in prayer. She made an inflexible schedule for herself, accounting for every hour of the day and forcing herself to live up, or rather down, to it. It may be of interest to give it here: Rise at 6:30. Church 7-7:30. Tidy room 7:30-8. Lie down and rest 8-8:30. Breakfast 8:30-9. Lie down and rest 9-9:30. Tend the canaries 9:30-10. Go to Library and read on research project (History of Bavaria) 10-12. Lie down and rest 12-12:30. Lunch 12:30-1. Rest 1-2. Practice Braille and sew 2-5. Free time: writing letters, reading, praying, resting, 5-6:30. Dinner 6:30-7:30. Free time: visiting, mending, reading 7:30-10. Bed 10:30. In order to give these activities purpose she developed a game of make-believe, in which she would pretend that she was a "lady." She concentrated on living up to this role. Yet these months were not altogether untroubled. There was a period when it seemed probable that financial support must be withdrawn and in spite of her promise not to look for work herself, she applied to her old employment agency. She wrote, "I did so hope I would be able to get work. I would have gone back to Mrs. B. [the last employer] but she does not need anyone now, so I really feel I have to come to you again. I cannot walk very far these warm days. I have taken a nasty cold. I really could do some kind of work as you know. It is very necessary for me as I need so many things. I do not like to be a burden to anyone if otherwise possible. I am quite happy here but I feel I shall be sick again if nothing is done for me to get to

104

D E M O N S T R A T I O N OF CASES

work. I cannot help but worry. Dear Miss Gay, please do not be angry with me for writing this letter . . . " A week later she was seen in clinic. The medical notes read, "Patient not so well. Complains of cardiac pain, attacks of dyspnoea and has occasional swelling of the ankles —pulse very rapid, heart barely compensating. Patient is very nervous and sensitive. Absolute rest is imperative at present." In view of this recommendation the agency agreed to continue support and to renew their efforts to find her work when she was able, and the patient agreed to stay in bed for a week. Arrangements were made to have meals served in her room. During the next two months she regained the lost ground. At the end of that time the cooperating agency, having become convinced that no suitable gainful employment could be found, felt that they should not continue support for an indefinite period and asked that she be placed in a chronic hospital. But the examining physician at the selected hospital found that she was not sick enough to justify admission, and the agency support continued for another two months. At the end of this time she caught cold, an ear abscess developed, and her heart again became decompensated; she was then admitted to the chronic hospital, where she died four months later. In the hospital she seemed fairly content and was still hopeful of regaining sufficient strength to return to work. She filled her days there with reading, sewing, and visiting the other patients. A week before her death she wrote, "I cannot rest any longer unless I know what may happen in the near future. Please do not blame me for this, but I am all right, I think. I should be up and doing. I get this ambition always when we have a bright, sunny day as do all lazy people. I feel I could do much if I had a chance to go ahead as long as there is life to be useful some way."

IOS

CHRONIC

The next two cases illustrate the significance of social factors in the medical care of chronically ill persons whose life expectancy was brief. DEMONSTRATION N o .

16:

DORA

LEVINE

Marital friction and interference by oversolicitous relatives encouraged self-pity in an undisciplined woman with progressive disease, increased her suffering, and prevented her from enjoying such normal interests and activities as her physical condition permitted. Removal of the patient to the controlled environment of an institution and limiting the contacts with relatives afforded some relief.

Dora Levine (Abstract 32) came to us in January, 1929, at the age of twenty-eight. She stated that for three years she had had a dry "winter cough," accompanied by a sensation of tingling all over, and for three months she had had four or five attacks a day of coughing and gasping for breath. In these attacks her neck veins became prominent, her eyes bulged, and her face became "scarlet." These spells were brought on by anger or by bending. A private doctor consulted a month before had told her that her symptoms resulted from "worry over financial affairs." Shortly after this she had had a cold, with pain in her right shoulder radiating downward on inspiration, and "burning" sensations in her right chest. She consulted another doctor, who strapped her chest; this afforded some relief. A week before her admission to our hospital a third doctor had fluoroscoped her chest. She then feared that her condition was serious since this doctor had told her nothing but had insisted on seeing her husband. It was this doctor who referred her to us and reported that his findings indicated carcinoma of the bronchus. She had been losing weight and her general physical condition was poor. Our findings tended to confirm the diagnosis of carcinoma and she was advised to have radiotherapy in our out-patient department.

106

D E M O N S T R A T I O N OF CASES

During the next year under treatment general improvement occurred; the size of the mass in her chest decreased, and she regained weight. In fact, her recovery was sufficiently remarkable to arouse considerable doubt as to whether she had cancer. Bronchoscopy and later biopsy of an enlarged lymph node proved carcinoma and located the primary tumor in the lung. When she was first discharged from the ward there was nothing to indicate that she could not have continued her usual role in life. Her fears about herself were not ascertained and no explanation of the nature and probable course of her disease was given either to her or to any member of her group. Made suspicious by our silence, the patient surreptitiously read her medical record, discovered that we believed her to have cancer, and left the hospital with the conviction that she was about to die. From that time she regarded herself as an invalid and concentrated her thoughts upon her illness, to the exclusion of normal interests and activities. This attitude aggravated already existing family problems, of which also we were at that time unaware, but which were to be forcibly brought to our attention by the patient herself, though only after habits of behavior and thought in regard to her illness had become so fixed in both the patient and her group that our efforts to influence them were to prove futile. These attitudes, we believe, greatly increased her disability throughout the course of her illness, and interfered with securing the nursing care she needed. This patient was a person of limited capacity. She was the youngest of nine brothers and sisters in a family where poverty and low standards prevailed. It was customary among them to give way to their feelings. Our patient had been regarded as the prettiest child and the one most likely to succeed in life. She had been indulged by her parents, had learned little self-discipline, and had become vain, self-

CHRONIC

107

centered, and demanding. To one another the members of this family were intensely loyal, but to people outside their immediate group they were usually unsympathetic and overbearing. Our patient had married at twenty-one. She had not been in love with her husband, but had believed him to be a person of considerable means. After their marriage she was unwilling to believe his income was as small as it proved to be and she persisted in extravagances which within three years drove him into bankruptcy. Her husband, fifteen years her senior, was a man of quick, violent temper. He came from a family of higher standards of living than hers. The couple had few interests or ideals in common, and from the first proved incompatible. Almost constant quarreling widened the breach between them. This antagonism was increased by the active and tactless interference of the wife's relatives, to whom she turned for sympathy and help, so that slight grievances which might have been forgotten crystallized into permanent bitterness. The husband resented having these relatives know about the discord which he regarded as only their private concern. But in giving birth to his son our patient had established a hold upon him which insured his loyalty and support. At the same time she resented his devotion to the child, and attempted by indulgences and by maligning the father to win the boy's undivided affection. The child was nervous, attention-seeking, and ill-mannered. From the time of her marriage until the onset of the symptoms which brought her to us seven years later she had had no major illness but she had felt "ailing" and had consulted many private doctors at great expense. The husband, who had at first been sympathetic, became skeptical of her many complaints which he came to interpret, perhaps rightly, as a means of gaining indulgence, and expressed annoyance with her "doctoring." Until about four months before her first admission to our

108

D E M O N S T R A T I O N OF CASES

hospital she had not appeared to be ill. Then her appearance during attacks of coughing alarmed him and he permitted her to bring her mother, aged and inefficient, into the home to help with the housework and the care of the child. She remained there as a dependent, and became another source of family friction. When the husband learned from one private doctor that she might have a cancer, he became remorseful and solicitous to do anything for her comfort, willing to excuse her outbursts of anger as evidences of sickness. Looking back at the situation we now know to have existed at the time of her first admission to our hospital two years before her death, we can recognize that there were potentially favorable elements. These, skillfully utilized, might have lightened the tensions in the home, which we believe increased the patient's suffering and disability. Those around her were sincerely interested to help her. The physical setting of the home was good. The income was sufficient to meet the family's needs. The patient during most of this time was not incapacitated and suffered little discomfort from the cancer. Such discomfort as she complained of was attributed to infection of nasal sinuses. She could without danger have continued to pursue her usual activities as housekeeper and mother. Instead of utilizing the many natural opportunities for diverting attention from her symptoms and fears, she focused her attention on them. At home she stayed in bed, getting up only to come to the clinic for treatments. Her mother continued to care for the home. Her relatives surrounded her with sympathy and solicitude, thus constantly reminding her of her pitiful plight. They encouraged her to seek expensive medical advice and care elsewhere. During the whole time she was under active treatment in our clinic she was going from doctor to doctor seeking cures and encouragement. Abetted by her relatives, she chose to consider her sickness the result of an unhappy

CHRONIC

109

marriage for which she held her husband entirely responsible. Her husband, who at first had accepted her report that the hospital believed her to have cancer, became incredulous as months passed and he observed her to gain in weight and strength. Beset by doubt and goaded beyond endurance by her angry demands, he frequently lost control of his temper and there ensued violent scenes in which she flung herself upon her husband, screaming, and struck and scratched him. It may have been that she provoked these quarrels from a blind impulse to obtain relief from her great fear; and indeed she seemed to derive some satisfaction from them and from her husband's later repentance and indulgence, as also from the sympathetic indignation toward him that her abuse aroused in her family. But these scenes, and especially the screaming, must have been harmful, since physicians considered even talking a strain, and had advised her to limit it. It became evident to us that proper care of the patient was impossible in these surroundings, and we recommended that the child be placed either with relatives or in an approved foster home, and that the patient enter a chronic hospital. The husband was skeptical, as were also the relatives, of the advice we offered, and there had been open conflict between them and him for so long that the mere consideration of the plan by him aroused their opposition. Although the patient herself had been in favor of this plan at the time we first discussed it with her, her husband's later acceptance of it blocked its fulfillment for almost a year, since she was convinced by her relatives that he was trying to cast her off. When she had lost motor control it was at last agreed in family conference that she should go to a chronic hospital and she was admitted to a city institution. The home was broken up, the child being placed with relatives, to the satisfaction of all. But the patient found care in the city

110

DEMONSTRATION

OF

CASES

hospital unacceptable, tried another hospital, and was discharged from there to a nursing home where she again found the care unacceptable. She then sought shelter in the crowded, noisy, and untidy home of one of her sisters, there sharing a bed, surrounded by pitying, weeping relatives. Her husband, in desperation, appealed to us to take some action in this situation. We were again able to persuade the patient to enter a chronic hospital, and in the remaining two months of her life intervened to prevent her family from removing her. At first her relatives kept her restless and fretful by criticizing the care she received and proposing impractical pleins, such as taking her to a summer resort. They were so disturbing to her that the superintendent limited their visits. Apart from them the patient herself became relaxed and more contented than we had ever known her. She ceased to find fault, and even expressed appreciation of the kindness of those around her and of the excellence of their care. This more peaceful state of mind continued to her death. DEMONSTRATION

NO.

17:

WILLIAM

MURRAY

This case illustrates the values of home care for chronic invalids when family relationship» and interests are congenial. It also illustrates the contribution which a hospital can make to the home care of a patient, even when rendering little actual service, by instructing those who would give care at home in what must be done and by inspiring them with confidence to persevere, through assuring them of help should they prove inadequate.

William Murray (Abstract 65) was admitted to the hospital in the spring of 1931. He was an emaciated colored man of fifty-two who had been suffering from progressive weakness and pain in his side for a year but had neglected to seek medical aid, since he had attributed his failing health to grief over the death of his two children, and to worry over unemployment and loss of savings. Operation revealed carcinoma of the left kidney with metastases, and the diseased

CHRONIC

111

kidney was removed. After a difficult postoperative period of seven weeks he gained enough strength to be able to sit up and move around slowly. On his discharge it was believed that he could not live more than two or three months because of extensive metastases and poor general condition. He had a draining incision which was not expected to close completely and for which surgical dressings were required. The patient impressed us as a person of good mental ability, emotionally well-balanced, considerate of others. He was observed to bear discomfort with fortitude and his general attitude was one of optimism. In the past he had worked steadily as a barber, had taken pride in his work, and had earned enough to maintain high standards of comfort. His married life of twenty-five years' duration had been congenial and happy. He and his wife had shared responsibility and interest in their home, had enjoyed each other's companionship, and had held common interests in their children, friends, and church. Their misfortunes in the year before he came to us (death of children, loss of economic security, and his failing health) had drawn them closer together. The wife was also an emotionally controlled, capable person. She had attempted to meet the emergencies arising from his sickness and unemployment by running a furnished rooming apartment. Mutual aid was an accepted tradition in their social group and with a little help from relatives and friends they had managed to meet living expenses until shortly before his admission to the hospital. But rooms had become vacant, and when he came to us they were in debt. The wife's health seemed also to be failing. In view of the rapid downhill course expected for the patient, his need of nursing and medical care, and the insecurity of the home, it was thought best for him to enter a chronic hospital. The wife, when informed of his condition and outlook, accepted the recommendation with courage and self-control, and arranged for his care in a suitable institu-

112

D E M O N S T R A T I O N OF CASES

tion. In spite of her grief, she always appeared cheerful and calm in the patient's presence. It was explained to the patient that because of the need of surgical dressings he could not go to a convalescent home; that he would need care for a time because his operation had been serious and very weakening; and that we therefore thought it best for him to go to a near-by hospital for a month. It was further explained to him that this hospital usually took only very sick people but that they were willing because of his need to make an exception in his case and to care for him as a convalescent. He was transferred directly from our wards to a hospital for the terminal care of cancer patients. Before a week was past he improved and was so depressed by the sufferings of those around him that he asked to return to his home. The wife felt that she could not insist on his remaining in the hospital and appealed to us to teach her how to care for him at home. It was then learned that she and our patient shared the belief of their group that cancer is an infectious disease. Although after repeated reassurance she accepted our statement that this is not so, she refused the service of a visiting nurse because she believed that his diagnosis might thus become known in their community, that his friends would shun him, and that he might himself suspect the nature of his illness. The doctor in our clinic therefore showed her how to dress the wound. During this period the hospital endeavored to lighten her load as much as possible. She was brought under the care of the clinic, and given treatment for the mild arthritis from which she was found to be suffering. It was believed that most of her distressing symptoms were induced by her fear that she too had cancer, for they disappeared when she was reassured that a tumor on her back was not dangerous. The hospital was able also to relieve some of her anxiety over the insecure financial situation by informing her of sources of relief should need arise.

CHRONIC

113

Under care at home our patient gained strength surprisingly; he was able to be up and to visit his friends. The wife was advised to encourage him in any activity he found pleasurable. He soon became able to pay a visit of several months to relatives in the country. A year after discharge from the hospital he was well enough to take part-time work at his old trade. He derived great pleasure from this and no adverse effects were observed. Rental of rooms, the wife's baking and selling of cakes and pies, the husband's small earnings, and occasional loans from relatives (promptly repaid) brought sufficient means to meet the needs of the couple. Not until two years later did the extensive growth of cancer confine him to the house and make it necessary that he have sedatives and special nursing precautions. On two occasions it was necessary for a physician to attend him in the home after his strength no longer permitted him to come to the clinic. Throughout this time the hospital's social worker visited periodically, took him such medication as was prescribed to aid nutrition and relieve pain, and gave his wife continuing instructions for his care as he became more helpless. The wife was encouraged to get in touch with the social worker whenever she felt the need of advice and was thus made to realize that the hospital was standing by and would safeguard the patient if for any reason she should prove unequal to the task. We believe that the happiness enjoyed by the patient in his home helped him to divert his attention from distressing symptoms and to make the most of his failing strength. Undoubtedly he would have had more skilled care in a medical institution, but it is our belief that the choice to rate social advantages above the advantages of more skilled nursing and medical care was a sound one. Care at home proved in the main adequate and its cost to the community was far less than care in any hospital would have been.

ν D E S C R I P T I O N O F A D V E R S E SOCIAL FACTORS ASSOCIATED WITH I N D I V I D U A L P R O B L E M S OF I L L - H E A L T H

INTRODUCTION T H E SOCIAL BURDEN OF

SICKNESS.—Social results of sickness

have long been recognized, studied, and in some measure compensated for by community endeavor. While we realize the great importance to human welfare of better understanding of these results upon all concerned, and of providing more adequate measures of relief, we have not been concerned in this undertaking with consideration of social and economic derangement resulting from sickness as they affect the general welfare.* It has been our purpose to consider the effect of these derangements in the health problem of the individual. We have been in each case particularly concerned to find any evidence of social economic deficiencies or strains which might have produced malnutrition, fatigue, or emotional tension in individuals, on the supposition that the resulting disturbance of energy might injure health. We attempt, in this section, to describe and classify the social factors which were adjudged to have a bearing on the health of the patients, and to indicate the frequency of their occurrence. This attempt to tear apart and consider in isolation factors that in real life are always found inter* For recent discussion of the nature and incidence of social problems causcd by sickness and disability in the United States of America, the reader is referred to: Medical Care for the American People, "Publications of the Committee on the Costs of Medical Care," No. 28 (1932) ; Mary C. Jarrett, Chronic Illness in New York City, "Studies of the Research Bureau of the Welfare Council," No. 5 (1933).

AFFECTING

SUBSISTENCE

IIS

related leads to classification that is frankly artificial. But we have convinced ourselves that describing and classifying these abstracted factors increases our ability to recognize them in their varied combinations and thus increases our ability to deal with them. discussing further these factors and the part that they played in the health of the patients, we must make clear one concept which is basic to the understanding of their significance; that is the concept of disability, a term which must be distinguished in use and meaning from disease. We use the term disease to describe a condition of the whole individual, or to describe an affection of parts of his body,—skin, teeth, etc. We express by it (1) states where loss of parts or other impairment of the body is found and associated normal functioning is disturbed; (2) states where no such loss or impairment is found, but where some important functioning is disturbed; and (3) states where loss or impairment is found but where no essential functioning is disturbed. We use the term disability to describe a condition of the whole individual characterized by deprivation of power to do something he needs or desires to do. Disease may or may not cause disability and does so only when important functioning is disturbed. Whenever functioning is disturbed, deprivation of power results. The person is then disabled for performing that activity which requires the power he has lost. (1) Disability may exist without organic disease. When the body fails to function properly even though it be in every part sound, disability usually exists. Thus, disability may result from faulty habits of eating, resting, posture, or use of parts (e.g., overexercise). Disability may also result from uneasy, depressing emotion, such as anxiety, THE

CONCEPT

OF

DISABILITY.—Before

116

A D V E R S E SOCIAL

FACTORS

remorse, grief, or tedium. Indeed, such disability when protracted may produce the same effect as serious organic disease, although no injury of the body can be detected. (2) Disability may be caused by organic disease, and it is in this association that the idea is most familiar to us. In fact, the importance of disease to most persons consists largely in the fact that discomfort is felt and ability to engage in desired activities or to attain satisfaction is diminished. A disease seldom has significance for a patient unless he fears it will disable or kill within a span of time that has reality for him. Witness the indifference of many patients, when free of symptoms, to defense measures against disease (e.g. syphilis, tuberculosis, rheumatic fever, etc.). It is the disabling disease rather than the fatal one that taxes our endurance most heavily, and is universally recognized as one of the great ordeals which men must learn to pass through. The severity of the ordeal for most is measured not by expectancy of death so much as by degree of disability. It is important to bear in mind several facts about disability which is caused by organic disease. There is no constant relationship between the degree of bodily impairment and the degree of disability. For example, disease such as cancer or syphilis may injure the body extensively or even fatally, before causing disability. On the other hand, affections which disfigure and repel others, though not in themselves disabling, may cause disability by hindering the person from engaging in activities or from enjoying associations with others. Again, the degree of disability varies from time to time in the same individual, though his bodily impairment remains virtually the same. Or his ability to engage in pursuits varies with their demands upon his strength, and he is thus, as a result of his bodily impairment, more disabled for some pursuits than for others. In like manner, the degree of disability from similar bodily impairments varies in different persons. It can even be that one with a great

AFFECTING

SUBSISTENCE

117

impairment suffers less disability than another with a small impairment. This is because one compensates for his loss of power in some part by ingenious use of power in another part; one compensates by the resources of his favorable situation; another fails to compensate though his intelligence is superior and his situation favorable. Our study is concerned with the part played by social factors in both disease and disability, for medical care of patients involves attention not only to pathological conditions, but also to disturbance in functioning regardless of whether it is due to pathological change in tissues or to other causes. In connection with disease, it is fairly well agreed that such factors as lack of materials or conditions necessary for subsistence, poor use of these materials, or excessive strain in securing them may enter into the medical problem of individual patients in that such states may reduce resistance to disease as well as power to recover from disease. An ill-nourished organism is more susceptible to infection; a diabetic who cannot secure proper diet cannot maintain chemical balance; a cardiac who undergoes excessive strain increases the damage which disease has caused in his heart structure. Review of our cases, as we shall show later, indicates that influences from social factors affected organic disease directly in few instances. In the majority of cases where social factors were judged to be significant it was in connection with the problem of disability, whether or not caused by organic disease. And just as we noted that not the degree of physical impairment alone but also the attitudes and circumstances of the patient determined his disability, so we note further that not the extent of environmental deficiencies alone but also the patient's feeling about such deficiencies determined their effect upon him. In seeking the significance of social factors in disability we find that those most frequently associated and varying

118

A D V E R S E SOCIAL FACTORS

with it so consistently as to warrant an assumption of relatedness were of the kind which induced the feeling of dissatisfaction. Whether this feeling, through creating tension, can produce in the body an effect which renders it liable to disease is a question for the physiologist. We present evidence to support the assumption that the degree of dissatisfaction influences the degree of disability. In so far as the evidence warrants this assumption regarding dissatisfaction, and interesting evidence is afforded in the material gathered for this study, we have reason for considering the social conditions and relationships that cause dissatisfaction in a patient as matter significant to the medical purpose. With these assumptions in mind the life experiences of the hundred patients were searched for harmful relationships with other persons and for harmful reactions to situations. We also searched for defects and deficiencies in the physical environment of these patients. In the preceding case demonstrations we have presented examples of adverse social factors, some appearing to be relevant and some irrelevant to the health problem. In the main, the relevance of factors derived, as has been said, from their effect in producing or relieving the state we are naming dissatisfaction. We realize that further data are necessary to establish the connection between dissatisfaction and disability. Suggestions for future effort emerge from even this imperfect attempt to analyze the patient's social experience and to relate this experience, factor by factor, to his medical problem. The assumption that disability may be produced by failure to secure satisfaction as well as by failure to secure subsistence has helped us to become somewhat clearer as to the manner in which social factors involved in these failures may specifically affect health as well as general welfare. We next review and attempt to demonstrate the particular social factors abstracted one by one from the complexity

AFFECTING

SUBSISTENCE

119

of the life experiences of our one hundred patients. These factors we have classified in two groups. 1.

ADVERSE SOCIAL FACTORS AFFECTING

SUBSISTENCE.

Subsistence we define as continuance of the individual in a state of being in which he can maintain adequate physical and social functioning, judged by authoritative knowledge regarding physical needs and by customary standards acceptable to the social group. 2.

ADVERSE SOCIAL FACTORS AFFECTING SATISFACTION.

Satisfaction we define as a state in which there is on the positive side gratification of the wishes and acceptance of one's place in life, and, on the negative side, absence of disagreeable or painful feelings. ADVERSE SOCIAL FACTORS AFFECTING

SUBSISTENCE

A list of materials and conditions usually accepted as essential to support life in human beings illustrates clearly enough for our present purpose the meaning of subsistence. For a satisfying life there is need of much more—at least some understanding of the world we share, some realization of our part in it, some enjoyment of our understanding and realization, and some expression of this enjoyment, even if only through reënacting the expression of others more gifted. Consideration of these will be given in the section on "Adverse Social Factors Affecting Satisfaction." For the moment we fix attention on the needs of subsistence so that it may become clearer how subsistence failures may affect medical care. It is fairly well agreed that in order to support life the following must be available: habitable geographical conditions, air, and sunlight; food and fluid; shelter, clothing, and fuel to protect against temperature changes; sanitary disposal of waste; protection from dangerous insects and animals; protection from the hostility and negligence of

120

ADVERSE

SOCIAL

FACTORS

other persons, in respect to assault, accident, fire, poisons, pollution of water and air, and spoiling of food; and finally, personal service to provide the above materials and conditions for those unable to provide for themselves, viz., young children, the aged, the sick, the crippled, and mental defectives. Reviewing the findings regarding these matters for each of the one hundred patients and trying to understand the medical significance of any item judged unfavorable to survival, we find one or more of such items described in the cases of 56 patients. INADEQUATE PHYSICAL PROTECTION

Unfavorable habitat and locality.—Eighty-six patients were born in one or the other of the two regions declared by Ellsworth Huntington * to have the "most highly stimulating and healthful climates of the world"; viz., the region between southern New England and Virginia in the United States of America (51 patients), and the region of northern and central Europe (35 patients). Of the remaining 14, 5 were born in far southern states of the United States, 3 in Puerto Rico, one in Jamaica, one in Costa Rica, 3 in Sicily, and one in Smyrna. These southern and semitropical regions are said not to give the optimum conditions for human welfare, but only one of the patients native of these regions showed any ill effects. This was the orphan child with hookworm disease (Abstract 7). Not only had most of these persons under study had the advantage of starting life in regions of best climate but most of them had had the further advantage of continuing to dwell in healthful regions. Yet for a few, these regions are thought to have been not the best. Because of this, we advised the parents of John Booth (Abstract 1) to take him perma* Ellsworth Huntington, The

Human

Habitat

(1927).

AFFECTING

SUBSISTENCE

121

nently away from New York City to the warm dry climate of the southwestern United States to escape recurrence of rheumatic fever. This meant that the family must break ties with their native city and neighborhood, that the father must sell out a business developed during more than half a lifetime, and that they must settle among strangers and find there means for subsistence. Santa Carlos (Abstract 11) was assisted by us to return to the warm and equable climate of Puerto Rico where it was thought her joints injured by rheumatic disease would heal and she would be less exposed to reinfection. Carrie Hinkelman (Abstract 37) was advised to accept domestic employment in Florida for as long as possible that she might recover completely from slight tissue damage following subacute rheumatic fever. Had other victims of rheumatic disease * been removed from the New York climate early in the course of the disease it is today believed they might have been spared reinfection and resulting disability. It is unlikely that all these persons could have been persuaded to uproot themselves and settle in faraway lands even had funds been made available for this purpose. At the time of the hospital admissions, 2 were dying, 2 were suffering from decompensation of hearts long before damaged by rheumatic infection, but from no reinfection; 3 were having active infection. These 3 might still benefit by removal to a semitropical climate where they would be less exposed to reinfection, if at the same time they could be protected there against undue strain in maintaining themselves among strangers. But besides the almost insuperable difficulty of financing such a venture for these women there is the further fact that every interest and tie they have in life is centered in this locality. Their families lack the courage and ingenuity as well as the financial reserves to undertake for these invalids what the family of * Abstracts 18, 19, 31, SS, 70, 72, 83.

122

A D V E R S E SOCIAL F A C T O R S

John Booth are attempting for him. Even for his family the risks to all in their far migration make the wisdom of the undertaking somewhat doubtful. The air pollution as well as the climate of New York City was held to be disadvantageous to 2 patients whose respiratory organs had been seriously damaged. Both might suffer less in cleaner air and in warmer and less variable climate. For Michael Maggenti (Abstract 16) (diagnosis: chronic bronchiectasis) freedom from irritating dust, smoke, and fumes was considered more important than climate, and this he has been fairly successful in obtaining, without leaving family and other social ties, by remaining in the suburbs away from the centers of industry and commerce. T o bring this about, it was necessary to persuade him to give up a job he had held for seven years at work which was suited to his capacity and which he enjoyed. In the case of Tony Reali (Abstract 17), had we known him four or five years earlier, before he had spent his savings on "asthma cures," and before he had settled into invalidism, it might have been possible to have encouraged and aided his own plan to return with his family to Sicily. When he first came to our clinic for treatment in 1928, the money which was to have transported the family to Sicily had been used up for doctors' fees and living expenses in New York City while he lingered here, hoping for cure of his asthma. The patient was an American citizen who was at that time judged by his physician to be unable to earn a livelihood for himself and his dependents. It was, therefore, not permissible under existing legal restrictions to transport him to another country or to another political area in the United States, even could assurance have been given that a change of climate would enable him to return to gainful employment. For S patients found to have tuberculosis, some change in their usual city environment was recommended. Cleaner

AFFECTING

SUBSISTENCE

123

air and more sunlight than this environment affords were advised. We questioned whether or not the general commotion of city environment, the crowds, the traffic, the noises, caused harmful fatigue in a number of the badly disabled patients, but found these patients not affected. The particular transportation hardships experienced by 4 of them in getting from their homes to their jobs were fatiguing, and are dealt with as problems of "Undue Effort to Secure Subsistence," but city traffic, crowds, and noise in general did not affect them. Street noises disturbed the sleep of one of the patients who worked at night, and this we deal with under "Inadequate Shelter (Noise)." Four patients whose ill-health proved to be caused mainly by mental states did appear to be affected by the general commotion of city life. They felt fear at being among strangers and in unfamiliar surroundings, or displeasure at being forced to leave familiar surroundings. Symptoms such as vomiting, diarrhea, and dizziness came on in street crowds and in subway traffic. These exterior influences are mentioned here because, though not the main cause of disturbance, they did somewhat reduce the capacity of these patients to maintain themselves in the city environment where social or economic forces had brought them to live. Some disadvantages from the geographical region or urban locality have been described for 20 of the one hundred patients. For the other 80, the climate and other physical conditions of the locality had not been unfavorable. Inadequate shelter and clothing.—Shelter is important to subsistence as a means of protecting from changes of temperature, from filth, from noise, from intrusion of hostile or unwelcome persons, and from dangerous insects or other living things. Housing, clothing, bedding, and fuel are here considered together as shelter. In order to be sufficient for supporting life these must make it possible to keep tempera-

124

A D V E R S E SOCIAL FACTORS

ture within certain limits, to secure rest and sleep, to prepare and eat food, to obtain water for drinking and cleaning purposes, and to dispose of waste. Here we consider the availability of these subsistence means. Under "Faulty Personal Habits Influencing Protection of Health," we consider their use. The esthetic values of houses, clothes, and furnishings are treated in the section "Adverse Social Factors Affecting Satisfaction." Housing. The physical environment of home and place of work was judged to be good in nearly all cases studied. Homes were visited and note was made of exterior and interior conditions, noise, stairs, space, light, sunlight, ventilation, temperature, heat, dampness, sanitary facilities, housekeeping equipment, sleep and rest arrangements. Five lived in dwelling houses which they owned, 66 in apartment houses, 12 in the apartments of relatives, 15 in furnished rooms, 2 in the employees' quarters of our own hospital. A rough grading of the physical state of these homes is as follows: conditions excellent, 30; conditions good, 49; conditions in some points defective, 21. In a few instances conditions which for persons in health would have been harmless were found to be unfavorable for persons with certain disabilities. In general, however, even the poorer homes could not be described as detrimental except in minor ways. Stairs. Climbing the stairs to their living quarters may have caused harmful fatigue in 9 patients. One, for example, in order to obtain low rental, lived where she had five flights of stairs to climb and where other inconveniences added to the strain caused by heavy family and home demands. Her general discomfort from glandular disease was, however, great, and it is doubtful whether muscular fatigue contributed. Another, a cardiac, because of his reduced earning power, thought it safer to remain where his family was known and trusted, and to manage the climbing of three

AFFECTING

SUBSISTENCE

125

flights of stairs slowly. A third became too ill to descend or to climb the five flights of stairs and was thus unable to escape the noise and clutter of family life. Space. There were only 2 instances of overcrowding in living quarters that seemed to affect health. One patient shared four small rooms on the sixth floor with five other persons, four being young children. Relatives who had an apartment in the same tenement house came and went frequently, thus adding to the commotion about the invalid. But the aid and protection which these relatives afforded influenced the family to remain in the same place and while undoubtedly discomfort of the invalid was increased by unrest it is unlikely that the fatal course of his disease could have been stayed by any change of environmental conditions. Quiet and privacy were unobtainable for another patient as long as she shared two small rooms on the fifth floor with three other persons, two of them lively children. Correction of these conditions was held to be important for this woman's treatment. (For full account, see Case Record, Catharine Monahan, pp. 346-400.) Noise. Noise sufficient to disturb rest was accounted an unfavorable factor in the environment of 2 cardiac patients. One worked at night and tried to sleep during the day. His home was in a house at the intersection of two main thoroughfares along which elevated trains, trucks, trolley cars, and other vehicles passed. Because of long association with the neighborhood, the patient for some time refused to move. Another occupied a room near the motor which operated the elevators of an apartment house. The advantage of low rental kept her there in spite of the annoyance and the interference with rest. Sleeping arrangements. Thirty-one patients had comfortable rooms of their own and habitually slept alone; 10 others shared a bedroom with another but slept in separate beds: 6 single and 50 married persons shared a bed with

126

A D V E R S E SOCIAL

FACTORS

another. Information is lacking about 3 single persons. These arrangements were acceptable to the patients and not physically harmful as far as we could discover. Only one patient reported sleeping in a bed with two other persons. His sickness was found to be caused by anxiety. He was habituated to sleeping with two brothers and did not find their presence uncomfortable. For 6 seriously disabled persons who occupied bedrooms alone we questioned the adequacy of protection. They needed at times someone near for actual services and also for allaying fear due to helplessness. (See "Lack of Personal Service.") Temperature, heat, ventilation, dampness. In no dwelling was any important failure in protection against temperature changes noted. Temperature changes experienced at work are reported to have been possibly harmful for 5 patients: one suffering from rheumatic fever experienced as waitress sudden changes of temperature in passing from a warm to a refrigerated room; 4 were exposed to wind and weather—a truck driver, a night watchman, a window cleaner, and a warehouse porter —one of whom suffered from arthritis and 3 from cardiac disease. Dampness is not reported as a problem of any dwelling or work place. No patients were found to be living or working where ventilation was not sufficient for ordinary needs. Ideal conditions were not arranged by 2 women recovering from pulmonary infections who were advised to follow the regimen of a tuberculosis "cure." Both refused to accept the aftercare in institutions that was arranged for them by the hospital and returned to live with their husbands in the apartments of relatives. Each occupied a bedroom with her husband and, while these rooms were quite adequate for ordinary needs, they did not afford the "open air" recom-

AFFECTING

SUBSISTENCE

127

mended. In neither case was the housing thought to have been injurious. Sunlight. For only 2 patients was sunlight prescribed as a major therapy. One, a child, had Still's disease, the other tuberculosis of skin and eyes. The improvement of both under this treatment suggests that they had not in the past had adequate exposure to sunlight. Both had led shut-in lives due to social and economic causes. (For details see Elsie Duff, Demonstration 2, and Emma Kovacs, Demontration 9.) Sanitation. No inadequacy of provision for water and disposal of sewage and waste was reported for any dwelling from which patients came directly to the hospital. All these dwellings were situated in localities where the community water supply and sewage disposal are most carefully provided for and supervised. Even for those living as roomers and sharing toilets, no condition judged actually unsanitary was discovered. In the environment of the young girl who had come to New York City from Costa Rica eleven months before we discovered hookworm disease there must have been failure to make safe disposal of excreta (Abstract 7). This is the single example of inadequate control of sanitation. Housekeeping facilities. The public utilities of New York City and of other municipalities in which these patients lived, by providing water, gas, electricity, sewage and rubbish disposal, give the housekeepers in these localities very great advantages over those of former days and over those situated today in communities where such conveniences are not available. In only 5 of the apartments and in the 5 private dwelling houses did the occupants have to spend any effort in supplying heat. All other dwelling places were heated from central plants. Our records show that most had electricity for lighting and gas for cooking. Many had tele-

128

ADVERSE SOCIAL FACTORS

phones and elevators. In only 2 dwellings was a bathtub not available for use. All, except 5 roomers who ate their meals outside, had facilities for cooking and serving food. All had beds and no complaint of insufficient bedding is registered. We may say then that housekeeping facilities within these dwellings were ample, being more often on a comfort than on a subsistence level. But one inconvenience affecting housekeeping was frequently found, namely, stairs—8 of our patients who were housewives complained of the fatigue of stair-climbing necessary to tending children and marketing, but for only two was the fatigue regarded as a hazard sufficient to warrant moving. (For details see Florence Daniels, Demonstration 3, and Catharine Monahan, Case Record.) Clothing. No lack of clothing for physical protection was discovered. There were, of course, some who wished better and more becoming clothes but this item we designate a satisfaction, not a subsistence, need. Insufficient food supply.—Theoretically it would have been possible to know the exact minimum of food necessary to maintain each patient. This can be said for no other item in our list of factors, exact knowledge not being available regarding other subsistence needs, as housing, clothing, etc. Regarding satisfaction needs our opinions have to be formed on even less substantial evidence. We claim no more for the findings than that they were derived from the observations and opinions of experienced persons. Data describing social factors were gathered by experienced social workers; opinions regarding the meaning of the data for medical care were expressed by experienced physicians. We attempted no more exact method in gathering and interpreting information about food need and supply than about other items, in part because of the great cost it would have entailed to do more, but mainly because we conceive it to be sufficient, for the present purpose of unraveling and pondering wherein social factors may have bearing on medical problems, to sort out

AFFECTING SUBSISTENCE

129

the factors as clearly as possible and note the combinations in which they occur. More than one-third of the patients were observed to be chronically malnourished (35 underweight, S overweight), but only 3 of them indicated that they had been deprived of the supply of foods necessary to maintain health. It was thought to be doubtful that even these 3 had really lacked foodstuffs for a sufficient length of time to cause lasting harm. They did certainly suffer anxiety, as did others of the hundred, lest they come to lack food and other necessities but it was never proved that anyone really lacked sufficient supply of food. We doubted, however, if the foods available to these 3 patients had been of the kind best for their maintenance. For example, the hospital's visitor found one of these patients (Selma Swenson, Demonstration 5) and her family at a meal consisting only of boiled potatoes. It was learned that this family had for some time depended chiefly on potatoes and oatmeal for nourishment. Yet neither father nor son appeared emaciated or weak; the mother, our patient, said she had lost 20 pounds during the year her husband had been unemployed, when the family had been supported by her earnings from odd scrubbing jobs and janitor's service. She appeared undernourished and chronically ill, but also she was found to have pernicious anemia in an advanced stage. Even after means adequate for food and other necessities were supplied it was almost a year before this patient showed satisfactory improvement. Another patient, Mabel Norton (Abstract 66), similarly reduced to want when she herself became too ill to continue at day's work and her husband and children were unable to find gainful employment, claimed a loss of 30 pounds in six months. For two years she had known that she had diabetes and had followed more or less carefully a prescribed diet until worry over her family's economic plight and loss of appetite for such food

130

A D V E R S E SOCIAL FACTORS

as was available made her negligent. She had consumed little besides bread and tea. Her weight measured in the hospital was 100 pounds; her best weight was reported to have been 161 pounds. The third patient who may not have had enough food or enough of the kinds of food to tempt flagging appetite was a man (Thomas Watson, Abstract 96), seventy-three years of age, slowly dying of cancer. He had for more than a year earned no money but had been provided shelter and one meal a day as payment for answering night calls and performing other small clerical services in an undertaking establishment. On examination in the hospital he, too, was found to be greatly emaciated, weighing but 80 pounds. His normal weight was reported to have been 134 pounds. The disease factor in all 3 of these patients would have reduced appetite and power to assimilate food even had the most desirable kinds of food been available. But it is probable that for 3 patients out of the total hundred there was scarcity of proper foods and some labor or inconvenience in securing any food. In other instances where malnutrition was chronic and serious, and not a temporary condition due to acute illness, the patients had not lacked an adequate supply of food. Nine of them had led very active lives before they became ill and may thus have depleted body substance faster than it could be replaced. Faulty habits of eating or resting, noted in these 9 and 12 other malnourished patients, probably played some part in disturbing nutritional balance (5 were overweight, all others underweight). As would be expected, such habits were virtually always associated with an anxious state of mind, and at times with absorption of attention in personal concerns that disarranged customary routines (hours for meals, sleep, preparation of food, etc.). For these persons, however, the problem was not scarcity of food but

AFFECTING

SUBSISTENCE

131

failure in utilizing foods available. (See "Faulty Personal Habits Influencing Protection of Health.") Lack of personal service.—In the city communities where these patients lived, common basic needs are supplied by public services or can be purchased with little effort, and even the ablest person in our industrialized society can support life only by utilizing the services of others. The need of the sick or disabled for more than such usual service may roughly be said to begin when strength or interest are lacking to procure or utilize unaided the commodities and conveniences made available by industry and government. The need for service and the service given before the patients came to us we only know by hearsay, but judging from reports some 42 of the hundred patients needed extra service because of sickness. One person only, in the entire series of a hundred, entered the hospital the same day his symptoms appeared. Only 7 had been acutely ill for as brief a time as a week. The majority had been ailing and to some degree incapacitated for months. Of the 42 we believe to have been in need of special service, 33 received this from their families and 3 from friends, but 6 patients lived alone and had no one to minister to their needs when they were compelled by sickness to remain in their rooms. It seemed probable that these 6 persons who had no service and 11 of those who had negligent or insufficient service from their families or friends were sicker and more disabled than they would have been had they had competent service. In several instances the persons who took responsibility for the care of these patients also had to earn the livelihood. An example of this is found in the case of Frank D'Orsay (Abstract 15). This patient, before being brought to our hospital, for ten months had been too ill to work, and for three and a half months had been almost totally disabled by cardiovascular disease. He was left alone in a furnished room from seven-

132

A D V E R S E SOCIAL FACTORS

thirty in the morning until seven at night every weekday while his wife earned the $18 a week which supported them. After discharge from the hospital 52 patients required special service. This was provided by their families for 36, by friends for 2, and by convalescent or medical institutions for 14. The importance of service for the adequate medical care of 26 who lacked associates competent to provide the necessary service led the hospital to intervene on their behalf and secure care for them in institutions or assist their relatives to give the care. Withal, however, the kind and amount of services rendered to many of these patients by their families through difficult and trying illnesses makes an impressive record. An account of one of the most successful is given in the demonstration of William Murray (Demonstration 17). This patient's wife managed his care for more than two years during his gradual decline from metastases following carcinoma of the left kidney and the removal of the kidney. Under the direction of the hospital the wife proved competent to render every service including surgical dressings and at the same time to earn a livelihood for herself and the patient by renting rooms and running a small bakery. The value of family and kin, even when they are ignorant and indifferent, we appreciate when faced with the problem of protecting a disabled person who is homeless or who lives alone. Ten patients of the hundred we are considering were so situated when stricken by the illness that brought them into the hospital. The strain of securing food and other necessities we thought contributed somewhat to the development of sickness in the case of 6 of them. Details regarding such strain, as also the problem of providing subsistence for disabled solitary persons, are illustrated in the case of Allie Bach (Demonstration 15), the lady's maid without funds or family. Another case that illustrates the difficulty of providing service for homeless invalids is that of Jerry Faulkner (Abstract 25), a young colored man suffering from progres-

AFFECTING

SUBSISTENCE

133

sive heart disease. Different friends gave him food and shelter but they did not give the personal service that his condition made almost as much a subsistence need as food and shelter. Four times in one year he was admitted to our hospital, where the most important assistance rendered was service that made adequate rest possible. Another patient of about the same age, with a heart condition of equal severity, remained at home where his wife's services made possible adequate rest during a year and a half. He became well enough to undertake light work. While some of the improvement may be attributed to the satisfaction which the second man's family life provided, in the main we believe the care and protection which he received, in particular the protection of services that enabled rest, accounted for his better adjustment and defense against increasing disability. the preceding section we have attempted to itemize and describe the physical needs of individual patients and to consider for the particular medical problem each presented the significance of not having the needs supplied. We now consider ( 1 ) the effect of effort expended by each patient in order to supply his needs, and (2) the effect of adequate or inadequate income available. Undue effort to secure subsistence.—Effort expended to earn subsistence, or to achieve any other purpose, is of medical concern primarily because of fatigue. If effort produces fatigue greater or more prolonged than the organism can recover from after normal rest, temporary or permanent damage may result. Effort that fails to yield satisfaction may also be of medical concern, if the emotional tension experienced interferes with proper functioning of the body. This latter effect is dealt with separately in "Adverse Social Factors Affecting Satisfaction," but we mention it here because of its frequent association with fatigue and the diffiINADEQUATE ECONOMIC PROTECTION.—In

134

A D V E R S E SOCIAL FACTORS

culty of distinguishing one from the other. It is further possible that, when effort is prolonged, depletion of body substance to a degree that impairs health may result. Our task, then, is to review the experience of the patients studied for indications of these three effects, and to offer such opinions regarding the effects of effort as our inquiry and inference yield. We estimated that effort to secure subsistence produced strain, physical or emotional or both, sufficient to cause chronic fatigue * in about one-third of the patients, viz., 12 housewives, 5 self-employed proprietors of business, 13 wage earners; that in only one patient was fatigue from mental activity noted; but that for most when work strain was noted there was also associated emotional disturbance. Strain from physical exertion alone, uncomplicated by emotional tension, was described in only 4 instances. Emotional tension, caused by worry or chronic anxiety under responsibility, or by discouragement and resentment under business failure, or by tedium under work dissatisfaction, was found in all other cases and in a number appeared as the sole cause of strain, excessive physical exertion not having been required to do the job. In only a few instances (e.g., housewives engaged in both gainful employment and homemaking) did we believe that the exertion or attention necessary to perform the job would have been excessive for persons of sound health, although for persons already disabled by disease, as many of them were, the effort expended was con* In "Industrial Fatigue and Its Causes," Health of Munitions Workers Committee Memorandum No. 7 (Ministry of Munitions, London, 1916), the following observations are important to medical interest in fatigue: " . . . the results of fatigue which advance beyond physiological limits ('overstrain') not only reduce capacity at the moment, but do damage of a more permanent kind which will affect capacity for periods far beyond the next normal period of r e s t . . . . For these reasons, chief among others, it will be important to detect latent fatigue, and since sensations of fatigue are unpunctual and untrustworthy, means must be sought of observing the onset of fatigue objectively."

AFFECTING

SUBSISTENCE

135

sidered harmful. Even for a number of those disabled by disease we felt that the requirements of the job might have been safely borne, had there not been other adverse influences such as family ill-health, loss of savings, prolonged economic insecurity. As usual, it was the complex of stresses that constituted the problem. Incidence

of harmful fatigue.—Before

sickness developed,

all of the hundred persons observed, except 3 school children, had put forth some effort to provide their own subsistence. The occupation in which the largest number were engaged was that of housewife. There were 28 of these, 22 of whom were mothers who had reared children or who were still engaged in this activity. All 28 were endeavoring to maintain a home, and 12 of the 28 had undertaken some gainful employment in addition to their homemaking labors. All lived in city apartments and had easy access to goods and services. Little effort was required to secure water and heat, or to dispose of sewage, garbage, and rubbish; the householder performed only the task of cleaning her own rooms. Hall, stairs, entrance, and sidewalks were cleaned by janitors, and repairs were attended to by landlords. Markets for food, clothing, and household equipment were within easy reach of all. Most of them sent sheets and heavy clothing to machine-operated laundries, undertaking themselves only the ironing and the laundering of the light pieces. Ice for refrigeration was placed in their iceboxes with no labor on their part. Ready-made clothing was within reach, and if sewing was undertaken it was done, except the mending or making over, for the pleasure in the doing or to satisfy a wish for some special display. Are there grounds for believing that the work of any of the 28 housewives was harmful to them? Evidence regarding 16 indicated that their work had not caused harmful fatigue. In the cases of the remaining 12, however, it seemed probable that harmful fatigue and tension had been experienced,

136

A D V E R S E SOCIAL FACTORS

since to great expenditure of physical energy had been added the spiritual burden of unremitting responsibility, accompanied usually by anxiety and sometimes by discontent. In one instance, the labor and responsibility of homemaking and the rearing of four small children seemed to induce considerable fatigue largely because of housing inconveniences and waste of energy through misdirection. The need to expend energy excessively and to assume unaccustomed responsibility arose in 10 instances because of the following occurrences: unemployment, illness, death, or reduced earnings of breadwinner—the housewife then assuming part or all of the breadwinner's role while continuing the role of homemaking and child caring. In addition, 3 women bore the labor and major share of responsibility in rearing large families (2, of fifteen children, and one, of seven). That some housewives may have experienced fatigue sufficient to have influenced the development of ill-health or to have increased disability caused by disease is illustrated by the following example: Mary Boehack (Abstract 47) had been under strain for many years. At the age of fourteen she had begun to work for wages in a cigar factory; she had continued so employed for thirty-eight years; that is, to the onset of the present illness. At the age of twenty-three she had married. Three children were born and successfully reared to adulthood. A few months after marriage the husband became ill and our patient gradually assumed most of the responsibilities of chief wage earner while still retaining those of mother and homemaker. Each day on returning home from the cigar factory she proceeded at once to cook, wash, and sew. Besides these regular duties she often nursed her husband through heart attacks, sometimes losing time from work and thus reducing the income and increasing her anxieties. She also took her senile mother into her home. When she came to us at the age of fifty-three, after a year

AFFECTING

SUBSISTENCE

137

of illness which had kept her from work, she was found to have adenoma of the thyroid (basal metabolism rate + 5 0 ) , auricular fibrillation, and hypertension. She was a thin, whitehaired woman, looking careworn and older than her actual age, with a weary and sad expression. The church visitor who had known her many years described her as always "nervous," even before illness. "She is the sort that is restless and moving about continually." During the thirty-eight years that she had labored and carried responsibility for her family, she had been in the main successful in achieving her purposes and had thereby enjoyed a fair measure of satisfaction. But success had been won at the cost of much anxiety and weariness. Worrying had become a fixed habit, as had also the habit of almost ceaseless and often useless activity. An operation on the thyroid relieved much of her distress; during a convalescence of six months she regained weight, strength, and courage. Yet restlessness and worrying persisted, indicating, we believe, deeply established habits rather than symptoms of disease. It has seemed to us reasonable to think that these habits were acquired in the effort to meet strains too great, and that they in turn produced fatigue which probably contributed to her premature aging and her general breakdown in health at the time she came to us. Other illustrations of strain upon housewives from the effort to gain subsistence for themselves and their families are given in the cases of Elsie Duff (Demonstration 2), who developed tuberculosis of skin and eyes while working as janitress, and Catharine Monahan (Case Record, pp. 346400), who overstrained her heart in trying to solve domestic and financial problems. The case of one woman (Abstract 82) burdened with a large family illustrates the strains experienced when funds are lacking to provide service. We knew her in the period when the children were growing up, though after the period

138

A D V E R S E SOCIAL FACTORS

when they were being born in quick succession. The first three pregnancies occurred at intervals of one year; the remaining four at intervals of two years. During the twentytwo years of her married life she had never ceased to carry the major share of responsibility for keeping the home and, except when sick in bed, for performing the major share of the labors. During most of these years the income had barely met subsistence needs even when she was able to supplement the husband's wages by keeping a boarder, giving a few lessons, or selling a few pieces of hand embroidery. The first home in which we observed this family was four flights of stairs above ground, the second five flights. Fuel as well as food and other supplies for the household were carried up these stairs. Ill-health began with an attack of sprue fifteen years before she came under our care. During the years we have treated her, deficiency of thyroid and pituitary secretion has kept metabolism low even when large amounts of the extracts of these glands have been administered. Her weight has at times reached 262 pounds. Damaged heart and arteries, chronic bronchitis, and other bodily defects, of which the glandular disturbance is held to be the most important, constitute a condition of ill-health no doubt sufficient to explain her disability without other cause. That there was some occupational strain is clear and it seems probable that fatigue from this contributed to her general disability. A somewhat larger contribution, but still minor compared to that of organic disease has, we believe, derived from her discontent over the family's loss of fortune and social position. Argument for this is presented under "Adverse Social Factors Affecting Satisfaction, Lack of Satisfying Social Status." To summarize, we find that for more than half of the 28 housewives their labor and responsibility did not cause strain. In instances where chronic fatigue appeared to result

AFFECTING

SUBSISTENCE

139

from physical exertion, anxiety from carrying responsibility also was noted. When gainful employment was added to the homemaking and child-caring job, chronic fatigue was always suspected. We next look for strains incident to the occupation of proprietor or entrepreneur. Thirteen patients had owned and themselves managed business enterprises, most of them with small capital investment. There were 2 real-estate brokers and one each in the following lines of business: garment manufacturing, barbering, tailoring, running a restaurant, pushcart peddling (fruits and vegetables), accounting, stamp trading, diamond setting, promoting, running a lodging house, vaudeville performing. The occupation of entrepreneur, like that of housewife, is unsupervised; that is to say, the worker is not directed by another but directs his own course of action, taking risks or playing safe, according to his own judgment. We reason that there is more strain of responsibility upon the unsupervised than upon the supervised worker. The former has the strain of making decisions, of accepting blame for his mistakes, and of planning as well as performing a daily routine. From such information as we were able to glean regarding the character of the activities of these 13 entrepreneurs, we considered it likely that some of them experienced strain of responsibility but unlikely that their work involved excessive physical exertion. For the pushcart peddler, Mark Selig (Abstract 89), the long hours, long standing, exposure to wind and weather, and irregular meals were believed to have caused fatigue. He was not robust, and in early life had been employed in a white-collar job. Migrating to the United States at the age of twenty-one and speaking no English, he had been unable to find employment as clerk and thereafter had engaged in peddling—a period of thirty-nine years. Ambition to advance his family's fortunes was his major interest. Fifteen years before he came to us, symptoms of

140

A D V E R S E SOCIAL FACTORS

digestive disorder began, and these continued. Four years before, and shortly after his wife's death, he became acutely ill; ulcer of duodenum was found by X-ray examination, and regulation of diet was prescribed. The patient continued to push the heavy cart of fruits and vegetables, leaving his home at seven in the morning, not returning until late evening, and snatching hasty meals at restaurants. From the difficulty we encountered in regulating his diet even after his critical illness, we doubt that he ever had strictly followed medical orders previous to this illness. His apparent ignorance regarding permissible foods and his habit of eating at irregular intervals led us further to doubt that a serious attempt had ever been made to instruct him. He appeared to have fair intelligence as well as courage and cheerfulness. After some distrust of the need for strict discipline respecting his diet, he accepted restrictions. When told but once of the harmfulness of smoking, he gave up this habit though it was one of the few pastimes he enjoyed. Five months after operation he felt so well that he again attempted peddling. There was no necessity for earning as his children were supporting him, but the tedium of idleness had been a trying ordeal and he was eager to be again in the streets buying and selling his wares. That this occupation, not usually held to be strenuous, was too laborious and taxing for this man became evident. Within a few days symptoms recurred and by the end of the second week he was again acutely ill. Signs of fatigue had early warned him of danger but the feeling that he must at least recover the money invested in goods drove him to exert himself beyond the point of safety. In this man's case we find grounds for believing that his work or effort to secure subsistence kept him under a somewhat heavier strain of labor and responsibility than he could tolerate, and that this strain may have contributed somewhat to the development of ill-health. Closely associated with the factor of work strain in this case is that of defective

AFFECTING

SUBSISTENCE

141

personal hygiene. His faulty eating and rest habits, developed in part from the exigencies of his work, probably influenced even more than work strain the development of ill-health. Had these two factors, work and hygiene (in this instance they virtually became one, viz., personal habits), been thoroughly investigated and adequately dealt with when symptoms began many years before, most of his illhealth and disability might have been prevented, for he was well-adjusted to life, his situation on the whole was favorable, and he showed a high tolerance to disease. We found no indication of occupational strain for 7 of the entrepreneur group, though concerning one of those who left the hospital against advice we know too little to be sure. Besides the peddler whose labor we have outlined, there were 5 others who must have suffered emotional tension from responsibility and probably some fatigue from exertion. These 5 persons when we met them had all failed in the business enterprises they had undertaken; with several this business failure occurred shortly before they became incapacitated by illness. The principal effect associated with failure was dissatisfaction, manifested as anxiety, discouragement, and in some instances, resentment and humiliation. This disabling effect of dissatisfaction we deal with under "Adverse Social Factors Affecting Satisfaction." These business failures were caused not by sudden disaster, but by the slower process of gradual loss. In each instance there was striving to hold on, to oppose adverse forces. The strain experienced was probably caused more by anxiety than by effort spent in striving. But supposing that the whole experience up to and during business failure meant unusual strain, have we indications of any specific connection between such strain and the breakdown in health which followed? * We * One may also ask of what use it is to know the connection, should such a connection be demonstrable, after the damage is done. The immediate use of recognizing a probable connection is for the purpose of treat-

142

ADVERSE

SOCIAL

FACTORS

can answer only in terms of the most probable meaning of the patient's itemized experience. In the case of Isaac Klein (Demonstration 11), one of the business men in the group, we have presented some reasons for believing that fatigue and tension consequent to failing in business contributed to the physical breakdown and continuing disability of this patient. The nature and extent of structural damage by disease at the time of breakdown of all 5 patients experiencing business failure indicated that disease had been developing for some years before the effect was recognized. Circumstances that forced such persons already weakened by disease to undergo excessive fatigue we have assumed would be harmful and therefore important to control. Besides the 28 housewives and 13 entrepreneurs, we observed for this study 56 other persons who had been engaged in some kind of gainful employment. We shall not attempt to describe each of the many occupations represented by the 56 wage earners. The list includes stenographers; post-office, store, and hotel clerks; traveling salesmen; teachers; domestic servants; factory operatives; drivers of motor vehicles; painters; porters; etc. The manifold requirements for proper performance of these various jobs does not concern us. What we seek to know regarding each is whether or not the physical exertion of performing his job and the responsibility for performance and outcome resulted in fatigue greater than the worker could safely tolerate. For convenience of presentation we sort the 56 wage earners according to their work, each group having some general characteristics which are familiar: (1) white-collar work, 23; (2) domestic and personal service, 11; (3) labor operating machines, 14; (4) labor without machines, 8. The physical exertion required to perform the tasks in the differment, to guide the patient in reorganizing his interests and endeavors so that he may defend himself against further injury or loss of power. The other use of recognizing fatigue or other harmful effect from work strain is for the purpose of preventing the first illness in others.

AFFECTING

SUBSISTENCE

143

ent groups may not differ in any important way. The whitecollar stenographer operating a typewriter may exert energy in a manner quite similar to the factory worker operating a power machine; the warehouse porter lifting and carrying heavy bundles may be spending no more muscular energy than the white-collar post-office clerk similarly engaged in lifting and carrying heavy bundles. Nor is the burden of responsibility, the deciding, planning, executing of tasks necessarily less in one group than in another. The lady's maid responsible for costly garments and jewels and called upon to serve as hairdresser, as courier for a trip abroad, and perhaps as confidante may be under greater tension than a teacher or traveling salesman. In general, though, we found the expenditure of physical energy increasing and the tension of responsibility decreasing from group 1 to group 4. Those employed in clerical and personal service jobs came less under supervision and regimentation than those in mechanical and manual labor jobs; that is to say, they took more responsibility for their acts. Our opinions in nearly all instances were derived from descriptions of the work and of its effect upon them given by patients themselves or by their families. These descriptions lead us to believe that none of the jobs required concentration of attention or muscular control during periods of time sufficient to be exhausting for persons in good health. But some of these patients, after they had been partially disabled by disease, appeared to increase their disability by expending more physical energy or assuming greater obligations than they were equal to. The following compose the white-collar group: 6 stenographers and office clerks; 2 store salesmen; 4 outside salesmen (insurance, commodities, real estate, etc.); 3 government office clerks ; one agent in an animal protective society; 3 management clerks (hotel, messenger boy); one accountant; 2 teachers; one golf club maker and teacher of golf. Physical overexertion is not emphasized in the work

144

A D V E R S E SOCIAL FACTORS

experiences of these 23 persons. In 4 cases mental and emotional strains are described. One man had been carrying a heavy schedule of study and teaching, the 3 others had been harassed and discouraged by their work. The first-mentioned, a man of thirty-two, John O'Connor (Abstract 56), was studying for a Master of Arts degree and for two years had supported himself by teaching. He is reported to have worked at times as much as nineteen hours a day; during "vacations" he continued his work. The second man, Frank D'Orsay (Abstract 15), age fifty-six, had been assistant manager of a hotel which was "running downhill"; long hours on duty, discouraging results, and small remuneration are reported. The 2 remaining cases of occupational strain among the clerical or white-collar group differ from the foregoing in that the men concerned were not only weary and discouraged, but had lost confidence in themselves. The first 2 men were still struggling against adversity; these last 2 felt themselves defeated. A brief note regarding each will indicate the nature of pressure which he tried to escape. One was a young man, Joseph Donato (Abstract 28), twenty-two years old, who, after graduating from college to satisfy his father's ambition, not his own, had secured an inferior clerical position from which he did not advance and in which he had little interest. The strain which we suspected in this case came from tedium rather than overwork. The other man, Benjamin Barks (Abstract 27), age forty-four, realized that during recent years his sales of insurance policies had gradually diminished and that in achievement he was near the lowest point the company would accept. His work had "got on his nerves." Besides this continuous and gnawing cause for worry, he had recently suffered the shock of losing his savings on the stock market. In these last 2 cases, work dissatisfaction rather than work strain may seem more clearly indicated. In both, dissatisfaction was great and, we believe, caused a consid-

AFFECTING

SUBSISTENCE

145

erable measure of the disability suffered. But underlying and partly creating the dissatisfaction (and there were other causes for it besides work) was the weariness of long effort to compete in work for which they were poorly qualified. In all 4 of these patients organic disease had been developing, though it had not been recognized, and it would probably at some time have incapacitated them whether or not they had been subjected to strains. But such strains as they experienced must have caused enough fatigue to constitute an additional handicap, and may have accelerated the sudden onset of acute illness. In the personal and domestic service group there were 11 persons: a barber, a bootblack, a Pullman porter, a hospital porter, 2 lady's maids, 3 general maidservants, a hospital orderly, and a seamstress. Strain of work is not reported for any of these, except for one of the lady's maids and for her only after disease of heart and arteries had rendered her unfit to hold any full-time position, unless her employer had understood her disability and enabled her to regulate service according to available energy. The social worker believes this might have been done had we early enough recognized and appreciated the emotional and financial factors entangled in this woman's medical problem. (See case of Allie Bach, Demonstration 15.) In the mechanical or machine-operating group there were 14 persons: 4 drivers of motor vehicles (3 drivers of small trucks and a driver of a taxicab); a subway switchman; a supervisor of heating plants in a chain of theaters ; a floor polisher (formerly streetcar motorman, painter, printer); and 7 factory operatives (a garment cutter, 2 stitchers, 2 pressers, a pocketbook maker, a metal stamper). Among these 14 patients there were 4 whose disabilities seemed in some measure aggravated by their efforts to earn a livelihood. Three had cardiac and one had bronchial disease which probably would have disabled them gradually

146

A D V E R S E SOCIAL FACTORS

even had it been made possible for them to maintain the ideal balance between activity and rest. One was the patient Harry Santos (Demonstration 12), whose case is of special interest for our inquiry because of the observed lessening of disability for a number of years apparently by the therapy of regulated, satisfying employment. It is further interesting because of the possible influence in the development of illhealth of long-endured overfatigue at work. In the case of Gladys Reynolds (Abstract 100), a woman fifty-seven years of age, seriously disabled by cardiac disease when she came to us, work strain is held to have been only a minor adverse influence among the other adverse influences to which she had for many years been subjected. Temper tantrums, economic insecurity, lack of social protection when ill, and above all the organic damage already caused by disease were greater hazards than the fatigue caused by her gainful employment. This last, however, is of sufficient importance to mention. During her lifetime she had tried various ways of supporting herself, the most lucrative being that of demanding the assistance of relatives, until their willingness or ability had been exhausted. She had run a poultry farm and been a private seamstress, a prison matron, and an inspector of trays in a restaurant. Finally, for six years she had worked in a necktie factory. Here she hemmed and pressed ties. Fatigue resulted from three kinds of strain: (1) rapid hand and arm motion in hand sewing and swinging a heavy pressing iron; (2) nervous tension of working on piece basis since she was able to make, even working at full speed barely enough for subsistence ($12 to $15 a week); (3) transportation to and from work, requiring one and a half to two hours. Otherwise conditions were advantageous: she worked seated and in a well-lighted comfortable room; she enjoyed the work and her associates. Her first cardiac break occurred two years after engaging in this work.

AFFECTING

SUBSISTENCE

147

The next 2 cases of strain in mechanical occupations differ from those just cited in that no emotional strains prior to breakdown were reported. The 2 young men in question had grown up in good homes and schools, and found satisfying recreation and employment during their twenty-two and twenty-three years of life. The first important shock came to them when they were told by their physicians that they must give up work. Michael Maggenti (Abstract 16), twenty-three years old, had for six years worked in the same factory, operating a power press by foot, and seated, stamping out metal parts for automobile lamps. Hours were eight to five-thirty with half-hour off for lunch, and half-day on Saturdays. The bronchiectasis found in this patient was dated back to pneumonia suffered three years before. His factory work was judged to have been harmful in two ways for a person with this bronchial disease; first, and most important, because of dust, smoke, and fumes in the atmosphere where the factory was located (the factory itself was found to be well-ventilated, well-lighted, and well-managed) ; and secondly because of fatigue induced by the long subway journey to and from work and the long hours of activity indoors. For a well person this work would have been pronounced safe. For this disabled person it was not safe. The case of the other young man, James Darrow, is described in Demonstration 10, and bears witness to the need which children with heart damage have for medical guidance in choosing their vocations. Although it was known that he had had rheumatic fever and that his heart had been injured in early childhood, he became a wage earner at the age of fifteen and performed fairly heavy manual labor for seven years. Failure of the heart then occurred, disabling him permanently for any but very light tasks. In the manual labor group there were 8 persons: a dock hand, a stableman, a warehouse porter, a laundry worker, a casual odd-job man (outside painting, etc.), a railroad pier

148

A D V E R S E SOCIAL FACTORS

watchman, a laboratory servant, and a theater scene painter. For 4 of these 8 persons it seemed likely that their regular work entailed strain harmful to them. These 4 patients were handicapped by cardiac disease and here again work and working conditions which could have been well-endured by the able-bodied presented difficulties for the disabled. Two of these handicapped workmen we can consider together. They were Negroes engaged in rough, fairly heavy labor, who suddenly and without previous warning became acutely ill and permanently disabled for self-support. Each was thirty-eight years old when thus stricken and had been gainfully employed since about the age of fourteen at fairly heavy work. They had been in the same jobs for eight and thirteen years respectively. One, Perry Jessup (Abstract 41), had steady daily work in a stable where work horses were boarded and wagons housed. He lifted or moved bags of feed, bales of hay, wagons, etc. This work, if skilfully handled, need not tax the strength of a man of even moderate muscular development. This patient was conspicuous for his powerful physique. He was proud of feats of strength, such as lifting horses. It was difficult for him, even after long suffering and weakness, to realize that use of his powerful muscles could in any way harm him. From his remarks, such as that his boss required more work of him than of others, we surmised that this strong man of amiable disposition was always encouraged to use his strength freely, and that in doing so he incurred greater strain than he could bear. His heart was found badly decompensated in this first illness (diagnosis: aortitis) and did not recover sufficient power to permit even sedentary work for eighteen months. The other man, Jerry Faulkner (Abstract 25), had for thirteen years been a casual or intermittent laborer on the docks, hired for periods of hours by different bosses when ships were being loaded or unloaded. The periods of activity were sometimes brief, sometimes long, and always intense

AFFECTING

SUBSISTENCE

149

while they lasted. Periods of idleness, frequently of several days, occurred between periods of hurried exertion. Such extreme changes in activity and in tempo have been found to tax the body more than the same amount of effort performed without haste during evenly spaced periods. We questioned further whether this man, small and of light build, had the muscular power and endurance to perform dock or longshore labor without strain. He had drifted into it after twelve years of seafaring. Yet the fact is that he did work at these two strenuous jobs, as seaman and dock hand, for twenty-five years and did not give out until luetic infection had caused great damage to his heart. Continuing at heavy labor after damage had occurred, as did these men, may have brought on the collapse earlier than it would have come from the disease, for patients with aortitis who do not exert themselves more than they can tolerate usually are spared protracted illness. The decompensation and illness suffered by both suggested injury by fatigue as well as by infection. After being incapacitated both men became dependent on others for their support. We learned of no emotional agitation that might have been disabling. They had been satisfied with their lot in life, seeming to accept whatever came as the will of God. In the same spirit they accepted their sickness and were helped by religious faith to avoid the restlessness and discontent which so often add another form of disability to that caused by disease. The third case, among the nonmechanized laborers, in which we find strain associated with work is that of William Mahoney (Abstract 64), the watchman on the railroad pier. He served on the night shift from 9 : 0 0 P.M. to 8 : 0 0 A.M. and his work kept him much of the time out of doors whatever the weather, and also much of the time standing or walking. In addition, considerable energy was required to get to and from work; three transportation systems were

ISO

A D V E R S E SOCIAL FACTORS

used, four flights of stairs climbed to reach these, and three more flights to reach his own apartment. Sleep during the day was disturbed by traffic noises (see "Unfavorable Habitat and Locality," p. 120). The above-mentioned activities and conditions did, we believe, put considerable strain on a heart damaged in youth by rheumatic fever and in recent years further overworked by toxic adenoma of the thyroid. Relief of the thyroid strain was achieved by surgery. When consideration was given to relieving work strain, it was found that another cause of strain, dissatisfaction, was involved. (A brief description of this is given under "Lack of Satisfying Social Status.") Unlike the dock and stable laborers we have just described, this man was high-strung and restless. He had aspired to achieve in his immediate family and in his community a position from which he could control others, and he realized that he had failed. His irascibility, childish and probably harmless to others (for his wife and children appeared tolerant of his outbursts), was, we judged, also important as a manifestation of emotional tension. He strove to retain the position of head of the household in his home. The home could have been maintained by the two children, and undoubtedly a cautious and less ambitious person would have protected himself from the fatigue of transportation and long duty which this man endured. Yet the medical opinion, reached after estimating all factors of strain, was favorable to the patient's continuing work since it was his chief source of satisfaction, and since increase of disability from dissatisfaction might do more harm than increase from fatigue. One cause of fatigue was lessened by the family's moving where there were fewer stairs to reach dwelling and subway trains. That this man could get so much work from his badly functioning heart is of importance for our better understanding of the multiple causes of invalidism. The fourth case of strain among laborers operating with-

AFFECTING

SUBSISTENCE

151

out machines was that of the warehouse porter, Sam Stone (Abstract 85). He was admitted for bed care in a severe attack of cardiac asthma. For twelve years this man had carried fifty- to sixty-pound bundles of silk through midtown traffic for distances of one-quarter to one-half of a mile. We must include also his labor at home in nursing a paralyzed wife, if we would estimate all the strain to which he was subjected. For ten years she had been disabled; for the last few years of her life she had been a helpless bed patient, and for the last year blind. One year before the collapse of our patient, she had died. Following her death and the breaking-up of the home which they had enjoyed together for thirty years, he had experienced great depression. But up to three months before this attack of asthma (the first in twenty years) he had not noticed unusual fatigue, though for three months he had been distressed by shortness of breath. Clinical findings (hypertension 200/130, arteriosclerosis, cardiac hypertrophy and insufficiency) signified not a rapid disease process but a slow degeneration of many years' development. Since this illness, there has been no problem of fatigue from overdoing to meet multiple obligations. There has been instead the problem of spiritual adjustment to illness and to new social relationships. His success has been greater than we expected, though not greater than one might have expected of a person who had enjoyed life and fulfilled all obligations as this man had. If any factor other than natural disease caused his disability, it was, we feel sure, not that of inner disharmony or resistance to destiny. Much fatigue had been endured and the likelihood that this influenced the development of disease is presented for consideration. Inadequacy of means to secure subsistence.—In this section we attempt to set forth such evidence as we have regarding the effects on health which it seems reasonable to attribute to the amount and the security of the incomes

152

A D V E R S E SOCIAL FACTORS

available to the hundred patients. Specifically, we seek to know whether definable injury to health appeared to result from lack of sufficient income or from fear that sufficient income might not be obtained. Income of patients. Before sickness occurred, the incomes reported for the majority are judged to have been sufficient to afford them protection under all usual conditions. Financial reserves sufficient to pay for the medical care they received, they did not have. Though medical care was a subsistence need of major importance for them, we omit consideration of it here because this hospital met this need. For subsistence needs which we have described in the foregoing section all but 9 patients had sufficient means. Many had savings and even some margin for comforts. The source of income for most had been earnings from gainful employment either of the patients themselves or of persons upon whom they naturally depended. Only 5 had been noncontributors to their own maintenance: 2 aged retired women, one school boy, and 2 young invalids never gainfully employed. Only one patient had received income from a charitable agency. Before sickness occurred, 34 had been the chief breadwinners of families; 28 had been housewives, 12 of these also being gainfully employed; 31 single persons had earned their own maintenance, 16 of these contributing to their families; 5 had been dependent on their families, one on charitable aid, and one on a small patrimony. Twenty-two lived alone and maintained themselves independently. The others lived as members of households. In 43 households there was but one person earning, in 34 more than one was earning, and in one no one was earning, but an adequate income was received from a charitable fund. Comparing the amounts reported as incomes received by these persons with amounts estimated to have been adequate for subsistence (excluding medical care) in New York City

AFFECTING

SUBSISTENCE

153

during the period 1928-30,* we find that 91 had incomes equal to or above the estimated amounts, and 9 had incomes below. But comparing actual incomes with estimated standards does not afford all the evidence necessary for judging the adequacy of the actual incomes; other variables influenced the resulting condition. Ability to budget, especially when incomes fluctuated, sagacity in buying, and fortitude in enduring the strain of protracted economizing or "scrimping" were found to affect in varying degrees the adequacy of actual incomes for individuals and groups. In some instances, though the reported incomes for individuals or groups had been below the subsistence standard, the persons who later became our patients appeared to have had necessary goods and services, and not to have suffered from worry. For only 5 of the 9 persons whose incomes had been below the subsistence standard do we regard inadequacy of means as a factor possibly contributing to breakdown in health; and this was by reason of the excessive fatigue and worry experienced in the endeavor to support themselves and their families. For the other 4 neither their deprivations, nor their effort to earn subsistence, nor the precariousness of their situation appeared to have resulted in malnutrition, fatigue, or emotional tension sufficient to injure health. On the other * Subsistence Standard: The income we estimate to have been adequate in New York City for fair subsistence without allowance for medical care, in 1929 and 1930, is SI ,620 a year for a family of father, mother, and 2 children under working age, the father being sole breadwinner. This amount we distribute roughly, as follows: $720 for the wage earner, $400 for the mother, and S2S0 for each child. In reckoning cost of subsistence for families differently constituted, calculation is made according to number of wage earners, number in school, etc. For example, the subsistence income for 3 employed adults, 1 housewife, and an adolescent child is reckoned for these years about S2,900; for 1 employed adult, 1 housewife, and 4 y o u n g children, about 52,100. For couples without dependents we assume that $1,200 supplied their needs when one was earning, and $1,500 when both were earning, and that for a single person, working and not living as member of a family group, $850 supplied actual needs.

154

A D V E R S E SOCIAL FACTORS

hand, the health of 15 persons whose incomes are reported to have been equal to or above the subsistence standard may have been affected unfavorably because dread of inadequacy and the struggle to avert it had been caused by business failures, loss of invested savings, irregular and uncertain employment, wage cuts, or loss of job. We shall presently try to show from actual cases the evidence on which we base these opinions. After illness occurred and had reached the stage which brought these patients to the hospital, many experienced a downward shift in their economic status. Only 9 were able to return to gainful employment immediately after convalescence, while a large number were permanently disabled, some totally dependent on others for subsistence, some handicapped in securing subsistence for themselves. Financial aid was given for a time by relatives to 20, by friends to 2, by welfare agencies to 15; 8 were aided in part by relatives and in part by agencies. No financial aid for subsistence other than that which the current incomes of their families afforded was required for 27; 5 maintained themselves on insurance or lodge benefits, and 7 on their savings. (Medical care was given by the hospital.) Of the 22 single persons who had before illness been able to live alone and maintain themselves, 8 after illness became unable to earn. Of the 78 self-maintaining households, 15 no longer had anyone earning. The one-wage-earner households dropped from 43 to 33, and those with more than one wage earner from 34 to 26. The one household maintained from charitable funds before illness continued to have this protection. Again, comparing the incomes reported with the estimated subsistence standards, we find that of the 93 patients who survived illness the number of persons reporting earned incomes equal to or above the standards had dropped from 86 to 61. Of 32 others, 11 reported earned incomes below

AFFECTING

SUBSISTENCE

155

standards, and 21 became dependent on financial aid from sources outside their immediate household (i. e., relatives, friends, or social agencies). It is not too much to say that all 32 patients in the substandard group suffered both mental and physical discomfort which more ample income could have relieved. Yet for many of them it did not appear that the experience affected health. They seemed to feel that loss of fortune and loss of health were two hardships which one had to endure and two problems which one strove to meet. Others suffered to a degree that seemed unfavorable to health, from anxiety due to insecurity, or from fatigue due to striving to earn a livelihood. For 9 of the 21 in the substandard group who became dependent, there were periods when aid was inadequate, or the patient feared it would cease, or he suffered humiliation because of his dependency. Of the 11 in the substandard group who received no aid, 6 we judge to have been harmed in some measure by lack of funds. All were harassed by financial worries, several continued at work beyond their strength, and 2 lacked service during times of illness at home. A few illustrations at this point, drawn from the case material, will make clearer the character of effects on health which we suppose to have resulted from actual or threatened inadequacies. Actual poverty was judged a major influence in causing the year of physical and mental suffering and incapacity experienced by the patient Grace Carter (Abstract 14). This woman's husband had tuberculosis and had died a year and a half before we knew her. For several months she continued the work she had been doing and boarded her infant son. Then, partly because of the child's ill-health and partly because of her own fatigue, she left her position and tried to earn a livelihood by renting rooms in her apartment. The income was insufficient to pay rent and provide food, and the child's sickness, as well as her own, prevented her from

156

A D V E R S E SOCIAL FACTORS

earning outside the home. She became dependent on relatives who gave somewhat grudgingly because they could ill afford to give. We estimate the income to have been about $200 below the annual amount required for healthy existence. She claimed to have lost 70 pounds in this period; we know from our own measurements that she lost 35 pounds in eight months. She complained also of abdominal pain and vomiting. The patient was examined in our clinics on several occasions in this period and tuberculosis of the kidney was suspected. The patient reluctantly consented to apply for sanatorium care. While waiting for a vacancy, her economic status changed. A friend provided a comfortable home and maintenance. Her mood, which had been sullen and at times panicky, became cheerful. She rapidly gained weight; she appeared well, and it was decided that she did not have tuberculosis. During the eight months when the patient's physical condition was studied in our clinic, no consideration was given to social factors, and the emotional tension caused by financial insecurity and inadequacy was not recognized. Insufficient income was but one of a number of social problems faced by Louis Crawford (Abstract 97). Illness developed when income was threatened and subsided when income again was stable, although other social problems remained. We therefore ascribe importance to economic insecurity in this instance. The income had been for some years insufficient to meet the heavy domestic obligations which he had assumed. Briefly these may be described as the support of an incompetent wife, intelligence probably below normal; three children, aged twelve, eight, and four, the youngest probably feeble-minded; the wife's brother, a dwarf; a sister reputed to be feeble-minded; and, for a time, the patient's nephew, described as a "wild person." We estimate an annual income of $2,500 to have been necessary for this family in 1928-30, while that available we

AFFECTING

SUBSISTENCE

157

judge to have been $2,000. For sixteen years this man had struggled to achieve a secure and respected position in the community, and had found satisfaction in his work, if little at home. In 1929 and 1930 he came to fear that he would lose his job. He then suffered pain in the head and fainting attacks, feared that he was seriously ill, and ceased to work. In the course of the year before we knew him he had consulted "twenty-five to thirty" doctors. His vision was corrected by glasses, teeth were extracted, operations were performed on nose and sinuses, and treatment was given to improve digestion. Such relief as he experienced was only temporary. Study of his condition by this hospital did not reveal any organic defect to account for symptoms. He stopped coming to our clinic but we learned later from a social worker (who had known and helped him since early adolescence when his father had deserted him and he had been adopted by foster parents) that after almost a year more of pain and worry his economic situation had improved and his complaints had diminished. Marian Rocher (Abstract 82), mother of seven children, illustrates the strain of long-endured and resented poverty in a person suffering also from serious glandular disease little if at all relieved by medical treatment. The earned annual income for the family was about $1,000 below the subsistence estimate, even when grandparents assumed the support of one child. The father was the only person steadily employed; his weekly wage was $25, and this supported two adults and five adolescent children. Our patient frequently spoke of their financial difficulties, and became greatly excited whenever she did, although naturally of a cheerful and tolerant disposition. We believe, therefore, that the inadequate income was one of several social factors which induced a more or less constant feeling of fear mixed with resentment, thereby adding the disability from chronic dissatisfaction to that from chronic disease. (For discussion of

158

A D V E R S E SOCIAL FACTORS

other social factors in this case, see "Undue Effort to Secure Subsistence," and "Lack of Satisfying Social Status.") Illustration is found in the case of Irene Barclay (Abstract 31) of the strain, both physical and mental, suffered by persons accustomed to cultured surroundings and pursuits, whose income has been reduced so that only by continual economy can they maintain even the semblance of their former status. This patient's father had been a physician; he died when she was a child. In adolescence her heart had been injured by rheumatic disease and she had remained always partially disabled. She and her mother, also a semi-invalid, supported themselves in part by taking lodgers. A married sister contributed to their income so that by rigid and unremitting economy they were able to live many years in fair comfort. Yet the loss of a lodger or the fear of losing one caused the patient constant anxiety and many times drove her to overexertion, such as washing bed linen, etc. Periods of cardiac decompensation often resulted. Economic insecurity has threatened this patient throughout the fifteen years the hospital has treated her, and even more taxing, perhaps, has been the lack of margin to permit carefree spending for some luxury, amusement, or gift. One episode of illness followed the family's indignation over her reckless spending of the budgeted clothing allowance to obtain a Persian kitten for a greatly beloved nephew. One of 3 patients in the group of single persons who after their first illness became destitute and homeless was Jerry Faulkner (Abstract 25). He accepted dependency without humiliation. Had the aid given by friends been adequate to ensure the physical protection his cardiac condition required, the economic factor would, we believe, have been of little importance. In considering occupational strain we described this man's irregular work and earnings. He had not saved money but had shared what he earned with friends when they were in need. In the year following his breakdown in

AFFECTING

SUBSISTENCE

159

health he moved from one household to another as these friends were able to succor him. They shared with him their food and shelter, but could not afford to give him the service he needed. Four times in the year he became acutely ill and was admitted to our hospital for bed rest. Then at last he recognized the hopelessness of his situation and accepted the plan for permanent care in a city hospital, which he had earlier refused. Another even more isolated single person whose income did not adequately meet her needs was Gladys Reynolds (Abstract 100). The probable harm to this cardiac from lack of personal service and from effort to support herself has been noted under "Undue Effort to Secure Subsistence." We also discuss the probable disability from dissatisfaction under "Lack of Satisfying Social Status." Her selfcenteredness and the friction which she had instigated largely accounted for her lack of economic protection. The weekly wage of $12 to $15 would barely have sufficed in 1929-30 for an able-bodied person who lived as a member of a cooperative group. Even this amount she was frequently unable to earn because of illness, and the supplements she exacted from relatives were sufficient only to enable her to continue a restless, fatiguing, and discontented existence. To the economic factor must be ascribed a good deal of the fatigue and discontent which we believe prevented her from ever successfully adapting her way of life to her low cardiac reserve. Allie Bach (Demonstration 15) became also an isolated destitute person. The physician in this case (Abstract 2) describes the patient's situation concisely: "Lady's maid, German, unmarried, alone in New York, homeless, not naturalized, and dependent on own earnings. Two years of underemployment through illness have exhausted savings. Fear of dependence has forced her to overexertion. Attacks of cardiac pain seem to be coincident with anxiety." Much

160

A D V E R S E SOCIAL FACTORS

oí her anxiety concerned relatives in Germany who since the war had been partially dependent on her, and who were, we judged, unable to provide for her. It was hoped that after sufficient rest she could again support herself, since her work required skill rather than strength. Means were secured to maintain her in good physical surroundings for convalescence and here she remained for a year. We had, however, misjudged her capacity for resignation. For thirty years this woman had earned good wages and had been the financial mainstay of her relatives. She had made the personal sacrifice of leaving her country and her own kin to live in England, Canada, and the United States, where she could earn more to send home. Except in the matter of dress and personal appearance we learned of no extravagant use of money, unless her generosity toward her relatives may be so described. She had made no provision for sickness, disability, or old age, and she was one of the patients who could well have afforded to make such provision and one for whom security against dependency might have had therapeutic value, for she proved unable to reconcile herself to dependency and insecurity. Emotional tension from these causes and from the tedium of idleness prevented her from benefiting fully by rest even when opportunity for rest was offered. After eight months of convalescence, when she felt able to work and no position could be secured, her anxiety and restlessness increased. Her cardiac attacks also became more frequent. After four months of failure to secure employment she was accepted for temporary residence in a chronic hospital where twice before in the preceding four months she had been refused because her physical condition was not thought to require bed care. In the hospital she did not improve and four months later died. The economic factor in this case appeared to be an important secondary cause of disability, both in driving the patient to overexertion before her first breakdown and during the year afterward,

AFFECTING

SUBSISTENCE

161

and in preventing relaxation during the year when we attempted to enforce rest. T h e history of another homeless patient, Bertha Eidelberg (Abstract 22), age fifty-three, resembles the above in several particulars. She too was a lady's maid, who for over thirty years had earned high wages and assumed financial responsibility for her family. Unlike Allie Bach, this woman had taken thought to provide for old age. She had partly paid for a plot of land where she proposed to build a cottage. She had further invested savings in speculative ventures hoping for large and quick returns. When the stock market break occurred in 1929, her savings were lost. The plot of land proved to be unsalable and a liability rather than an asset. But in 1928, a year before these financial losses occurred and when she still felt secure, she had given up work on account of illness and had rested for eight months. Again in 1929, before experiencing financial reverses, she was forced to leave another job because of illness and she then entered our hospital. The cause of illness was not discovered but she appeared to recover. Then followed a year of adversity. For four months she failed to find employment, then secured part-time work from which she earned less than living expenses. Her savings were lost. Her mother died. She was deeply attached to her mother, and part of her distress was caused by regret at not having remained with her. During this year of adversity she became progressively more disabled. Hyperthyroidism and hypertension developed, and neurological symptoms which had been noted earlier became more pronounced: staggering gait, weakness of hand, and temporary loss of sight in one eye. It is unnecessary here to quote in full the many complications that made diagnosis and treatment of this patient difficult. Our interest at the moment is in considering whether, during the year when disease developed rapidly and disability became great, the financial reverses and the

162

A D V E R S E SOCIAL

FACTORS

insecurity of livelihood were an important influence in precipitating this development of disease. We knew that she was disturbed and at one time supposed that anxiety and discouragement were disabling her. However, as we came to know her better during the succeeding two years, when her economic status did not improve and her disability continued great, we ascribed less importance than we had to economic or any other external influences. Her intelligence was always contriving some way to overcome the difficulties that confronted her. She was usually stoical about the whole experience, like a player who wins or loses, but is determined to finish the game. If her own efforts failed to provide subsistence she did not hesitate to ask and to accept aid, and she suffered no emotional turmoil over her dependency. She was more self-reliant than the previous patient, Allie Bach, less sensitive to the regard of others, more tolerant of physical hardships. While we assumed that this woman's economic failure and her homelessness were factors unfavorable to retarding the progress of disease, and, as the agency responsible for her medical care, did all we could to secure her support and protection, we concluded that these factors were not as destructive to this patient as they were to Allie Bach, who was disabled not only by disease but by anxiety and discouragement. This woman was disabled by disease only; anxiety and discouragement she conquered. Income for medical expenses. To complete our inquiry regarding the significance of the financial factor to the health of these patients, we now briefly report what we learned of the adequacy of their resources to supply professional services and environmental protection necessary for medical care proper. No delay in seeking and securing the services of a physician at the time symptoms were first noted was reported in any instance solely because money had been lacking to pay for this. Delay there had been, but in most instances there

AFFECTING

SUBSISTENCE

163

were only such usual reasons for neglecting health as unawareness of danger signals, absorption in the interests of daily life, gradual habituation to slight discomforts believed not dangerous, or the inescapable accompaniments of worry, grief, fatigue. The majority did report that they had felt ill for some time before seeking the help of a physician and probably some did delay in order to avoid the expense. We lack full information on this point. Again, after illness developed no one reported failure to secure the services of a physician solely because of inability to pay. Many had had the care of private physicians before they came to us. After being accepted by our hospital, medical care was given them whether or not they could pay any part of the cost. But had there not been available endowed or tax-supported institutions similar to this one, all but a few of these persons would have been poorly cared for and many would have been in dire straits, because of their inability to purchase expert services and conditions necessary for protection during illness. More than half would have lacked the service of even an unskilled person to nurse them; 22 of these lived alone, having no one to give service; 29 lived with someone, but this person was employed away from home one-third or more of every week-day and his earnings were necessary to support the household; 4 lived with another person who was also ill at the time our patient became ill. The remaining 45 patients were members of families able to provide ordinary personal service as well as all ordinary subsistence needs, but in only 2 instances did we judge these families to have been able to pay at private rates for the kind and amount of professional care required. After the period of hospitalization the patients who continued under our care were treated without charge or at clinic rates adjusted to their ability to pay, and therefore they encountered no important difficulty in financing the professional care they needed. For the sake of brevity, therefore,

164

A D V E R S E SOCIAL FACTORS

we shall omit further mention of this item of cost, and consider only the adequacy of their resources for obtaining environmental conditions favorable for aftercare. In this connection it must be kept in mind also that institutions for convalescent and chronic care provided, free or at rates below cost, the aftercare conditions required for a number: convalescent homes, 20; sanatoria for tuberculosis, 3; and chronic hospitals, 12. Excluding those patients who left the hospital restored to health, those who died in the hospital, and 4 who left the hospital against advice, there remained 85 for whom aftercare was planned. In addition to medical supervision for all 85, and specific therapies for 17 of these (e.g., radiotherapy, antiluetic therapy, etc.), the aftercare required was regulation of daily life according to prescribed routines, and control of environment. Regulation of daily life, chiefly affecting nutrition and expenditure of energy, was the major recommendation for 35 patients handicapped by cardiac disease, diabetes, pernicious anemia, etc. Control of environment was emphasized for 50. It was designed to protect from occasions inducing fatigue and anxiety; also to provide adequate food supply and convenient opportunity for rest and occupation. It was applicable (a) to 13 patients expected to recover entirely in from one to six months (convalescents from pneumonia, thyroid disease, tuberculosis, etc.); (b) to 13 whose virtual recovery was attained, but for whom there was liability of recurrence (patients suffering from syphilis, arthritis, neurosis, etc.); (c) to 6 for whom partial recovery but permanent partial disability was expected, and who must avoid fatigue and maintain a hygienic routine continuously in order not to increase disability (patients suffering from arthritis, hemiplegia, arteriosclerosis); and (d) to 18 on the downhill course for whom comfort was the chief objec-

AFFECTING

SUBSISTENCE

165

tive (patients suffering from cancer, Hodgkin's disease, etc.)· About the aftercare of 7 of these 85 patients we were unable to get satisfactory reports. Four left the city to be with relatives said to be able to provide properly for them, the move in each case having been approved by our physician. Three refused to have the treatment advised (we know that one called in a private physician). All 7 patients had resources of their own sufficient to provide the care recommended or else had relatives able to provide this for them. For 43 of the remaining 78, all conditions recommended for aftercare were satisfactorily arranged and maintained; for 26 the conditions recommended were only in part obtained and in part satisfactory; while for 9 some conditions important to their care were not obtained. Our reports show a total of SO patients whose aftercare was in some way jeopardized or hindered by inadequacy or insecurity of income, even when the physician's service was given without charge to them. Supplement to income or free institutional care was finally obtained by most of these patients, so that care in the main was made satisfactory. For 9 either the patient's unwillingness to accept such care as the community offered or our inability to supply needs such as service or to remedy irritating conditions at home resulted in failure to achieve entirely satisfactory aftercare. (See the case of Hilda Pogany, Demonstration 4, for an example of failure.) When we consider the several ways in which insufficient or insecure incomes affected certain of the one hundred patients, whether as a cause of emotional tension, malnutrition, or fatigue from striving to secure means, we must conclude that the economic factor had been an unfavorable influence of considerable importance both preceding and

166

ADVERSE

SOCIAL

FACTORS

following the development of ill-health. Our purpose in presenting the various reactions to economic strain is to call attention to a factor that is important for the medical understanding and treatment of many persons and that can be determined with fair reliability and more often relieved than can other adverse factors of the patient's social make-up. FAULTY

PERSONAL

HABITS

INFLUENCING

PROTECTION

OF

HEALTH

Habits interfering with the carrying out of medical recommendations.—In preceding pages we have described inadequacies in materials and conditions necessary to support life and have discussed the probability that such inadequacies were harmful to certain patients. We would next consider the effect upon health of the habitual practices of patients in utilizing materials and conditions available to them, for we know that the mere presence of things or conditions does not insure their utilization for a healthful way of life. This is difficult partly because we lack information and partly because the significance of the information we have is not clear. Since, however, the topic is important to the whole subject under consideration, especially in many instances where regulation of habits and conduct in general was the major medical treatment, it seems advisable to set forth such information as we have regarding any habits which deviated from standards usually accepted as best for health. Deviations from such standards were noted in the conduct of 31 patients. The most reliable information we have about the patients being studied is that acquired during the time they were under treatment and were being observed at the hospital or in their homes. During this time we were able to observe many of them long enough to form an opinion about their usual behavior, and for the majority we were able also to

AFFECTING

SUBSISTENCE

167

gather fairly reliable testimony both from the patients themselves and from their associates. By relating the problem of habit control immediately to medical recommendations requiring the patient's participation, the significance of success or failure will become clear. The recommendation which required the highest degree of participation by the patient was one very frequently given; namely, that for protection against fatigue and agitation. T o more than a third of the patients (39) recommendations concerning activity limitations and rest were made and for a number of these it was the treatment most important for restoring or maintaining health. In addition to these 39 patients to whom this specific recommendation was given to enable them to "carry on" and to prevent as much as possible the recurrence of disease or further impairment, general advice to avoid overdoing was given to 8 others in the terminal stages of disease, whose comfort to some degree could be controlled by their habits of expending energy and utilizing the protection offered by their environment. To carry out these recommendations for controlling rest and expenditure of energy meant for all of these persons change in usual habits: for some, change of occupation or cautious continuing of the usual occupation with restrictions of pursuits outside of work; for some of them it meant complete abandonment of customary gainful employment. In only 6 instances was the disability temporary and were the restrictions applicable to no more than six months or a year. For most, the damage suffered had left permanent disability for usual pursuits. But whether the restrictions were temporary or permanent, they necessitated self-discipline and usually the cooperation of other persons. Lessening of activity was for many a natural and unavoidable result of sickness. We are at the moment not concerned so much with the patient's resignation in accepting sickness as with his use and regulation of energy to prevent further impairment.

168

A D V E R S E SOCIAL FACTORS

When for a number of patients their situation was satisfactory to them or was made so, no serious difficulty in regulating the expenditure of energy was experienced. These persons adapted themselves to the changes required in order to avoid fatigue. (For illustration of this, see Demonstration 13, Rita Larson, who for twelve years, when disability from nephritis was increasing, continued at work.) Indeed, without specific endeavor on their part to bring this about, habits of worrying and restless overactivity subsided when improvement in the situation occurred. This was noted in the cases of four patients whose illness was attributed almost solely to a violent, and it might be said natural, reaction to very distressing situations. For example, Theresa Fleming (Demonstration 6) had maintained a well-ordered, temperate existence and though not robust had usually been in fair health until confronted at about the age of fifty by difficulties beyond her power to overcome. She then ceased to consume adequate food, to get fresh air and exercise, and to rest sufficiently. Great emaciation, weakness, and epigastric pain suggested the presence of malignant growth. Exploratory operation revealed no growth nor any organic cause for the patient's illness and incapacity. Although the emotional problem (marital) was not really solved, nevertheless a resumption of hygienic living in a somewhat more protected environment restored her to a fairly comfortable state of health. For 19 patients the acceptance of restrictions to activity presented grave difficulties. Either their environment remained unfavorable or they could not accommodate themselves to it. All were persons thwarted in obtaining some desired objective. In order to avoid fatigue and agitation they had not only to solve the problem of restricting activity within tolerance limits, but the far more complex one of mitigating resentment, self-reproach, and other depressive feelings. Four were unhappy in their marriages; 3 were

AFFECTING

SUBSISTENCE

169

young persons broken in health before they had had the chance to enter upon any career; 5 had failed to make the place in life for themselves which they desired, and regarded themselves as failures; 7 had enjoyed fairly successful lives in business, family life, and other relations, but were habituated to a life full of interest, activity, and responsibility, and when ill-health rendered them unable to continue this life they were demoralized. With all these patients deeply settled habits unfavorable for the best adjustment to disability were involved. Even when prescribed routines of rest and limited activity were dutifully attempted, they failed to give the protection sought because of the inner turmoil of emotions. In the preceding case-demonstrations are presented examples of endeavor made by several of these patients to overcome the injurious habits and to acquire others which might allow them the use of such powers as they had. In the case of Jerome Edwards (Demonstration 14), a suitable mode of life was planned and successfully maintained. Intellectual interests, cleverness in devising ways to satisfy these, happy family life, fair economic security, and disciplined intelligence and self-direction gave him a better start than other patients had. No less earnest endeavor to avoid fatigue and emotional tension but less beneficial results are described in the case of Allie Bach (Demonstration 15). This woman kept her prescribed rest periods but could not rest. She gave up working finally when advised to, but could never overcome the humiliation of accepting charitable aid, nor could she derive durable satisfaction from the pastimes and "made work" allotted to her in lieu of her customary interesting employment. Thus in the very endeavor to avoid the activities which caused physical fatigue, against which she had been cautioned, she developed habits of worrying not less disabling, perhaps, than the fatigue had been. In the demonstration of Harry Santos (Demonstration

170

A D V E R S E SOCIAL FACTORS

12) is described an interesting example of over-anxious and quite literal acceptance of medical advice to avoid fatigue. For five years this man gave up gainful employment and all responsibility for his family. In idleness he too developed habits of worrying and fretting. This patient's release from these habits is described also. By utilizing the opportunities for work and recreation which withdrew his attention from symptoms, his depressed mental state was largely overcome and he was able to resume much of his former role in life, even though his disability from disease slowly progressed. All of the unhappily married patients gave way to feelings of resentment and spite which appeared to exhaust energy and increase discomfort, and probably reduced their capacity to carry on. From what we could learn, no one of them made any serious effort to alter habitual conduct. In the case of one of these patients, Dora Levine (Demonstration 16), it is suggested that symptoms were aggravated by daily quarreling, screaming, weeping, etc. Similar, although less exaggerated, outbursts of ill-feeling frequently indulged in toward the partner in marriage were held indications of inner tension harmful to 2 patients suffering from duodenal ulcer. With all of the 3 young persons debarred by ill-health from the normal life of youth, regulation of their activities was considered an important phase of treatment. All 3 failed at times to accommodate themselves to their limitations. Illness had come to 2 of them in early childhood before self-control had been learned, and the indulgence of solicitous mothers had retarded the learning of self-control. It is believed that the lack of so important a means of protection was an adverse factor which appreciably diminished the capacity of these children to reach their best adjustment to disabling disease. (For discussion, see demonstrations of Emma Kovacs, chronic arthritis, Demonstration 9, and Pasquale Di Lorenzo, rheumatic heart disease, Demonstra-

AFFECTING

SUBSISTENCE

171

tion 8.) And always it was dissatisfaction that led them to reckless overdoing or induced moods of inaccessible depression. Indeed, of all 19 of these patients who found it difficult and in some instances impossible to secure the protection of health that was possible through the regulation of personal habits, it may be said that unhappy states of mind hindered them far more than did ignorance or circumstances. Even for those whose unhappiness was due chiefly to ill-health, and most were thwarted by other conditions, this remained a continuing cause of unhappiness since they could not reconcile themselves to the restrictions it imposed. In addition to the recommendation for regulating the expenditure of energy, there were two recommendations which required the patient to form the habit of acting in a prescribed way. These concerned diet and medication at home, and return to clinic to receive specified treatment. Changes in food habits were necessary for 8 patients, 2 suffering from diabetes, 4 from gastric ulcer, 2 from obesity. Two of the patients with ulcers found it difficult to restrict themselves to the foods prescribed and all 4 were advised also to give up the long-indulged habit of excessive smoking. Neither of the 2 women suffering from obesity proved able to abstain from eating the fattening foods they provided for their families, and their means did not permit them to secure a supply of food which would have made reducing less uncomfortable. Both had heavy labor to perform and were absorbed in caring for families dependent upon them. For 3 undernourished patients the consumption of more food was prescribed, but this did not entail a radical change in food habits. When attitudes and environment were changed, normal appetite was restored. Medication important to take at home was digitalis for IS patients, liver extract for 2, glandular extract for one, and insulin for 2. The insulin was taken regularly. Three

172

A D V E R S E SOCIAL FACTORS

patients failed to take digitalis regularly and suffered relapses attributed largely to negligence in this matter. Their resistance to following advice appeared to be a phase of a general resentment of ill-health and all things therewith associated. They failed also to acquire habits for protection against fatigue. Both the patients suffering from pernicious anemia failed to take the liver prescribed. One stopped it after a few months' trial and sought healing from a "faith cure." After 16 months she returned in a far more disabled state; since that time she has taken the liver regularly. The other patient neglected to take the liver for periods or took less than the amount prescribed. Six months passed before the habit of taking the right amount regularly became established. This woman, like those above described who failed to reduce weight, was absorbed in caring for her family and took little thought of herself. (See demonstration of Selma Swenson, Demonstration 5, for a detailed account of the difficulty experienced in establishing so simple a habit.) Mention must be made here also of one other treatment of great importance in protecting one patient, Michael Maggenti (Abstract 16), which required his faithful performance daily at home. This was postural drainage, recommended in a case of bronchiectasis where profuse mucopurulent secretion was to be removed by gravity. He was told to hang the upper part of the body over the edge of the bed for half an hour morning and evening. Having taught him to do this in the hospital and learned that he had continued it at home during several weeks, we believed that the value of the treatment was understood and the habit firmly established. But the procedure was unpleasant not only to the patient but to those in proximity to him and when he felt better he abandoned it. A relapse followed, and he had to undergo another long period of hospital care. This patient appeared to control his conduct less than is usual by ideas and reasoning and more by obedience to authority. Failure to continue

A F F E C T I N G SUBSISTENCE

173

the treatment resulted not only from the wish to escape unpleasantness but also from the fact that his parents had not ordered it, and had indeed objected to its continuance. T h e above-described failures of patients to do their part in treatment day by day at home we account for as caused sometimes by preoccupation with other concerns more important to them, or by discouragement at finding that the treatment did not accomplish the hoped-for miracle, but more generally by inadequate self-direction and self-control. ( I n the section on "Description of Measures Undertaken to Remedy Unfavorable Social Factors," the endeavors made to aid patients to direct and control their attention, to influence their choice, and to foster certain habits important to health are discussed.) Failure to return to clinic to receive specified treatments was caused in some instances by the same attitudes and habits that interrupted home treatment; though, in addition, circumstances difficult for the patient to control interfered more with clinic attendance than with self-treatment at home; such circumstances included hours of employment, family responsibilities, lack of money. B y and large, however, the return visits for advice and information, and for radiotherapy ( 6 patients) and physiotherapy ( 6 patients), were managed.* With only one type of clinic therapy was there failure. This was the antiluetic therapy prescribed for 8 patients. Two stated that they could not arrange their affairs to permit attendance in the clinic hours but would seek treatment from private doctors. They have not been * In all 64 patients were advised to return for medical care. Others were transferred to the care of private physicians ( 6 ) , and of other hospitals ( 8 ) , or were not advised further care. Only S patients of the 64 failed to return for the treatment recommended. T h r e e refused t r e a t m e n t : dental extractions ( 1 ) , nose and throat operations ( 2 ) ; 2 left the city to secure better social-economic protection. W e have not attempted to include all the kinds of medical treatment prescribed but only treatments t h a t required of the patient that he carry them out at home or plan to come to the clinic for them.

174

A D V E R S E SOCIAL FACTORS

heard from. Only one of the remaining 6 came regularly and had all the treatment recommended. The others had few treatments and these irregularly. The one patient successfully treated was a woman who learned also to carry out at home a diabetic regimen in which previously she had been negligent. After several periods of acute and serious illness she finally applied herself diligently to recovering her health. It is unlikely in the cases of 3 of these luetic patients that resourcefulness or self-discipline alone could have enabled them to make the trip to the clinic. Their reserves of strength were low. The major recommendation for them was to avoid fatigue. They were to come to clinic for treatment only when they felt able. Some misdirection of energy, lack of means to allow the least fatiguing transportation, and with one of the patients the responsibility for her two small children also hindered treatment. When, after trial, more accurate estimate of the usable strength of these three patients was possible, the recommendation for clinic treatments was withdrawn. The other two patients who had irregular and insufficient antiluetic treatment were more hindered by circumstances than by negligence or lack of strength. One, Lillian McKenzie (Abstract 58), was a woman dependent on her own earnings, a bare subsistence wage from unskilled labor. At first she could not afford to take time from work or to risk unemployment by letting it be suspected that her health in any way unfitted her for work. On her weekly "afternoon off" she came for treatment with fair regularity. When she was referred to another clinic held in hours more convenient, she attended regularly and received an adequate amount of antiluetic treatment. The other, Florence Daniels (Demonstration 3), was a mother who had four small children to guard, and the housework to do unaided. Lack of money to pay someone to care for the children in her absence or sometimes even to pay carfare, and the children's sicknesses, frequently interrupted treatment. But so great

AFFECTING

SUBSISTENCE

17S

was the relief this woman had experienced from thyroidectomy and a few antiluetic treatments that she was fired with ambition to restore her health as fully as possible. She continued not only the antiluetic treatment when possible but also made many visits for injection of varicose veins and for much-needed dental care. So far we have considered the part of habit control in carrying out medical recommendations for protection and treatment after illness. Habits of energy expenditure, food consumption, and resourcefulness and persistence in obtaining special treatments have been considered. In 22 instances poor habit control hindered to some extent the carrying out of prescribed treatment. We next review the data gathered and make note of habitual practices which may have undermined the health of patients before disability began. In 21 instances such practices are noted. Habits unfavorable to maintaining health.—As stated above, the information we have is too meager for continuous history of personal hygiene. Regarding many, we know little about habits of nutrition, elimination, activity, and rest, and cannot therefore assume that there were no errors in personal living that unbalanced the energy budget. And even when we have evidence that the habits of certain patients with regard to eating, sleeping, working, or seeking diversion did not conform to accepted precepts and practices, we cannot offhand assume that these habits were of importance in disabling the persons in question. For example, Marianne Hart (Abstract 36) is reported to have led a reckless, undisciplined life from early childhood, flouting accepted precepts regarding wholesome habits of eating, dressing, resting, working, and associating with other persons. No illhealth appeared to result from her recklessness up to the age of twenty-six; then nephritis developed during her first pregnancy and caused her death four years later. Since nephritis

176

A D V E R S E SOCIAL FACTORS

is not an uncommon complication of pregnancy even in women who exercise every care for self-protection, we are not warranted in designating this woman's unhygienic mode of living as an important influence in causing her sickness and death. It may even have been that for one so doomed, her indifference to bodily well-being and safety spared her the very frequent increase in disability which habitual concern over symptoms brings. Faulty habits of activity and rest. In 6 instances we have report of inefficient work-habits and associated fatigue. Three women were described as clumsy; that is, their muscular coordination was more than ordinarily defective. They also performed their work unsystematically, spending energy in a hit-or-miss fashion. These 3 and 3 others, whose actual performance was more skillful and better planned, lessened efficiency by not pausing sufficiently for rest. For a number of years these 6 persons had been in a state of chronic fatigue. The cases of Florence Daniels (Demonstration 3), Elsie Duff (Demonstration 2), and Selma Swenson (Demonstration 5) illustrate other unfavorable factors which affected and were affected by the inefficient work and rest habits of these persons. See also the example of "overdoing drive" in the case of Mary Boehack (Abstract 47) noted under "Undue Effort to Secure Subsistence," pp. 133-151. Faulty habits of food consumption. The habit of eating too much, too little, or unwholesome food and eating at irregular hours was reported of 5 persons. One of these, Alexander Petrakis (Abstract 10) said that his reason for seeking hospital care was to avoid indulgence of appetite for rich foods. For five years he had suffered gastric distress but had never been able to limit his eating to foods prescribed. A bleeding duodenal ulcer was found and a rigid dietary regimen enforced during five weeks' stay in the hospital. When somewhat relieved he left, against medical advice; he did not continue under clinic supervision. Irregu-

AFFECTING SUBSISTENCE

177

larity in eating and also eating of unsuitable foods probably contributed to the discomfort and lowered capacity of another patient, Mark Selig (Abstract 89), found to have a bleeding duodenal ulcer. He had complained of indigestion off and on for fifteen years, and since his wife's death, four and a half years before he came to the hospital, his distress had increased. In this instance, too, no consistent effort had been made by the patient to regulate his eating habits. For description of associated factors in this man's problem, see "Undue Effort to Secure Subsistence" and "Imparting Information Regarding Problems of Subsistence and Satisfaction," pp. 242-252. The probability that unhygienic eating and other habits increased disability and discomfort is further illustrated in the case of Anna Merman (Abstract 59). For twelve years this woman had been disabled, before the discovery of intestinal cancer when she was sixty-three. It seems unlikely that the cancer which finally obstructed the colon was present twelve years in a condition to cause the multiple discomforts and almost complete disability which she suffered during all these years. Besides cancer, physical defects observed when she came to us that could perhaps have accounted for her condition were deformity of spine, arthritis of hip joint, arteriosclerosis, hypertension, and arrested pulmonary tuberculosis. But in addition the patient had been constipated for many years and had daily taken Epsom salts and other strong cathartics. Her family testified that she had always eaten more food than did her sons, who were engaged in heavy manual labor; she demanded, for example, heavily salted and peppered meat three times a day. For years also she had done no work and seldom had gone outside the small rooms of the apartment where she lived with a married son and his family. Her infirmities and the four flights of steep stairs kept her housebound, but in addition the animosity which she felt toward her daughter-in-law

178

A D V E R S E SOCIAL FACTORS

led her to confine herself to her small hall bedroom. There she brought her food to consume it in solitude, and there for the most part she passed her days and nights in resentful idleness. The excess food, the lack of stimulation by fresh air and sunlight, the cathartics, the inactivity must have interfered with the functioning of her body even had organic disease not developed. Social influences that may explain her mode of living were: (1) the continuing in a shut-in city environment of food habits appropriate to an out-ofdoor life of hard labor (such practice being not unusual even among second and third generation city-dwellers engaged in sedentary indoor occupations); (2) the custom of administering drugs to herself without medical direction; (3) the tradition of her sons that it was their filial duty to enable their aging parent to be sustained in idleness; and (4) conflict between members of the generations with regard to the right of a mother to dictate to her adult children. (For further discussion of this case, see "Incompatibility and Friction with Associates," p. 191, where we note how a patient benefited by the independence secured through an old age pension.) Addiction to poisons and drugs. In addition to faulty habits of eating, the case just quoted illustrates also the cathartic habit. It is, however, the only instance of this habit commented upon as a probably disabling practice. Indeed, addiction to drugs or poisons of any kind was noted in few instances. In not one was addiction to narcotics found. Use of alcohol and tobacco was common but was judged to have been temperate and unimportant in all but a few instances. Three patients said they had been for many years "heavy drinkers" before they became ill. All 3 manifested serious and long-standing deterioration of the arteries. The continuous absorption of alcohol was thought to have been perhaps directly harmful in some degree, and indirectly harmful also by dulling awareness of fatigue. The situation of one

AFFECTING

SUBSISTENCE

179

of these patients, William Mahoney (Abstract 64), is presented to illustrate fatigue under "Undue Effort to Secure Subsistence," and to illustrate dissatisfaction over loss of position in community under "Lack of Satisfying Social Status," pp. 198-203. The situation of another, George Weil (Abstract 99), also is presented under the latter topic. Cigarette smoking to excess was reported by 4 patients, several packages a day being usual. Because of the fact that these patients suffered from gastric ulcers, special inquiry about their use of tobacco was made and they were advised to give up smoking. Faulty mental habits. Information gleaned about the previous life of 10 patients and confirmed by our own observation of behavior that appeared habitual suggested that these patients had for a long time been controlled by impulses and emotions that kept them more or less constantly restless and depressed. That such a state of mind would have had the effect of lowering vitality seems not too much to assume. Although we are far from being sure of the correctness of our interpretations of the mental habits of these patients, the important role of such habits in the social make-up leads us to include in this section such reports as we have. Fault-finding. Seven of these persons, one man and 6 women, had the settled habit of finding fault with other persons and with conditions, whether or not these other persons and conditions directly affected them. To outsiders the complaint often seemed unreasonable, and the fault-finding usually proved ineffectual to alter the state against which it was directed. At the time we came to know these patients, all were invalids. Their ill-humored criticism might have been ascribed to the demoralization of long-endured restrictions and discomfort, had it not been learned that the habit of unconstructive criticism had been indulged in previous to illness. Florence Baker (Abstract 62) is described by the

180

A D V E R S E SOCIAL

FACTORS

physician as "A misanthropic old maid who enjoys a vigorous martyrdom in preventing cruelty to animals . . . a case of sufficiently abnormal temperament and social situation to account for a large part of her symptoms." Much of this woman's ill-health appeared to us to be caused by her unhappy loneliness, which also might in part account for her hypercritical attitude toward other human beings (see "Lack of Family Group," p. 188). While no doubt her righteous indignation concerning the faults of others was primarily a manifestation of her own restless unhappiness, it also had the effect of augmenting this unhappiness rather than that of relieving pent-up feeling. This we thought also to be the case with Anna Merman (Abstract 59), whose dietary idiosyncrasies have just been cited (p. 177). It seemed probable that both these women behaved as they did because of feeling that they had abilities which others did not recognize and for the exercise of which they were allowed no suitable opportunity. The habit of criticizing others, her relatives in particular, was a conspicuous trait of the patient Gladys Reynolds (Abstract 100). From early childhood she was said to have been vain, selfish, and self-centered. Her interest in others, even in her own son, appeared to be for the purpose of gaining some personal advantage. When frustrated in her design to secure such advantage, she expressed her resentment in quite unwarranted criticism. Exploiting others. The intent to exploit others was reported of three of the fault-finders and should be rated as another mental habit which may have reacted unfavorably upon those who indulged it. Whether or not the habit proper had such immediate effect within those exhibiting it, we are sure that the resentment which it aroused in others created around the patients conditions which were unfavorable. For illustration of this habit and associated factors, see presentations of the case of Gladys Reynolds (Abstract 100) under "Undue Effort to Secure Subsistence," p. 133, "Inadequacy

AFFECTING

SUBSISTENCE

181

of Means to Secure Subsistence," p. 151, and "Lack of Satisfying Social Status," p. 198. Indecision, irresolution. To complete our review of mental habits which we suggest may have played some part in undermining health previous to illness we next consider habits of indecision and irresolution manifested by 6 patients, all young men. These cases are especially difficult to interpret because of the complexity of the life histories, and because 3 of them left the hospital against medical advice before study and prescribed treatment were completed. With 4 of them no organic defects sufficient to account for symptoms were found; the other 2 had serious organic diseases but these diseased states were not thought to account for all the disability suffered. In one instance the mental symptoms were so pronounced that treatment of the organic condition for which the patient had sought care was deferred and transfer to a psychiatric clinic was arranged. For discussion of related aspects of this patient's problem see Joseph Donato (Abstract 28), "Lack of Satisfying Social Status," p. 198, also "Undue Effort to Secure Subsistence," p. 133. We learned of this patient that in submitting to the dictates of a stern father he had been forced into competitive relationships, in college and business, that were distasteful to him and to which he had never been able to accommodate. It did not appear, either, that he had ever considered plans for extricating himself. He seemed benumbed by the experiences rather than clearly conscious of unhappiness against which he might have struggled. The other S patients whose customary behavior we have characterized as undecided and irresolute endured experiences which produced similar humiliation and confusion of mind. Two of them were entirely relieved of physical symptoms— diarrhea, fainting spells, etc.—by psychotherapy. This was accomplished in the main by aiding them to itemize one by one the difficulties confronting them and to decide upon a

182

A D V E R S E SOCIAL

FACTORS

course of action. The facing of problems in this way appeared to be for them a new and enlightening experience. It had been, we suspected, the lifelong habit of these 2 patients, as of the other 4 here considered, to evade problems which they could not readily solve, not even being clearly aware that they were thus retreating, but rather remaining in a chronic state of confusion and wavering. As few human beings have not at some time suffered physical discomfort from indecision and want of resolution, the claim that these states when they have become habitual may be somewhat disabling and may even cause illness will hardly arouse controversy. It is much more doubtful that the emotions accompanying antisocial behavior weakened or disabled those who displayed it; but it is likely that some trace of remorse or hesitation confused their thought and action and thus set up such tension as appeared to exist. Habits making difficult the endurance of disability.—The patient who endured great pain and weakness with the most composure and fortitude was Thomas Watson (Abstract 96), a man seventy-three years old, dying of cancer, who lived alone in an undertaker's establishment, earning a room and one meal a day in exchange for answering the office calls and keeping the undertaker's accounts. H e was reported to have been formerly wealthy and engaged in large business enterprises. Business failure with loss of fortune preceded his loss of health. Never once did he refer to his past style of living or complain of his present life. He appeared to be absorbed in working out a system of shorthand which he said had engaged his thoughts many years and which he was eager to complete before his death. The 2 patients who endured sickness with the least composure and fortitude have been demonstrated. Isaac Klein (Demonstration 11), at the age of fifty-two suffered his first attack of coronary thrombosis, also shortly after failure in business. During the six years that passed between his first illness and his death

AFFECTING

SUBSISTENCE

183

we learned of no undertaking that had really engaged his interest. His dread of another attack was so overpowering, apparently, that his attention could not be focused on anything else. While difference in the nature of the symptoms suffered may partly have accounted for the difference in behavior of these patients, this alone did not seem sufficient to explain the difference in disability suffered. Many patients with coronary thrombosis have been known to lead full active lives and many patients with incurable cancer suffering less than the man described above have been known to become demoralized and unable to live out their span of life with as much comfort as was possible for them. The other patient, Dora Levine (Demonstration 16), presented a distressing instance of suffering from the overwhelming fear of disease rather than from the disease itself. Treatment prevented this woman from suffering physical distress, but knowledge of the fatal nature of the disease induced a state of dread so extreme as to render her incapable of enjoying any happiness. Such contrasting behavior in facing the ordeal of incapacitating sickness forces those concerned with relieving human suffering to consider the differences in character that may account for the contrasts. In so far as some difference can be traced to experience, that is, culture and training, it is at least in some measure within human power to make use of experience to strengthen advantageous characteristics. The question has immediate practical bearing even when character has long been fixed in patterns. Every character is made up of a multiplicity of habits, and influences can be directed to bring into prominence now one set and now another. A most instructive example of this is presented in the case of Harry Santos (Demonstration 12). The recovery of hope and courage and the ability to carry on, in a cardiac not less demoralized during a period of five years than the man with coronary thrombosis above referred to, is here described. And this

184

A D V E R S E SOCIAL FACTORS

was accomplished not by any miracle of conversion or of healing but by influencing him to undertake the arduous task of bringing into play a set of habits which had been employed throughout a life of usefulness, but which had become submerged when he realized that he was permanently disabled for a man's work in the world. Unfortunately, we do not have as full and reliable information about all of the patients as we have about this man. But since a majority of those whose life histories were reviewed for this inquiry were compelled to attempt adjustment to permanent disability, it may prove of some value to give our impressions regarding the help or hindrance to such adjustment which previous habit formation seemed to bring. For more than half of those who had to alter in some way their accustomed management of their affairs, it may be said that they accomplished this task, and in a manner that to an onlooker appeared quiet and dignified. For the others the task of reorganizing life meant inner struggle and suffering, and only partial success. Fourteen of these continued always so disturbed that it was evident they failed to achieve adjustment. Those patients who succeeded in making a fairly satisfying rearrangement of life suitable for their diminished capacities exhibited, quite generally, one characteristic— that of sharing and enjoying the experiences of other persons. When cut off by ill-health from many activities which previously had filled their days, they still retained this interest in persons and affairs outside their immediate personal concern. Narrow range of interests. Those who failed to achieve a good adjustment of their lives were reported to have had as a rule a much smaller range of interests, and these interests more narrowly personal. This does not mean that these ill-adjusting patients had been in every instance concerned

AFFECTING

SUBSISTENCE

185

only for their own advantage and that they were less capable of benevolence, generosity, and self-sacrifice. Indeed, the contrary was true of at least 2 of them. See Allie Bach (Demonstration 15) and Harry Santos (Demonstration 12). A major interest throughout Allie Bach's life had been the earning of money with which to aid her own relatives. When ill-health made it impossible for her to carry on this activity, she became as one without an object in life. Self-centeredness, dependency, conformity. It was found, however, that most of those who could not accommodate to the vicissitudes of ill-health had been concerned chiefly with what affected themselves. Even their sharing of the lives of others or their participation in joint endeavor generally had been for the purpose of acquiring some personal advantage. Three patients were said to have been spoiled children, petted and pampered and made to feel that they were more attractive and more important than other children (see Pasquale Di Lorenzo, Demonstration 8). Five others, somewhat less childish in their vanity, felt entitled to more than ordinary personal deference because they believed themselves better born or better reared than their associates. These fictitious evaluations of themselves had the double disadvantage of isolating them from the enjoyment of real companionship with others and of preventing them from cultivating their own inner selves. In spite of their conviction that they were in some undefined way superior to others, they were singularly dependent on others. The periods of solitude, which could not always be avoided after illness had disabled them, were especially hard for them to endure. All had been to a great extent dependent for incentive to action on following or rebelling against purposes defined for them by other persons, or else on purposes customarily sought by the social group in which they had been brought up. Few even of the well-adjusted patients in the group had had the ability to choose independently their

186

A D V E R S E SOCIAL FACTORS

purpose and goals in life. They had, however, accepted purpose or goals with some appreciation of their value, made them their own, and directed their energies toward their achievement. Most of the ill-adjusted appeared to us to have the habit of following decisions ready-made for them or else of going contrary to such decisions. Neither course of action was determined so much by inner need for the action itself as by need either to conform or to flout conformity. For example, they married because they thought it the thing to do. Someone selected the marriage partner for Tony Reali (Abstract 17); Dora Levine (Demonstration 16) accepted her husband because she thought he had money. Both she and Gladys Reynolds (Abstract 100) felt that marriage was expected of them and tried to interest themselves in domesticity which they did not enjoy, and gave up business employments which they had enjoyed and in which they had found opportunity to exercise pent-up abilities. Even Allie Bach's money contributions to faraway relatives, given at so great personal sacrifice, seem to have been inspired by romantic loyalty rather than by deep personal interest or attachment. The children of these relatives she had never known. Again, we feel that Louis Crawford (Abstract 97) allowed his wife's relatives to live in his home and to add to its confusion and unattractiveness not because he wished to help them or please his wife or because he had means adequate to provide for them and his own family but because he felt the code of chief breadwinner required one to exercise such magnanimity. We consider that 14 of the hundred patients were ill prepared for the ordeal of enduring permanent disability, by reason of such habitual modes of behavior as confining interests to a few subjects, and those mostly of personal concern; lack of purpose and self-direction in living; undue conformity to group standards or capricious resistance to such standards.

VI D E S C R I P T I O N OF A D V E R S E FACTORS

ASSOCIATED

WITH

SOCIAL INDIVIDUAL

P R O B L E M S O F I L L - H E A L T H (Continued) A D V E R S E SOCIAL FACTORS A F F E C T I N G

SATISFACTION

In the preceding section we outlined the essentials for the maintenance of life, and demonstrated how failures to obtain these seemed to affect the health of certain individuals. In this section we shall discuss the conditions usually found necessary to keep the individual in a state of emotional equilibrium. The former task was somewhat facilitated by the fact that we have scientific data as to the general body-requirements of human beings, and that accumulated and tested experience has contributed evidence as to the harmfulness of certain living conditions. We lack scientific data as to the minimum satisfaction-requirements of the individual, and as to the harmfulness of shortages or unbalance in the supply. In order to avoid undue tension and to attain the power of regaining emotional equilibrium following frustration or deprivation, the individual must possess some inner harmony and some sense of integration with the world without. We are fairly sure that this state cannot be reached nor maintained unless his deeper needs and wishes are to some extent satisfied. We are also fairly sure that such wishes are concerned with his affectional relationships with others, with opportunities to seek and enjoy new interests, with the attainment of enough success to win him the respect of

188

A D V E R S E SOCIAL

FACTORS

others, and with a reasonable degree of security.* Even if some of these be lacking, the individual may preserve his emotional balance if he can find compensation in the sources of satisfaction remaining, or strength and courage from religion. But if the individual is unable to find compensation for his ungratified wishes they are likely to result in active dissatisfactions. W e suggest that the undue emotional tensions caused by dissatisfactions produce an effect on the body similar to that produced by fatigue, one important difference being that fatigue, when caused by physical activity at any rate, is likely, when the stimulus is withdrawn, to induce a state of rest in which regeneration occurs, whereas emotional tension may be prolonged by recollection, even after the stimulus is withdrawn, and m a y thus become self-renewing. W e find, among these sick and disabled, 39 who manifested in degree above that common to all such feelings as loneliness, resentment, tedium, restlessness, anxiety, depression, and 61 who in general maintained equanimity. At this point we discuss the bearing on health of the various dissatisfactions experienced, according to the same method used to discuss the bearing on health of the subsistence failures experienced. DISSATISFACTIONS GROUP

CONNECTED

WITH

FAMILY

OR

OTHER

RELATIONSHIPS

Lack of family group.—The presence or absence of a suitable home environment as sanctuary for the sick person is generally recognized to be a matter of importance in medical care. For most of these one hundred patients, especially for those who remained disabled, this was important either because the influence of family life was beneficent and hence an aid in care, or because absence of any home life was a * See W. I. Thomas, The graph No. 4 (1925).

Unadjusted

Girl,

Criminal Science

Mono-

AFFECTING

SATISFACTION

189

source of anxiety or grief, or because relationships in the home were irritating or depressing. Under "Adverse Social Factors Affecting Subsistence" we have dealt with the lack of physical protection which the sick person living alone or with unsympathetic associates suffers through lack of service. We consider here the fear and depression suffered because the patient lacks the consolation which a congenial group affords. Eight patients who lived apart from relatives or intimate associates were ill cared for because they had no one to minister to their needs. Five of these, in spite of increasing discomfort and loss of power, were so occupied with some personal concern that to a remarkable degree sickness and loneliness were ignored, and we doubt if they suffered any harm except that which came from lack of service. But 3 of these persons who had no sustaining group with which to live were unhappy and frightened because of their isolation and loneliness. Discouragement overwhelmed them, so that they could make little use of their powers. They were given much costly hospital care and during the time they were actually in the hospital and subject to its protection and care they were somewhat relieved and comforted. When the time to leave came, the old discouragement and fear took possession of them and soon undid the benefit that had accrued from the hospital stay. Absence of family or friend with whom to take refuge hindered, we believe, efforts to relieve suffering and lessen disability, and the depression caused by loneliness was, in itself, a disabling influence. Allie Bach (Demonstration 15), a generous, warm-hearted person, in addition to suffering physical discomfort and lacking service and suitable habitation and maintenance, was also deprived of affection and companionship. In our demonstration we have shown the multiple difficulties that beset her, of which fear of dependency on strangers was one of the most disturbing. But another important difficulty was her

190

A D V E R S E SOCIAL

FACTORS

isolation from sympathetic and congenial associates. Beneath her quiet, friendly manner, her distress was always perceptible, even when she was utilizing to the full available outlets—her church, the public libraries, and the occasional friendly association in the charitable institutions where she boarded. These outlets were for this woman artificial and did not relieve her loneliness and her feeling of insecurity. No one she met needed her, no one really cared whether she came or went. She was given the best that our community affords for a person alone, destitute, and incapacitated, but for all the effort and expense a situation adequate for her was never provided, because the opportunity for satisfying social relationships was absent. Several patients in this series we are considering have been able, with organic disability similar to this patient's, to achieve a fair degree of serenity and contentment. These all lived as members of loyal protecting family groups; the support of these groups and the sharing of interests and endeavors within them did much, we feel sure, to enable these patients to avoid dissatisfaction and the disability which seems often to be associated. Another of the 3 patients who were disturbed by loneliness was Florence Baker (Abstract 62). We at first supposed that the reassurance given her in the hospital and the instruction as to how to lead a more hygienic life would suffice to restore her to fair health. Letters from her in succeeding months, however, indicated that she was not improving but was growing worse. By the end of a year she was bedridden. Another long period of treatment in the hospital failed to lessen her discouragement or restore function. Organic defects were believed not sufficient to account for her helpless condition. A remark made by her may perhaps have been the key to her problem. "If my sister had lived, things would not be so bad with me." Reviewing her past for explanation, we find that she had been unable to wean herself from the

AFFECTING

SATISFACTION

191

parental home at the proper age; even while remaining within the protection of this home she had failed to achieve an independent career for herself in business or public service, and had accepted the old tradition of middle-class America that unmarried daughters remain in the parental home and consecrate their lives to the service of aging parents. After the death of parents and sister, the realization came that now when she was approaching old age she was alone and unprotected, and with this realization came a great fear. This woman still has from her patrimony income sufficient to maintain herself. She has never attempted to cultivate friendships outside her own family and now cannot really accept the idea that any benefit could come to her from sharing the life of others. It seemed, however, from her enjoyment of talking to the social worker and from her long letters to her that she craved companionship and that her almost total lack of intimate sociable life caused dissatisfaction which added to the slight disability from general cardiac and arterial deterioration. Incompatibility

and friction with associates.—Discord

be-

tween patients and their associates appeared sufficiently disturbing in 18 instances to warrant consideration of it as a factor in the medical problem, for the discord not only made manifest existing inner tension of kind and degree probably unfavorable to health but usually reacted upon the patient to intensify such tension. In the case of only one of these 18 patients did the friction with others seem to distract attention from symptoms and thus perhaps have value as a counterirritant. This patient was Marianne Hart (Abstract 36), whose incompatibility with her mother had existed from early childhood after the mother had abandoned her to the care of relatives. Evidence of her resentment and of her futile efforts to force her mother's affection were found throughout her history. The relationship had, furthermore, led to friction with other persons in the group, especially

192

A D V E R S E SOCIAL

FACTORS

her mother's lover, and the patient's own devoted husband, whom she finally deserted. She had lived in constant emotional turmoil. Her disregard of medical advice and apparent indifference to self-protection were, we believed, caused largely by the conflicting feelings about her mother. Whether the course of her nephritis would have been different in any important way even had she been careful, is doubtful. Likewise it is doubtful whether the attitude toward such a primary need as mother love could have been in any important way altered, and attempts to do so might have proved irritating rather than helpful. In any case, the existence of tension and friction was not recognized until the present investigation was made, at a time when the patient had already reached the last stage of disease. Therefore, no attempt was made to alter the relationship other than to inform the mother and the husband of the fatal nature of the patient's sickness. Had they been informed earlier, they would probably have been more tolerant of her capriciousness and therefore better able to protect her. She was, we felt, comforted by their attentions to her in the hospital in the three months before her death. Freedom from oversolicitude about symptoms and personal safety in general, which this woman had by virtue of absorbing herself in concerns of greater moment to her, can be of great value. Hers was, however, not a real freedom but rather one bondage overshadowing another. One cannot refrain from speculating on the potentialities within this patient and within her situation which, carefully developed, might have alleviated her suffering. Had the problem causing the friction been recognized earlier, the patient might have been helped to realize that failure of a parent to develop love for the offspring is not infrequent, that the parent also suffers and deserves pity more than blame, and that she herself might have had the same experience had her baby lived. Had she also been helped to realize that many others

AFFECTING SATISFACTION

193

have suffered the same deprivation of love in childhood, she might have come to have a less narrowly personal view of the relationship between herself and her mother. Could she thus have reached a more mature and tolerant view of her mother, the mother might have become less afraid of her and better able to deal with her as an equal. Total separation might have been the best arrangement for them both. Whatever the mother's response, we believe the patient would have experienced great relief could she have learned even imperfectly to look upon her whole experience, herself and all concerned therein, as though it had been the experience of another. Being thus relieved of an overpowering passion, she might have been able to employ her great vitality for less destructive and more satisfying ends during whatever span of life remained for her. If, however, with increase in reasonableness, there had come timidity and overconcern about health, the reasonableness would have been won at a price perhaps too dear. For no other of the 18 patients did discord with associates appear to have value in diverting attention from ill-health. It had rather the contrary effect of intensifying concern about themselves. Evidences of discord in their relationships with others were derived from the testimony of the patients themselves, from that of their associates, and from our own observations of the behavior of these persons. For example, the wife of one patient, Alexander Petrakis (Abstract 10), quarreled with him shortly after he entered the hospital ward and when he was still very ill from a bleeding gastric ulcer. Her manner toward him was scornful and his response was angry. In the hearing of others she charged him with infidelity. When an attempt was made to instruct her as to the right selection and preparation of food for him, she declared openly that she would not prepare the diet. The wife of another patient, Donald Beck (Abstract 23), who had been operated on for duodenal ulcer, was equally

194

A D V E R S E SOCIAL FACTORS

downright in refusing to prepare the diet prescribed. H e r refusal, which was probably based on resentment at his previous desertion and at his return when ill and incapacitated, his expressed dread of returning to an unfriendly home where he claimed that quarreling was habitual, and the unkept condition of this home, together with the fact that this wife was away from the home during the day to earn the livelihood for herself and the patient, led us to procure for him prolonged care in a chronic hospital. Five other patients had been separated for long periods from husband or wife, whom they felt to be hostile or antipathetic. All but one of these married patients who separated corresponded in some way with the partner in marriage during their separation and in time came together again. In addition to the separation of married couples, there was one other instance of separation caused by friction. One son had left his mother, whose domination he resented, at the age of fourteen. His petulant responses to her when she was with him in the hospital and his expressed feeling that "she had never loved him as other mothers loved their sons" suggested that the unhappy relationship between them had long been a disturbing influence in his life and had perhaps played some indirect part in bringing on the functional disorders for which he sought treatment. W e were not able to learn just what the separation had meant to any of these patients. Perhaps the period of respite from quarreling had been beneficial. Little resolution of difficulties had been effected, however, and it seemed more likely that the whole experience of tension and irritation endured by them had been to their disadvantage. (See Catharine Monahan, Case Record, Appendix, pp. 346ff., where recovery from rheumatic disease seemed to be retarded by hardships experienced largely as a result of incompatibility and friction with husband.) Only one patient broke off entirely her relationship with

AFFECTING

SATISFACTION

195

her husband. This woman, Gladys Reynolds (Abstract 100), by her extravagant demands and outbursts of rage, also brought about estrangement between herself and her son, his wife, and her brothers. Five other patients were said to be similarly overpowered from time to time by rage. Only 2 were ever known to go to the length of using physical force in attacking others. Usually expression was limited to speech and gesture. One who sought to inflict bodily injury was the woman, Dora Levine, described in Demonstration 16. Anger against her husband was expressed not only by words and looks but by striking and scratching. T h e other was the asthmatic, Tony Reali (Abstract 17). His wife declared that he had threatened her with a knife on several occasions. He did actually attack and injure a person of whom he was jealous, a young man who boarded with his family. Police were called in by neighbors to end this fight. Shortly afterward the wife separated from him, saying that she feared for the safety of their children as well as for herself. The patient submitted to observation in a psychiatric ward. Grounds sufficient for putting him under restraint were not found, but much was then learned of the discord that had long existed between this patient and his wife. Since the open break between them occurred, no change has been noted in the health of either. Both husband and wife had been for several years patients of this hospital, both being quite seriously impaired in health. During these years the hospital had not had knowledge of the conflict within the family, which had been hidden from even fairly close associates until there occurred the outburst of passion and the separation related. Even without assuming that any direct relationship existed between asthmatic symptoms and the emotional tension experienced by the husband (the patient we are considering), such tension may be regarded as in itself a factor which might have caused some part of the patient's disability.

196

A D V E R S E SOCIAL

FACTORS

The effort made by certain patients to rectify distasteful conditions for which associates were responsible was taken to indicate the nature and extent of disharmony that existed between them. Thus, repugnance for what she regarded as dishonorable business dealings on her husband's part led Catharine Monahan (see Case Record, p. 346) on two occasions in the early years of her marriage to separate from him and earn maintenance for herself and her child; and later, after the second child was born, to take part-time work in order to have money to meet obligations. She persisted in this course even when ill and when she had been warned by her physician that she was injuring her health permanently. Mary Boehack (Abstract 47), because of the discord between herself and her son's wife, took the radical step of negotiating another mortgage on her house and repaying her son $3,000, all he had contributed toward a joint plan for purchasing the house. Full details of the relationship between these women we did not learn, but it appeared to have been sufficiently unpleasant to have caused the son and his wife to move away from the jointly owned home. Our patient's insistence on refunding the son's share even though he protested against it indicated, we thought, considerable resentment and offended pride on her part. The increased worry over financial problems which this whole transaction entailed gave additional significance to the irritating relationships. For discussion of another factor in Mary Boehack's situation, see "Undue Effort to Secure Subsistence." In addition to such overt behavior as that displayed in quarreling, physical violence, separation, and effort to rectify distasteful conditions, from which we have inferred the existence of disharmony sufficient to create injurious emotional tension, we had also the spoken expression against associates. Some patients expressed to us their dislike of

AFFECTING

SATISFACTION

197

certain associates or found fault with them, as Florence Baker (Abstract 62) with her sister-in-law and others, Anna Merman (Abstract 59) with her sons' wives and their children. Some complained of being humiliated by the treatment of intimates, as Irene Barclay (Abstract 31) by the concern of mother and sister to protect her, which she interpreted, and we think correctly, as belittling her intelligence and reliability; as George Weil (Abstract 99) by the continuous interference of his wife's relatives; as Catharine Monahan (Case Record) and Nellie Rand (Abstract 78) by the infidelities of their husbands. Some of the discord noted in the relationship of all these patients with their associates came not from incompatibility as such, but from their resentment of discomfort and of restrictions which disability imposed upon them. For 2 these were the major sources of friction. Thus the friction between Isaac Klein (Demonstration 11) and his wife which finally made their life together well-nigh unbearable for both had not existed or in any case had not been manifest until after the patient had become ill and housebound. So too the irritation which Emma Kovacs (Demonstration 9) displayed toward her mother was not, we believe, caused by any fundamental incompatibility between them but was rather the child's blind reproach of the mother for all she had been deprived of and especially for the separation from her mother which long hospital and convalescent care had entailed. But even friction provoked largely because the patient must vent his discontent on some one appeared significant for these patients because of a circular effect: once it had been produced, it reacted to increase the discontent which was its source; and discontent thus made cumulative acted to increase the disability already caused by disease. Friction of this common type was, however, for all but these 2 of the 18 patients, added to previously existing friction provoked by differences in standards and tastes and

198

A D V E R S E SOCIAL FACTORS

by other forms of dissatisfaction. The conditions arousing such dissatisfaction are listed in the following somewhat loose and overlapping classifications, as these seem to describe more adequately the conglomerates of fact and sentiment found than do more logically differentiated expressions: (a) Difference in cultural background (nationality, education, religion) resulting in different esthetic and ethical views (b) Difference in general patterns of behavior (personal habits, philosophy of life, general attitudes toward mutual concerns) (c) Resentment of economic status (d) Lack of response from others (affection, sex response, appreciation) (e) Ungratified desire for personal power and recognition ( f ) Restriction of personal freedom

2 9 6 9 12 8

The incompatibility and friction which these 18 patients experienced were in the following relationships: (a) With husband or wife (b) With parent or child. ., (c) With relatives by birth or marriage

10 7 8

For most of these patients disharmony in relationships with associates had existed before sickness occurred. For a few the disharmony appeared only after ill-health had made the patient more vulnerable to every kind of irritation, and in the case of the child Emma Kovacs it was probably entirely a result of the general irritability caused by her prolonged incapacity. But however the disharmony originated, our opinion is that the emotional tension it reflected was an influence in itself disabling, one which in some instances probably aggravated the impairment caused by disease. Lack of satisfying social status.—We discuss under this heading the effects of dissatisfaction from failure to secure or to maintain recognition and prestige. In most instances these effects came with a downward shift in career or vocation, but in a few they came from failure to satisfy ambitions or to maintain standards, or from elevation to a position which the person in question was inadequate to fill.

AFFECTING

SATISFACTION

199

For a number of patients their dissatisfaction (humiliation, resentment, dread) from loss or threatened loss of prestige seemed itself to be a cause of disability which was not easily distinguished from that caused by disease. See Demonstration 12, Harry Santos, where the patient's feeling about his loss of position in the community seemed to increase his disability. Occupational retrogression. Four patients were forced to change to a less highly regarded type of work. Whether or not the new occupation held interest for them, to these patients the loss of the old occupation meant loss of caste, and the resulting depression was accounted an unfavorable factor. For example, William Mahoney (Abstract 64), after prohibition was enforced, was compelled to give up the ownership of a saloon and the associated political ward power. He had then secured the position of railroad detective. After a few years he had to leave this interesting position because the excitement and exertion entailed too great strain. He then became night watchman on a railroad pier. His resentment of this degradation was strong and probably not favorable for the best functioning of a heart already much damaged in early life by rheumatic disease. Further illustration of occupational retrogression with resulting depression is given in the case of Allie Bach (Demontration 15), a skilled lady's maid, who became a general domestic; in that of Harry Santos (Demonstration 12), who changed from an established position as a skilled printer in a government office to various forms of semiskilled and less secure work; and in that of Norris Cabell (Abstract 8), who had been supervising engineer of a chain of vaudeville theaters, but because of failing health at the age of fifty-eight had been compelled to give up this work and find casual employment as window washer. Business failure. For 6 patients failure in business,

200

A D V E R S E SOCIAL FACTORS

associated with anxiety and strain, preceded the onset of incapacitating illness. These enterprises had been launched and developed as private enterprises. Success had meant for these persons prestige in the community, and failure in business had produced in them feelings of personal inadequacy and a belief that they had lost the esteem of the community. We suggest that the shock and discouragement of failure may have played some part in the development of their disability. We are sure that social and economic status was a matter of deep concern to them and also that business failure meant to them loss of prestige. For example, the patient George Weil (Abstract 99) had from an early age worked hard and assumed responsibility for others. After achieving a respected position in the garment trade he finally established a small tailoring business of his own, the success of which had been a source of pride. An important constituent of his business success was the fact that largely through it he had won the regard of his wife's family. After the business failed the disapproval of the wife's family appeared as an important source of irritation and distress. Incapacitating illness developed within a few months after the business failure. The great arterial degeneration found, when he was seen a year later in our hospital, indicated that disease had been present for many years before the discouragement of failure was met. But it appeared also to be probable that the shock and strain of failure had precipitated his illness, which might otherwise have come more gradually, and that the financial and domestic situation which resulted was unfavorable to arresting the progress of his disability. Financial losses. Lowered earnings and loss of financial reserves with some attendant degradation of style of living was found in 6 instances. In 3 instances incomes dropped from between $5,000 and $10,000 a year to bare subsistence, and finally charitable assistance became neces-

AFFECTING

SATISFACTION

201

sary. In 3 others, investment losses or shrinkage of income from investments reduced the style of living and even rendered the tenure of position insecure. Benjamin Marks (Abstract 27), an insurance agent, who had thought his future to be secure because of the thrift he had practiced during twenty-five years of steady employment, had, six months before his illness developed, lost his invested savings in the stock-market crash. During this time his income from insurance writing also diminished. When his asthma developed he gave up work entirely and was supported by his wife's brother. The physical defects found did not seem sufficient to account for his condition. His symptoms were believed largely caused by the demoralization occasioned by the above-noted experiences, which lowered his prestige and threatened his career. Because of his attitude toward social status, it proved impossible to provide much-needed medical and nursing care for the old gentleman, Thomas Watson (Abstract 96). Two years before he sought medical treatment a large business venture which he was promoting failed. He had lost a fortune, reported to us by an associate to have been $3,000,000. The culture and learning of this man impressed all who came in contact with him. He remained incognito up to his death a year and five months later, refusing to appeal for help to wealthy kinspeople or friends. Differences in cultural standards. For 6 patients a shift in social status came about through enforced association with other individuals or with groups whose cultural standards differed sufficiently to provoke disturbing reactions. These reactions are considered specifically in regard to the same patients under "Incompatibilities and Frictions with Associates." We here emphasize not the friction and discontent but the shift in social position or status. For example, Marian Rocher (Abstract 82) had grown up and been educated in convents in France and Germany, and

202

A D V E R S E SOCIAL FACTORS

had become a proficient musician and linguist, speaking five languages. During her girlhood and early maturity she had associated with people of similar artistic interests and abilities. She had married into a Cuban Spanish family of some wealth, proud of its lineage. As a result of lack of capacity and of ill-health, the husband had barely earned subsistence for his family as an elevator man. Most of our patient's married life had been consumed in drudgery, and in the discomfort of her tenement home she had brooded over the fact that she no longer had time, energy, or money to pursue interests and maintain associations which she had previously enjoyed. In the five years the hospital has attempted to care for Gladys Reynolds (Abstract 100) no adequate control of her environment has ever been possible because she has never been able to reconcile herself to her loss of social position, and has always felt entitled to the style of living enjoyed by her affluent relatives. Her own unconventional way of living and lack of consideration of others have alienated husband, son, and relatives. Her dingy furnished room and meager factory wage have provoked an abiding resentment. Periods of cardiac decompensation have followed quarrels brought about by attempts to force these relatives to maintain her in the style she demanded. For all but 2 patients of the group who presented a problem of maladjustment because of their position in community life, the maladjustment had come about through a downward shift in status. For these 2 patients, difficulties occurred because of the attempt of associates to elevate them to a status in the community which was above that of their families, which was uncongenial to them, and for which they lacked capacity. Joseph Donato (Abstract 28), complying with the wishes of an Italian peasant father, struggled through college. The mental disturbances reported by the patient to have been

AFFECTING

SATISFACTION

203

associated with this experience are judged to have been the first symptoms of ill-health. In the ensuing year alone in New York City, when he was attempting to make a place for himself in the financial world, he developed not only hyperthyroidism and gastric ulcer, for which he was treated in this hospital, but also symptoms of incipient mental disease. Louis Crawford (Abstract 97), a New York slum child of alcoholic father and insane mother, both Italian immigrants, who had been found delinquent at the age of twelve and committed by the court to the supervision of a childcaring agency, was placed as foster child in a pious, upright and conventional American farmer's home. He had endeavored to conform to the standards of his foster parents and in adult life to create a career for himself which would assure him of their approval. Outwardly he achieved the desired status in the community. When at the age of thirtysix he asked medical care for a condition which he claimed incapacitated him, no signs of organic disease sufficient to explain incapacity could be found. His boastfulness about his business success and his protestations regarding his enjoyment of his work made us suspect that he was seeking an excuse for some failure. It then came to light that his business was seriously endangered and that he feared not only financial insolvency but loss of the social position which he had earnestly labored to establish. DISSATISFACTIONS CONNECTED W I T H RESTRICTED OUTLETS.

—We concluded that in a number of instances success or failure in carrying out appropriate and satisfying activities affected the degree of disability experienced and of adjustment reached. The problem was noted in 47 cases, and in 5 others where information was insufficient it was suspected. For only 17 of these persons was the blocking of outlets due solely to illness; for 30 others it had occurred previous to

204

A D V E R S E SOCIAL FACTORS

illness either from failure to find outlets commensurate with desires and ambitions, or from the disruption of an accustomed way of life through bereavement, loss of home, business reverses, or incompatibilities with associates. Illness came as an additional ordeal to render more difficult the attaining of a satisfying role in life. Some did find ways of compensating for the restrictions to which they were subjected; for some these restrictions were but minor handicaps. We are sure, however, that for 34 the loss of usual outlets or the failure to find outlets both suitable and satisfying was a depressing or irritating experience, which was unfavorable to best functioning. Whether the blocking of outlets was occasioned by illhealth or by social and economic derangements, the resulting discouragement or resentment appeared to increase the patient's disability. Discouragement seemed to reduce the capacity for utilizing the ability that was available. Tedium increased and therewith a feeling of defeat, until in some instances a state of total invalidism was reached. This we have demonstrated in the case of Harry Santos (Demonstration 12). The opening of outlets for this man and his gradual resumption of activity showed that his organic capacity was greater than had been supposed and that discouragement and tedium, as well as disease, had interfered with his functioning. Waste of energy through resentment was demonstrated in the cases of Pasquale Di Lorenzo (Demonstration 8) and Isaac Klein (Demonstration 11). With failure of his business the latter lost the chief outlet for his interests and abilities. He made no attempt to substitute other means for gleaning even momentary satisfaction, but nursed his grievances in almost complete physical inactivity. His deep and abiding discontent was expressed in constant fretfulness and frequent outbursts of irascibility. Pasquale Di Lorenzo expressed his resentment in rebelliousness and unsatisfying overactivity. The energy expended in allaying the tedium

AFFECTING SATISFACTION

205

of idleness was in his case probably greater and more destructive than that required for many jobs. We believe that, had the problem been understood sooner, both these persons might have been helped to direct the energies which they wasted toward the satisfaction of some real interest and thus to reduce the dissatisfaction which we claim constituted part of their disability. The loss of or inability to use outlets for desired activity and the resulting tedium led, in the 3 cases just cited and in a number of others, to dwelling on symptoms, thereby intensifying them. The fear thus aroused increased further their disability. An extreme manifestation of this condition was shown by Tony Reali (Abstract 17). For him and for Harry Santos (Demonstration 12) the withdrawal of attention from symptoms was partially achieved by supplying outlets; that is, setting them tasks suited to their ability and gradually engaging their interest by persuasion and encouragement until performance became a routine which they could to some extent maintain without outside help. Observation of the disabled among the one hundred patients studied tends to confirm medical opinion that capacity for finding and utilizing suitable outlets is by no means solely determined by the extent to which disease has damaged the organism. Many reported as having suitable and satisfying occupation had sustained great damage, often mortal, from disease; while others whose bodies had been far less injured by disease, perhaps not at all injured, proved unable to conceive or carry out any constructive action. In a true sense these latter persons were more disabled than the former, even though death may have been longer postponed. In many instances this invalidism or hypochondria appeared caused in part by lack of opportunity for constructive action, as well as in part by habits of worry and self-centeredness, acquired in ignorance of their baneful effect. The surprising improvement experienced by some of these patients, even

206

ADVERSE SOCIAL FACTORS

those seriously damaged by disease, when satisfying outlets were made available substantiates the opinion here set forth that dissatisfaction over restricted outlets is a factor of sufficient importance in many illnesses to warrant study of it and more experiment with measures to relieve it. The outlets blocked for the patients we are here considering were ( 1 ) work, industrial and domestic, ( 2 ) recreation, and ( 3 ) sociable life. Lack of satisfying work.—The conception of work as a means for achieving satisfaction encompasses not only the satisfaction of earning a livelihood and winning recognition for achievement, but also the satisfaction of mastering difficulties, of displaying skill, of sustained performance, of participation with others in the rhythm and design of an enterprise and thus expanding and enriching one's experience. Among the hundred persons followed for this study there were only 3 young and 4 aged unemployed dependents. The others were adults, most of them in middle life, most of them persons who had been self-maintaining and occupied in ways they had been satisfied to follow until interrupted by illness or some other catastrophe. After illness 28 were left permanently disabled for their usual occupations; 22 others were invalids for eight months or longer (11 remaining partially disabled for life). The interruption of gainful employment for these persons at once created disturbing problems of subsistence for them and their dependents. T h e anxiety suffered because of this problem and the concern to resolve it we have considered under "Adverse Social Factors Affecting Subsistence." T h e aspect of the problem featured in this chapter is not the fact of having no occupation but the meaning of the experience: the uneasy feeling of having nothing to do; of being a prisoner within oneself shut off from opportunities to share the activities of others; of resentment at the interruption or miscarriage of the career

AFFECTING

SATISFACTION

207

which ambition craved. Failure in career occurred in IS instances, and this was the cause of much distress. In addition, there was tedium which the loss of the habitual routine of work and the companionship of fellow workers occasioned. We have stated this important outlet was restricted or blocked for about half of the patients. For 16 this blocking was a major cause of dissatisfaction, for 11 more it was an important secondary cause. The disabling effect of dissatisfaction from this cause we have tried to demonstrate in several of the cases.* For many of these patients it became their main concern to find work they could do. But it is the exceptional person who can devise occupation for himself even in sound health and in favorable circumstances; when handicapped by disease and limited to few opportunities, sustained accomplishment is rare. Only 5 of our patients had the interest or the ingenuity or the previous experience to accomplish this successfully. Most had been accustomed to enter into and to contribute a share to some already organized pattern of cooperative activity. Four patients who, in spite of the gravest handicaps, held on tenaciously to their work found the regulated, time-filling employment a boon. It appeared to us that they thus avoided or mitigated the usual tedium and discontent of the invalid state. About half of the 27 patients who were anxiously concerned to find for themselves occupations that would satisfy some interest or at least fill some vacant hours did find work to do, suited to their handicap. In all cases the work was less attractive and less remunerative than that they had previously done. Nevertheless, it relieved tedium and in several instances diverted attention from bodily discomfort and reduced the fears that watching symptoms had aroused. Of the 14 who did not find work, only 4 reconciled themselves to their fate. The 10 others remained always discontented. They too were seri* See Allie Bach (Demonstration I S ) , Isaac Klein (Demonstration Emma Kovacs (Demonstration 9 ) , and Harry Santos (Demonstration

11), 12).

208

ADVERSE SOCIAL FACTORS

ously and permanently damaged by disease, but had opportunity for protected and regulated work been available to them, we feel sure that most of them would have suffered less physical discomfort and less disabling from tedium, anxiety, discouragement, or resentment. The important part that an understanding and resourceful family can play in lessening a patient's disability by planning occupation for him is illustrated in the case of Jacob Ludwig (Abstract 52). This patient had an incurable disease which incapacitated him for his usual work, traveling salesman, and, it was believed, for any gainful employment. Indeed, it was anticipated that he would grow worse rapidly and would soon die. The patient's family pooled their resources with those of relatives, shared the upkeep of the same house, and opened there a small dress shop. The patient found his previous selling experience useful. On days when he was not able to work, others in the family carried on the business. But when the patient was able to exert himself there was something to engage his interest and to reward his efforts. Lack of satisfying recreation.—The blocking of outlets for habitual ways of finding diversion and pleasure did not in any sense seem of importance commensurate with the blocking or lack of outlets for work or a desired career. This was probably due in part to the maturity of the group and in part to the city environment, which offered many means of diversion. In a city it is possible to have entertainment without expending much energy. One tends to rely on being entertained by the theater, the movies, sports, and the pageant of life about one. But for a few patients a measure of their discontent came, we believe, from the loss of recreation to which they had been accustomed. Learning to compensate for these and other deprivations constituted part of the difficulty of adjusting to disability and we therefore mention them here.

AFFECTING SATISFACTION

209

Physical incapacity for play. Only 9 patients manifested regret over being cut off from recreations requiring physical activity, such as athletic games or travel, which had previously filled an important place in their lives. These varied recreations were: basketball, aviation, gardening, violin playing, stage entertaining, traveling, and reading. The loss of these pleasures, each in itself not a great deprivation for the persons in question, became part of a total deprivation for them that meant discontent or tedium and, we believe, added the further disability of dissatisfaction to the physical disability of disease. For 4 of the 9 the loss seemed important. These persons were also cut off from the outlet of customary work, and realized that they would never again be able to follow the career they had previously enjoyed. Lack of spending money. This term is used to mean the margin of income over and above that required for necessities. Lack of spending money for 18 persons meant loss of usual ways of entertaining themselves and others. The outlets of which they were deprived were the adventure of travel, the collection of art objects, materials for mechanical inventions and hobbies, adornment of person (clothing, cosmetics, jewelry), general diversions such as theaters and concerts, entertainment of others in the home, or gifts to others. Again, the dissatisfaction caused by the loss of these outlets constituted but part of a larger discontent. For no single person was it ever a problem of major importance, but when occurring in combination with interruption of work, bereavement, and incompatibility it intensified the difficulty of adjusting to ill-health. It appeared to be of some importance in 9 instances. Lack of satisfying sociable life.—This term as used here expresses enjoyment of the fellowship of others and participation in endeavors which promote the solidarity and enjoyment of a group. The relationship may be in a family or kin

210

A D V E R S E SOCIAL

FACTORS

group, or in one drawn together by mutual interest in some enterprise; e.g., church society, fraternal order. The sociable life of most of the one hundred patients was reported to be satisfactory to them. The majority were members of family groups, nearly always fairly congenial, and even in some instances where incompatibilities were noted there were common interests and pleasures within the group. We have less information about associations outside the family or near kin group, yet we do have in many cases report of such association in clubs, church, and civic organizations, and circles of friends, and in the main these provided pleasurable outlets for sociability. For 10 patients the blocking of such outlets for extrafamily association meant loss of a source of enjoyment. The loss occurred in 3 instances after sickness had made conservation of energy necessary. William Mahoney (Abstract 64) and Rita Larson (Demonstration 13) undertook no activities outside of their jobs. The former had for many years taken a hand in ward politics and cultivated a large acquaintance; the latter had, also for many years, been a constant attendant at the services and social gatherings of her church. Jerome Edwards (Demonstration 14) had also been an active member of church and social clubs and civic organizations in his community. Ill-health led him to renounce all of these activities except some clerical work for his church. He undertook this in order to fend off the depression which came with the abandoning of an active business career and he also thereby kept in touch with a group of friends. Donald Beck (Abstract 23) ceased to attend the meetings of his fraternal order because he had not the money to pay dues. Such an outlet might have mitigated appreciably his physical suffering and bitterness of spirit. In demonstrating the case of Theresa Fleming (Demonstration 6), we have indicated the beneficent influence of her association with a religious group and with congenial rela-

AFFECTING

SATISFACTION

211

tives and friends. The main cause of her ill-health was found in her relationship to a psychotic husband, but to the anxieties and disgust connected with that experience was added the loneliness and tedium of life among strangers in city lodgings. In the neighborly contacts of a small village, the congenial companionship of relatives, and the close bonds of a devout religious sect, this woman had before found all her satisfaction. When as a therapeutic measure she was temporarily restored to the old environment, her rapid improvement indicated the importance to her of sociability and the probable correctness of treating her illness through this means. In the old environment she continued in fair health for more than a year even though the psychotic husband remained with her. When they returned to a furnished room in a New York City lodginghouse where our patient was again cut off from her congenial associates, she once more became ill. The same symptoms recurred and she again appeared almost as critically ill as when we first saw her. This sequence of experiences led us to think that the presence or absence of outlets for sociable life had some effect on her health. RECAPITULATION INCIDENCE OF UNFAVORABLE SOCIAL F A C T O R S . — B e f o r e

dis-

cussing measures undertaken to relieve or rectify social factors judged unfavorable for these patients, we shall briefly indicate the incidence of factors with reference to ( 1 ) the development of disability; ( 2 ) the adjustment of the patient to disability, and (3) the defense of the patient against increasing disability or the recurrence of disability. Obviously these divisions are artificial and not exclusive. Defense may be affected through adjustment, and development may continue throughout attempted adjustment and defense. Yet massing the material according to these artificial periods and considering the problems of each period separately

212

A D V E R S E SOCIAL FACTORS

stimulates the imagination to conceive practicable measures of relief and to estimate the effort requisite for carrying out such measures. In the individual case, the development of disability has usually gone far before the patient seeks medical care. Some of the factors which have contributed to development may persist and the elimination or abatement of them may become the appropriate treatment of the defense period. Or the state of disability may itself be a corrective of factors which produced it. For example, effort to earn subsistence, by causing excessive fatigue has, let us say, been a factor in the development of cardiac insufficiency. At this stage of disability the effort to earn usually must cease and subsistence must be provided by others. For a time the factor of effort ceases to operate. New factors of strain may then intrude, as that of resentment at being thwarted in one's career, anxiety for dependents which, as emotional tension, increases and complicates the disability to be relieved. Adequate measures for relief include abatement of anxiety by protection of dependents, defense for and by the patient against having to expend again the amount and kind of effort for subsistence, and also his adjustment to the amount and kind that is safe for him to expend and that in some measure satisfies his interests. Thus recognizing and defining factors in the development of disability guides the selection of measures for defense and for adjustment. Furthermore, the massing of such factors may indicate dangers to which others not yet disabled are subjecting themselves and may indicate the need of mobilizing protective measures, either of personal hygiene or of community control. SOCIAL FACTORS A F F E C T I N G T H E D E V E L O P M E N T OF DISABIL-

ITY.—The sickness and disability experienced by 49 patients appeared to be caused solely by organic diseases, chiefly infections, malignant growths, and metabolic disturbances. If

RECAPITULATION

213

physical strain or deprivation or disturbing emotions had been experienced in these cases, we failed to learn of them. Most of these patients had achieved fair security and comfort, and wished to continue the way of life to which they were accustomed. It was learned that 9 of the 49 had suffered some reverse of fortune before the onset of illness: financial loss, the death of a loved person, the failure to satisfy some ambition; and they were as a result saddened, and yet their reaction to adversity did not seem to have produced tension to a degree which depletes strength. For several indeed effort to escape misfortune or divert attention from remembrance of sorrow or bitterness tended to lessen the disabling effect which disease was expected to cause. They ignored to some extent the discomfort resulting from disease because attention was preoccupied with other discomforts or concerns more important to them than their personal safety. In so far, however, as they were actually disabled for work or the pursuit of any interest, it was by organic damage from disease, not, that we could discover, aggravated by physical strain, deprivation, or dissatisfaction. Evidence in 47 * cases makes it appear likely, though not always certain, that social factors led to physical strain, deprivation, or dissatisfaction which may have contributed to the development of disability in instances when organic disease was found, as also in others when it was not found. No organic disease was discovered in 3 patients and in 4 others the defects discovered were not thought sufficiently damaging to the body to explain the disability manifested. These 7 patients did, however, manifest emotional disturbance in connection with social problems which faced them. Alleviation of the social problems in 4 instances was followed by alleviation of disability. It seems reasonable, then, to assume that at least much of the disability of these 7 patients was caused by the social problems. Furthermore, it does seem * Four cases are omitted because they are incomplete.

214

ADVERSE

SOCIAL

FACTORS

consistent with normal human experience to suffer grave disability when subjected to such distress of mind and physical hardship as certain of these patients experienced. (See examples: Theresa Fleming, Demonstration 6; Grace Carter, Abstract 14.) Serious organic damage was found in the other 40 patients and was regarded as the major cause of their disability. Yet it did appear probable that in 23 the organic damage was accelerated or intensified by strain or deprivation, and that in 8, strain resulting in chronic fatigue, or deprivation resulting in malnutrition, or a combination of these lowered resistance, and thus may have influenced the onset of disease.* Illustration of factors which may have affected onset is given in a case previously demonstrated: Elsie Duff (Demonstration 2). In addition to influencing the development of organic disease, there appeared to be an augmentation of the disability suffered by 22 diseased patients, caused by depressive or destructive feelings—compounds of anxiety, resentment, despondency—which we have expressed by the one word, dissatisfaction. We mean here explicitly that these dissatisfied patients had less energy available to spend, and wasted much of what was left in their disease-impaired organisms, because of dissatisfaction, as a result of which they were sicker patients than others equally or even more damaged by disease. We list below in order of frequency the unfavorable social factors thought to have affected the development of disability in 47 instances. Undue effort to earn subsistence Inadequacy of means Habits unfavorable to maintaining health Lack of satisfying social status Unfavorable habitat and locality Incompatibility and friction • S e e Abstracts ó, 18, 28, 29, 38, 56, 57, 79.

30 21 19 15 14 11

RECAPITULATION Inadequate shelter Lack of satisfying work Lack of personal service Lack of satisfying recreation and sociable life

215 11 10 6 6

they were leaving the hospital after the first illness treated by us, the need to alter their usual mode of life and to reorganize in some particulars their accustomed environment was faced by 74 persons. The problems of these persons, for whom some adjustment was judged necessary to insure the minimum discomfort and the maximum use of powers possible for them, have more meaning if considered with reference to the likelihood of recovery from disability and of return to full or at least adequate functioning. There were (a) those afflicted with mortal disease who could never again resume their activities and responsibilities and their place in society; (b) those who could in time recover and continue virtually the same life to which they were accustomed; and (c) those permanently disabled who must always restrict activity and guard against one or more special risks likely to arise in their environment. (a) The main concern of the hospital in caring for 8 patients in the terminal stages of disease was to relieve discomfort. All but 2 endured their illness in a calm and courageous manner. In the case of these 2 it was believed that the long-existing incompatibility and friction with associates in the home increased sufferings and since neither patient nor family seemed able to improve the relationship, removal to hospitals for chronic care was deemed best for the patients. Two others were hospitalized because they lacked means, one for skilled nursing service and one for all means of protection since he was homeless. The families of the remaining 4 patients provided for them adequately without assistance. ADJUSTMENT TO DISABILITY.—When

216

ADVERSE

SOCIAL

FACTORS

(b) Of the 24 patients temporarily disabled, 7 had no difficulty in adjusting their social situations; for the remaining 17, unfavorable social factors proved to be hindrances to adjustment. (c) All of the 43 permanently disabled patients encountered difficulties in restricting activities and arranging sufficiently protected situations in which to continue a satisfying life. Of 8 we may say that the problems encountered in making the required adjustment were not beyond their capacity to resolve. Illustrations of such adjustment are Jerome Edwards (Abstract 24) and Jacob Ludwig (Abstract 52). Social problems difficult to resolve are described in most of the 35 remaining cases, in most more than one adverse factor being present. Combining the three groups of patients for whom some adjustment in habits and in surroundings was necessary to insure minimum discomfort and maximum capacity, we find that for 56, unfavorable social factors hindered such adjustment. These factors are listed below in order of frequency of occurrence: Lack of satisfying work Lack of personal service Lack of satisfying recreation and sociable life Habits interfering with the carrying out of medical recommendations Habits unfavorable to maintaining health Inadequacy of means Incompatibility and friction Habits making difficult the endurance of disability Lack of satisfying social status Inadequate shelter, etc Unfavorable habitat and locality Undue effort to secure subsistence Inadequate food supply Lack of family group

27 25 22 22 21 17 IS 14 13 10 9 7 3 3

DEFENSE.—For 32 patients of the hundred no defense against recurrence or progress of disability was attempted.

RECAPITULATION

217

Some had recovered, some had died, and others were suffering from incurable maladies. For the remaining 68, liability to recurrence or increased disability, either from physical or mental states, was recognized, and for 43 of these, social factors were deemed component parts of the liability. Social factors interfered with defense against disability or would have, we believe, had they not been righted, for 9 of 31 patients liable to recurrence or progress of organic disease. Three of these had had rheumatic fever and for them removal to a safe climate was accomplished. Inadequacy of means to secure subsistence was a hazard to 4 patients with damaged hearts, also to one patient suffering from advanced pernicious anemia, and to one suffering from syphilis. The last 2 were further handicapped in managing their affairs by poor intelligence and by ignorance. Only by constant guidance was their medical care carried on. The circumstances and attitudes toward life which induced dissatisfaction sufficient to aggravate the disability caused by disease in 28 patients or to cause the disability of 6 who manifested no organic disease to some extent continued as difficulties actual or potential, against which they must constantly defend themselves. Many of the difficulties had been relieved by supplying goods and services or by effecting compromises such as removing the patient temporarily from an unfavorable situation or substituting a new activity for one he was obliged to renounce. Even when fair adjustment was achieved, this was always in the nature of a compromise and never quite satisfactory, and it was usually necessary that the patient make some effort to maintain the compromise. For example, those who found some form of employment better suited to their handicap than the work they had engaged in before they became disabled were better and happier than when restless from idleness. Yet lowered earnings, loss of the place in life which had been achieved, or lack of interest in the

218

ADVERSE

SOCIAL

FACTORS

new job rendered them constantly liable to dissatisfaction. Those too disabled to engage in any regular employment suffered even more dissatisfaction, and only partial relief of this could be won by the best devising of small tasks to fill empty days. For those unable to earn their livelihood, the supplying of needs by relatives or charitable agencies usually caused some depression or humiliation. Moreover, the supply was not always adequate or regular, and thus a feeling of insecurity was common. In short, we found that many of the social factors that had proved obstacles to adjustment continued as hazards or even obstacles to defense. Social factors considered component in defense against increasing or recurrent disability were: Habits interfering with the carrying out of medical recommendations Habits unfavorable to maintaining health Inadequacy of means Lack of satisfying social status Lack of satisfying work Incompatibility and friction Unfavorable habitat and locality Lack of satisfying recreation and sociable life Inadequate shelter, etc Undue effort to secure subsistence Lack of personal service Lack of family group

22 17 12 11 11 8 8 7 S 4 2 2

No social factors unfavorable to health or general welfare were found in the cases of 20 of the hundred patients. Social factors in some degree unfavorable were found in the cases of 74, though in 9 of these 74 cases the ingenuity of the patient or of his family forestalled actual harm to the patient. In 65, however, the unfavorable social factors were adjudged component in the medical problem. In the 6 cases remaining we were unable to determine the significance of social factors. The incidence of unfavorable social factors considered

RECAPITULATION

219

component in the medical problems of the 65 patients is indicated in the following list : Inadequate physical protection Unfavorable habitat and locality Inadequate shelter Insufficient food supply Lack of personal service Inadequate economic protection Undue effort to secure subsistence Inadequacy of means to secure subsistence Faulty personal habits influencing protection of h e a l t h . . . . Habits interfering with the carrying out of medical recommendations Habits unfavorable to maintaining health Habits making difficult the endurance of disability Dissatisfactions connected with family or other group relationships Lack of family group Incompatibility and friction with associates Lack of satisfying social status Dissatisfactions connected with restricted outlets Lack of satisfying work Lack of satisfying recreation and sociable life

44 14 15 3 28 36 30 25 31 22 21 14 30 3 18 17 34 27 22

VII D E S C R I P T I O N OF M E A S U R E S UNDERT A K E N TO R E M E D Y UNFAVORABLE SOCIAL FACTORS INTRODUCTION

The material gathered in our inquiry does not warrant extensive discussion of the adequacy of the means for aid and protection which are offered by the social institutions of the community. It seems, however, appropriate to mention by way of introduction to this section two types of need which occurred frequently and for which the community has not made adequate provision. The first and most urgent need was for the support of persons too disabled to maintain themselves; the second need was for useful and interesting employment to serve as therapy for the disabled, the question of remuneration being secondary. Both as individuals and as a nation we make inadequate provision against dependency due to disability. It remains our custom for the family or near kin to care for stricken members, although we no longer maintain the mode of life and the loyalties and deferences to family and kin which, perhaps, in the past made this custom reliable and satisfactory. Many of the patients we followed for this inquiry were thus cared for. Only one of his own volition had carried disability insurance, although 5 others were actually insured as employees of the custom house, the post office, a private bank, and the New York Stock Exchange. (Two of these had also the protection of medical care under the terms of their employment, as had also the 3 employees of our hos-

TO CONTROL ENVIRONMENT

221

pital.) Yet these one hundred persons had been as well off as most in our communities and were it our national custom to insure collectively against disability most of them could have contributed.* They had given little thought to the matter of protection against sickness and destitution. T o most of them disability from sickness, and even the decrepitude of old age, came as a surprise and an affliction, to which was added a feeling of shame at the necessity of accepting the aid of others. They accepted support from even son or daughter with reluctance, feeling that the obligation was unfair to the younger generation. And it must be said in justice to the younger generation that few were so prosperous that they could undertake without some sacrifice the burden of a sick or disabled relative. Dependency on charitable agencies was endured with even greater reluctance. In contrast was the feeling of security and contentment experienced by the 4 patients who received pensions for disability or for old age. These they accepted without any feeling of shame or stigma, for pensions were not to them "charity," and most of the patients under consideration here would, we are sure, have been spared much suffering from anxiety and humiliation had means of self-maintenance been provided through sickness and disability insurance. Social institutions broad and strong enough to provide such protection exist now only for the more prosperous minority of the population; for people of small means they do not exist, and doubtless can not come into existence until the liability to permanent disability is more generally realized and until the idea of collective action for mutual aid, as against sporadic charity, becomes more acceptable. Y e t we have seen that economic insecurity and insufficiency were the problems most frequently associated with disability and that these were the source of other problems and of great * We are not referring here to provision for paying the cost of medical care, as these patients were cared for at charity rates.

222

REMEDIAL

MEASURES

misery. Only about one-quarter of the patients were able to provide their own maintenance after sickness. Others were maintained for months, and many for the duration of their lives, by relatives or charitable agencies, and we must not leave out of our estimates of the cost of this maintenance the free medical care provided. Even had means of subsistence been insured, some special arrangements for the protection of certain patients might still have been necessary, but the allowance from insurance-savings or pension from public funds would have made possible more adequate and more acceptable maintenance for many. T h e other relief measure which we believe only largescale collective action can supply is, as we have said, employment opportunities for the handicapped. N o other social measure unless it be insurance has in our opinion value comparable to this one in lessening or removing the disability induced by dissatisfaction, and it is our conviction that a large share of the disability suffered, whether or not the sufferers were disabled by disease also, derived from dissatisfaction which no purely medical remedy could relieve. That it is not impossible to organize this type of assistance has been proved by the successful operation of large-scale "made-work" projects during the present economic depression. T R E A T M E N T OF SOCIAL FACTORS AFFECTING THE HEALTH OF

this section we attempt to describe measures undertaken to relieve social problems believed to increase disability or to hinder the carrying out of medical treatment. INDIVIDUAL P A T I E N T S . — I n

T h e purpose which the hospital had in undertaking the treatment of social problems caused by various combinations of unfavorable social factors is the same as that underlying all its care of patients. That is to say, treatment is directed not only to the general humanitarian end of alleviating suf-

TO CONTROL ENVIRONMENT

223

fering but is specifically directed to removing the cause of disability, when possible; to lessening the disability when only partial recovery is possible; and, finally, to aiding the patient to adjust to the disability when it is recognized that this must be permanent. The contribution made to medical care by treating social factors may be described as the regulation oj the patient's energy, through instituting protective measures to increase and conserve his energy and educational measures to enable him to expend his energy to the best advantage. The prerequisite to effecting any change of environment or of attitude and conduct is understanding of the factors involved. The importance of understanding the social problems of the patient before undertaking to relieve them, we would stress here, because of the very common notion that such problems can be solved readily by gifts to the needy or advice to the ignorant or erring. More than a superficial hearing of difficulties is required to reach true understanding, but once understood, a good deal can be done to unravel difficulties and supply deficiencies. Specific lacks, such as those of food, shelter, drugs, appliances, can usually be met by specific relief. Other needs often associated with these and even more keenly felt, as some degree of economic security, the reëstablishment of a home or a place in industry, opportunity to make trial of one's powers and win recognition, especially for disabled young persons, can sometimes be supplied, but the difficulty is great, and much depends on the capacity of the patient to accept and utilize the little that can be done for him. On the other hand, change in the attitude and conduct of the patient, or of his associates toward him, may so alter relationships within an environment that the desired change is thus achieved and removal or any radical alteration becomes unnecessary. Furthermore, in order to accomplish change and control of environment, it is usually necessary to influence the attitude and conduct of the patient and others.

224

REMEDIAL

MEASURES

N U M B E R OF PATIENTS FOR WHOM SOCIAL TREATMENT WAS U N D E R T A K E N . — I n 40 instances among the one hundred under consideration the hospital undertook specific measures to relieve or rectify problems arising from social factors judged unfavorable to health. In 14 more instances information and advice were given to patients and their associates regarding measures which they themselves could carry out. For the remaining 46 patients no specific treatment of social factors was undertaken. Of this number 7 died; 8 left the hospital's care before the significance of social factors was understood or before they could be persuaded to accept treatment. In 16 no social problems affecting medical care were observed, factors being found favorable or else not relevant. In 15 others the patients and their families in their own way resolved relevant social problems without specific counsel or intervention by the hospital, e. g., work adjustments were made, service and maintenance were supplied by relatives, satisfactory outlets were developed by the invalids themselves. Since it was unnecessary for the hospital to take measures to meet the social problems of the self-adjusting, we omit them in the present discussion. MEASURES UNDERTAKEN TO REMEDY UNFAVORABLE SOCIAL

FACTORS.—Any case treatment is peculiar to the individual, as is demonstrated in the records quoted in Chapters I I I and IV of this report. At the same time treatment measures and resources are found in use repeatedly in case after case, and they can therefore be grouped and analyzed in the same general manner in which the social factors have been analyzed. The measures used in treatment of the social factors fall into two main divisions: measures designed to change and control the patient's physical and social environment, and measures designed to influence his conduct. In actual treatment there is no clear distinction. Removal from unfavor-

TO CONTROL E N V I R O N M E N T

225

able environment may change the undesirable conduct, and conduct changed by education creates a different environment. In order to change a person's environment, furthermore, it is usually necessary to bring about a change in the person, enabling him to see the new experience as possible and desirable, for a social plan is impossible or futile unless the persons most concerned are party to it. Yet in thought a distinction can be made and by doing this our understanding of the treatment process becomes clarified. MEASURES

DESIGNED

TO CONTROL

ENVIRONMENT

To ensure conditions in which disabled persons could achieve and maintain the best adjustment possible for them and could be not unduly exposed to influences which caused fatigue, depletion, worry, resentment, or some form of dissatisfaction, the following measures were attempted: 1. Supplying deficiencies in patient's environment; as food, shelter, service, occupation, sociable life. 2. Helping patient utilize available resources in his environment: social, physical, economic, recreational, cultural. 3. Removing from patient's environment persons, things, or occasions causing him labor, responsibility, and irritation. 4. Removing patient from an unfavorable environment to one where protection was assured, and contentment was possible. During the process of becoming acquainted with the patient's social situation and his personal needs, the purpose constantly in mind was to discover resources for his relief. The character of resources needed was determined primarily by the character, degree, and probable duration of his disability. Success in supplying needed resources was determined in large part by the ability and willingness of the

226

REMEDIAL MEASURES

patient and his associates to cooperate in making and carrying out a plan of relief; in part by the availability of resources in the community; and in part by the ability of the hospital's social workers to discover and utilize available resources, whether within the patient's own immediate sphere of influence or provided by agencies in the community, i. e., health and welfare agencies of city, state, or nation. Having information both of unfavorable social factors thought to affect the patient's health and care and of resources available to relieve or to rectify these factors, the doctor was in a position to advise concerning the selection of the best obtainable environment. SUPPLYING DEFICIENCIES IN ENVIRONMENT.—On b e h a l f o f

14 patients the attempt was made to supply deficiencies in their accustomed environment. For 5 of them opportunities for occupation were sought rather to relieve dissatisfaction than to provide maintenance. For 14, funds were supplied by relief agencies to meet subsistence needs. Four of these 14 patients were fathers of families who until disabled by illhealth had supported themselves and their families unaided; 5 were mothers, 4 of them contributing to the family income because of their husbands' unemployment. Four were single women disabled by ill-health for self-support; one was a man totally disabled for work, whose wife could not give the nursing care he required and at the same time earn their livelihood. Recognizing the extent and probable duration of disability which these patients were to suffer, the hospital followed its usual practice and assumed the responsibility for inquiring into the resources for their maintenance and proper protection. Since in this group the resources were found to be inadequate, the patients were informed of what aid was available and how it was to be secured, and were consulted whenever choice was possible as to their preference for

TO C O N T R O L E N V I R O N M E N T

227

source of aid. Applications for aid having been made by the patient or the family of the patient to the agency selected, the hospital then informed the agency regarding the patient's disability and the environmental conditions required for his protection and adjustment. If the application was accepted by the agency, the hospital and agency entered into a cooperative endeavor to remedy the social factors unfavorable to the patient. The agency met the cost of supplying adequate subsistence, the hospital the cost of medical care (as hospital board, drugs, convalescent care). By conference or written report each party to the joint endeavor was kept currently informed regarding developments in the patient's health and in the social situation. It is hardly necessary to comment on the value of supplying the essentials for existence—food, raiment, shelter—to those who lack them. We do, however, call attention to the importance not only of meeting the needs of the patients but of meeting them in a way that gives the patients a feeling of security and that offends their self-esteem as little as possible. Much effort was expended in helping these patients to accept their dependency on society, computing with them the budget needed, paying the allowances regularly, noting and appreciating good management, in some instances finding means to meet unusual needs as they arose. All 14 patients, we are sure, derived benefit not only from the protection afforded but also from the relationship with the agencies' and hospital's social workers who, through understanding of their difficulties and disabilities, and through appreciation of their endeavors, helped to satisfy the universally felt need for regard and approbation. Furthermore, we are quite sure that in 3 of these relief cases the concern and appreciation manifested by the hospital and the relief agency on the patient's behalf influenced the family's attitude and conduct toward the patient so that tension in the home was relieved and happier relationships were estab-

228

REMEDIAL MEASURES

lished. Some lessening of the patient's disability seemed to result. (For more detailed representation of the effects of supplying goods and services we refer the reader to Harry Santos, Demonstration 12, and also to the case record of Catharine Monahan.) Failure to remedy the environmental deficiencies of 3 patients may have resulted in some damage to their health. For Jerry Faulkner (Abstract 25), the West Indian Negro dock hand, without family or kin and disabled for any work he was capable of performing, a city hospital for chronic invalids seemed the only available protection. Unwilling thus to shut himself off from friends and usual pursuits, he secured uncertain and inadequate aid during a year of great suffering and increasing ill-health, until he was finally forced to accept care in the city institution. We question whether it would not have been better for this patient if our hospital had refused further care on discovering, after his first stay, the inadequate protection afforded by his social situation. He would then probably have accepted care in a public hospital where he could have remained. Since, however, the obligation for medical care was assumed, an allowance for subsistence should in some way have been provided. On four occasions, in the year, he was admitted to our ward, and each time, after a short stay, he was allowed to return to the same ill-protected situation. For Hilda Pogany (Demonstration 4) and her husband, the acceptance of aid from a "charitable society" meant social degradation and for two years it proved impossible to persuade them to apply for aid, even though they knew that many, like themselves made penniless in the worldwide depression through no fault of their own, had accepted aid with little if any loss of prestige. The deprivations and anxieties to which this patient was subjected kept her in a state of emotional perturbation probably unfavorable to best recovery.

TO CONTROL

ENVIRONMENT

229

H E L P I N G PATIENT UTILIZE AVAILABLE R E S O U R C E S . — M e a s u r e s

for making the environment either safer or more satisfying without bringing in additional resources were undertaken on behalf of 16 patients. Often the possibility of using an available resource or making some desirable rearrangement, although very simple, did not occur to the patient until it was pointed out. For example, the tuberculous patient, Elsie Duff (Demonstration 2), was taught and persuaded to get the outdoor life prescribed by utilizing her own back yard and a near-by city park. Florence Daniels (Demonstration 3 ), reduced the fatigue of caring for four small children by moving to a house where there was an enclosed yard in which the children could play in safety. In 3 other instances "effort" problems were solved by work adjustment. For these patients, the day's work with all its associations provided the major satisfaction, and its adjustment aided them to maintain composure and thus ward off a cause of disability. Counseling better utilization of income helped to improve the living conditions of 4 patients and their families. In the case of George Weil (Abstract 99), his relatives had been aiding irregularly as they felt moved to do so. Discord in the group and between the patient and his wife appeared to derive from this planless as well as inadequate providing and, we believed, increased the patient's disability. In conference between his relatives and the social agency a plan of action was made, and therafter the allowances were given regularly, the agency supplying the deficiency in amount. Emotional tension was thus greatly lessened. Interpretation by the hospital to the wife, relatives, and agency of the degree and permanence of the patient's disability constituted the basis for the plan of action. Similarly in 2 other cases the hospital's explicit statement as to the nature and duration of the care needed by patients had both a stimulating and a stabilizing influence upon their

230

REMEDIAL

MEASURES

families. Basing plans on this knowledge, better financial as well as household management was achieved. The husband's same wage sufficed to provide a housekeeper for the family of Elsie Duff (Demonstration 2 ) , a tuberculous patient, so that she was able to rest and have sufficient nourishment in her own home during the prescribed year of "cure." In the case of William Murray (Demonstration 17), a man dying of cancer, care at home until his death two years later was undertaken and carried through by his wife. Without experience in nursing the sick, and without income other than the precarious one she might earn by renting rooms and by casual domestic labor, it seemed at first impossible to her to care for this invalid. His wish to remain at home rather than in a chronic hospital led the wife and the hospital social worker to review the situation and plan an experiment. Income was to be provided through renting rooms in her apartment and the sale of bread and pies. She was taught to do the dressing of the patient's wound, and was assured that, if her earnings did not suffice, relief would be obtained for her, or the patient would be provided for in a chronic hospital. Winning confidence from success, she went through to the end. Nutrients and sedative drugs were the only supplies given by the hospital in the long period of care. Learning to utilize their own resources also brought interesting and valuable health results in some cases. Harry Santos (Demonstration 12), having become totally disabled for the mechanical trades in which he was expert, sank into deep invalidism as well as poverty. He was persuaded to help do the marketing, cooking, and other housework, and he became so proficient at this and also so much stronger that his wife was able to take full-time employment and support the family. This patient is included also among those whose environmental deficiencies were supplied by relief agencies. Economic security proved, we thought, a

TO CONTROL

ENVIRONMENT

231

therapeutic measure. The self-confidence and self-esteem revived in this man by becoming even a small contributor in the family had perhaps equally great therapeutic value. In this instance, also, as well as in that of William Murray (Demonstration 17), we ascribed considerable importance to the patient's utilization of such opportunities as his quite restricted environment afforded for recreation. For 6 other patients besides these 2, the opportunities sought for them in their environment were safe and satisfying outlets for activity. Three were young men for whom a job paying wages was the dominant interest. For one of these, James Darrow (Demonstration 10), this problem of outlet was fairly well solved by persuading the father that his son could never again hold a regular job but might with benefit assist part-time in the father's small grocery shop. For the other 2 our efforts to secure gainful employment suited to their handicap proved unsuccessful. Their restlessness was nevertheless somewhat alleviated and the long unused hours were shortened by following up the clues suggested and by performing small tasks at home. In the case of another young man, Richard Jenkins (Abstract 43 ), a return to regular employment was effective in completing the therapy begun by the psychiatrist. The employer was willing to take him back when the desirability of his resuming work was explained. Another measure made use of to relieve the disability that was believed to have been caused largely by dissatisfaction was the encouragement of patients to revive or increase their contacts in sociable life. Tony Reali (Abstract 17) was for this purpose persuaded to do the family marketing and other business, to visit relatives and friends, to work with others in our occupational therapy shop, and to spend periods in a convalescent home where group activities were promoted. When his attention was thus diverted from himself, his respiratory functioning improved, and in the

232

REMEDIAL

MEASURES

year that our efforts continued, the patient's color and vigor improved. We doubt if any durable gain was made, for this patient lacked interest to carry on the activities. Jealous suspicion of his wife remained a source of emotional tension. Absorption in this passion and in self-pity provoked a degree of invalidism that has resisted all the physical and psychological measures attempted. A more fortunate outcome followed our attempt to divert the attention of another patient, Theresa Fleming (Demonstration 6), from marital incompatibility and other grievances by helping her to utilize all available resources for sociable life in her environment, and encouraging her to remain apart from her husband for a few months. Health was regained for the period of a year, and the same treatment, following recurrence at the end of the year, again appeared to restore equilibrium. It should be recalled that this patient presented symptoms so serious as to warrant an exploratory upper abdominal operation for malignant growth. When illness recurred a year later, the suspicion that some malignant condition must exist again led to extensive reinvestigation. On both occasions symptoms were finally ascribed to emotional tension rather than to organic disease. decision as to whether an attempt should be made to alter the patient's environment by the removal of some obstacle to care, or whether he himself should be removed to a more favorable environment was usually determined by the patient's choice and the expediency of one or the other method. Both methods were found useful at different periods in our care of the patient, Catharine Monahan (Case Record, p. 346), as well as the other two methods of controlling the environment, i. e., supplying deficiencies and utilizing available resources. The purpose was always the same, viz., protection of the patient

R E M O V I N G OBSTACLES TO CARE.—The

TO CONTROL E N V I R O N M E N T

233

from depletion, fatigue, or emotional tension. Mrs. Monahan was first removed from her home on the fifth floor of a walk-up apartment house. In her absence in a convalescent institution the husband prepared a place for her to continue convalescence where she had no stair climbing and no housekeeping. With the assistance of relatives and a social agency, the children were removed during a period of about six months to insure the good care of the children as well as the protection of our patient from overexertion. During this time also this patient, under medical guidance, learned to regulate her conduct to meet the requirements of a cardiac regimen. Control of the social factor "Undue Effort to Secure Subsistence" by relieving this woman of the necessity for gainful employment and of the care of two active children constituted an important phase of her medical treatment. She was thus able to restrict her activity and avoid fatigue. The absence of the children also lessened her emotional tension, provoked in part by continual discord between herself and the father as to disciplinary measures and in part by her realization that the children were mismanaged. The removal of the insane wife of Cyrus Wood (Abstract 98) effected likewise relief of effort and of emotional strain. This woman had been paroled from a state asylum. For three months before our patient collapsed from cardiac failure, the couple had been living a hand-to-mouth existence. Both his cardiac weakness and his advanced age (seventyfive years) unfitted him, in our opinion, to be the guardian of a deranged person, and by police intervention she was returned to the asylum. Responsibility for our patient's support and care was then assumed by his relatives, who had been unwilling to have the wife in their home. In the 2 instances cited the patients were protected by the removal of persons from their environment. Inanimate things were removed in only one instance. It was determined

234

REMEDIAL

MEASURES

that feather and wool bedding were irritants to Tony Reali (Abstract 17), who suffered from asthma, and these were removed and other materials were substituted. The conduct of persons in the patient's environment which in some definable way jeopardized his health may be here considered as an obstacle or an unfavorable environmental condition. Attempts were made to alter the conduct of these persons in order to render the environment favorable. (The procedures are similar to those used to influence the conduct of the patient which are noted in Chapter VIII.) The husbands of 2 patients required of these women that they resume family and household responsibilities before they had recovered. The expressed or implied opinion was that the patients were feigning greater disability than illness necessitated. One of these women was persuaded by her husband to return home from the convalescent institution before the prescribed period of care had ended; the other woman was offended by slighting remarks. In each case itemized explanation of the care prescribed was given the husband and he was persuaded to help the patient to comply. The method of itemizing the requirements of care proved more effective than general advice, such as "not to overdo." In one case, the husband showed he understood the explanation by moving the family to a house where better facilities lessened the patient's work. In the other case, the husband's personal irritability was lessened as a result of his securing employment and financial aid, and greater consideration for the patient may have been caused more by his improved state than by the hospital's explanation of her need of his care. But he, too, showed in his altered conduct that he understood the explanation. The advice of the hospital regarding removal of children and change of residence was accepted and acted upon, although he had been at first strongly opposed to the former suggestion. The improving of conditions about the patient by changing the

TO CONTROL E N V I R O N M E N T

235

attitude and conduct of associates was achieved in these cases largely by establishing an invalid status for the patients. We consider this treatment measure again under "Measures Designed to Influence Conduct," where defining and dignifying the concepts invalid status and invalid role are described as measures deliberately used to help the patient adjust to his disability. Other environing conditions which we attempted to alter were maternal oversolicitude and indulgence in the cases of 2 young patients (Pasquale Di Lorenzo, Demonstration 8, and Emma Kovacs, Demonstration 9), and unconstructive though well-intentioned interference of relatives in the affairs of 2 patients (Dora Levine, Demonstration 16, and George Weil, Abstract 99). Explanation and advice to the mothers of the young patients proved ineffectual and no other method of influencing them was tried, but we helped the patients to wean themselves from their mothers by providing for them such opportunities as Boy Scout membership, camp life, employment, etc. Explanation to the interfering relatives also failed to secure the conditions sought, although in one instance, George Weil (Abstract 99) the establishing of the patient's invalid status in the minds of these relatives counteracted their unreasoning assumption that the patient could, if he would, return to work and support his family. More convincing of disability in this case than explanation, however, was his being granted regular financial relief. In the other case of harmful influence on the patient (Dora Levine, Demonstration 16) from the interference of overwrought and solicitous relatives, it proved impossible to dissuade them from conversing with the patient about her symptoms, thus causing her great suffering from imagination in addition to some inevitable suffering from disease. After trying for several months to alter their attitude and conduct toward the patient, we concluded that protection of this patient at home was not adequate in spite

236

REMEDIAL

MEASURES

of the fact that service was given by her mother and that the husband earned enough to maintain a well-appointed home. Removal from the scene, which both patient and her husband finally accepted, was accomplished, and in the wellordered and disciplined life of the chronic hospital the patient found sanctuary. REMOVING PATIENT TO MORE FAVORABLE E N V I R O N M E N T . —

Of the four methods by which control of the patient's environment was undertaken, his removal from the environment was the one most frequently used. It was applied to the entire group, of course, in providing hospital care. We are, however, referring here to changes made in the period following discharge, when some inadequacy or annoyance in their usual environment hindered patients from having the care prescribed. It was held desirable, even necessary in some instances, that 39 patients should move temporarily or permanently to a more favorable environment. Besides these whom the hospital assisted to move, there were 11 others who, through their own efforts or assisted by their relatives, moved in order to secure better protection. Thus more than half of the patients who survived to leave the hospital were found to need this method of environmental control. Removal from the locality was arranged for 3 patients suffering from rheumatic fever and 3 suffering from tuberculosis. In 2 of these cases the patient's family planned and financed the change, the hospital aiding only by giving information and counsel. In the other 4, the hospital undertook not only to inform and counsel, but to assist with making and carrying out the plan. Two were recent immigrants, one from Germany, the other from Puerto Rico. The first obstacle encountered was the unwillingness of these patients to leave New York City. To both, sickness was an unfamiliar and demoralizing experience. It was finally arranged that the German go as domestic to Florida for the winter

TO CONTROL E N V I R O N M E N T

237

months. The Puerto Rican returned to Puerto Rico to live with one of her relatives. For the latter, funds to finance the trip were secured and the responsibility for her protection in Puerto Rico was accepted by the Red Cross. One of the patients suffering from tuberculosis was also a recent immigrant and therefore was not eligible to the care provided for residents of the city. Deportation to his own country seemed at first to be the only way in which protection and medical treatment could be secured. The young man's dejection over this solution of his problem was judged a serious hazard to his recovery, and he was therefore kept in the hospital until funds were secured from a relative to pay for six months' care in a private sanatorium. The other tuberculous patients went to city sanatoria. One patient suffering from bronchiectasis was persuaded to leave his work environment where the atmosphere was polluted by smoke, dust, and fumes. Failure in this case to secure out-of-door employment under prescribed conditions provoked some discontent and physical restlessness, and may have counteracted the benefit of removal from atmospheric irritants. Removal of 12 patients to dwellings where stairs and other fatigue-causing conditions were avoided was accomplished, in 7 instances by advice to them and their families and in 5 by advice and supplying funds. Five of these 12 patients were advised to move because of their need for service and congenial associates as much as because of their need to avoid fatigue. Lack of adequate skilled service to protect them at home made it seem advisable to provide long-time care in chronic hospitals for 10 permanently disabled patients, and shorttime care in convalescent homes for 8 patients who were recovering from acute illness and were expected to be well or sufficiently restored to return to their accustomed environment. As patients and families both recognized the need

238

REMEDIAL

MEASURES

of service, little or no difficulty was encountered in persuading them to accept institutional care. The cost of financing this was in most instances met by the institutions providing the care. For 7 patients special arrangements were required and funds for this purpose were raised by the social service department of the hospital. Only 2 patients paid for care, one in a convalescent home, one in a sanatorium. For the latter, funds were solicited by us from a relative. Seven patients lacked not only service but all other subsistence means and their removal to protecting environments was imperative. Four found refuge in local hospitals until death; 3 were sent to relatives, one to Ohio, one to California, and one to Puerto Rico, the last being one of the patients suffering from rheumatic disease for whom change of habitat was advised. Two patients were removed for a time from homes adequate in material resources and in service to care for them, on the assumption that their suffering and disability to a considerable extent were caused by tedium and incompatibilities developed in long years of invalidism spent in these homes. Both regained a measure of composure and seemed somewhat less disabled in the ordered life of chronic hospitals where diversions as well as routines suitable to their needs were fostered. This need for outlets or opportunities for different and sometimes new experience was recognized in a number of those patients previously classified as lacking some condition of physical protection. In advising Florence Baker (Abstract 62), whom we have counted among those sent to convalescent homes because they lacked service, to leave the rooms where for years she had dwelt quite alone, and to board with a neighbor, the purpose even more urgent than to secure service was to divert her mind from hypochondriacal concern for herself through the opportunity to interest herself in the lives of others. In the boarding home she became interested in others and her intense rest-

TO CONTROL E N V I R O N M E N T

239

lessness subsided. Whether this change in behavior was caused entirely by removal of adenoma of thyroid or in part by protection and companionship in the boarding home may be questioned. For many, also, the benefit to be derived from the discipline of the convalescent or chronic institution was one of the purposes of removal. In all, 20 were sent to convalescent homes, 3 to tuberculosis sanatoria, and 10 to chronic hospitals. During the period of stay in these institutions, a hygienic way of life was made easy to follow. The twenty-four hours of every day were apportioned to rest and activity, to solitude and sociability. Meals were served at fixed hours every day and the foods were selected and prepared to meet nutritional needs rather than invalid whims. If the patient was strong enough and wished to take part in religious exercises, this was made convenient for him. If he wished some other recreational outlet, several more were available, as books, magazines, newspapers, radio, indoor games, and in the convalescent homes outdoor games and walks. Several of these patients, doomed to permanent disability, thus gained the peace and strength which an ordered environment and a regulated way of life afford.

Vili D E S C R I P T I O N TAKEN

TO

ABLE

OF

MEASURES

REMEDY SOCIAL

UNDER-

UNFAVOR-

FACTORS

(Continued)

MEASURES

D E S I G N E D TO I N F L U E N C E

CONDUCT

In this section we use the term conduct as distinguished from total behavior, to mean that part of a person's behavior which is conscious and voluntary and which usually in some w a y involves other persons. Medical interest in a patient's conduct is in theory quite sharply confined to ways of acting which prevent or induce ill-health and ways which aid or hinder restoration of health. A sick criminal is given as much attention as a just man. Conduct we may describe as medically "right," whatever it be ethically, which conforms to a metabolic rhythm in which energy production, conservation, and expenditure are kept in balance for the person in his situation. Conduct which disturbs this balance is medically "wrong." In the analysis of cases and description of social factors, we have from time to time indicated modes of conduct judged harmful to health. Patients who habitually drove themselves into states of overfatigue or permitted themselves to remain in states of excessive and unpleasant emotional tension acted in a w a y that was medically "wrong." T o rectify the conduct of such patients was part of treatment and in so far as it was possible to recognize social factors which motivated or conditioned the "wrong" conduct, effort to change these factors became a part of treatment.

TO I N F L U E N C E

CONDUCT

241

N o doubt most of the processes of medical care in some way influence a patient's conduct; but we would here strictly limit discussion to measures undertaken to change conduct, in respect to subsistence and satisfaction factors. We designate these measures as (1) imparting information, (2) influencing choice, (3) fostering habits, and (4) standing by. Such measures or processes obviously are not sharply separated but overlapping—imparting information influences choice, and choice fosters habit formation, etc. In a few instances all of these measures were used and constituted a more or less continuous process. In others one measure alone sufficed. Giving information motivated the patient to take all the steps necessary to resolve his difficulties; but if he lacked sufficient incentive to carry out this task additional measures were employed. In reviewing our dealings with the one hundred patients we find that measures for influencing conduct were undertaken less frequently and were prosecuted more hesitatingly than were measures for controlling environment. In many cases the environmental difficulties were well understood, and carefully planned measures of relief were effectively carried out. In contrast to this assurance in handling environmental difficulties, there was hesitation in attempting to influence the patient's conduct. Indeed, attempts to influence conduct were abandoned or avoided in some instances from uncertainty as to whether measures aimed to relieve might hurt more than help; or from inability to understand motives, and hence inability to choose the appropriate measures. In retrospect, however, it appears probable that more harm resulted from our lack of courage and persistence in clarifying a patient's conduct difficulties for him and opening for him new or different outlets in which to expend his energies, than resulted from overconfident or misdirected interference. Such interference can not properly be said to

242

REMEDIAL

MEASURES

have occurred. Failure to influence conduct successfully came rather from giving advice too general and too little itemized, without estimating the patient's reaction to it. For instance, conduct medically "wrong" occurred sometimes after general advice was given to limit activity by abandoning usual pursuits, and was manifested as overdoing from rebelliousness or as preoccupation with symptoms. It is further to be noted that in some instances no attempt was made to influence patients whose conduct later became harmful as a result of dissatisfaction, because it was not recognized soon enough that dissatisfaction existed or that conduct was harmful. The selection of measures to change conduct was naturally influenced by the intelligence and circumstances of the patient. Basic to any change must be some understanding, on the part of the patient, of the change desirable, and some willingness as well as ability to institute change and to persist in forming the habits necessary to make permanent the desired new patterns of behavior. Influencing such changes involved first of all establishing a relationship in which the patient and the physician, or his adjunct the social worker, met on a common ground of understanding. Effort was made to get the patient into a frame of mind in which he could respond to instruction and influence. He was encouraged to reveal his hopes and fears, as well as his actual knowledge of his health problem, of the treatment proposed, and of the effect to be expected on his usual way of life. This was done to enable him to "externalize" his problem and to see it with less emotion. IMPARTING

INFORMATION

REGARDING

PROBLEMS

OF

SUB-

SISTENCE AND SATISFACTION

Explaining.—We use the term explaining to describe advice and instruction based on knowledge of particular social factors and aimed to rectify or control such factors.

TO I N F L U E N C E C O N D U C T

243

When the advice given was specific only to diet, activity, medication, or other therapy, and not to social factors involved in following the advice, we have not included it among measures undertaken deliberately to remedy specific social factors. For example, the patient Isadore Volk (Abstract 94), diagnosis: arteriosclerosis of coronary arteries, was advised to restrict activity in work and other pursuits; he was informed of symptoms by which he could gauge his tolerance. He was not told that certain work processes or work habits were safe or unsafe but rather how to discover his tolerance and to guide his energy expenditure. Reexamination from time to time showed that he was regulating his conduct to meet the requirements of his handicap, and thus justified the opinion that this patient could manage his affairs when once he had grasped the significance of fatigue symptoms and had taught himself how to avoid and relieve these. That one can err in forming the opinion that a patient can and will himself control the social factors so that he will be able to follow medical advice, and that specific explanation may be safely omitted, is illustrated in the case of Mark Selig (Abstract 89). After operation for duodenal ulcer this man was advised not to work, not to smoke, and to consume a specific diet. Much care was taken to instruct him about the preparation and consumption of proper foods and the breaking of his long-continued habit of smoking to excess. The diet and smoking prescriptions were duly followed. After several months of idleness the work prohibition was disregarded ; the patient returned to his job and became exhausted and again ill. In retrospect it seems possible that the relapse might have been forestalled by adequate explanation of the hazards involved in his particular work. Perhaps explanation alone would not have sufficed, for conduct in this instance seemed influenced largely by the tedium which unoccupied time produced in this man. But explanation of the need for repose together with some time-filling

244

REMEDIAL MEASURES

diversions might have proved effective and might have been attempted had we not supposed the patient and his family capable of devising and maintaining conduct controls as well as environmental controls. We have included among measures deliberately undertaken to remedy specific social factors advice given to selfdirecting patients whose circumstances, we felt reasonably certain, permitted them to make the necessary adjustments without assistance. For these, explanation was limited to a plain, forthright statement of favorable conditions to be sought and the course of action recommended. This type of explanation was given to 8 patients. A case of rheumatic fever offers an example of the procedure. The boy John Booth (Abstract 1) and his parents were informed of the liability to heart and joint damage from overexertion before the infection had completely subsided, and abandonment of school and all athletics was recommended, for a period of six months; they were informed also of the liability to recurrence of the disease in this geographical area, and where safety might be found. Acting on this information, the patient's convalescence at home was intelligently managed and his removal to the Southwest was accomplished, the hospital giving no aid further than that of approving plans worked out by the family and of informing the patient when he could again resume normal activity. Explanation was found to be necessary in order that patients might protect themselves against real dangers as well as against unnecessary restrictions, so that they might lead as full a life as their handicap permitted and thus avoid recklessness on the one hand and invalidism on the other. See Elsie Duff (Demonstration 2 ) for successful management of a patient through the stages of "cure" for tuberculosis and of resuming activity. (Also the case of Pasquale Di Lorenzo, Demonstration 8, for unsuccessful management.)

TO I N F L U E N C E C O N D U C T

245

While many patients had ignored or misunderstood their symptoms, and thus delayed seeking medical care, only 2 can be said to have guided their action by misinformation. These were Etta Kean (Abstract 44), who had read in an old medical book that pernicious anemia was incurable and fatal, and stopped taking liver, and Anna Merman (Abstract 59), who was convinced that a heavy diet of meat and starches was necessary to maintain strength and persisted in consuming such a diet during many years of an almost completely sedentary life. The majority of patients, however, were not misinformed but rather uninformed. A deliberate attempt was made to explain to 26 patients the most desirable conduct for them to pursue respecting specific subsistence and satisfaction problems. The factor described as "Undue Effort to Secure Subsistence" was the one most frequently explained; that is, the effects to be sought or avoided from engaging or not engaging in their customary work activities. Explanation as a measure for influencing conduct was used in 20 instances to effect change in work habits; in 7 to effect change of habitat or locality; in 11 to secure suitable physical protection, as housing and service; in 6 to give a sense of security as to adequacy and regularity of economic protection; in 10 to show need of and proper use of outlets for satisfying interest; and, finally, in 4 to alleviate unhappiness arising from humiliating or irritating encounters with associates. For all but 2 of the 20 to whom explanation was given regarding changes in work habits, some radical change in kind of work or work place, and usually both, was recommended. The 2 who continued in the same work were a young housewife, Florence Daniels (Demonstration 3), taught to plan her work and to utilize labor-saving facilities, and an elderly night watchman, William Mahoney (Abstract 64), persuaded to restrict stair climbing and all exertion to the minimum required to reach his place of work

246

REMEDIAL

MEASURES

and fulfill his duties there. The latter was first advised to discontinue all gainful employment. His restlessness during convalescence, his own insistence that he must have occupation, and the opinion of his family that he was better when regularly occupied led his physician to approve of his continuing his customary employment. Explanation of the benefit to be derived from increasing activity in routine work was made to 2 patients, Tony Reali (Abstract 17), and Harry Santos (Demonstration 12). These were persons seriously disabled who had come to fear that any exertion would injure them further and increase their suffering. The attempt was made to have them understand that fixing attention on breathing, heart beat, etc., disturbed functioning and thus reduced further their capacity, whereas holding attention on things and events not related to their distressing symptoms relieved suffering and increased capacity. Even more effective for influencing the conduct of these patients than explanation was the finding of opportunity for work suited to their limitations. For most patients, however, the problem was to limit activity, for they were eager to continue at their usual employment and had to be persuaded to stop or to learn new work habits. Explanation of the change advised was based on knowledge of the kind of work each person had done and of his personal preferences, requirements, and circumstances, as well as on knowledge of his physical condition. In the case of Irene Barclay (Abstract 31), explanation was used as a measure to influence conduct and it gave fair results. The subject of explanation here was the nature of the patient's emotional outbursts, and their disabling effect. This was accomplished in the main by helping her to talk freely of relationships with her mother, sister, and nephew. Describing encounters with these persons, who had made up her group of intimate associates, she came to realize the

TO I N F L U E N C E

CONDUCT

247

feelings of jealousy, rivalry, and resentment toward them or about them to which she was subject. Much of the understanding which we believe helped her to alter her relationships resulted from seeing herself and her family, and her own really valiant struggle to conquer disease and theirs to aid her to do this, as they appeared to other persons (doctor and social worker). These family relationships, of so much value to her, were thus cleared of ill will accumulated from daily trivial irritations. Elucidating.—For 10 patients it was necessary that the original explanation be from time to time reiterated and further elucidated to conform to changing experience or to counteract the tendency to let slip from memory the facts or probabilities that were unwelcome or vague. This further elucidation was employed during the period when the patient was endeavoring to assimilate and make use of the information which had been imparted. It was during this period that the patient more and more took the initiative in bringing out his fears and difficulties, and that the hospital suggested cause-and-effect relationships in his experience. Thus Irene Barclay (Abstract 31) learned to see a relationship between her moods of jealousy, her drives of competitive activity, and her heart attacks. Likewise this same patient came to realize that, by increasing her knowledge of foods and her skill in spending money, she won the approval so much desired from mother and sister. The informing process, which we aim to sketch here, was used longer and more continuously for the 10 patients noted than for others because the lessening of their disability and their adjustment to their disability depended largely on the regulation of their conduct. To enlist their participation, and without this little could be done to help them, it was necessary that they understand the role they must play in their treatment and the hindrances to this

248

REMEDIAL

MEASURES

which their own attitudes created. All of them had to learn the role of invalid and all reacted to this role in some way that was unfavorable to best adjustment. To make clear to each the conduct medically best for him to pursue from week to week or month to month, as his physical condition or circumstances changed, it was found necessary to direct attention again and again, usually for as long as a year, and in some instances for many years, to undesirable propensities or to different manifestations of a continuing situation to which it was difficult for the patient to accommodate himself. The need of such elucidation has already been implied in several cases: Theresa Fleming (Demonstration 6), Harry Santos (Demonstration 12), Allie Bach (Demonstration 15), and Catharine Monahan (Case Record). It was many months before the patient Harry Santos (Demonstration 12) convinced himself that heart disease had not reduced him to a useless member of society. Experiments with light tasks, for which he already had skill, gradually proved to him that he still had capacity for work, and that when his mind was directed away from his symptoms he had more capacity and felt better. But again and again fear of harm from activity overcame him and he had to be reminded not to watch symptoms, not to brood over his misfortune, but to occupy his hands and his thoughts until he had learned his tolerance for exertion and had regained selfreliance. Even after a routine of activity became established, he was subject to moods of depression in which he bemoaned his failure to achieve the position in society to which he felt entitled and which he desired for his family's sake as well as his own. How disabling such moods were has been discussed under "Adverse Social Factors Affecting Satisfaction." For this problem, as for the problem of fixing attention on symptoms, we tried elucidation as one remedial measure. Preceding and accompanying any information to the patient regarding ways and means for withdrawing his

TO I N F L U E N C E

CONDUCT

249

attention from considerations of prestige or status was the endeavor to arouse his interest in some present and usable opportunity and to encourage trial. In time it seemed feasible to discuss with him how he could himself, to a considerable extent, control his attention, directing it toward pleasant or at least neutral activities, thus withdrawing it from remembrances that made him despondent. This man's intelligence was still alert enough, in spite of years of irritable and self-centered invalidism, to comprehend the information imparted. He was impressed probably more by experience than by elucidation but both seemed to aid a weakened person to abandon an established habit and learn a new one. In connection with elucidation it is perhaps appropriate to mention a way of elucidating, which for several of these badly disabled patients was of great value, and by means of which information was conveyed. We have in mind the appreciation which the hospital group comes to have, and directly or indirectly to express, of a patient's character in terms of his endurance and striving. Appreciation of such qualities stimulated these patients to cultivate them, and to shape in their own minds an ideal of the kind of invalid it was desirable to be. The mere realization that the hospital group looked upon the role of invalid as dignified and one to try the mettle of the bravest, rather than as a pathetic or revolting experience, tended to make some patients take the same attitude. Thus we believe the patient Allie Bach (Demonstration 15) was influenced by the ideal of invalid role which the hospital imparted to her (as well as by desire for approval) to strive unceasingly to accept with grace her isolation and dependency on strangers and to learn to "outwit her nerves." Also we believe the patient Catharine Monahan (Case Record) acquired courage to take up the role the hospital advised and persist in it against opposition and indignities—not only because the role was described in

250

REMEDIAL MEASURES

reference to her particular circumstances and usual conduct, but also because the hospital made clear and vivid the moral and intellectual qualities required to play the role well. Demonstrating.—Somewhat like this last method of imparting information is the method of imparting by example or by the actual doing of something. The experience of other patients may be cited and may serve as example, or the patient in question may be associated with others as in cardiac, diabetic, and food classes, occupational therapy shop, etc. Several patients on our list attended such group demonstrations and benefited by acquiring the knowledge and influence which these demonstrations aimed to give, as for example knowledge of food selection, preparation, cost, and use. In a general sense, such demonstrations referred to subsistence problems, and seem a proper subject for mention here. In so far also as the demonstrations included and affected specific problems of the individual patients concerned, as for example, change of habits with regard to food, work, rest, etc., the method can rightly be said to have been used to influence social factors. It has been our purpose, however, throughout this study to find limits in which to confine the meaning conveyed by the term "social factor." We have excluded instances of advice relative to activity limitation, medication, etc., unless such advice applied specifically to a definable conduct or situation problem peculiar to the patient in question. Instances of demonstration have been excluded except when we could define a social factor which was peculiar to a given patient and which the demonstration was intended to affect. We have included instances of demonstration to 12 patients made to impart information regarding the following subjects: 1. Capacity for kind and amount of work.—Demonstration to one patient in occupational therapy shop, the main

TO I N F L U E N C E

CONDUCT

2S1

purpose being that the patient himself note his improved respiration when interest in his own work performance and in that of others made him forget himself and that he learn to use the information in everyday life; to another patient in his own home and later outside by "made work," furniture repair, etc., the purpose being similar to the above; to another in an office by work selected and controlled, the purpose here being that the patient learn to win satisfaction through new experience and through approbation for performance, and thus learn important sources of satisfaction and acquire the habit of using them. 2. An ordered way of life appropriate for the invalid in question, including (a) suitable meals served at regular hours in the company of others, whims not being indulged, (b) periods of solitude and rest at regular hours, (c) periods of sociability at regular hours, (d) religious or devotional exercises, (e) means for recreation, as books, radio, games, (f) controlled physical exercise when indicated. It was in part for the demonstration of the value to be gained from an ordered way of life that 4 patients were sent to convalescent homes, 3 to tuberculosis sanatoria, and 2 to chronic hospitals. 3. Similar handicaps in others.—Emma Kovacs (Demonstration 9), after her own improvement was well under way, was asked by the social worker to visit a young girl suffering from the same disabling disease and from moods of despair similar to those from which our patient had recently emerged. This contact afforded opportunity for self-study and self-appraisal, and incidental to the purpose of helping the other girl was also the purpose of demonstrating to our patient her marked improvement by comparison with the other patient (in order to encourage her striving) ; the visit also demonstrated the fact that our patient was not the only afflicted young person in the world, and that resentment vented on innocent associates who were trying to help (her

252

REMEDIAL

MEASURES

mother and the hospital group) was foolish as well as unattractive. Perhaps the most important purpose of the demonstration was to arouse her compassion for another and the wish to console, as a backfire to her self-centeredness. Influence attempted by means of demonstration as here described resembles that attempted by means of environmental control described in "Measures Designed to Control Environment." It is by means of things and events in the environment that demonstration is made. But demonstration differs from the influence of a controlled environment in being a method of teaching rather than of control. The learner's attention must be caught and he must be guided to act in ways designed to instruct him. The chief aim is to prepare him to accept and maintain independently the attitudes and habits inculcated by the demonstration. The distinction is, we believe, important. The chief aim of environmental control is to provide immediate protection, whereas the aim of demonstration is to educate. As a result of confusing the two methods, conduct changes may be sought from environmental influences alone without taking pains to direct these influences to specific educational ends; on the other hand, demonstration may be made to patients who are unable or unwilling to learn, but who can be benefited by removal to an environment better adapted to their needs. INFLUENCING CHOICE REGARDING PROBLEMS OF SUBSISTENCE

AND SATISFACTION.—In a number of instances the acquiring of information relative to work, food, and other habits which might promote best adjustment to or defense against disability proved sufficient incentive to influence patients to practice such habits. For some the influencing of choice was not required, for their choice had in a sense already been made when decision was reached to seek medical care, as

TO I N F L U E N C E

CONDUCT

253

reaching this decision resulted from a previously acquired disposition to seek and to respect and to rely upon the guidance and service of others whose expertness exceeded their own. These persons, when advised by the doctor to adopt a certain course, experienced no conflict of choice, even when the prescribed course ran counter to cherished desires and lifelong habits. Thus several patients gave up without resistance customary employment, undertook less remunerative and less attractive employment, renounced customary recreation, and in general accepted changes or restrictions of their usual way of life. Such unresisting acceptance was shown by the young man, Michael Maggenti (Abstract 16). His father accepted without question the doctor's advice that the patient change kind of work and place of work, and the patient, always guided by his father, seemed not even to contemplate an alternative course. Several other patients also acquiesced in the way of life prescribed for them by the doctor because they were too weak or ill to devise and seek another course. Yet we believe that choice in one respect was made by all these seriously disabled sick persons, even the gravely and hopelessly ill; namely, the choice as to whether they would submit to destiny in a spirit of resignation or a spirit of defiance. For example, the manner in which a number endured unavoidable suffering and faced approaching death, or each day strove to achieve the self-discipline to live as full a life as possible, exemplified the spiritual conquest of disability which was the goal the hospital sought for most of the seriously disabled. Other disabled persons seemed to be so firmly settled in their choice to carry on their same way of life in disregard or defiance of medical advice or were so habituated to following impulse without critical judgment that measures to influence their conduct were abandoned and only such protection as could be given through environmental

254

REMEDIAL MEASURES

control was undertaken for them. In this group were 7 persons whose past histories revealed them to have been always stubborn and self-willed and resentful of any thwarting of their desires. They resented especially the handicap their illness placed upon them. Advice to these regarding habits to change or to cultivate influenced their conduct little if at all. Thus while some needed no more than information or appropriate advice to induce them to make the changes in conduct held to be advantageous for them (and the majority fell into this class), others proved to need stronger incentives than information, when the recommended change entailed personal renunciation of a preferred way of life or sacrifices of others, or was difficult to achieve because of other complications. On behalf of only 12 patients was the attempt made deliberately to stimulate them to choose the course of conduct which we believed would reduce risks of increasing disability and would allow as full a life as was possible for them. These 12 had gone through severe illness and were permanently disabled by disease. Disability from disease appeared to be considerably increased for all by dissatisfaction, in some instances due directly to the deprivations which ill-health caused, in others due largely to unhappy relationships with associates. All 12 were advised to accommodate themselves to unwelcome restrictions, to abandon usual employment and the effort to earn subsistence for themselves and their families, to accept financial dependency on others, and to lead lives carefully regulated as to rest, activity, and peace of mind. Four of the 12 were in addition advised to change their place of residence in order to secure suitable physical protection; 5 were urged and aided to find timefilling occupations in order to relieve dissatisfaction and divert attention from symptoms; and 3 were encouraged to face the disharmonies in their relationships with associates, and to seek ways to mitigate these.

TO I N F L U E N C E

CONDUCT

2SS

For all of these patients, incapacity and the radical changes in way of life which this brought about caused them to look upon themselves as failures and useless burdens upon others. Such loss of self-regard and the resulting despondency proved a serious deterrent to making use of the capacities they still had. Much of our endeavor was to change their point of view as to what constituted failure on their part. These persons, accustomed to rate their value according to commonly accepted measures (wages earned, job held, serviceableness to their families), which is to say, largely according to the value which they believed others set upon them, were ill-prepared to reevaluate themselves in other terms. Indeed, they were little accustomed to reflecting upon any subject. Yet in order to effect durable relief of their suffering or restoration to usefulness, it was necessary that each learn to value himself not in competition with well persons nor in terms of what others could achieve, but rather in terms of his own abilities and their utilization, weighing alternatives, choosing his course deliberately, and persevering in the chosen course. He must improve his game by striving to better his own score, not another's. If he compared himself at all with another it must be with another invalid similarly disabled and similarly striving to understand and play a new role. The interest which the hospital manifested in helping each of these patients to play the role of invalid to the best of his ability tended to arouse his interest in performance, while the hospital's appreciation of his endeavors in this direction proved an incentive to further endeavor. Such appreciation we consider one of the most important influences in determining the patient's attitude toward his disability, and also in stimulating his striving to regulate his conduct to achieve best adjustment. In the fullest sense it means understanding the difficulties of his situation, his inadequacy to meet these, his fears, his regrets, but also it means under-

256

REMEDIAL MEASURES

standing reserves of strength in him that in his despondency he cannot estimate correctly. Appreciation, expressed as sympathy for suffering, proved a valuable relief measure even when there was little understanding of the patient's individual difficulties. Where understanding existed also it constituted a major relief measure in a number of instances. This we believe was true in the case of Harry Santos (Demonstration 12), of Allie Bach (Demonstration 15), of Catharine Monahan (Case Record), of Irene Barclay (Abstract 31), and in lesser degree of others. In fact, it was only on the basis of some understanding of their resources as well as their needs that it was possible to impart to certain patients information to aid them in regulating conduct. Realization by Catharine Monahan that the hospital, through the personal contact of the social worker with her husband and relatives, understood their disapproval of her for allowing her children to be cared for by others and for allowing her home to be broken up, and that it nevertheless continued to urge her to pursue this course until her health was sufficiently restored to allow her to resume her responsibilities, was, we feel sure, strong support to her resolution to follow the course prescribed. Having herself much concern for social conventions and the esteem of others, this was no easy decision. On two previous occasions when illness from rheumatic disease overcame her, she had succumbed to this social pressure and had resumed her responsibilities before her doctor deemed it safe for her to do so. Remembrance of these previous experiences no doubt influenced her resolution on this occasion. But also on this last occasion, as there had not been previously, medical advice as to risks was based on sound and detailed information of what these risks were. It was not general advice suitable for any person suffering from rheumatic disease, but advice specific to her condition, her character, her circumstances. Fortified by the hospital's assurance that her course was right for her and not unfair

TO I N F L U E N C E C O N D U C T

257

to her family, and by the hospital's approval of her, she persisted in the course until disease subsided. In this instance another method of influencing choice was used, namely, threat. The probability of permanent damage and permanent incapacity, unless precautions were observed, was made clear. This method was used also in the case of the Puerto Rican, Santa Carlos (Abstract 11), stricken six months after arrival in New York City by rheumatic disease, who resisted advice to return to Puerto Rico where her family offered the protection she needed and where, because rheumatic disease is rare, she would be less liable to recurrence. Representation was made to her in the strongest terms as to the danger she risked of becoming totally disabled should she persist in her determination to remain in New York City, away from all relatives, and entirely dependent on her own small earning capacity. At the same time hope was aroused in her that, in the more favorable climate and under better environmental protection than she could expect here among strangers, she would be well and able to maintain herself. In 2 instances the mild threat of a little ridicule was used as persuasion to moderate a settled habit of worrying and overdoing. These 2 women, Mary Boehack (Abstract 47) and Florence Baker (Abstract 62), had been admonished to "do all things in moderation," a more difficult course for them to keep, as perhaps it is for most people, than would have been one imposing explicit restrictions. Encouragement to take risks was used as an influencing measure for 3 patients, an asthmatic, Tony Reali (Abstract 17) and 2 cardiacs, Verna Larue (Abstract 55) and Harry Santos (Demonstration 12). Two of these patients exemplified in a striking manner the common experience of fear invoking the very conditions we fear and would avoid. To help them overcome fear and its very disabling effect on them, the following means were used: diverting attention

258

REMEDIAL MEASURES

from symptoms and their present plight by leading them to tell us about past achievements and satisfactions, suggesting that an activity similar to one they had previously enjoyed was still possible for them as a pastime even if not as a responsibility, and helping them to find opportunity to experiment with such activity. Both men were thus persuaded to undertake light tasks, as woodwork, upholstering, family marketing, etc. Pointing out to them from time to time the abatement of symptoms and increase of strength which accompanied their immersion in interests other than their own misfortune stimulated their participation in the experiment and gave reassurance until interest alone came more and more to suffice as incentive. For Verna Larue (Abstract 55), a young rheumatic cardiac, the choice of major concern to her was whether to take the risks entailed in marriage, childbearing, and child rearing, or to break an engagement to marry, protracted through several years by reason of repeated severe rheumatic illnesses. Fear of the danger to herself or of failing as a wife and reluctance to renounce the happiness and security which marriage held out to her caused her to suffer much perturbation. Quietly talking over her many perplexities with the social worker helped her, we believe, to estimate the risks in both directions. The explanations of the physician that marriage held the lesser risk and that some risk must be taken led her finally to accept marriage with only as much apprehension as was reasonable for one in her condition to retain. Even when little or no expectation might be encouraged that a patient could ever again engage in the pursuits that he really desired, or when the pursuits open to him aroused only faint interest, it still seemed worth while to urge him to hold to a schedule of activity and rest periods, in part that rest be possible, in part that concentration on symptoms and misfortune be as much as possible forestalled. As a measure to aid conduct regulation, such a schedule, designed

TO I N F L U E N C E C O N D U C T

259

to inculcate positive routines * as opposed to prohibitions, proved beneficial to several patients. Its effects came partly from reducing the number of occasions when the patient felt he should exercise choice. When already weak and dispirited the problem of making even a simple decision became difficult. To such patients a practicable schedule approved by the doctor was a boon. This the schedule devised for Allie Bach (Demonstration 15) proved to be for her. Habituated through many years of service as lady's maid to well-ordered homes and, within her own somewhat limited sphere, to exacting self-discipline, she became seriously demoralized when forced by ill-health to endure prolonged idleness. She was not habituated to enjoying herself except in association with other persons and in performance of tasks required by other persons. Then she had enjoyed herself and by her sweetness and gaiety of mood as much as by her fidelity and competence had won affection and esteem. But solitariness was an ordeal from which she shrank and rather than endure it she had repeatedly driven herself to undertake activities she realized must soon result in another cardiac break. We are sure that she did this in part because of unwillingness to lose status by becoming financially dependent. Yet there was evidence too that fear of her own thoughts, her own internal life was at times greater than fear of illness. Hers is one of the cases where appreciation of her problems did much to help her solve them or to accept solutions offered. (Indeed, her case exemplifies the relevance to disability of all the social factors listed, except that of friction with associates, as well as the use of nearly all the measures by which attempt was made to remedy these.) The establishment of a schedule of positive routines * The term positive routine is devised to express a specific and itemized program given to a patient for his use daring a period of convalescence or disability. The main characteristic of such a program is that it omits prohibitions or "don'ts"' and stresses permissible activities in which the patient has some interest and for which he has opportunity.

260

REMEDIAL

MEASURES

also did much by restoring a slender frame of imposed order to long days and nights that otherwise seemed purposeless. B y scrupulously carrying out the routines she felt that she was at least doing her best not to become more disabled and thereby an even greater burden than she was. This motive, as also the prescribed routine, served the purpose, in her case and others, of support similar to that given by a life preserver to a weak and unskilled swimmer. Support of the particular motive and routine became somewhat less needed by this woman as she came to be more and more used to thinking her own thoughts and less afraid of being alone with herself, but abiding peace she never seemed to realize. She did, however, seem to conquer fear to a considerable degree, thereby reducing tension and restlessness and thus making it possible for her heart to function better.* T o influence choice of conduct deemed medically

right

(whether the influence was b y imparting information, by appreciation, by threat, b y encouraging to hope and to take risks, or by positive routines) the conjunction of three conditions was found to be necessary: 1. A wish regarding something to be gained from the conduct in question, in order that enough power might be generated to start the person off. 2.

A t least.the potential ability to do what was proposed.

3.

Opportunity to make trial.

T h e fact is well attested that patients may be in possession of all three conditions and yet not realize this. Or they may be deficient in one or another, that is, they may lack * It is interesting to note that among some 30 chronically disabled, many of them totally disabled, w h o m we had the privilege of knowing rather intimately during a year, and longer in many instances, about one-third appeared to have acquired inner peace and strength and were able calmly to go through the ordeal of losing health, work, and other cherishcd concerns. Neither creed nor color seemed a determining influence, but sex did. Men greatly outnumbered women. W e note also that this state of equanimity had been manifested previous to loss of health and did not appear a product of soul-searching induced bv illness.

TO I N F L U E N C E CONDUCT

261

opportunity, distrust their ability, fail to recognize a clear relationship between their wish and the conduct advised, or even be unaware of their wish. Justification for interference by the hospital in a matter so personal as conduct (and any attempt to influence another person is, strictly speaking, interference) derives from the assumption that patients want help or they would not seek medical care, that conduct regulation is important for bettering their state, and that they are themselves unable to accomplish the regulation in some important respect without interference by the hospital. T h e attempt to influence conduct was not always considered advisable, even when it appeared clear that illregulated conduct aggravated disability. When it was discovered that a patient lacked the wish sufficient to start his participation in the educational process or that he had not demonstrated in the past or in the present even moderate ability for the ordeal, we concluded in several instances that it was wiser and also kinder not to attempt to influence him to regulate his conduct. We refrained from exhorting or admonishing such patients because experience has shown that these methods, though probably as a rule harmless, may aggravate the problems presented; for example, conduct problems deriving from resentment of authority or oversolicitude (see Pasquale Di Lorenzo, Demonstration 8 ) . When regulation of conduct was held to be important, considerable effort was made to gather information regarding the patient's previous conduct in various situations and relationships. Also, some experiment was made to test the presence and power of the three conditions of choice described above. Such discovery and testing were usually accomplished in the process of imparting information and noting the patient's reaction. Decisions regarding the advisability of interfering or not interfering in personal conduct were in some instances so difficult to make as to lead us to

262

REMEDIAL

MEASURES

feel that more critical consideration of the whole subject is needed. is necessary to hold in mind the thought that to relieve the social problems of most patients several remedial measures were usually operative simultaneously. In imparting information or influencing choice it was found necessary to discern and reckon with the patient's habitual modes of reacting; so also, in order to stimulate the forming of new habits or the altering of old habits, it was necessary to impart information and influence choice. The process of fostering habit, too, is coincident with other processes. A person cannot acquire habits just by knowing what is desirable to do or choosing to do this. There must be suitable environmental conditions to allow opportunity for habits to develop. Much of our purpose in control of environment was to moderate habits unfavorable to health, as habits of work, of idleness, of reacting to and dealing with associates, of irascibility, etc.; or, on the other hand, to stimulate and encourage habits held important for recovery or adjustment to disability, as habits of nutrition, of rest, of recreation, habits in household management and child-caring, habits of teamwork and of self-reliance. Habits fostered as a by-product of measures undertaken for some other end are not reviewed here. Nor do we review here the change and control of habits worked out for themselves by many patients who thus largely effected a satisfactory adjustment to their disability. A most interesting and instructive example of such self-regulation is described in the case demonstration of Jerome Edwards (Demonstration 14). Noteworthy were his intelligent choice of suitable interests, selection of and ingenious use of means to gauge his strength, avoidance of activities proved to excite or fatigue him unduly, and, not least, his skillful use of his doctor as critic and adviser to this self-regulating. This FOSTERING HABITS.—It

TO I N F L U E N C E C O N D U C T

263

patient studied and solved his own social problems, reorganizing both his environment and his habits to meet the limitations of a damaged heart. Others did likewise, though few demonstrated comparable ability. Our purpose in this section is to describe measures deliberately devised and used by the hospital to bring about a result. We therefore consider only 7 patients whom we thus attempted to help by fostering change of the habits that involved social factors which affected health. With one exception, they were the same patients whose choice respecting conduct we attempted to influence, and the fostering of habits was essentially a prolongation of that activity. They all were patients also to whom information was imparted. Circumstances in each instance made reorganization or regulation of their habits difficult for them (lack of means, unscrupulousness in securing means, isolation from relatives, friction with associates, unfavorable physical surroundings). With 4 of these also the long-indulged practice of brooding over what they had missed or lost in life, over their mistreatment by certain persons or by the "world," had made them self-centered, gloomy, listless, vulnerable to a high degree by reason of always anticipating harm. Measures by which they were aroused to make trial of a more rewarding existence have been indicated. Need for continuing attention on our part came from such usual lapses as flagging interest, failure in supply of opportunities or means for trial, selfbelittling from the ineradicable habit of judging their achievements by external results and comparison with achievements of other people rather than by the meaning to themselves. These 4 persons were classed as industrially unemployable because of permanent disabilities. When efforts were begun to rectify deficiencies in their environment and to foster less disabling habits, they had already for years been more or less incapacitated and on several occasions very ill. It is not surprising that they resisted interference,

264

REMEDIAL MEASURES

but rather is it surprising that they were able to rally at all from the deep invalidism which had overwhelmed them and to realize even intermittently that the struggle of life can be interesting and its rewards satisfying. The other 3 patients were not so disabled, though they had been losing ground slowly for a long time. Yet they expected to get better and to make no permanent change in their way of life. Two of these were married women with young children; one was a single woman, fifty-two years old, alone, and up to this point in her life always able to support herself comfortably and to contribute to the support of her relatives. The first care for these patients was to prevent overexertion which had been a contributing factor in their breakdown. This necessitated environmental changes and financial assistance in order that they should be free of obligation to overexert. In the case of the married women it also necessitated persuading their husbands and other persons associated with them to aid in planning and maintaining right environmental conditions. It may be said, then, that for each of the 7 patients the environment had to be in some particulars reorganized to afford the opportunity to improve in health, and that in order to take advantage of the opportunity thus afforded it was necessary that they alter some long-established habits. The medical purpose was to stimulate and guide them in this endeavor, since for the health problems which these particular patients presented, regulation of habits was the major therapy. (Diagnosis: 1 tuberculosis, 1 bronchial asthma, 1 arthritis, 4 heart disease.) It was not expected that settled tendencies could be radically changed or a wholly different course of conduct instituted. It was hoped, however, that from the total of habits that made these persons what they were those favorable to lessening disability could be cultivated and those unfavorable could be subordinated. The following examples illustrate the ways by which attempt

TO I N F L U E N C E

CONDUCT

265

was made to foster habits deemed important to the medical purpose. The humiliation felt by 2 patients, Catharine Monahan (Case Record) and Irene Barclay (Abstract 31), because of the conduct towards them of intimate associates caused them to be in a more or less constant state of tension and futile striving for self-assertion or vindication. Such a state, leading as it inevitably did to periodic disputes and outbursts of recrimination, was unfavorable to the best functioning of damaged hearts. Complete change of conduct could not be expected on the part either of patients or of associates.* But mitigation was achieved. The hospital's contribution was twofold: toward associates and toward patient. To these associates, careful interpretation of the patient's condition and of the recommended medical treatment was given, the treatment being chiefly environmental protection and regulation of energy balance. The relevance of specific social factors to protection and regulation was made explicit, the social factors including effort in child-caring and home management, friction, and restricted outlets. Thus their understanding was enlisted as a means, of major importance, for remedying what was essentially a common family problem. Their cooperation was further enlisted by showing appreciation of the problems they were experiencing because of the patient, and of their endeavors to meet these problems. In these 2 instances, as in others, the hospital's manifest concern and regard for the patients had a strong influence on their associates, sensitizing them to the patients' peculiar requirements, and awakening their concern and regard. Although the greater regard and consideration of associates •The attempt to influence associates has been referred to under "Measures Designed to Control Environment" but is again introduced here because it involves essentially the same processes as are involved in influencing the patient, and because the relationship with associates affected strongly the ability of the patients in question to maintain habits medically right.

266

REMEDIAL MEASURES

did much to lessen the number of occasions when these patients felt belittled or chagrined, there were, however, stubborn realities present. To alter habitual reactions to these was the difficult task to which we recommended that the patients set themselves. Irene Barclay (Abstract 31) (see references under "Inadequacy of Means to Secure Subsistence") envied her younger sister for sound reasons: the sister was more able, better looking, and more admired, and had the things in life Irene Barclay most desired and could never have. The mother, with no intention of giving offense to our patient, depended on the well daughter's support and counsel and not on the invalid's. When allowed to handle the family's meager income our patient had often indulged an impulse to buy unnecessary things. It was better not to entrust her with responsibilities. Her impulsiveness, her temper tantrums, her frequent illnesses all made it natural to continue treating her as the ailing child of the family, the weak member, and an incompetent person, and to underrate the really important service she rendered. For it was she who did most for the mother, a childish and at times fussy invalid, she who kept going the lodging house which was their chief source of income, she who looked after the sister's child while the sister was at work during the day. No one, not even the patient herself, had ever thought of these services as in any way noteworthy. The sister's work as secretary in an important office was work that deserved recognition; the drudgery at home was not. She felt she had never had a real chance to show her ability; anyone could do what she was doing. She deeply resented being treated as a child. Persuaded by the hospital's social worker to learn more about household management, including nutrition, food values and costs, budgeting, and purchasing, she did so and gradually came to take genuine interest in the subject for itself. She learned also that scientists are engaged in study

TO I N F L U E N C E

CONDUCT

267

of the subject, that it is taught in colleges. Her own activities came to seem less humdrum. She found she could improve her performance of these activities, and that improved performance won the approval of others whose approval she desired and needed. T h u s two ends were attained by arousing interest and directing it into a practicable outlet: first, diversion from habitual brooding upon and thereby in part provoking humiliation; and second, well-earned recognition for merit. T h e result was the lessening of emotional tension from dissatisfaction and of physical fatigue from spasmodic and futile expenditure of energy to gain approval. For the other patient, Catharine Monahan (Case Record), overcoming strong reactions when subjected to slights and indignities was more a process of resignation to relationships with persons themselves disgruntled and helpless to resolve their own problems. T h e husband's easygoing, always somewhat unscrupulous conduct was not improved by the trying experiences to which he was subjected in the patient's illness and slow convalescence: unemployment, dependency on public relief, separation from wife and children. T h e motherin-law, expecting to receive, not to give, aid, could not be gracious about assuming the guardianship of a very naughty nine-year-old boy on behalf of a daughter-in-law against whom, not altogether unjustly, she harbored grudges from the past. Her own failure to lend aid to her son's family in time of crisis only increased her resentment against them. The hospital's contributions to Catharine Monahan's endeavors to learn and practice habit regulation, besides enabling measures for her environmental protection, were understanding of her problems, appreciation of her endeavors, and continuing encouragement to persevere, helping her both to itemize her experience (thus distinguishing the important and feasible) and to universalize i t — " O t h e r s have lived through this and so can I . " Learning to pass over the slights and unkindness of "in-laws," even to laugh about

268

REMEDIAL MEASURES

them finally, appeared to be not too difficult. But reconciling herself to her husband's inadequacy, irresponsibility, and growing irritability was a long process of self-discovery and compromises between cherished illusions and daily realities. The opportunities afforded her in a long association with the hospital's social worker, a disinterested and sympathetic listener, to talk out her perplexities and grievances helped her to look at her problems in perspective, and to decide in favor of caution or risk to her health as emergencies arose, not on the basis of impulse or hurt feelings but on the basis of long-range advantage. Her statement, made after three years of close association with the hospital, that she had ceased to blame her husband because she had come to realize he lacked the qualities necessary to overcome the difficulties they had encountered, was interpreted, rightly, we believe, as an indication of fair adjustment to a major source of harmful emotional reactions. This achievement and similar achievements in regulating habitual conduct contributed to a slow but continuous regaining of health. The odds overcome by this woman to attain this result, i.e., the continuing economic insecurity and friction in her home, lowering of standards that to her meant loss of status, restriction of accustomed recreational outlets, made the regaining of serenity and power to enjoy life seem especially noteworthy. Now that these attributes have been stabilized under the stress of a protracted struggle with disease and social hardships, it seems probable that they may be counted upon as aids in defense against recurrence of ill-health. Already she has shown on several occasions that she has learned to recognize early the symptoms of recurring rheumatic disease and quietly to take measures to protect herself, even when domestic conditions have been adverse. For only 2 of these 7 patients did it prove difficult to encourage their interest in the idea of altering habitual conduct. In all some interest already existed, as general de-

TO I N F L U E N C E

CONDUCT

269

sire to feel well again. Nor was it very difficult to persuade them that a change of habit would be a step in the direction desired. But it was difficult to maintain interest sufficiently strong and steadfast, in persons demoralized by ill-health, to overcome discouragement, and to acquire the skill of hand or the knowledge necessary for a new activity, or merely to follow painstakingly the rules laid down by medical authority for becoming a competent invalid. When the object was the blocking off or the strengthening of habits, the procedures used were in general similar to those we have attempted to describe. The particular situations and capacities of different patients indicated a need to emphasize now the imparting of information, now the influencing of choice, or to emphasize one or another phase of imparting or influencing. The worker's relationship with the patient usually continued long enough for the patient to establish by practice the habits he had set out to learn. The procedures commonly used by the worker were: giving information to guide, stimulate, and reassure; suggesting or enabling opportunities to carry on activities; and stimulating interest in performance and choice of means. Interest was stimulated chiefly by the "back-fire" method of engaging the patient in activities not associated with the trouble area and by the "positive routine" method of providing the support of an ordered framework for activities the patient might be too timid or too listless to carry on unaided. BY.*—Influencing conduct is an educational process. The teacher attempts to exert influences upon the learner. The learner attempts to utilize these influences. The competent teacher does not insist overzealously that the learner must follow one defined way, for he realizes that the learner may have abilities or controlling motives he has not discovered. He may suggest a possible way or a way he

STANDING

* This expression was given us by Dr. Richard C. Cabot.

270

REMEDIAL

MEASURES

has himself found or known to be satisfactory. In the end, however, he must leave the learner to choose for himself, if his aim is to educate rather than dominate. So on behalf of certain patients, by ill-health deprived of vitality and usual opportunities, unable to accommodate themselves to this change, and by worry and fretfulness rendering themselves still less able to cope with life, influences were exerted which might perhaps help them learn another way of life more serene and in better harmony with their present circumstances. What they really learned was their own way, the influences having helped or hindered or been ignored. In the actual process of learning their own way, the hospital's attitude was one of noninterference. This was not in the sense of withdrawing but of awaiting developments. One meaning of standing by is this quiescent waiting. It might be described also by the expression action in inaction. Actually, in standing by we did nothing overt, but the patient felt assured of our readiness to help should he need help.* He knew also that we understood much about his situation and personal problems, and more than he did about his sickness. It is not stating it too strongly to say that with two or three exceptions, those patients to whom the standingby service seemed helpful all believed that the hospital understood their needs and difficulties better than any other one person or aggregate of persons. There were patients whose problems, health or social, were not understood by us but they are not considered in reference to the standing-by process. The 24 persons here considered we claim in the main to have understood. In any case, whether we under* AU discussion in this report pertains only to social factors and measures for influencing these. We have tried to use terms for factors and measures suggesting their general meaning, and, by illustrating and explaining, to circumscribe each factor or measure as much as possible. Standing by might be used to denote the process of noninterference or watchful waiting when disease is allowed to take its course. That process is perhaps more active than the one we are attempting to describe. But we are not here attempting to describe any process for dealing with disease proper.

TO I N F L U E N C E

CONDUCT

271

stood them correctly or not, they entertained belief both in our understanding of them and in our willingness to help them. This belief accounted for much of the value of the standing-by measure. In addition, these patients realized that the hospital expected something of them, something no one could do for them, that they must do for themselves. Some of the doctor's interest in restoring function was imparted to them, thus keeping active the effort to do the things expected, things often tedious to do and usually requiring restraint. The hospital's expectation was part of the standing-by process and might refer to the patient's carrying out of positive routines or some other specific endeavor; or to the far harder disciplines involved in mastering the invalid role, that is, becoming as competent an invalid as he could; or to the exercising of intelligent regulation of conduct in order to remain as able as possible when partially disabled. T h e point we would make is that in the unremitting struggle most of these patients went through to maintain adjustment or to live above their sickness, they were influenced both by the natural desire to get all they could out of life for themselves, and by the feeling that the hospital had, as it were, a stake in their course. It is our opinion that much of the help manifestly derived by patients from the so-called "follow-up for end results" comes from their belief that the hospital understands their problems and that it stands ready to help should their own resources fail, and from the realization that it expects them to live up to their part in a joint enterprise. Standing by, as we use the term here, helps the patient only in his own handling of his health problem, and specifically in his regulation of his own conduct to this end. It is a kind of remote unspoken persuasion and encouragement. Evidence appears to us ample to warrant our claiming that this measure affected the conduct of patients to whom it was

272

REMEDIAL

MEASURES

applied. Reference to our experiences with certain patients whose medical care was complicated by social disabilities may perhaps make clearer the nature of the measure in question. We select for illustration instances where little was done directly to relieve the social disabilities. The hospital did, however, stand by and as a result of this the patient and his family were better able to carry on. Following thyroidectomy, the patient Hilda Pogany (Demonstration 4) continued to return to the hospital at intervals for more than two years. The operation had relieved the thyroid symptoms, but she continued to need treatment of other conditions: eye defects, phlebitis, childbearing injuries. Throughout this period the patient continued in a state of emotional turmoil over social and economic failures. The financial failure and ensuing insecurity of subsistence were significant for this woman almost entirely because of the great concern she had for social position, displayed as material possessions, educational opportunities for her children, etc. Details of her misfortunes and of her courageous and able attempts to counter them have been presented (see Demonstration 4). Both she and her husband resisted all persuasion to seek financial relief from welfare agencies. Although it seemed probable that the patient's health was being undermined by excessive anxiety and perhaps by overexertion in trying to earn support for the family as well as to maintain the home, it was not possible to force them to accept relief. We did what we believe this patient wanted us to do and what was all she could then accept. We stood ready to help when, if ever, she should ask. Each time she came to the doctor for treatment she voluntarily sought out the social worker and reported her trials and errors in handling the family's social problems. The social worker gave uninterrupted time to listen to accounts of the son's education, the husband's former business success, or whatever the patient desired to express. What she

TO I N F L U E N C E C O N D U C T

273

appeared to desire always was recognition and approval. This was given. When she chose to tell of her fears that her husband's morale was breaking from his repeated failures to find employment and to meet financial obligations, suggestions were offered as to how the problem might be met and as to how others were meeting similar problems. We knew, as the patient did also, that during the dearth of 1930-33, little if any attention could be given by relief agencies to matters of social position. They had neither business opportunities nor college scholarships to offer, and it was primarily these matters that gave this woman concern. Had her husband or her son found employment suited to his ability and training, small salary would not have seemed an undue hardship. When, after two years, the son found clerical work in a clothing store at $7 a week, this seemed far better than the truck driving he had before found at $12 a week. But after strongly advising once, when their situation appeared to be especially precarious, that they apply for the subsistence relief we were sure would be granted, we never again urged this action upon them. In the end, after two and a half years, relief was asked for and received. That, however, is a later episode and does not belong to the subject we are illustrating. The question we seek to answer is whether this patient derived any help in resolving her problems by virtue of telling them and the solutions she desired to persons (doctor and social worker) who she knew had no power themselves to alter the facts confronting her. The main reason for believing that she did derive help is the fact that she herself repeatedly sought opportunities to tell us of her difficulties as they occurred through the many months of association. It seemed important to her security and self-esteem that we should understand the ordeal she was experiencing and how excellently she was managing, and also that she was doing all she could to retain equanimity in the face of calamity. If she did not do

274

REMEDIAL

MEASURES

so at times, the harsh realities excused her. It also seemed that she derived some satisfaction from seeing her troubled situation through the eyes of another person, and of a person she knew was interested in her and respected her more for the courage and ability she now demonstrated in adversity than for her past possessions and social position. There was, doubtless, also the feeling that if she were defeated and driven finally to accept support from charitable funds, it would be somewhat less ignominious to do this because the hospital affirmed her need on health grounds. But of importance equal to the importance of the material safety which she believed we could secure for her was our understanding of her problems and our recognition of her ability. In 2 instances, standing by was maintained by exchange of letters, the patient writing to the social worker, the social worker, after consulting the doctor, writing a reply to the patient. One was Florence Baker (Abstract 62). This woman had for many years sought to escape loneliness and tedium by occupying her days with volunteer activities on behalf of a community service. In doing this she kept herself in a more or less constant state of overfatigue. Moderation of activity was advised. To help her in this very difficult task, we advised that she develop more sedentary work habits. She might, perhaps, write of her experiences in the service and by this means, and also by direct instruction of others, prepare for continuation of the work in the community when she should no longer be able to carry it on. Later we advised her to board with a neighbor in whose home she could have companionship and service when she needed it. Her letters consisted mainly of detailed and interesting descriptions of her work and of her efforts to follow medical advice. In reply we expressed interest in her and appreciation of her endeavors, which we felt really deserved praise, and during two years this relationship with the hospital appeared to keep before her the idea of moderating her overdoing.

TO I N F L U E N C E

CONDUCT

275

T h e other patient for whom relationship with the hospital was maintained by letters was Theresa Fleming (Demonstration 6). Here again we believe her realization of the hospital's interest in her and of our appreciation of the difficult problem she sought to master encouraged her endeavors. In both these last instances, it seemed probable that the patients were somewhat helped also by the fact that their relatives likewise had the belief that the hospital stood ready to aid and advise regarding care of the patients. The needs of these patients and the conditions deemed best for them had been explained to their relatives. Having better understanding, they gave more discriminating sympathy and consideration. In 3 other instances the hospital's standing-by service was given directly to members of the patient's family and was mainly through them of benefit to the patient. The patients had cancer in the terminal stage and were being cared for in their own homes. In the case of William Murray (Demonstration 17), standing by was, we believe, a service of very considerable value. (During the last months of his life more active intervention was required, such as supplying nutrients and narcotics, instructing his wife as to how to prevent bed sores, etc.) His wife really took the part of nurse as well as that of breadwinner for the family during two long years of anxiety and hard work. She herself had not believed she could do this even for the few months her husband was at first expected to live. Courage to carry on came largely from finding that what she did was satisfactory and that her husband became more comfortable and far happier than he had been in the chronic hospital where we had at first thought it best to send him. But there was also sustaining strength for her in her confident belief that the hospital stood ready at all times to come to her aid should she prove unequal to the responsibilities she had assumed. It meant a good deal, too,

276

REMEDIAL

MEASURES

that we thought her able to learn to nurse the patient and that we gave approval of her accomplishment. To the hospital's visitor also she expressed her doubts, fears, and distress as she could not to anyone else, for she felt it was best that neither the patient nor his friends and neighbors should know the nature of his disease. In these ways, she was aided to maintain serenity, and through her serenity and the cheerful home life she fostered about him, the patient remained calm and happy. This indirect influence in regulating the conduct of a patient seemed in this case, as in a number of others, more effective than direct influence. RECAPITULATION

From our previous illustrations it is evident that several measures to remedy unfavorable social factors adjudged component in the medical problems were at times used in certain cases, and the same measure at times repeated. As the figures below represent the number of patients on whose behalf the measures named were used, whether once or more than once, the total therefore greatly exceeds 54, the total number of patients to whom they were applied. The measures undertaken and the number of patients affected by each are shown in the following list: Measures designed to control environment Supplying deficiencies in environment Helping patient to utilize available resources Removing obstacles to care Removing patient to more favorable environment Measures designed to influence conduct Imparting information regarding problems of subsistence and satisfaction Explaining Elucidating Demonstrating Influencing choice regarding problems of subsistence and satisfaction Fostering habits Standing by

48 14 16 8 39 41 31 28 10 12 12 7 24

RECAPITULATION

277

From the use of these measures on behalf of the 54 patients the following results were obtained. For 28 patients the change of social factors recommended by the doctor was in the main satisfactorily accomplished. For 17 the change was partially accomplished. For 9 the change recommended was not accompanied; yet 4 of these patients eventually achieved fairly good results in ways they themselves chose to follow. In addition to the 54 patients for the relief of whose social problems the hospital took remedial measures, this study includes 46 for whom no such relief was undertaken by the hospital. Of these, 15 patients, without aid from any social agency, themselves effected the change of social factors which the doctor recommended. In the cases of 4 others there appeared considerable evidence of need for change, but little was accomplished or even attempted for these patients because they refused to follow medical advice. For 20 patients no need for change of social factors was indicated, the social-economic situation and personal adjustment of each appearing to be reasonably satisfactory. Adding the 7 patients who died early in their first admission to the hospital and whose care required no use of measures to relieve social problems, the classification given of the remaining 93 according to social treatment attempted or not attempted accounts for the hundred persons studied.

IX CONCLUDING

OBSERVATIONS

The idea which emerges most clearly from the material assembled for this report is that of disability variously manifested. We attempted to make this idea the dominant theme of our report concerning the social component, for it seems that adverse social factors have significance in medical care chiefly because of their power to disable. We have claimed that these factors expressed as deprivations, strains, and dissatisfactions have physiological effects, viz., depletion of body substance, fatigue, emotional tension. These effects seem of special importance in aggravating disability already started by organic disease. The number of instances in which control of social factors was accomplished and yielded benefit leads us to conclude that medical care can be more adequate and probably more economical when discovery and control of adverse social factors is made a routine procedure. Regarding the responsibility of the medical practitioner for controlling or directing control of social factors, our conclusion is that it is a responsibility which it is necessary for him to assume, since, if our findings are correct, these social factors constitute part of the medical problem which he undertakes to solve. A service adjunct to the practitioner, like that of a social service department in a hospital, can, when given the kind of medical direction secured for this undertaking, be made a practical means for accomplishing discovery and control. The method employed to determine the character of the patients' reactions to adverse social factors and their effect on health is displayed in the copy of a whole case record,

CONCLUDING OBSERVATIONS

279

in the seventeen demonstrations, and in the descriptions and illustrations of the classified social factors and measures undertaken to remedy them. This threefold presentation brings out the interrelatedness of factors constituting the health problem. When read in connection with the Abstracts, prepared by Dr. Knauth, of the whole series of one hundred cases, this gives the reader a fairly complete statement of our endeavor to interpret the social component in medical care. The main point we have tried to make as to method is that the more clearly concepts of factor and of remedy are formulated in the mind of the worker, the more sure is he in ability to find the factor and apply the remedy. We have tried to state our ideas as clearly as possible, even oversimplifying them for the purpose of analysis. At the same time we recognize that a scheme must be general and flexible enough to admit constant growth and variety of content, so that preconceptions may as little as possible blind the searcher to hitherto unperceived meanings in the facts which present themselves afresh in each new case. The process of subdividing and classifying human experiences as "social factors" and "remedial measures" has brought to those who participated in the task a deeper realization of the meaning of these experiences and an intensified appreciation of the nature and potentialities within each of the ideas or concepts listed and described specifically as social factors or remedial measures. The framework of these concepts has proved useful as a scheme of reference which can be applied to any individual for defining his social problems and the means for relieving them. An imperfection in the factoring scheme is that the concept "nurture" (i.e., fostering development, bringing up, education) is not specifically included. Had our subjects for study been taken from a children's instead of an adult ward,

280

CONCLUDING

OBSERVATIONS

the data dealing with nurture would have made so large an aggregate that this concept would have been a necessary section of the factoring scheme. The idea is, however, implicit in the subsistence-satisfaction scheme, especially in the section "Faulty Personal Habits Affecting Protection of Health." Even had it seemed expedient to include a division "Nurture," in order to provide a more universal scheme of reference, its content must have consisted virtually of the items treated under subsistence-satisfaction. Regarding some points discussed, distinctions are drawn which we believe to be useful for those who aim to assist patients to achieve more vigor or less discomfort. In particular, we call attention to the distinctions between insufficiency of means to support life and of means to support a desired manner of living or social status ; and between actual insufficiency and fear of insufficiency or insecurity. Likewise it is useful to learn to distinguish accurately the several strains that frequently are associated in the experience described as undue effort to secure subsistence, when to regular gainful employment is added, during hours needed for recuperation, the care of an invalid or other home responsibilities, or when, because of dissatisfaction with duties or conditions, employment, not otherwise taxing, results in weariness. The physiological effects from any of these conditions may be quite similar, usually an excess of tension and fatigue, but measures for rectifying the effects may have to be quite dissimilar. Lessening of labor is required in some instances, change or even increase of labor may be required in others. A distinction emphasized is that between restless idleness and restorative rest. Rest by limitation or modification of activity was a frequent and important prescription which many patients found difficult and many failed to observe. The influence of social factors in preventing rest was repeatedly noted. Indeed, it is our impression that in relation

CONCLUDING

OBSERVATIONS

281

to no other medical therapy did social factors appear to have as much importance. Our findings indicate that study and experiment are required to render the rest therapy a more reliable measure. Akin to the problem of restlessness and learning to rest is that of fixing attention on symptoms or any subject that induces feelings of discontent and depression, with resulting increase in disability. This is an old problem in medical care and one repeatedly discussed in this report. We attempted to demonstrate the complex of interrelated social factors that usually are elements in this problem. A good deal of space is given also to displaying measures employed to lessen the baneful influence of some of the factors. We call attention to two measures generally used for alleviating factors associated with both restlessness and concentration on unpleasant subjects: ( 1 ) aiding or influencing the patient's family or other associates to organize for him a favorable environment; ( 2 ) providing for the patient and influencing him to utilize opportunities and outlets in order that attention be diverted from unpleasant subjects. For many patients much was done to stimulate them to utilize outlets. In the main the results seemed to be a lessening of disability and hence seemed to afford some basis for the conclusion that part and often much of the disability of these patients was due to dissatisfaction. Objection may be made that merely diverting attention from conditions causing dissatisfaction, whether they be symptoms, friction with associates, economic insecurity, etc., is superficial relief and cannot endure. The criticism is valid if the outlet is used instead of more radical measures to correct handicap (physical or emotional) or intolerable conditions which can be corrected. But many times the handicap cannot be altered and diversion of interest is the only possible method of compensation. Also many times the conditions surrounding a patient are so much a part of his dissatisfaction, and hence

282

CONCLUDING

OBSERVATIONS

of his disability, that changing these conditions by providing new outlets reaches the root of the trouble. Here again we have a problem that requires more study and experiment. It is most important for sound future development that more accurate and concise terms be invented for expressing social factors and remedial measures and that such terms come to be the habitual mode of expression of all who engage in the social work of medical institutions. A generally agreed upon terminology for expressing practicable measures to remedy social factors would at the present time do much to counteract both unawareness of the effects of adverse social factors and lethargy about overcoming them. For to have a clearly articulated purpose, and means whereby this can be achieved, of itself supplies motive and direction to action. Because we ourselves are convinced that disability can be decreased by controlling adverse social factors affecting individual patients, we hope the whole subject of this component in medical care will be given the serious consideration and the thorough exploration we believe necessary for dealing with its many intricate problems.

APPENDICES

APPENDIX ABSTRACTS

OF

ONE

1

HUNDRED

CASES

ABSTRACT 1

Admission December 9, 1930

Male; age 16

Diagnosis.—Subacute Rheumatic Fever; Chronic Cardiac Valvular Disease, Mitral Insufficiency. Medical.—A boy of 16, with painful feet for 6 weeks; rheumatic pains 6 years ago for 2 months. No fever during 2 weeks' stay here. No cardiac symptoms. Question as to whether there was active heart lesion. Social.—Temporary activity limitation accepted by an active, adolescent, American boy, in spite of regret over school interruption for 6 months. Favorable economic, family, and personal factors. Plan.—Convalescence at home for several months. Move to Southwest if possible. Course.—No further heart involvement noted after 7 months. Family moved Southwest without help. Summary, September, 1931.—Intelligent and resourceful patient and group. Able to change whole mode of living to protect son from further illness. Note added March 1, 1935.—Private physician reported patient had no recurrence of rheumatic disease to date. He remained in Southwest until autumn of 1934, then returned to New York.

ABSTRACT 2

Admission November 11, 1930

Female; age 53

Diagnosis.—Arteriosclerosis; Hypertension; Coronary Sclerosis; Cardiac Hypertrophy and Insufficiency.

A B S T R A C T S O F CASES

286

Medical.—Third admission, within 1 year, of a woman of 53 for severe cardiac decompensation and frequent anginal attacks not relieved by medication. Discharged after 8 weeks still slightly decompensated, with poor prognosis. Social.—Lady's maid, German, unmarried, alone in New York, homeless, not naturalized, and dependent on own earnings. Two years of underemployment through illness have exhausted savings. Fear of dependence has forced her to overexertion. Attacks of cardiac pain seem to be coincident with anxiety. Plan.—Extreme restriction of activity. Attempt to be made to accomplish this outside of chronic hospital because of patient's fear of dependence. Course.—Convalescent home 6 months. Maintenance then provided in supervised residence club through welfare agency until suitable resident position could be found. Interest in church, reading, etc., stimulated. Continues under clinic care; barely compensated. Summary, October, 1931.—Case of advanced cardiac disease. Permanent institutional care was unacceptable to patient, in whom anxiety seemed to be related to symptoms. Consequent mobilization of social resources involved much time and effort. Note added March 1, 1935.—Patient remained 5 months in residence club where small tasks requiring little exertion were assigned her. Despite this, she continued to be anxious and restless. I t was finally decided that proper protection outside a hospital could not be secured for this homeless woman. She was admitted to a hospital for chronic care on November 28, 1931, and died there April 1, 1932.

ABSTRACT Admission

October

6, 1930

3 Male;

age 54

Diagnosis.—Carcinoma of Stomach with Metastases. Medical.—A man of 54, with epigastric distress for 1 year. Carcinoma of stomach was suspected. Exploratory celiotomy was done and metastases were found. Patient was discharged after 4 weeks, unimproved, with downhill prognosis. Social.—Clerk, German, chief wage earner, with progressive occupational handicap; economic insecurity a potential worry,

ABSTRACTS OF CASES

287

but children of age to work. Active man whose activity must be greatly diminished; but has many personal resources and interests. Good home, intelligent wife; home care possible. Plan.—Permanent care at home. Course.—Much interpretation to wife. Finally patient was turned over to local doctor satisfactorily. Died April 5, 1931, at home. Summary, September, 1931.—Unusually favorable home situation made possible the satisfactory terminal care of the patient.

ABSTRACT Admission

December

20, 1930

4 Male;

age 21

Diagnosis.—Chronic Nephritis; Hydrothorax; Tuberculosis of the Pleura. Medical.—Second admission of a 21-year-old youth with serofibrinous pleurisy and chronic nephritis of moderate degree. Tubercle bacilli found in chest fluid. Chest tapped 3 times but fluid persisted after 4 weeks. Guarded prognosis. Social.—An intelligent and ambitious single American youth, good-looking and conventional, of Irish stock; trained clerical worker out of work, dependent on parents for 3 years because of illness. Intelligent and congenial family group whose high standards are threatened by the economic depression. Apprehensive and oversolicitous mother. Patient sensitive over dependence and depressed by physical restrictions on his normal social outlets. Plan.—Tubercular and nephritic regimen. Prolonged convalescence and continued observation. Course.—In convalescent home for 3 weeks followed by stay with friends in Florida for 3 months at large expíense to family. Patient lost weight and did not improve. Therefore sanitarium care seemed advisable. Summary, October, 1931.—Need for restricted activity made it necessary to stimulate other interests. Uncertainty of prognosis made planning difficult. Note added March 1, 1935.—Patient admitted to sanitarium November 11, 1931. Death occurred March 2, 1932.

288

ABSTRACTS OF CASES ABSTRACT

5

Male; age 51

Admission December 26, 1930

Diagnosis.—Malaria; Choroiditis; Syphilis. Medical.—A man of SI, with chills every 4 days for 2y 2 years. Found to have quartan malaria, choroiditis, and hemorrhage into vitreous body of eye. Wassermann plus 4. No more chills following quinine treatment. Discharged after 2y2 weeks without symptoms. Social.—Had been teaching in Turkey, to which country he planned to return. Family self-sufficient and well-educated. Wife chronic invalid. Plan.—Antiluetic treatment. Course.—Discharged to pleasant home of relatives. Transferred to hospital out of city for antiluetic treatment. Summary, October, 1931.—Habitat important etiologically, because of malaria. No other pertinent social findings. Note added March 1, 1935.—Not followed. ABSTRACT

Admission April 10, 1931

6

Female; age 25

Diagnosis.—Serofibrinous Pleurisy. Medical.—A young woman, whose mother died of tuberculosis, admitted after having had pain in chest for 2 weeks. Thoracenteses done. Sputum negative. Course satisfactory. Discharged after 3 weeks. Social.—Exposure to tuberculosis; financial worry; overexertion in effort to earn subsistence; husband depressed over long unemployment and showing symptoms of diabetes; dependent on relatives; standards above income. Intelligence, interest, and the support by kin were advantages. Plan.—Sanitarium care. Course.—Sanitarium care arranged but fell through because patient refused to leave home. Regimen carried on well at home, under supervision. Summary, September, 1931.—Excellent response on part of family group in home care of serofibrinous pleurisy. Note added March 1, 1935.—Patient continued under care of City Health Department. In 1932 returned to this hospital for

A B S T R A C T S OF CASES

289

care during pregnancy and confinement. Normal baby. Discharged from post-partum care in good condition, except for being underweight. ABSTRACT

7

Admission April 27, 1931

Female; age 13

Diagnosis.—Chronic Tonsillitis; Acute Cervical Lymphadenitis; Scabies; Uncinariasis. Medical.—A girl of 13, very miserable with acute torticollis, showed bad tonsils and malnutrition, and was found to have hookworm and scabies. Improved remarkably with tonsillectomy and treatment for parasites. Discharged after 1 month. Social.—Behavior difficulties; retarded development; no English. Had never been to school; little training; no knowledge of hygiene. In a foster home, misunderstood and not wanted. Plan.—Training in health habits. Building up. Convalescence 1 month. Course.—At convalescent home in the country she gained 11 pounds. General improvement in physique and behavior. Summary, September, 1931.—Response to treatment of infections and parasites was good. Referred to child welfare agency. Patient finally was committed to a school for the feeble-minded. Note added March 1, 1935.—Not followed further.

ABSTRACT

Admission May 15, 1931

8

Male; age 59

Diagnosis.—Chronic Multiple Arthritis; Secondary Anemia. Medical.—A man with painful joints for 41 years; marked deformity of joints, some myocardial damage, large liver, and secondary anemia. History of alcohol and lues. On salicylates and iron he improved in his 2 weeks' stay. Foci being cleaned up. Social.—Skilled American Negro workman who had been reduced to window washing and dependence on children. No fixed residence or home since death of wife 1 year before. Recently living in basement apartment. Children able and willing to care for him. Plan.—Convalescence and slightly restricted activity. Course.—Left hospital to spend 3 months with relatives in the

290

A B S T R A C T S OF CASES

South. Plan made with son to finance newspaper stand for patient. N o follow-up obtained. Summary, October, 1931.—The cooperation of an intelligent and self-sufficient family group seemed to make it possible for this mild chronic to adapt his life to the ideal medical plan. Note added March 1, 1935.—Patient lost. ABSTRACT

9

Admission February 17, 1931

Male; age 20

Diagnosis.—Serofibrinous Pleurisy. Medical.—Boy of 20, with serofibrinous pleurisy. Course uneventful, aside from streptococcus throat while in hospital. Gained 6 pounds in 7 weeks and was discharged in good condition. Social.—Irish country boy of 20, in the United States 5 months, adjusting to city life; long hours of strain and exposure to weather as grocery boy. Uncle died of tuberculosis, but patient was not exposed to the disease at the time. Alert, ambitious boy with good home, habits, and standards of living, but limited education. Interested relatives. Plan.—Sanitarium care. Course.—Private sanitarium care arranged and paid for by relatives. Discharged after S months symptom-free and apparently well. Plan to send patient back to Ireland vetoed in view of good medicosocial prognosis and patient's discouragement at the prospect. Summary, October, 1931.—Environmental, racial, and hereditary factors all predisposing to tuberculosis. Family group able to carry out ideal treatment. Note added March 1, 1935.—Not followed. ABSTRACT

Admission October 20, 1930

10

Male; age 38

Diagnosis.—Ulcer of Duodenum (bleeding) ; Syphilis. Medical.—First admission of a 38-year-old man with S-year gastric history, admitted with bleeding duodenal ulcer proved by X ray. Wassermann positive; symptoms cleared on Sippy diet. Left, against advice, in 5 weeks.

ABSTRACTS OF CASES

291

Social.—Bookkeeper, Greek; faulty eating habits; irregular working hours. Overdoing, mainly because of economic pressure. Personality: tendency to worry; critical, haughty attitude. Marital friction—wife suspicious of infidelity. Intelligence; independence; good living standards. Adequate income, for ordinary needs. Plan.—Ambulatory ulcer regimen. Antiluetic therapy. Course.—Patient refused clinic treatment; said he would return to private doctor. After 6 months, still had symptoms. Social treatment was blocked because of patient's attitude. Summary, September, 1931.—Attitude, economic pressure, and home incompatibilities made it difficult to treat patient. Note added March 1, 1935— Not followed.

ABSTRACT Admission

April

3, 1931

11 Female;

age

34

Diagnosis.—Arthritis Deformans ; Chronic Tonsillitis. Medical.—A woman of 34, with multiple painful joints for 3 weeks. Severe polyarthritis of rheumatoid type. Gradual response during 3 months' stay with rest, salicylates, and tonsillectomy. Social.—Limited intelligence and education in a Puerto Rican woman; no English; came to New York 6 months ago from rural Puerto Rico. Earned meager living as machine-operating pieceworker in a dress factory; unhygienic, crowded home. No relatives in United States; friends unable to help; family in Puerto Rico impoverished, ignorant, but willing to give shelter. Plan.—Return to Puerto Rico. Course.—Investigation of Puerto Rican home situation. Transportation arranged through state agency. Sailed immediately on discharge. Summary, October, 1931.—Social problem seemed direct outgrowth of the medical. Medical may well have been precipitated by her recent move to poor conditions in the North. With no social resources here and less exposure to infection in the South, return to Puerto Rico seemed advisable. Note added March 1, 1935.—Social worker reported from Puerto Rico, December, 1931, that patient is unable to use her hands freely since she cannot close the fingers. Also unable to walk because of pain in feet. Happy with relatives.

292

ABSTRACTS OF CASES ABSTRACT

12

Admission December 17, 1930

Female; age 32

Diagnosis.—Hyperthyroidism; Exophthalmic Goiter; Syphilis. Medical.—A woman of 32, with thyrotoxic symptoms for 6 months; a partial thyroidectomy reduced basal metabolism rate from plus 45 to minus 17. Wassermann found plus 4; deafness; salpingitis; varicose veins; bad teeth. Discharged in 4 weeks much improved. Social.—American housewife; heavy family duties; 4 small children. Affectionate but selfish husband. Living close to margin, with no extras for illness. Plan.—Guarded convalescence and clinic observation. Antiluetic treatment. Course.—Explanation given concerning necessity for further rest after leaving convalescent home early. Completed first antiluetic course. Moved to better home. Continued clinic care. Patient was assisted in adjusting to disability and putting through the treatment plan. Summary, September, 1931.—Not unusual home burdens proved too heavy for a patient with exophthalmic goiter and other physical defects. Note added March 1, 1935.—Patient continued under care of this hospital; thyroid satisfactory, general condition good; able to do her work.

ABSTRACT

Admission November 10, 1930

13

Female; age 54

Diagnosis.—Acute Bronchitis and Sinusitis; Arteriosclerosis and Hypertension. Medical.—'Third admission of 54-year-old woman; had had an upper respiratory infection for 2 weeks. She was found to have hypertension, arteriosclerosis, a big heart, as well as acute bronchitis and sinusitis. Discharged after 2 weeks, improved. Social.—Presbyterian Hospital employee, Irish, well adjusted in work and home. Plan.—Convalescence.

ABSTRACTS OF CASES

293

Course.—Convalescence with friends. Returned to work afterward. Summary, September, 1931.—Protected life through long association with the hospital; no outside problems. Note added March 1, 1935.—Patient has continued at usual work and remained in fair health. ABSTRACT Admission

October 6, 1930

14 Female;

age 25

Diagnosis.—Probable Tuberculosis of the Left Kidney and Lungs ?; Chronic Salpingitis. Medical.—A colored woman of 25, with a 1-year history of loss of 65 pounds, indigestion, pain on right side, and chronic salpingitis. Discharged after 3 weeks without definite diagnosis but to be treated as tuberculosis suspect. Social.—Young, unskilled, widowed American Negress of limited intelligence and education, had been supporting self and ailing 2-year-old child by heavy day work since husband's death 1 year ago of tuberculosis of the kidney. Irregular and insufficient financial aid given by poor relatives and friends since illness. Unhygienic home, poorly ventilated and ignorantly managed. Patient lonely, suggestible, frightened. Plan.—Treat as probable tuberculosis. Course.—Instructed in care of child who was placed under clinic supervision; no tuberculosis found in child. As patient's symptoms persisted she was sent to tuberculosis ward of city hospital pending sanitarium admission. Signed herself out and went elsewhere for treatment of salpingitis. At this time she began living with a pleasant colored man. Complaints disappeared and she gained weight rapidly. Summary, October, 1931.—Functional element suggested by coincidence of illness with economic and emotional insecurity following husband's death, his symptoms similar, and by immediate improvement on regaining security and treatment of chronic salpingitis. Corroboration was difficult because of evasiveness. Note added Marek 1, 1935.—Patient last seen in the clinic December, 1931. Had had no recurrence of symptoms. Had worked and gained weight.

A B S T R A C T S OF CASES

294

ABSTRACT Admission

IS Male;

April 3, 1931

age 56

Diagnosis.—Cardiac Insufficiency; Aortitis; Syphilis; Coronary Occlusion. Medical.—First admission of a man of 56; had had cardiac insufficiency for months. Cerebral accident 10 months ago and another while in the hospital, probably embolic. Arteriosclerosis and a large heart found. Wassermann plus 4. Died 2 weeks after admission. Social.—An American bank clerk who had been ill and dependent on his wife since his marriage one year ago. Wife unable to care for him at home, because of her outside work. Plan.—Patient's death occurred before plan was made. Course.—Rapidly downhill. Died in hospital, April 18, 1931. Summary, September, 1931.—A potentially difficult problem of care for a cardiac.

ABSTRACT Admission

January

26,

1931

16 Male;

age 23

Diagnosis.—Bronchiectasis. Medical.—A young man was admitted because of hemoptysis for 3 weeks. He had had pneumonia 3 years ago and had never fully recovered. Found to have bronchiectasis. Abscess of jaw developed while in hospital. No evidence of tuberculosis. He was discharged after 7 weeks, improved. Social.—Italian; power press operator; of low-grade intelligence, but cheerful and willing. Dependent on family for decisions. Only experience was factory job in congested city area. Excellent suburban home and cooperative family. Financial circumstances favorable. Plan.—Conservative treatment; postural drainage. Convalescence. Change of work to avoid exposure to dust. Course.—Three weeks' convalescence. Plan explained to patient and family accepted, but they were not able to carry it out alone. Social worker unsuccessful in obtaining work in the country for him, because of industrial depression. Summary, September, 1931.—Change in patient's whole life

A B S T R A C T S OF CASES

295

advisable, but difficult because of patient's low intelligence and the industrial depression. Note added March 1, 1935.—Postural drainage not faithfully carried out through lack of family cooperation. Following second admission July 29 to August 3, 1932, treatment conscientiously followed and condition much improved. Able to work.

ABSTRACT

Admission October 6, 1930

17

Male; age 45

Diagnosis.—Asthma. Medical.—Second admission of a 45-year-old man; had had hay fever for 20 years before his desensitization 3 years ago, and asthma for the last 8 years. Chronic nasal and bronchial infection found and sensitivity to jute, ragweed, and dust, for which he was desensitized in the Out-Patient Department; there was little relief. Patient completely dependent on the clinic for relief of frequent and severe attacks. Very little change, however, in the yearly course. Discharged after 1 week. Social.—A skilled Italian barber; unable to work for 7 years; he and his family with 3 small children have been completely dependent on organized charity for 3 years. Uncertainty of prognosis, and treatment bred fears and anxiety and he grew progressively more passive, introspective, and depressed. Wife recurrent patient for kidney disease. Plan.—Continue in Allergy Clinic. Try change of habitat and try to get him to work. Course.—Did not remain in country where he was sent. Occupational therapy was started; patient exhibited interest. Use of staphylococcus vaccine was begun. Patient was readmitted a year later for same complaints, with no change in medical or social situation. Cooperation between agency and hospital was maintained. Summary, October, 1931.—Problem of the emotional adaptation of an unintelligent patient to a chronic disability with invalidism already quite far advanced. Note added March 1, 1935.—Patient continued under treatment intermittently until October 2, 1934. Neither domestic situation nor patient's condition was much affected by hospital's efforts.

ABSTRACTS OF CASES

296

ABSTRACT Admission

February

18 Female;

9, 1931

age 28

Diagnosis.—Acute Rheumatic Fever; Mitral Stenosis and Insufficiency. Medical.—A woman of 28, with joint pains for 4 months. Had a previous rheumatic history. Very slight functional disability; foci removed. Patient responded well to treatment. Discharged after 4 weeks nearly symptom-free. Social.—Resourceful and cooperative young housewife with 2 active and unmanageable children and an unsympathetic, irresponsible, and underemployed husband. Heavy work as waitress as well as heavy housekeeping duties (4 flights of stairs). Irregular eating and sleeping, and overwork, despite instructions by local doctor. Marked anxiety caused by economic insecurity. Marital friction for 10 years. Plan.—Convalescence and restricted activity. Course.—Children placed for 6 months to enable hospitalization and convalescence and to lighten strain when patient returned home. Interpretation of disability to patient, husband, and relatives, thus insuring better cooperation. Family persuaded to move to elevator apartment. Family agency gave financial aid. Relatives cared for one child and institution for one. Physiotherapy for S months. Summary, October, 1931.—A complete change in environment was necessary in order to carry out the medical plan, along with many hours of interpretation and readjustment of social setting. Results after 8 months seemed to justify efforts. Note added March 1, 1935.—Patient continued under care of this hospital. After 6 months resumed home duties, later gainful employment. Generally symptom-free.

ABSTRACT Admission

December

27, 1930

19 Male;

age 22

Diagnosis.—Chronic Rheumatic Fever; Chronic Cardiac Valvular Disease; Mitral Stenosis and Insufficiency; Cardiac Hypertrophy and Insufficiency; Auricular Fibrillation.

ABSTRACTS OF CASES

297

Medical.—A youth of 22, with chronic rheumatic fever since childhood, cardiac insufficiency, mitral disease, and fibrillation, with symptoms for 5 months. Improved on rest and digitalis. Poor ultimate prognosis. Social.—An Irish-American youth who had experience only in heavy unskilled work, now unable to do this. Financial pressure; father's income inadequate. Ignorance and limited interests. Passive but friendly. Poor home for cardiac with 2 flights of stairs. Plan.—Convalescent care. Marked restriction in activity. Course.—Remained compensated, on digitalis. Found satisfactory light work in father's shop. Summary, September, 1931.—Problem has been one of adjusting to restricted life a patient who had previously no understanding of his limitations and was handicapped by resources below average and by low intelligence. Note added March 1, 1935.—Patient has continued under care of this hospital. No rheumatism. Condition in the main satisfactory. ABSTRACT

Admission October 24, 1930

20

Male; age 27

Diagnosis— Bronchopneumonia ; Sinusitis ; Tonsillitis. Medical.—A young man of 27, with a S-day history of cough. Treated here 2 weeks for respiratory infection; made an uneventful recovery. History of sanitarium care 1 year ago without evidence of tuberculosis. Social.—Hospital porter, Irish, had worked here 4 months (since arrival from urban Ireland). Nervous mannerisms; defiant and suspicious attitude. Plan.—Convalescent care and return to former position. Course.—Plan carried out in 2 weeks. Refused tonsillectomy. Six months later had gained 20 pounds. Health and social adjustment good. Summary, October, 1931.—Potential tuberculosis warrants some continued supervision. The emotional maladjustment (unrelated to present illness) is masked by his protected life but is a potential source of future trouble. Note added Marek 1, 1935.—Patient has continued under care of this hospital. Worked regularly except for occasional acute respiratory illness. Tonsillectomy in August, 1932.

298

ABSTRACTS

OF

ABSTRACT

CASES

21

Admission April 6, 1931

Male; age 32

Diagnosis.—Lobar Pneumonia. Medical.—A man of 32, with acute lobar pneumonia; whole right lung was involved. Uneventful recovery. Discharged on 15th day. Social.—An American chauffeur leading a moderately successful existence except for acute financial difficulties precipitated by illness. Eviction threatened. Living beyond income. Plan.—Convalescence. Course.—Convalescence cut short by financial crisis; but no ill effects. Some assistance was given in adjusting bills. Summary, September, 1931.—Acute economic situation precipitated by illness in a man of about average intelligence who was living just beyond his income. Note added March 1, 1935.—Six months after discharge social worker reported patient had gained weight; was working regularly. ABSTRACT

Admission October 8, 1930

22

Female; age 52

Diagnosis.—Adenoma of the Thyroid; Hyperthyroidism; Hypertension. Medical.—Second admission of an unmarried woman of 52; had had symptoms of nervousness for 6 months. She had a partial thyroidectomy done. Discharged, improved, after 6 weeks. Additional neurological findings: weakness of hand, staggering gait, and temporary loss of vision of one eye. Diagnosed as probably disseminated sclerosis. Social.—Lady's maid, elderly, Bavarian, out of work following a year's illness, unable to get work because of age and disfiguring thyroid; had used up all her savings and was living in a crowded dormitory in contrast to luxury in the past. Distressed by death of mother and loss of money. No close relatives or friends. Plan.—Convalescence and return to work. Course.—Convalescence obtained; aid from former employer secured. Improved for 3 months, supporting herself with sewing.

A B S T R A C T S OF CASES

299

On undertaking resident position in poor and noisy home she developed weakness and fainting. Sent to country where she suddenly again lost vision of one eye; she was readmitted. Ataxia and weakness were more marked than on previous admission. Vision returned slowly. Diagnosis of retrobulbar neuritis; other symptoms still a puzzle. Remained in convalescent home for 3 months, and spent a summer with relatives with whom she was unwelcome. No success in getting employment. Returned to New York a year after first admission without job or money, in the same condition as a year ago. Summary, October, 1931.—Toxicity of thyroid developed in a year of unusual emotional and physical strain, caused mostly by unemployment. No recurrence after operation and convalescence although social factors remained very unfavorable. Uncertainty of etiology and prognosis of the neurological condition and the obviousness of her handicap were a serious bar to economic rehabilitation. Note added March 1, 1935.—This patient became less and less able to maintain herself. Diagnosis by neurologist: multiple sclerosis. Finally, in June, 1933, arrangements were made for her to return to her native land, Germany, to live with a friend, where she obtained a small disability pension. Last report, by letter from her, indicated increasing disability.

ABSTRACT Admission

January 27, 1931

23 Male;

age 51

Diagnosis.—Ulcer of Stomach; Syphilis; Arthritis; Cardiac Hypertrophy; Iritis; Optic Atrophy. Medical.—Fourth admission of a man treated here for 2 years for tabes dorsalis; he was found to have an ulcer of stomach, secondary anemia, a large heart, iritis, and arthritis. Posterior gastrojejunostomy was done; uneventful recovery. Discharged after 10 weeks, somewhat improved. Social.—Slovenly, quarrelsome old man, an American painter, totally dependent financially, because of illness, for the last 8 years on a slatternly, senile, nagging second wife who earned scant living by day-work and letting rooms. Always lived in tenement; home dirty, unkempt, up 3 flights. Wife unwilling to cooperate

300

ABSTRACTS OF CASES

in diet or care despite much effort to explain, but they clung together apparently enjoying the friction. Plan.—Permanent chronic care. Course.—Admitted to chronic hospital but signed himself out 2 months later to his home where conditions were unchanged. Summary, October, 1931.—Hopeless case from every standpoint. Disease, personality, and social setting all unfavorable for breaking the vicious circle. Even institutional care fell through. Note added March 1, 1935.—Patient left chronic hospital, was readmitted here for clinic care. Slow downhill course to date. Financial aid has permitted him to remain at home.

ABSTRACT Admission

April 10, 1931

24 Male;

age 51

Diagnosis.—Angina Pectoris; Coronary Sclerosis; Acute Gout. Medical.—A man of 51, with cardiac pain for 18 months. Recurrent severe angina pains relieved temporarily by paravertebral alcohol injections and decreased by nitroglycerin and theocalcium and encouragement. Discharged after 3 months, with total disability for work. Social.—Resourceful and intelligent insurance agent of outgoing disposition who had built up a good social and economic position which had been seriously threatened by the depression. He had been under much strain and worry for 2 years and now was cut off from all old activities of work and recreation by illness. Financial and home situation excellent. Plan.—Strictly limited activity at home. To be followed in clinic. Course.—Rate adjustment made because of long stay in hospital. Much reassurance and interpretation in planning satisfactory medical regimen. Created new interests by developing a ward newspaper and writing poems. Summary, October, 1931.—Prolonged strain prior to development of angina; excellent readjustment to a permanent disability necessitating complete change of life. Note added March 1, 1935.—Patient continued under care of this hospital to January, 1933. Cardiac condition about the same. Report from patient in 1934 and February, 1935, indicate general condition good. No return to work.

ABSTRACTS OF CASES

ABSTRACT

301

25

Admission May 1, 1931

Male; age 38

Diagnosis.—Cardiac Insufficiency; Aortitis; Syphilis. Medical.—Man of 38, with cardiac insufficiency for 6 months; luetic heart. Wassermann plus 3. Slow return of compensation in 4 weeks. Antiluetic treatment started. Prognosis poor. Social.—Unskilled Negro laborer. No savings, no income. Lodger, with no family. Unintelligent and only fairly cooperative. Plan.—Rest indefinitely, digitalis, and continued antiluetic therapy. Course.—Lived with friends who supported him. No change in condition. Summary, September, 1931.—Cardiac unable to return to old work. Without resources or capacities for adjustment to other work. May become a public burden. Note added March 1, 1935.—Readmitted to this hospital 3 times in the next year. In October, 1932, was admitted to a public institution for chronic care, where he died in August, 1933.

ABSTRACT

Admission February 5,1931

26

Male; age 43

Diagnosis.—Arteriosclerosis; Hypertension; Secondary Anemia ; Cardiac Hypertrophy and Insufficiency. Medical.—A man of 43, admitted for work-up because of epistaxis, albuminuria for 3 years, and hypertension for 1 year. No kidney damage found. Social.—Jewish cutter; faulty eating habits; reduced income (business depression). Situation otherwise excellent. Placid temperament. Plan.—Iron, low salt and protein. Avoid overeating. To work in 2 weeks. Course.—Patient was slow in getting back to work because of "weakness." Continuing normal activity. Summary, September, 1931.—A mild chronic hypertensive, who needed a regimen of moderation which was carried on after discharge.

ABSTRACTS OF CASES

302

Note added March 1, 1935.—Patient last seen October, 1931. Felt fine, no headaches, still showed vasomotor disturbances. Failed to continue under care of this hospital. ABSTRACT Admission

November

27

17, 1930

Male;

age

43

Diagnosis.—Bronchial Asthma; Sinusitis and Nasal Polypi. Medical.—First admission of a 43-year-old man; had had nocturnal dyspnoea for 6 months. Diagnosis of bronchial asthma and nasal polyps made, but patient refused operation in Ear, Nose and Throat Service and left, with misunderstandings. Not to be readmitted. Social.—Insurance agent, Hebrew; economic insecurity, with worry resulting from stock market losses, and from unemployment caused by illness. Apprehensive type of person. Uncertain prognosis. Increasing symptoms. Desire to get well. Interest and support of kin. Plan.—Effort to clear up infection. Course.—Left hospital refusing operation. Summary, September, 1931.—An asthmatic whose medical treatment was cut short because of apprehensiveness and unallayed fear, which made him leave the hospital suddenly. Note added March 1, 1935.—Patient not seen again. ABSTRACT Admission

February

16, 1931

28 Male;

age 21

Diagnosis.—Ulcer of Duodenum; Hypothyroidism; Schizophrenia. Medical.—Second admission of a boy admitted here 1 year ago for partial thyroidectomy because of pressure symptoms, presenting a 14 months' history of duodenal ulcer, proved by X ray. Hypothyroidism (31 + ) and definite dementia precox history. Left against advice. Social.—An Italian youth living alone in New York. Irritable, depressed, unstable, possibly psychotic. Unskilled work as broker's messenger. Family pressure for career above patient's capacity. Ignorant, emotional, immigrant family. Conflicts with parents in another state.

ABSTRACTS OF CASES

303

Plan.—Convalescence and continued observation. Course.—Plans for convalescence broken by leaving against advice. Attempts at follow-up. Carefully supervised transfer to hospital near home in another state where he became neuropsychological patient. Summary, September, 1931.—Psychotic factors became more and more prominent. Probably poor social setting in which to carry on treatment program. Note added March 1, 1935.—Learned from hospital to which patient was transferred that in October, 1931, "patient had suddenly appeared in the clinic, bright, cheerful, and apparently in a normal state of mind." Letter from patient's father in August, 1933, reported patient in good condition: "No trouble at all from his thyroid." In August, 1934, patient himself reported that he had been feeling fine the last year. ABSTRACT Admission

February

16, 1931

29 Female;

age 29

Diagnosis.—Lupus Erythematosis ; Incipient Pulmonary Tuberculosis; Tuberculosis of Cornea?; Pansinusitis. Medical.—A woman of 29 admitted for diagnosis of rash and photophobia; had had fever for 4 weeks. Tuberculosis seemed best to explain all lesions including signs in lungs. Possibly a staphylococcus infection of face. Discharged improved in 4 weeks. Social.—A Scotch housewife, moved to New York City from rural Scotland 2 years ago. Confined to dark basement by heavy janitress duties and care of 2 small children. Diet lacked milk, fruit, and fresh vegetables. Irregular rest and eating habits. Anxiety over reduced income but expenses have been met so far. Cooperative patient and group of fair intelligence but limited education. Plan.—Instruction in hygiene and regimen. Health supervision for children. Convalescence and continued clinic contact. Course.—Detailed instruction and interpretation of disability, hygiene, and diet given. Gave up work as janitress and arranged for lightening of household duties. Children placed under supervision of tuberculosis clinic. Six weeks' country convalescent care for patient and children, and 2 weeks' vacation later. Clinic contact continued. Had gained 16 pounds and was symptom-free after 6 months.

ABSTRACTS OF CASES

304

Summary, October, 1931.—Case of probable tuberculosis where race, environmental factors, and the development of the disease are interrelated. The symptoms cleared under proper hygiene and diet, and country care. Note added March 1,1935— Patient last seen May, 1932. Condition satisfactory. ABSTRACT Admission

February

30

6, 1931

Male;

age 41

Diagnosis.—Carcinoma of unknown origin. Medical.—A man of 41, with 2-year gastric history. Mass in abdomen and loss of 30 pounds in 3 months. Multiple tumors and Wassermann plus 4. Improved with radiotherapy. Discharged after 4 weeks. Prognosis downhill. Social.—Scottish man, golf-club maker, unemployed; insecure, irregular income. Good home, devoted wife; interest and aid of kin and Masons. Equable temperament. Plan.—Return for radiotherapy. Course.—Intensive radiotherapy with good cooperation on part of patient. Summary, September, 1931.—Financial problem handled by his social group. Wife found work. Note added March 1, 1935.—This patient continued under our medical treatment. He died in this hospital November 6, 1931.

ABSTRACT Admission

September

29, 1930

31 Female;

age 44

Diagnosis.—Cardiac Hypertrophy; Fibrillation; Double Mitral Lesion; Manic Depressive Psychosis. Medical.—The 10th admission of a woman of 44, with cardiac complaints for which she had been treated here since 1915. She was in a state hospital for manic depressive psychosis in 1928. Heart not decompensated, but some dyspnoea and pain. Improved on rest and digitalis. Discharged in 10 days. Social.—An intelligent and genteel American spinster, who ran a rooming house with her ailing old mother, had been developing

ABSTRACTS OF CASES

305

psychotic symptoms which assumed major proportions. Restricted life, lack of outlets, anxiety, and jealousy of sister present. Decreasing income from roomers and increasing hard work, but pleasant environment and well-planned routine were well adapted to patient's disability. Plan.—Return home. Continue activity restrictions and clinic attendance. Course.—Recommendations carried out. Patient was readmitted for a few days after a heart attack but continued about the same. Summary, October, 1931.—Increasing difficulty in adjusting to cardiac regimen complicated by manic depressive psychosis. Note added March 1, 1935.—Has continued under care of this hospital. Many ups and downs. Both the patient and her mother becoming less able to take care of themselves.

ABSTRACT

Admission February 1, 1931

32

Female; age 30

Diagnosis.—Carcinoma with Metastases following Carcinoma of the Lung; Serofibrinous Pleurisy; Sinusitis. Medical.—Fourth admission of 30-year-old woman; had had a carcinoma of the bronchus, proved by biopsy, for over 2 years; has held her own very well but now has a serofibrinous pleurisy and sinusitis. In hospital 3 weeks with slight improvement. Social.—Young Jewish housewife, of quarrelsome habits, had lived in a state of friction with husband for 7 years; friction intensified by her increasing weakness and irritability for 2 years. Unmanageable child, high-strung husband, interfering relations. Unwillingness to accept diagnosis blocked plans for protection. Home physically adequate to meet needs. Plan.—Terminal institutional care. Course.—Discharged home after refusal to accept plan. Three months spent in and out of hospitals and nursing home. Finally persuaded to remain in cancer hospital; visits of disturbing relations were limited. Died there July 17, 1931. Summary, October, 1931.—Case of carcinoma where appropriate terminal care was hindered because of the personalities involved, and the hospital was called on repeatedly to act in emergencies arising from the social situation.

306

ABSTRACTS

OF

ABSTRACT

CASES

33

Female; age 62

Admission March 23, 1931

Diagnosis.—Chronic Lymphocytic Leukemia. Medical.—Second admission in 6 weeks, of a woman of 62; had had swollen glands for 10 months and dyspnoea and weakness for 1 month. Thought to have an atypical lymphatic leukemia or a neoplasm. Very slight improvement on radiotherapy; relief from thoracenteses. Prognosis poor. Social.—A German housewife; husband was ignorant and inefficient; income irregular and inadequate. No other relatives to help with patient's care. Public institutional care refused. Plan.—Chronic hospital care. Course.—Supervision of home care after first discharge and continued radiotherapy pending admission to chronic hospital. Persuading patient and arranging for admission to chronic hospital; difficult problem of interim care after second admission. Left one hospital dissatisfied within a day or two. Visiting nurse gave care at home. Admitted to another chronic hospital and died there 4 days later (May 18, 1931). Summary, September, 1931.—Appropriate care in a hopeless case difficult to arrange because of prejudice against public institutions and long waiting list at private institution chosen.

ABSTRACT

Admission April 17, 1931

34

Male; age 57

Diagnosis.—Thrombosis of Coronary Arteries; Cardiac Insufficiency and Hypertrophy; Emphysema. Medical.—A man of 57, with cardiac insufficiency for 7 weeks; severe coronary disease. Very little improvement. Prognosis downhill. Social.—A German-Jewish clothier, ill for 4 J/2 years. Patient nervous and irritable. Home facilities inadequate for care. Wife ill. Insufficient finances for extra medical needs. Past status above present one. Plan.—Chronic hospital care. Course.—Application for chronic hospital. Intensive investiga-

ABSTRACTS OF CASES

307

tion of resources. Nothing acceptable for interim care found. Patient sent home. Summary, September, 1931.—Disrupting effect of chronic illness on a family in a case in which a hospital for acute illness cannot care for patient indefinitely and patient is unwilling to accept city care. Note added March 1, 1935.—Patient admitted to private institution for chronic disease July 20, 1931, and remained there about 5 months. Marked lessening of discouragement and selfcenteredness noted. He lived at home during the following year. Died in another hospital November 26, 1932.

ABSTRACT 3 5 Admission

May 2, 1931

Female;

age 58

Diagnosis.—Chronic Cholecystitis; Diabetes Mellitus; Bronchopneumonia; Fissure of Anus. Medical.—Two-year history of indigestion and nervousness in a woman with diabetes; hypertension; previous jaundice and operation for fatty tumor of stomach. Cholecystectomy was done and fistula to duodenum found. Because of fissure, sphincter ani was divided. Diabetes was easily controlled. Convalescence was slow. Discharged after 2 l/¿ months still bothered by gas, slightly dyspnoeic on exertion, and having pains in legs, hand, and shoulders. Tonsils and teeth removed. Social.—Irish Roman Catholic housewife, reticent about social situation; had had 8 children in rapid succession, 3 dying in infancy and 1 at 21. Remarriage 8 years ago at SO to German Protestant against wishes of children. Husband alcoholic. Economic insecurity and unwilling dependency on children. Nevertheless refused assistance of social worker. Plan.—Convalescent care. Instruction in diabetic regimen. Course.—Convalescence at home, with visiting nurse caring for dressings. Diabetic instruction to patient and husband. Family dispossessed and patient taken to home of son. Address unknown and patient lost sight of temporarily. Surgical follow-up, at 5 months, found the gastrointestinal symptoms somewhat better but nervousness worse. Summary, October, 1931.—Anxiety and insecurity in relation to family group and finances seem important factors in both

A B S T R A C T S OF CASES

308

bringing on symptoms and resistance to treatment of nervousness and gastric symptoms. Note added March 1, 1935.—Recovered from operation; diabetes kept under control. However, patient continued to complain of not feeling well. Social situation remained unsatisfactory, but patient was never willing to consider any proposal for relief. Lost contact after August 11, 1934.

ABSTRACT Admission

October

36

6, 1930

Female;

age

26

Diagnosis.—Chronic Nephritis; Chronic Uremia; Hypertension; Cardiac Insufficiency. Medical.—Seventh and last admission of an American housewife of 26, with a 4-year history of chronic nephritis, beginning with her first pregnancy. Repeated thoracenteses were done. Nitrogen retention and hypertension. Steadily downhill course with death after 3]/2 months. Social.—Patient was temperamental, romantic young woman, who had led an irregular and undisciplined life. Her antagonism to restriction of any sort, either social or medical, led to separation from husband and estrangement of friends and relatives, and interfered with medical regimen. She was now alone, without home or resources. Plan.—Institutional care. Patient died in hospital. Course.—During hospitalization several tentative plans for discharge were formulated. Reconciliation to her husband and mother was effected and patient was reassured about her condition. Summary, October, 1931.—This patient's irritability and recklessness led to the breaking up of her home and estrangement from husband and relatives. Adequate care was therefore impossible outside of an institution. Her inability to accept medical restriction possibly hastened her downhill progress.

ABSTRACT Admission

October

29, 1930

37 Female;

age

23

Diagnosis.—Subacute Rheumatic Fever. Medical.—A young woman of 23, with a painful knee for 5

309

ABSTRACTS OF CASES

weeks. Tonsils removed and sinuses treated. No heart involvement. Improved greatly on salicylates in 3 weeks. Social.—Patient a young domestic, honest, cooperative, hardworking, who had developed present illness after arrival in New York City from rural Germany 2 years previously. Lived with interested relatives in comfortable apartment, S flights up. Went out to do full-time housework. Plan.—Convalescence, change of habitat, and continued medical supervision. Course.—Patient was sent to convalescent home for 2 weeks. Slight joint pains persisted. Need of restricted activity was explained to patient and patient's group. Returned to work 6 weeks later. Interpretation given employer and cooperation enlisted in restricting patient's activity. Patient accompanied employer to Florida for 3 months. General condition improved. Persistent pain in knee found referable to orthopedic difficulty and was corrected by arches. Patient symptom-free at present time. No serious recurrence since discharge. Summary, October, 1931.—A case where medical recommendation of restricted activity conflicted with patient's occupation (domestic) for which she was mentally and emotionally adapted, but where, through medium of interpretation to patient's group and clinical follow-up, condition was satisfactorily controlled. Note added March 1, 1935.—Patient continued under care of this hospital. No recurrence of rheumatic symptoms.

ABSTRACT Admission

November

18, 1930

38 Female;

age

41

Diagnosis.—Neuritis of Sciatic Nerve; Chronic Arthritis of Sacroiliac Joint. Medical.—A woman of 41, with sciatica for 2 weeks and history of numbness of leg and recurring pain in hip for 3 years. Some improvement on physiotherapy in 3 weeks. Social.—A Russian housewife with a good home but suffering from anxiety over recent failure of husband's business. Onset of symptoms began with death of father and with the physical fatigue experienced at this time. Emotional patient and family group. Physical setting good. Plan.—Physiotherapy.

ABSTRACTS OF CASES

310

Course.—Some improvement and no social problems noted on follow-up. Summary, October, 1931.—Fatigue and anxiety may have been predisposing factor in case of sciatica. Note added March 1, 1935.—Patient continued under care of this hospital until June, 1931. Great improvement under physiotherapy. Discharged.

ABSTRACT 3 9 Admission

November

26, 1930

Female;

age 54

Diagnosis.—Chronic Cholecystitis; General Arteriosclerosis. Medical.—A woman of 54, with right upper quadrant pain for 4 weeks. Typhoid 23 years ago, jaundice 2 years ago, recurrent epigastric distress for years. Cholecystectomy was done. Cholecystitis and perihepatitis found without stones. Discharged after 5l/2 weeks with little change in symptoms. Social.—Hypersensitive, frail, American housewife, married late in life to an unstable and now paranoid husband (suffering from violent jealousy). Confined to furnished room because of husband's jealousy, and separated from relatives and from the friendly atmosphere of the small town to which she was accustomed. Irregular meals and habits. Decline in financial status and exhausting attempts to earn a livelihood. Similar illnesses previously at times of emotional stress. Plan.—Convalescence. Course.—Returned home and then went to country with relatives, where she gained weight and improved considerably in general health. Summary, October, 1931.—Organic findings insufficient to explain all the symptoms. The operation apparently was of less importance than the removal of social strain in relieving this patient's symptoms. Note added March 1, 1935.—Patient continued in moderately good health for about 2 years. In January, 1933, she again reported symptoms similar to those first noted. Complete medical work-up failed to show organic disease which would account for her distress. She was again advised to remain out of New York City and in the more protecting environment of her native community.

ABSTRACTS OF CASES ABSTRACT

311

40

Female; age 25

Admission December 27, 1930

Diagnosis.—Bronchopneumonia. Medical.—A woman of 25, with 6-day respiratory history. Bronchopneumonia of right lower lobe of the lung resolving by slow lysis. Previous tuberculosis history but no evidence of present tuberculosis found. Social.—A Puerto Rican housewife accustomed to warm climate. Narrow city existence. Financial insecurity. Plan.—Convalescence. Observation for possible tubercular condition. Course.—Convalescent plan fell through because of patient's timidity about leaving home. Gained IS pounds at home. Returned to Puerto Rico; she reported she was doing well. Summary, September, 1931.—Puerto Rican in New York less than 2 years. Had had 2 respiratory infections while here. Question of tuberculosis. Patient's move South probably satisfactory. Note added March 1, 1935.—Letter from patient in Puerto Rico reported she had gained weight and felt well and happy in her father's home in the country.

ABSTRACT

Admission March 11, 1931

41

Male; age 38

Diagnosis.—Cardiac Insufficiency; Aortitis; Syphilis; Osteoma of Frontal Sinus. Medical.—A man of 38, with dyspnoea for 4 months and edema for 3 weeks. Improved when kept in bed for 5 weeks on digitalis and antiluetic treatment. Prognosis guarded. Social.—Illness precipitated financial difficulties for a Negro laborer. Family destitute. Unheated apartment. Unsuitable work. Poor intelligence, but pleasant personality. Congenial family. Plan.—Rest indefinitely. Antiluetic treatment. Course.—Temporary care away from home and later long convalescence continued at home through aid of welfare agency. Summary, September, 1931.—Family made dependent by illness of wage earner, probably progressive. Patient's composure

ABSTRACTS OF CASES

312

and his happy family life favorable, but otherwise, social and medical prognosis not very favorable. Note added March 1, 1935.—Patient continued under care of this hospital to March 8, 1934; antiluetic treatment given and patient improved. Reported then doing heavy work and advised not to. Fracture of leg at work made long care in public hospital necessary. Then continued cardiac treatment in same public hospital, requiring several periods of bed care. Discomfort and disability increased. ABSTRACT Admission

December

42

29, 1930

Female;

age 70

Diagnosis.—Chronic Multiple Arthritis; Secondary Anemia; Chronic Myocarditis. Medical.—A woman of 70, with joint pains and loss of weight. No malignancy found. Secondary anemia, chronic myocarditis, and chronic multiple arthritis. Improved slowly on physiotherapy. Social.—An American widow who had a long, hard life. Found it difficult to readjust to dependence. High standards. Interested and resourceful family group. Plan.—Physiotherapy in clinic. Course.—Impossible to get to clinic because of age and arthritis. Moved to daughter's home. Case turned over to local doctor. Summary, September, 1931.—Hospital care was only an incident in prolonged care for chronic disease, where readjustments were difficult but were handled by patient's group. Note added March 1, 1935.—Not followed. ABSTRACT Admission

November

24, 1930

43 Male;

age

20

Diagnosis.—Anxiety Neurosis; Umbilical Hernia (reducible); Chronic Tonsillitis. Medical.—-A boy of 20, with fainting attacks and weakness for 5 months. Enlarged tonsils only physical defect noted. Symptoms thought to be largely psychic problem. Social.—-Colored American office messenger recently promoted to executive position; symptoms began immediately after he be-

ABSTRACTS OF CASES

313

came engaged to be married. Seemed childish and overdependent when with his mother. Physical setting satisfactory. Plan.—To be treated by psychiatrist. Course.—Intensive psychiatric treatment and arrangement with employer to hold job and let patient return to work as part of treatment resulted in immediate relief of symptoms. Six months later, work reported regular and satisfactory and he was symptomfree. Summary, October, 1931.—Fear of responsibility in work and marriage seemed to have been cause of symptoms, which were relieved by psychiatric treatment. Note added March 1, 1935.—Patient failed to continue under care of this hospital. ABSTRACT Admission

December

44

26, 1930

Female;

age

40

Diagnosis.—Pernicious Anemia. Medical.—A woman of 40, with severe pernicious anemia and cord symptoms, which improved markedly on one transfusion and large doses of liver extract. Discharged in weeks still weak but able to walk about. Social.—Intelligent Welsh housewife. Superior home and cooperative friends and family. Finances adequate. Plan.—Convalescence. Continued liver therapy. Course.—Plan carried out. Patient apparently in normal health 8 months later. Summary, October, 1931.—Adequate instruction made possible the carrying out of the regimen, with excellent results. Note added March 1, 1935.—Patient failed to take liver and did not attend clinic regularly. Went to Wales. Returned to clinic after an absence of 16 months. Disease much advanced. Patient then followed treatment faithfully with gradual improvement. Last seen June 20, 1934. ABSTRACT Admission

November

7, 1930

45 Female;

age 36

Diagnosis.—Chronic Cholecystitis ; Cholecystectomy. Medical.—A woman of 36, with 4-year history of right upper quadrant pains and occasional jaundice. Question of gallstones or

ABSTRACTS OF CASES

314

hepatitis. Exploratory operation done, showing neither. Uneventful recovery; discharged without symptoms after 8 weeks. Social.—An American housewife; some financial pressure, but not a source of undue worry. Intelligent. Good general situation. Plan.—Convalescence at home. Observation. Course.—Symptoms nearly relieved following operation. Summary, October 1931.—Neither medical nor social findings explained condition but patient improved. Note added March 1, 1935.—Patient continued under care of this hospital until July, 1934. After being completely relieved of symptoms for 3 months, these recurred. Patient claimed these symptoms not relieved by restricting diet. Did not return to clinic after June, 1934, and was not followed further. ABSTRACT Admission

November

24, 1930

46 Female;

age 42

Diagnosis.—Hyperthyroidism; Exophthalmic Goiter; Cardiac Insufficiency. Medical.—A woman of 42, with symptoms of exophthalmic goiter for 1 year. Partial thyroidectomy done, with reduction of basal metabolism from SO to 8 and uneventful recovery in 4 weeks. Social.—A Hungarian housewife; loss of husband's and son's jobs brought insecurity, hard work, and lowered social status. Worrying type but intelligent. Previously successful family group with high standards. Plan.—Decrease activities and worries. Course.—Hospital treatment made possible by free care and enlisting husband's persuasion. Free treatment obtained for daughter who was source of worry. Symptoms continued after 6 months. Family refused to accept aid of welfare agency. Activities and worries increased but patient improved nevertheless. Summary, September, 1931.—The high standards of this woman with Graves' disease caused her to balk at ward routine and care until social service and psychiatrist gave her special attention. Home situation could not be improved by ordinary social service methods. Note added March 1, 1935.—Patient continued under care of hospital with thyroid condition satisfactory but other physical ailments appeared. Three years of unemployment persuaded

ABSTRACTS OF CASES

31S

family finally to accept aid from welfare agency. Social condition improved somewhat, but patient still discontented. ABSTRACT

47

Admission January 26, 1931

Female; age 53

Diagnosis.—Hyperthyroidism; Adenoma of the Thyroid; Auricular Fibrillation; Hypertension. Medical.—A woman of 53, with nervousness and dyspnoea for 1 year. Toxic adenoma with basal metabolism rate of plus SO and an arteriosclerotic decompensated heart. Partial thyroidectomy, with excellent recovery in 4 weeks. Social.—A widowed Bohemian cigar-maker who has had a long, hard life. Strain of husband's chronic illness was followed by shock of his death 1 year ago. Feeling of economic insecurity. Pressure to get back to work. Senile mother in home. Active, nervous, independent type. Excellent home and intelligent daughter. Church interested. Plan.—Convalescence. Protection from worry and too hard work. Course.—Convalescent care. Friendly contact. Close clinic and social service supervision. Continued worried. Summary, September, 1931.—Toxic adenoma of thyroid with excellent result from operation despite social difficulties, age, and temperament. Note added March 1, 1935.—Patient returned to work after 6 months and has continued at work to this date. Remained under medical care of this hospital. Has complained of some fatigue, but has been in moderately good health. ABSTRACT

Admission April 27, 1931

48

Male; age 35

Diagnosis.—Chronic Pulmonary Tuberculosis? Medical—A man of 35, with cold in chest for 1 month, was admitted because of spitting blood. Although he ran a low fever and had râles at right base and X-ray signs on the right, his sputum was negative and general condition excellent. On this basis diagnosis was considered uncertain. Social.—American postal clerk; apprehensive; of limited in-

A B S T R A C T S OF CASES

316

telligence; excellent suburban home; devoted to wife and 2 children. Steady employment in post office. Employed in a dusty office 2 years before. Plan.—Return to work under observation after a month's rest. Course.—Convalescence at home; leave of absence extended; patient returned to work. After 5 months condition continued good. Summary, October, 1931.—No social problem found in a potential tuberculosis case treated at home. Note added March 1, 1935.—Patient continued under care of this hospital until March, 1932. Condition satisfactory. Working regularly. Discharged. ABSTRACT Admission

November

7,

49

1930

Male;

age 36

Diagnosis.—Cardiac Insufficiency; Syphilis; Aortitis; Arteriosclerosis; Coronary Disease. Medical.—A 36-year-old man, with cardiac insufficiency after sudden collapse 8 weeks before. Probably narrow coronary orifices associated with lues and aortitis; early tubercular condition suspected. Improved considerably in 11 weeks here. Poor prognosis. Social.—A vaudeville actor; successful work and family life. Strenuous occupation. Irregular income. Home broken up because of illness. Active, humorous, sociable type. His intelligence and initiative and the support of relatives were favorable factors. Plan.—Complete rest for an indefinite time. Course.—Plans for going to relatives in a western state were facilitated by Social Service Department. Patient died February 26, 1931, in hospital there shortly after his arrival. Summary, September, 1931.—Organic cardiac disability with uncertain prognosis. Excellent cooperation on part of patient and family in carrying out plan for future care.

ABSTRACT Admission

January

7,

1931

50 Male;

age

20

Diagnosis.—Chronic Colitis? ; Psychoneurosis. Medical.—A youth of 20, with unexplained frequent and painful defecation for one year. Anxious temperament. Calcified nodes

A B S T R A C T S OF C A S E S

317

of mesentery suspected but not proved. In hospital 2 weeks. Seen by psychiatrist who felt difficulty was of psychic origin. Social.—An unmarried Polish youth had suffered from food deprivation and had been exposed to tuberculosis in childhood. Overcrowded home. Family income irregular and inadequate. Irregular employment; dependent on family. Feeling of inferiority (statement of psychiatrist). Family solidarity. Plan.—Convalescence. Further psychotherapy. Course.—Convalescent care. Encouraging response to psychotherapy. Summary, September, 1931.—A case of psychoneurosis where the social conditions, although unfavorable, did not seem of primary importance. Note added Marek 1, 1935.—Patient returned to psychiatrist for advice in June and December of 1932. No return of diarrhea with anxiety or nervousness. Apparently made a very good recovery. ABSTRACT

Admission December 31, 1930

51

Female; age 38

Diagnosis.—Undiagnosed Condition of Neck; Mixed Psychoneurosis. Medical.—A woman of 38 admitted for diagnosis of a swelling of the neck which had lasted 2 weeks, and hoarseness 2 years. Paralysis of vocal cord with nothing found to explain it. Previous nervous breakdown. Discharged after S days with no etiology discovered. Social.—An Austrian housewife of a marked anxiety type. Lack of insight. Exaggerated need for security and social status. Exaggerated cleanliness. Narrow interests, centering in only son. Inadequate resources and failure of husband's business, bringing excessive work for patient and economic insecurity. Assets: cooperative family and confidence in Presbyterian Hospital. Plan.—Further study. Course.—Free treatment. Reassurance. Later, psychotherapy. Relief of severe economic pressure provided by social agency. Summary, September, 1931.—Increasing psychoneurotic element precipitated by economic insecurity. Note added March 1, 1935.—Psychotherapy continued to date. Patient continued depressed and complaining of discomfort in different parts of her body. Husband almost totally disabled by

ABSTRACTS OF CASES

318

thromboangiitis obliterans. Allowances from relief agency and later pension from disability insurance have barely sufficed to meet family's needs. ABSTRACT Admission

October

52

28, 1930

Male;

age 46

Diagnosis.—Cirrhosis of Liver; Ascites; Syphilis; Splenic Anemia. Medical.—A man of 46, with a swollen abdomen for 2 years, and known syphilis. Thought to have cirrhosis of liver with splenomegaly and rapidly recurring ascites. Discharged after S weeks unimproved. Social.—A Russian-Jewish salesman who had had no unusual difficulties in the past. Some economic pressure now. Moved temporarily to overcrowded quarters with relatives. Level-headed man with initiative. Plan.—To return for paracentesis when necessary. Course.—Patient made own adjustment to lighter work and better home. No return of ascites but not feeling well. Summary, September, 1931.—A chronic, probably progressive, disease; patient, with assistance of his group, was able to make an adequate adjustment without social service aid; but a potential social problem remained. Note added March 1, 1935.—Patient readmitted January 22, 1932. Exploratory celiotomy resulted in ligation of splenic artery and vein. Remarkable recovery and disappearance of symptoms, until an intestinal hemorrhage, caused probably by esophageal or gastric varices, from which he recovered in June, 1932. Sudden death following automobile accident November 11, 1932. ABSTRACT Admission

April 24, 1931

S3 Female;

age 22

Diagnosis.—Exophthalmic Goiter; Pyelitis. Medical—First admission of a young woman of 22 ; symptoms of thyrotoxicosis for 2 months, for which partial thyroidectomy was done. Basal metabolism fell from plus 64 to plus 27 on medical care for 2 weeks, and to plus 2 after operation. Onset possibly dated from pregnancy \ l /i years before which was followed by pyelitis.

ABSTRACTS OF CASES

319

Social.—Cooperative young college graduate, American, with 2-year-old child; under much stress and greatly worried for past year, because of husband's unemployment and death of second infant. Home broken; patient and family living with parents who have lent them all their savings. Plan.—Convalescence. Limiting of strains. Course.—Returned home. After 5 months was symptom-free and had gained 23 pounds. Summary, October, 1931.—Anxiety, grief, and physical exhaustion associated with onset of hyperthyroidism. Excellent understanding and ability to handle home situation makes prognosis good. Note added March 1, 1935.·—Patient has continued under care of this hospital. Condition satisfactory. Able to carry on her work. ABSTRACT Admission

54

April 9,1931

Female;

age 49

Diagnosis.—Chronic Nephritis; Hypertension; Arteriosclerosis. Medical.—Fourth and last admission of a middle-aged woman with a 12-year history of nephritis, followed here for 10 years. She had general arteriosclerosis, hypertension, and repeated strokes. Social.—An American clerical worker constitutionally somewhat inferior. Steady employment in work adapted to her disability, with a good adjustment to chronic disease. Plan.—Institutional care. Course.—Died in hospital, May 2, 1931. Summary, October, 1931.—Good adjustment to a chronic disability made possible during 10 years by exceptional cooperation of employer with hospital. ABSTRACT Admission

May

11, 1931

55 Female;

age 22

Diagnosis.—Mitral Stenosis and Insufficiency; Aortic Insufficiency; Cardiac Hypertrophy. Medical.—A girl of 22, with rheumatic heart; known history of rheumatism for 13 years. Slight insufficiency for 2 months. Improved by rest in bed in 2l/i weeks' stay in the hospital.

A B S T R A C T S OF CASES

320

Social.—A young typist who had a low income, because of work interruption from illness. Standards above earning capacity. Intelligent girl; suitable skilled work. Good home. Plan.—Convalescence. Restricted activities. Course.—Convalescence; interpretation to mother. Another break 3 months later at convalescent home. Summary, September, 1931.—A young cardiac with some financial pressure but a pretty good adjustment to the present situation. Insecurity increasing with recurrent cardiac breaks. Note added March 1, 1935.—This patient continued under medical care of this hospital. In 1933 she married, with her physician's approval. Although her heart is badly damaged, she has in general maintained excellent health. ABSTRACT Admission

May

17,

56

1931

Male;

age

32

Diagnosis.—Double Mitral and Aortic Disease; Fibrillation; Aphasia; Hemiplegia. Medical.—A man of 32, with paralysis and aphasia for 6 weeks, thought to be of embolic origin, in a case of rheumatic valvular disease with fibrillation. Some improvement in 3 weeks. Social.—An American theological student with no savings or work. Dependent on elderly father. Intellectual interests. Sympathetic bond with mother. Vigorous, resourceful person. Plan.—Limited activity. Plans for future await further developments. Course.—Continued improvement in aphasia. (Considerable interpretation to mother.) Summary, September, 1931.—Disability may interrupt career but patient and group are probably able to adjust. Note added March 1, 1935.—Patient continued under care of this hospital. Some improvement, but disabled for gainful employment. ABSTRACT Admission

April

3,

1931

57 Male;

age 36

Diagnosis.—Lobar Pneumonia. Medical.—A man of 36, admitted on the 1st day of lobar pneumonia. Process spread to all but left upper lobe. He grew

A B S T R A C T S OF CASES

321

progressively worse and died of heart failure on the 10th day. Social.—An American chauffeur who had had frequent pneumonia and empyema while employed in an iron foundry. After move to country he was perfectly well for 14 years. Returned to city where he had exposure and long hours as night taxi driver. Unhappy over death of wife and over debts arising out of previous unemployment. Plan.—None possible. Course.—Acutely ill. Died April 12, 1931. Summary, October, 1931.—Association of strain of urban living with recurrent pulmonary disease in a man of Irish stock who remained well while in an easy job in the country. ABSTRACT

58

Admission February 2, 1931

Female, age 27

Diagnosis.—Acute Arsphenamine Poisoning; Syphilis; Stricture of Urethra; Salpingitis; Retroversion of Uterus. Medical.—A colored woman of 27, with toxic hepatitis 4 months after last arsphenamine injection. She had been treated for 6 months in the Out-Patient Department for retroversion of uterus, stricture of urethra, and lues. Improved in 3 weeks' stay on high carbohydrate diet and thiosulphate. Social.—Lodger without family. Irregular work. Financial pressure. Plan.—Antiluetic, gynecological, and genitourinary care. Course.—Clinic attendance irregular because of patient's inability to take time from work. Persuaded to attend evening clinic of Health Department. Summary, September, 1931.—Mainly a problem of making arrangements for continued antiluetic care. Note added March 1, 1935.—Patient continued under care of this hospital to date for gynecological and genitourinary conditions. Work fairly regular in spite of much discomfort. ABSTRACT

Admission November 25, 1930 Diagnosis.—Carcinoma of the Sigmoid Colon.

59

Female; age 69

with Metastases following Carcinoma

322

ABSTRACTS

OF

CASES

Medical.—An elderly woman with constipation for years, followed in clinic for 7 months. Admitted with signs of intestinal obstruction. Carcinoma of sigmoid with metastases to lymph glands found. Colectomy done ; wound slow in healing. Discharged in Syi months for permanent care. Social.—Ignorance and low standards of living in the case of a shrewish old widow long dependent on children. Poor hygiene and diet, with cathartic habit for years. Inadequate facilities for chronic care at home. Plan.—Permanent chronic care. Course.—Signed herself out of institution after S months. Summary, October, 1931.—Social problem of the group was obviated by institutional chronic care for a time. Patient satisfied in institution and her general health improved. Note added March 1, 1935.—This patient died February 13, 1934. She was readmitted to a cancer hospital, May, 1933. During the 20 months she was able to remain in her son's home, she was fairly comfortable and contented. Her dependency was relieved by receipt of old age pension.

ABSTRACT

Admission December 28, 1930

60

Female; age 65

Diagnosis.—Acute Bronchitis; Arteriosclerosis; Chronic Myocarditis. Medical.—A woman of 65, with an acute upper respiratory infection. Evidence of some myocardial damage and hypertension. Able to leave hospital in 2 weeks. Social.—A single American dressmaker who lived with her sister, an identical twin, suffering from same illness. Succession of minor illnesses, temperament, old age deterioration; irregular employment; partially dependent on agency. Plan.—Convalescence. Course.—Convalescence for patient and her twin. Summary, September, 1931.—Recurrent minor ailments in elderly woman with few resources. A chronic social rather than a medical problem. Note added March 1, 1935.—Patient continued under care of this hospital to date. Chief complaint dizziness. Many discomforts relieved.

ABSTRACTS OF CASES ABSTRACT

323

61

Female; age 20

Admission October 22, 1930

Diagnosis.—Exophthalmic Goiter ; Hyperthyroidism. Medical.—A girl of 20, with symptoms of exophthalmic goiter for 5 years, following a shock. Basal metabolism dropped from 64 to 35 on rest, then partial thyroidectomy was done. Uneventful convalescence. Basal metabolism rate plus 13 on discharge after 4 weeks in the hospital. Social.—Hebrew stenographer ; employment irregular because of illness. Seasonal employment of family. Good personality, cooperation, and environment. Plan.—Protection from worry and overactivity. Course.—Emotional problem suspected but never determined. Social situation generally favorable. Summary, September, 1931.—Apparently no social problems. Falls into group of severe cases with slow improvement, postoperative. Note added March 1, 1935.—Patient continued under care of this hospital. Radiotherapy given. Twenty months after operation condition found satisfactory. Happily married in February, 1932.

ABSTRACT

Admission November 14, 1930

62

Female; age 58

Diagnosis.—Adenoma of Thyroid; Arteriosclerosis; Hypertension; Mild Cardiac Decompensation; Anxiety Neurosis. Medical.—A woman of 58, with tachycardia and sense of choking for 2 years. Findings were insufficient for diagnosis of hyperthyroidism and she was sent home after 8 days. Social.—A misanthropic old maid who enjoyed bringing to justice those guilty of cruelty to animals in a rural up-state county. Meager income from investments sufficient for her needs. Plan.—Convalescence. To return home; slightly limited activity. Course.—Did not adjust to convalescent home or restrict her activity as recommended. It was felt that psychotherapy would be useless at her age with such well-crystallized idiosyncrasies. Letters 8 months later indicated no change in her symptoms.

A B S T R A C T S OF CASES

324

Summary, October, 1931.—A case of sufficiently abnormal temperament and social situation to account for a large part of her symptoms. Age and type of psyche made therapy futile. Note added March 1, 1935.—Patient continued under care of this hospital. Partial thyroidectomy in 1932. In hospital again in 1933 and 193 S for tremor, tachycardia, numbness of entire body, abdominal distress. Arthritis of spine found. Has become a chronic invalid. ABSTRACT Admission

October

63

27, 1930

Male;

age 26

Diagnosis.—Acute Disseminated Lupus Erythematosis. Medical.—A man of 26, acutely ill with ascites, disseminated toxic erythema, petechiae, large heart, albumen, and casts, having had the skin lesion for 9 months. H e died in 3 weeks. Social. Young real-estate man, recently married, with excellent home and bright prospects for the future. N o social problems. Plan.—None. Course.—Died in hospital, November 13, 1930. Summary, October, 1931.—Acute fatal illness with no abnormal social factors found.

ABSTRACT Admission

November

24, 1930

64 Male;

age

62

Diagnosis.—Adenoma of the Thyroid; Chronic Myocarditis; Auricular Fibrillation. Medical.—A man of 62, with adenoma of the thyroid. Basal metabolism plus 35. Cardiac symptoms since adolescence. On digitalis heart responded well. Partial thyroidectomy was done with good result. H e was discharged improved after 5 weeks. Social.—High-strung Irish night watchman, formerly a saloonkeeper, etc., who had drunk to excess in the past, and had a rough life with gradual decline in status. Exposure at work and increasing anxiety recently. Ignorant family but m a n y group resources. Home cold and inadequate for convalescence. Plan.—Convalescent care. Restricted activity. Occupational adjustment.

ABSTRACTS OF CASES

325

Course.—Refused to leave city for convalescent care or to change occupation. After 6 months he was not decompensated and still working as watchman. Later developed a moderate decompensation, with recovery on rest. Summary, October, 1931.—A cardiac with a toxic adenoma of the thyroid that developed after anxiety and steady decline in his social status; no change in social situation was possible but patient improved after thyroidectomy. Note added March 1, 1935.—This patient continued under care of this hospital until his death in October, 1934. During most of this time he carried on his regular work.

ABSTRACT Admission

April

20, 1931

65 Male;

age

52

Diagnosis.—Carcinoma of the Kidney; Complete Nephrectomy. Medical.—A man of 52, with failing health and pain in left side for 16 months. Found to have carcinoma of left kidney, which was removed. Postoperative shock necessitated two transfusions. Discharged after 7 weeks feeling well. Life expectancy short. Social.—A skilled and well-paid Negro barber who had had cumulative social catastrophes in the last year: both children died; he was laid off; his savings were exhausted. Now dependent on ailing wife, superstitious and uneducated, who earned a precarious living by day's work and letting rooms, with financial aid from relatives. Well-cared-for home and devoted wife. Plan.—Institutional care. Course.—Free hospital care and transfusions. Entered institution but signed himself out as he was ignorant of diagnosis and felt well. Wife remarkably cooperative on careful explanation of diagnosis and instruction in home care. Patient still without a break after 5 months and wife able to manage. Summary, October, 1931.—Very unpromising situation for terminal care with remarkable response by patient's wife to explanation, supervision, and encouragement. Note added March 1, 1935.—Patient died at home July 19, 1933. For the most part he remained fairly comfortable and in good spirits.

326

ABSTRACTS OF CASES ABSTRACT

66

Female; age 46

Admission February 6, 1931

Diagnosis.—Diabetes Mellitus; Syphilis; Undiagnosed Condition of the Abdomen. Medical.—A woman of 46, with epigastric pain, loss of 30 pounds in 6 months, and diabetes for 3 years. Carcinoma or ulcer suspected but not confirmed. Wassermann found to be plus 4. Symptoms decreased on insulin, Sippy diet, and potassium iodide and mercury treatment. Discharged after 3 weeks without adequate diagnosis. Social.—A married Negress, until onset of present illness gainfully employed as a domestic. Adolescent children for whom she was very ambitious were forced to leave school to contribute support. Conversion to fanatical religious faith was coincident with onset of diabetic symptoms 3 years ago. Patient manifested much fear at her own illness and the family's economic insecurity. Plan.—Return to clinic for diabetic and antiluetic treatment. Course.—Followed diet and antiluetic treatment regularly. No change in social situation. Summary, October, 1931.—Fear element made adoption of satisfactory diabetic and antiluetic treatment slow. Note added March 1, 1935.—Patient continued under regular treatment of this hospital. Diabetes controlled with insulin; antiluetic treatment carried out until condition satisfactory ( for about 3 years) ; no recurrence of abdominal symptoms. Fear for her own safety overcome by learning to use insulin and proper diet. Relief supplied by welfare agencies, either as cash allowance or work, brought economic security.

ABSTRACT

Admission October 6, 1930

67

Male; age 20

Diagnosis.—Bleeding from Oral Cavity. Medical.—A youth of 20, with bleeding from tooth socket for 7 days. Old rheumatic heart found without symptoms. Bleeding factors all normal. Transfusion. Discharged in 2 weeks. No cardiac disability or blood dyscrasia found.

ABSTRACTS OF CASES

327

Social.—A young salesman who had been leading a restricted life because of old cardiac disease. Protective attitude of mother. Good adjustment, on patient's part, to restrictions. Favorable general situation. Plan.—Advised against further extraction. Slight restriction of activity. To be watched for cardiac changes; real heart problem. Course.—Returned to former life. Summary, September, 1931.—Mild rheumatic case with probably unrelated bleeding episode. A good social situation not affected by this illness. Note added March 1, 1935.—Patient continued under care of this hospital to date. Frequent respiratory infections in winter months often accompanied by epistaxis. Otherwise symptom-free and in good condition.

ABSTRACT

Admission April 5, 1931

68

Male; age 29

Diagnosis.—Ulcer of Duodenum. Medical.—A man of 29, with ulcer symptoms for 1 year, and bleeding for 2 weeks; diagnosis of duodenal ulcer confirmed by X ray. Excellent progress on Sippy diet. Discharged after 3 weeks on ambulatory regimen. Social.—Temperamental but intelligent single young Irishman who had drifted from job to job and country to country for 10 years, always earning good wages. Underground job in subway for 9 months, with irregular meals and rest. Excess smoking. Worried over mother's illness in Ireland. Plan.—Convalescence, ambulatory ulcer regime, and continued medical supervision. Course.—Patient seemed intelligent and ready to adapt usual way of life to regimen. Left for Ireland 2 days after discharge, with medical approval. Summary, October, 1931.—A case of nervous temperament and irregular habits related to development of gastric ulcer. Prognosis is good because of patient's understanding and the flexibility of his social setting. Note added March 1, 1935.—Patient lost.

ABSTRACTS OF CASES

328

ABSTRACT Admission

May

11,

69 Male;

1931

age 37

Diagnosis.—Aplastic Anemia. Medical.—A man of 37, with marked anemia and fever for 4 months. No response to liver extract, hydrochloric acid, nucleic acid, or iron. On repeated transfusions there was some improvement. Discharged after 9 weeks. Social.—A Greek stamp-importer, a lodger, with no immediate family in this country. Dependent on his own business. Doing well previous to illness. Narrow range of interests and contacts. Quiet and cooperative. Plan.—Rest at first. Observation. Liver and red meat diet. Course.—Stationary. Summary, September, 1931.—Problem not clearly defined because of uncertainty of diagnosis. Isolation leaves chronic care a potential problem. Note added March 1, 1935.—Patient continued under the care of this hospital until his death, February 8, 1932. An arrangement made for him to live with his cousin gave the protection needed. ABSTRACT Admission

January

20,

1931

70 Male;

age 19

Diagnosis.—Acute Rheumatic Fever; Cardiac Insufficiency; Chronic Cardiac Valvular Disease. Medical.—Tenth and final admission of 19-year-old boy with a 13-year history of rheumatic heart disease. Known to Presbyterian Hospital for 6 years during which time he had become progressively more decompensated with recurrent rheumatic flare-ups. On this occasion he had an active pancarditis and what was thought to be a mesenteric thrombosis but which was not found at operation. He died in the 9th week of cardiac failure. Social.—The only child of a solicitous and overindulgent mother. He would never accept the restrictions of a cardiac regimen. The discipline of school was far more satisfactory than the unrestrained activity of vacations. Extensive explanation by

ABSTRACTS OF CASES

329

doctors and social workers of no avail. Attempted restraint provoked overactivity. Plan.—Restricted activity. Course.—Died in hospital, March 22, 1931. Summary, October, 1931.—Refusal of patient and mother to accept the limitation. Activity increased rather than diminished by prohibitions. ABSTRACT Admission

March

71

11, 1931

Male;

age 39

Diagnosis.—Hodgkin's Disease. Medical.—A man of 39, with general glandular enlargement noted for 1 month. Biopsy showed Hodgkin's disease. Swelling decreased on radiotherapy, but anemia increased and patient lost 10 pounds in 5 weeks. Social.—An Italian diamond-setter with decreased income, because of the economic depression and illness. Partially dependent on public relief. Previously successful existence. Plan.—Continued radiotherapy. Course.—Rather quickly downhill. Died in another hospital, May 25, 1931. Summary, September, 1931.—Economic dependence brought on by illness plus industrial depression, but relatives aided. Course of illness not affected by financial difficulty.

ABSTRACT Admission

February

2, 1931

72 Female;

age 17

Diagnosis.—Chronic Multiple Arthritis; Psoriasis. Medical— First admission of a 17-year-old girl with polyarthritis and subcutaneous nodules for 7 years. Admitted for study. Discharged after 1 month. Social.—Progressive disease in an adolescent girl supported by her superstitious and solicitous mother and promising young brother, who sacrificed his education to help. Poor but clean home up 5 flights; diet lacking in fresh foods; alcohol taken regularly. Isolation because of illness tended to make patient self-centered and demanding.

ABSTRACTS OF CASES

330

Plan.—Return to home and continue in arthritis clinic. Outside interests to be developed. Course.—Recurrence of severe polyarthritis and rapid spread of psoriasis over whole body necessitated mother giving up job to care for her and, after 6 weeks, readmission to hospital. Patient in suicidal despair by this time. No improvement in 3 weeks. Temporary transfer for special study to another hospital where she improved markedly in 4 months on ultraviolet light, psoriasis disappearing. Eight months after first admission patient was without symptoms, and employed half time. Summary, October, 1931.—Chronic illness had serious effects on the temperament and emotional development of an adolescent girl in a poor environment. Patient's response to ultraviolet light treatment and improved diet suggested that in the past sunlight and proper food had been deficient. Note added March 1, 1935.—Patient continued under care of this hospital; worked regularly, and remained in fair health.

ABSTRACT Admission

November

19, 1930

73 Female;

age

56

Diagnosis.—Intestinal Hemorrhage; Hypertension; Obesity; Chronic Multiple Arthritis. Medical.—-Second admission of an obese woman of 56 for study of intestinal hemorrhage of unknown origin. Was here for 3 weeks in January, 1930, with severe anemia; condition improved on iron. X rays negative but polyp suspected as cause. Discharged in 3 weeks. Social.—An American housewife whose husband, the chief wage earner, had incurable illness. Patient had previously earned own livelihood. Good environment and adaptable temperament. Plan.—Watch and repeat gastrointestinal X ray. Course.—Husband died and patient moved out of town; therefore nothing done medically or socially. Summary, September, 1931.—Social factors probably unrelated to illness. Case incomplete medically. Note added March 1, 1935.—Private physician reported patient had had no hemorrhages from the intestinal tract in past year. Has felt well except for arthritis.

ABSTRACTS OF CASES

331

ABSTRACT 74 Admission January 30, 1931

Male; age 43

Diagnosis.—Cardiac Insufficiency; Coronary Thrombosis; Bronchopneumonia. Medical.—A man of 43, with cardiac and upper respiratory complaint for 10 days; an apparent coronary thrombosis. He grew progressively worse and died on the 15th day, with pulmonary edema. Social.—A German salesman; overworked; long hours; reduced income; good environment. Lack of nursing care during 3>4 months of illness at home before admission to hospital. Plan.—None possible. Course.—Patient died in hospital February 13, 1931. Summary, September, 1931.—Sudden coronary accident in patient who had been under strain. ABSTRACT 75 Admission December

13, 1930

Male; age SO

Diagnosis.—Cardiac Insufficiency; Double Mitral Disease; Arteriosclerosis; Hypertension; Fibrillation. Medical.—A man of 50 with sudden onset of mild cardiac symptoms 6 months before admission. Discharged after 10 days, improved. Prognosis poor. Social.—A Scottish violinist and entertainer whose usual occupation involved strain. Vivacious, restless type; overdoing drive. Work interruption led to economic insecurity. Intelligent, sympathetic wife and daughter. Excellent home except for stairs. High standards. Plan.—Indefinite rest. Moving to ground floor. Course.—Interpretation to wife and patient. Patient moved and got himself a sedentary job. Summary, September, 1931.—Limitation of activities hampered by patient's temperament and by economic pressure in a family of high standards. Note added March 1, 1935.—Patient had private medical care until November, 1933, when he reëntered this hospital acutely decompensated. He died November 17, 1933.

A B S T R A C T S OF C A S E S

332

ABSTRACT Admission

February

24,

76 Female;

1931

age 26

Diagnosis.—Tumor of Brain?; Chronic Rheumatic Fever; Mitral Stenosis and Insufficiency. Medical.—Fourth admission of a woman of 26 with a known rheumatic heart and repeated headaches which caused suspicion of brain tumor. Insufficient evidence for this diagnosis. Considered to be hysterical. Discharged after 1 week. Social.—Complicated unverifiable history of a young American married Negress with abnormal childhood, excessive drinking, early luetic infection, many head injuries while drunk, anxiety over sterility, etc. Entirely unreliable in her statements. Superstitious and indulgent husband. Plan.—To be followed in Psychiatry Department. Course.—Patient seen twice by psychiatrist who described her as "constitutional inferior, hysterical." Followed in psychiatry. Occupational therapy started. She stopped coming and reported that she had gone to a private physician. Summary, October, 1931.—Emotionally unstable and maladjusted person whose symptoms could not be accounted for on organic basis. Note added March 1, 1935.—Patient not heard from until April, 1932, when she again asked to be treated in this hospital. Did not keep appointment given her.

ABSTRACT Admission

April

2,

1931

77 Male;

age

28

Diagnosis.—Acute Bursitis; Aortitis; Arteriosclerosis. Medical.—Third admission of a Negro of 28 with severe pains in chest and shoulders for which he had been treated here for 10 months. Degenerative mesoaortitis with negative Wassermann and progressive widening of heart shadow despite antiluetic treatment. Acute bursitis of shoulder. Poor prognosis. Social.—Negro truck driver had led a reasonably successful existence up to present illness. Irregular work due to illness. Dependent on wife's earnings. Dreaded hospitalization. Home 2 flights up. Assets: good wife and group of friends.

A B S T R A C T S OF CASES

333

Plan.—Much-restricted activity. Continued clinic visits. Course.—Progressively downhill. No relief to pain. Died 4 weeks later, May 12, 1931, in another hospital, with meningitis. Summary, September, 1931.—Sudden disrupting illness in a previously satisfactory social situation.

ABSTRACT

78

Admission October 10, 1930

Female; age 34

Diagnosis.—Syphilis. Medical.—A woman of 34, with Wassermann plus 4 and marked positional dyspnoea and swelling of the neck for 4 years. Was thought to have syphilis of superior vena cava. Marked improvement on antiluetic treatment. Therapeutic abortion done. Social.—Pleasant young colored housewife whose savings have been exhausted in procuring private medical care. Second husband underemployed, so partially dependent on relatives. Insufficient contraceptive information. Comfortable home and cooperative family. Plan.—Restricted activity at home. Contraceptive instruction. Antiluetic care and Wassermann examination of husband and children. Course.—Patient continued antiluetic treatment faithfully. Family examined. Symptoms slowly increased. Readmitted because of toxic reaction to antiluetic treatment 6 months later. Found to be 3 months' pregnant. Complete hysterectomy performed. Returned to relatives in the South for convalescence. Summary, October, 1931.—Adequate antiluetic treatment delayed because of ignorance and implicit confidence in expensive private care. Note added March 1, 1935.—Patient has continued intermittently under the care of this hospital. Continued dependent on sister. Health improved somewhat, but prognosis still guarded.

ABSTRACT

Admission February 16, 1931

79

Male; age 38

Diagnosis.—Chronic Multiple Arthritis. Medical.—A man of 38, with generalized joint pains and fever

A B S T R A C T S OF C A S E S

334

for 2 weeks, slow in clearing up. No heart involvement. Probably an acute infectious arthritis. Social.—Italian presser, unemployed for S months, suffered from worry and strain. Wife working and supporting family. Dependence on wife a cause of discouragement. Happy relationship and good home. Excellent initiative. Usual work had exposed him to dampness and changes of temperature. Plan.—Tonsillectomy. Salicylates. Course.—Tonsillectomy performed. Continued care in arthritis clinic. Obtained work himself, after 6 months, in his old trade. Summary, September, 1931.—Fatigue of looking for employment as well as discouragement may have played a part in flare-up of arthritis. Note added March 1, 1935.—Social worker reported in May, 1933, that patient had seemed to be in good health. H a d only occasional pains in ankles. Economic reverses continued. ABSTRACT Admission

November

80

21, 1930

Male;

age 24

Diagnosis.—Catarrhal Jaundice; Chronic Arsenic Poisoning; Acute Follicular Tonsillitis. Medical.—A young colored man, with sore throat and jaundice. Luetic history; intravenous treatment 1 Yi years ago. Question of arsenic etiology. Discharged after 3 weeks. Social.—Marital separation. Unemployment. Insufficient income. Ignorance. Shiftlessness. Plan.—Tonsillectomy. Course.—Recovery from jaundice; at work again. Never returned for tonsillectomy. Summary, September, 1931.—Unfavorable social factors unrelated to present medical problem. Note added March 1, 1935.—Patient lost. ABSTRACT Admission

February

11, 1931

81 Male;

age 39

Diagnosis.—Carcinoma with Metastases following Carcinoma of the Lung. Medical.—A man of 39, complaining of weakness and loss of

ABSTRACTS OF CASES

335

20 pounds in 5 months, with pain in right chest for 1 month. Biopsy and X ray showed cancer of bronchus. Symptoms relieved by X-ray therapy. Discharged after 4 weeks. Social.—An Irish checker; unemployment and illness were causing financial pressure and breaking up home. Dependent on relatives who offered sympathy and support. Headstrong type, restless over dependence and insecurity; drinking previously. Plan.—Return for X-ray therapy. Course.—Slight cough and loss of weight continue after 4 months. Decrease in shadow after 52 X-ray treatments. Living with parents. Interpretation to family regarding care and to patient regarding regular treatment. Summary, September, 1931.—Poor prognosis in a young man where problems were met by family. Note added March 1, 1935.—This patient continued under our care and died in the hospital September 15, 1931. ABSTRACT

Admission January 1, 1930

82

Female; age 42

Diagnosis.—Hypopituitarism ; Hypothyroidism. Medical.—A woman of 42, with endocrine dyscrasia; was treated here in 1928 and followed in Endocrinology Clinic; admitted with weakness, puffy eyes, and pains, for study. Discharged in 4 weeks unimproved. Social.—A French housewife who had had a chronic struggle to raise a large family on an inadequate income. Standards above resources. Heavy household duties. Always feeling below par. Crowded, unheated apartment 4 flights up. Oldest daughter mentally deficient. Cheerful, congenial family. Plan.—Continued glandular treatment. Complete dental extractions. Course.—Regular clinic visits, diet, and medication. No improvement noted but patient fairly comfortable while taking medication. Summary, September, 1931.—Parallel medical and social disabilities. No apparent relation between social factors and disease except that finances interfered with glandular therapy. Note added March 1, 1935.—Patient continued under care of this hospital. Condition remained about the same. Normal girl baby born here in December, 1933. Repair of cystocele and

A B S T R A C T S OF CASES

336

rectocele advised. Extracts of thyroid and pituitary taken regularly. Economic and other social problems have changed little.

ABSTRACT Admission

November

83

6, 1930

Male;

age 46

Diagnosis.—Subacute Bacterial Endocarditis; Cardiac Insufficiency; Double Mitral and Aortic Lesions; Aortitis; Fibrillation; Arteriosclerosis. Medical—Third and last admission of a man of 46 with severe cardiac disease treated here for 11 years. Presenting symptom was severe angina. Developed subacute bacterial endocarditis. Died in the 8th week after admission. Social.—A skilled Puerto Rican printer unemployed for 8 years because of illness, with dependence on family and social agency and consequent despondency. Physical aspects of home were altered to meet patient's need, under hospital direction; he became housekeeper while wife worked, and by careful management wife and children were able to provide. Plan.—None. Course.—Died in hospital, December 29, 1930. Summary, October, 1931.—Direction and assistance of a welfare agency to a demoralized patient and a poor and ignorant family in arranging cardiac regimen over a period of 10 years made adequate medical care possible outside of an institution.

ABSTRACT Admission

November

7, 1930

84 Female;

age 38

Diagnosis.—Pernicious Anemia. Medical.—A woman of 38, with a 4-year history of weakness and 5-week history of sore tongue. Thought to be a case of pernicious anemia with slight combined sclerosis. Response to liver poor; therefore readmitted for further care. Found to have been taking liver in too small quantities. Social.—A Norwegian housewife. Mentally dull. Delay in seeking treatment. Poor hygiene for 3 years; basement apartment. Inadequate, unbalanced diet recently. Economic distress; depend-

A B S T R A C T S OF CASES

337

ent on charity. Heavy work as janitress. Husband unemployed. Young son found mentally deficient and source of anxiety and fatigue. Plan.—Liver treatment and further study. Course.—No improvement for months. After intensive supervision and liver treatment improvement was apparent. Summary, September, 1931.—Combination of constitution, mental dullness, and poor social environment contributed to development and difficult treatment of this disease. Regulation of social environment may control medical prognosis. Note added March 1, 1935.—Patient continued under medical care. Remained in fair health and able to work. This was accomplished only by having the social worker give constant supervision.

ABSTRACT

Admission April 28, 1931

85

Male; age 63

Diagnosis.—Asthma; Hypertension; Cardiac Insufficiency; Arteriosclerosis. Medical.—A man of 63, with a severe attack of cardiac asthma; previous attack 20 years ago; probably on a cardiac basis with hypertension of 200/130, arteriosclerosis, and cardiac insufficiency. Gradually failing vision with choroiditis. Cardiac symptoms improved in 2 weeks' stay. Social.—Negro warehouse porter accustomed to heavy work, through illness dependent on intelligent, married daughter in good home. Depressed by dependency, death of wife, and break-up of home in the last year, and by restricted activity. Plan.—Permanent chronic care at home. Course.—Returned home. Chronic regimen planned with daughter. Spent summer in country. Gained 15 pounds and after 5 months was in good shape. Summary, October, 1931.—Satisfactory chronic care at home made possible by interpretation and planning with patient's group and encouragement of patient who was depressed by his limitations. Note added March 1, 1935.—Patient continued under the care of this hospital and remained in fair condition.

A B S T R A C T S OF CASES

338

ABSTRACT Admission

October

86

6, 1930

Female;

age 37

Diagnosis.—Acute Myositis of Posterior Cervical Muscles; Transposition of the Heart. Medical.—A woman of 37, with an acute myositis of the neck; foci of infection in sinuses and teeth. Improvement with diathermy in 1 week. Social.—An American housewife with a good home and sufficient finances. Unhappy over moving to New York from Middle West. Plan.—Discharged. No further treatment indicated. Course.—No known recurrence. Summary, October, 1931.—No medical-social problems. Note added March 1, 1935.—Not followed. ABSTRACT Admission

November

87

3, 1930

Female;

age 50

Diagnosis.—Chronic Nephritis; Chronic Uremia; Ascites. Medical.—A single woman of SO. Died the week after admission, of chronic glomerular nephritis and uremia. Onset may have been after scarlet fever at age of 5 years. Condition known for 3 years but she did not follow doctor's orders. Social.—Single woman, alone, active at clerical work up to admission. Plan.—None. Course.—Died in hospital, November 9, 1930. Summary, September, 1931.—Terminal admission. ABSTRACT Admission

October

30, 1930

88 Male;

age 17

Diagnosis.—Acute Follicular Tonsillitis. Medical.—Uneventful recovery from a streptococcus sore throat in 9 days. Social.—Presbyterian Hospital employee with adequate home. Plan.—Return to work after 1 week. Course.—No sequelae.

A B S T R A C T S OF CASES

339

Summary, September, 1931.—No medical-social problem in a mild acute illness. Note added March 1, 1935.—No medical follow-up. Patient kept regularly at his work all the next winter and had no severe colds. ABSTRACT

89

Male; age 60

Admission November 15, 1930

Diagnosis.—Ulcer of Duodenum; Arteriosclerosis; Exploratory Celiotomy; Jejunostomy; Duodenorrhaphy. Medical.—A man of 60, with ulcer symptoms for IS years. Positive X ray 4 years before. Bloody stools for 4 days. Operation for possible perforation after 8 days on Sippy diet. Discharged after 5 weeks improved. Social.—A Russian-Jewish peddler who dated symptoms to wife's death 4 τ/ι years ago. Formerly bad eating habits. Occupation involved exposure, exertion, long hours. Work interruption led to financial strain and dependence on family. Sensitive; independent; narrow interests. Good home and standards. Support and sympathy of children. Plan.—Ambulatory ulcer regimen. Possible gastroenterostomy later. Course.—Well for 4 months. Recurrence of symptoms on returning to work. Improvement on rest. Summary, September, 1931.—Long gastrointestinal history with irregular habits, lowered finances, and emotional shock contributing to bleeding ulcer, the treatment for which was interfered with by same factors. Difficult to readjust to lower level of activity. Note added March 1, 1935.—Patient continued under care of this hospital. He was readmitted in November, 1931, for posterior gastroenterostomy. Patient died on the 19th day after operation from a pulmonary embolism.

ABSTRACT

Admission February 17, 1931

90

Female; age 20

Diagnosis.—Chronic Ulcerative Colitis. Medical.—A woman of 20, with bloody diarrhea for 1 month; loss of 30 pounds; worrying, high-strung type. Improvement dur-

A B S T R A C T S OF CASES

340

ing 7-week stay with transfusions and beginning psychiatric investigation. Neurosis or dementia precox suggested by terrors, etc. Social.—Emotional instability in the case of an American housewife with little intelligence and resources. Inadequate and irregular income. Unhappy marriage. Broken home; lived with ignorant parents, under crowded conditions. Plan.—Rest. T o return to Gastrointestinal and Psychiatric Clinics. Course.—Plans for convalescence and treatment terminated by patient's going to local doctor and then to another hospital. Summary, September, 1931.—A very difficult problem with very poor prospects; medically, psychiatrically, and socially incomplete. Note added March 1, 1935.—Learned from another hospital where she was a bed patient for 5 months, that she was discharged home unimproved. Two years later patient herself claimed that following laparotomy in a third hospital she had felt well for a year and a half. In August, 1933, however, intestinal symptoms recurred. No further report. ABSTRACT Admission

April 13,

91 Male;

1931

age 36

Diagnosis.—Acute Pharyngitis. Medical.—A man of 36, with an acute upper respiratory infection; recovered in a week without complications. Social.—No problems in the case of this Presbyterian Hospital orderly, well adjusted in work and home. Plan.—Return to work at once. Course.—Complete recovery. Summary, September, 1931.—Hospital employee. Mild acute illness. N o problem. Note added March 1, 1935.—Patient has continued as an employee of this hospital and under medical care for occasional mild respiratory disorders. ABSTRACT Admission

December

22,

1930

92 Male;

age

62

Diagnosis.—General Arteriosclerosis; Arrested Pulmonary Tuberculosis; Undiagnosed Condition of the Gastrointestinal Tract.

A B S T R A C T S OF CASES

341

Medical.—A man of 62, with epigastric distress and diarrhea for 4 months, with loss of IS pounds. Left against advice after 2 l/z days before work-up was completed. Carcinoma suspected. Social.—Highly emotional and evasive Austrian Jew, who claimed that his business had been going badly, that his wife was uncooperative in providing diet, and that his children caused much worry. Plan.—None. Course.—Not known. Summary, October, 1931.—Case dropped because of patient's lack of cooperation.

ABSTRACT Admission

October

93

20, 1930

Female;

age

60

Diagnosis.—General Arteriosclerosis and Coronary Sclerosis; Cerebral Hemorrhage; Acute Uremia, etc. Medical.—Final admission of a woman in coma, who had been followed in Out-Patient Department 4 months for advanced cardiovascular disease. She died on Sth day after admission. Social.—Elderly colored widow, mother of IS children, dependent on married children. Plan.—None possible. Course.—Died in hospital, October 25, 1930. Summary, September, 1931.—No social problem.

ABSTRACT Admission

February

16, 1931

94 Male;

age

43

Diagnosis.—Arteriosclerosis of Coronary Arteries; General Arteriosclerosis. Medical.—A man of 43, with dypsnoea for 1 year and precordial pain for 2 months. Marked improvement on rest in bed for 4 weeks. Poor prognosis. Social.—A German-Jewish postal clerk with a good home and steady work. Two flights of stairs was the only bad feature. Plan.—Rest at home 1 month. Resume activity gradually, remaining greatly restricted. Continue under medical care. Course.—Returned to work.

ABSTRACTS OF CASES

342

Summary, September, 1931.—Patient's intelligence, equable disposition, and good environment accounted valuable assets. Note added March 1, 1935.—Patient continued under care of this hospital. Worked regularly without symptoms. Electrocardiograms showed changes in the direction of normal.

ABSTRACT Admission

95

April 7, 1931

Male;

age 46

Diagnosis.—Polyneuritis; Fever of Unknown Origin. Medical.—h colored man of 46, with diarrhea and vomiting for 2 weeks and known glycosuria. He presented a confusing picture of anemia, fever, and neuritis. He died after 2J/2 weeks without any cause for his illness having been found clinically or post mortem. Social.—Colored porter. Marital friction over finances. Employed regularly up to present illness. Plan.—None possible. Course.—Died in hospital, April 25, 1931. Summary, September, 1931.—Cause of death unknown. Apparently no social problems contributory to the disease.

ABSTRACT Admission

November

25, 1930

96 Male;

age

73

Diagnosis.—Carcinoma with Metastases following Carcinoma of the Prostate; General Arteriosclerosis; Hypertension. Medical.—Second admission of a 73-year-old man for pain in the neck; known to have carcinoma of the prostate. Metastases to neck proved by biopsy and metastases to cervical vertebra shown by X ray. Discharged after 1 week to a chronic home. Social.—A well-educated old man who had lived a life of affluence was without resources and refused to communicate with wealthy relatives or friends. Irregular existence in an inadequate single room. Plan.—Terminal institutional care. Course.—Signed himself out of the institution after 5 weeks' stay and went back to work; readmitted to institution 16 weeks later and remained there 10 weeks. Again signed himself out.

A B S T R A C T S OF CASES

343

Report received that he had died 10 days later, about July 7, 1931, at a camp in the mountains, following a fall. Summary, October, 1931.—Carcinoma in an old man who had sunk from affluence to penury and was too proud to call on relatives when institutional care was necessary. ABSTRACT Admission

November

97

10, 1930

Male;

age 36

Diagnosis.—Undiagnosed Condition of the Head; Anxiety Neurosis. Medical.—A man of 36, with pains in the left side of the head for 1 year. Nothing found to account for his symptoms. He refused lumbar puncture and was discharged after 6 days. Social.—A machinist, of Italian descent, who had a poor heritage (father alcoholic, mother insane) and abnormal childhood (poverty and delinquency) ; feeble-minded and unsympathetic wife; poorly run home; belligerent attitude on his part. Had been from one doctor to another without relief. Plan.—Vision to be corrected in clinic. Course.—Glasses provided. Interpretation to outside social worker; case not carried further here. Summary, October, 1931.—No organic basis found for pain. Environmental factors indicate functional basis. Note added March 1, 1935.—Outside social worker reported that patient's discomforts had continued for about a year. His business then improved and symptoms subsided. ABSTRACT Admission

April 24, 1931

98 Male;

age 75

Diagnosis.—Cardiac Insufficiency; Auricular Fibrillation; General Arteriosclerosis. Medical.—A man of 75, with cough for 4 months and dyspnoea for 3 weeks. He was found to have arteriosclerosis and fibrillation, with a persistent irritating cough. He was discharged after 7 weeks just able to be around. Social.—The first illness of an active, undisciplined old night watchman who lived in a poverty-stricken home with a psychotic wife and interfering relatives and who refused city care.

A B S T R A C T S OF CASES

344

Plan.—Permanent institutional care. Course.—Refused institutional care. Returned home and did not cooperate in cardiac regimen. Wife was committed to hospital for the insane where she died 3 months later. Patient went to live with relatives able to provide for him. Summary, October, 1931.—Provision of care for wife relieved patient of both physical and mental strain. Note added March 1, 1935.—Patient continued to live with relatives. He was readmitted for S days in February, 1931, with fluid in the chest. He failed to keep clinic appointments after March, 1932, and was lost.

ABSTRACT Admission

November

99

19, 1930

Male;

age

48

Diagnosis.—General Arteriosclerosis; Hypertension; Sclerosis of Coronary and Tibial Arteries; Chronic Multiple Arthritis. Medical.—A man of 48, admitted for typhoid vaccine injections to relieve pains in legs caused by arteriosclerosis of arteries of legs. Improvement with two injections. Discharged after 2 weeks to return for weekly injections. Social.—Jewish tailor, ignorant; worried; 4 small dependents; inadequate noisy home S flights up; uncooperative wife; irregular support from interfering relatives, since failure of his own business. Attitude of despair ; history of fatigue from long working hours and of excessive use of tobacco and alcohol. Plan.—Continue injections in clinic and arrange home care. Course.—Plan carried out with aid of family social agency which helped reorganize the home and change attitude of family toward patient. Five months later patient was definitely improved but still unable to work. Died at home suddenly in June, 1931. Summary, October, 1931.—Chronic care at home made possible for patient by cooperation between the hospital and an outside agency. ABSTRACT Admission

April

20, 1931

100 Female;

age

57

Diagnosis.—Cardiac Insufficiency; Auricular Fibrillation; Mitral Insufficiency and Stenosis.

A B S T R A C T S OF CASES

345

Medical.—Second admission of 57-year-old woman for cardiac insufficiency with double mitral lesion and fibrillation. First break 2 years ago. This break followed a cold 2 months before. Improved on rest and digitalis; discharged after 1 month on limited activity. Social.—Vain, self-centered American woman who had led a self-willed and irregular life; estranged from all relatives; without resources, and dependent on her earnings as factory pieceworker. Periods of decompensation seemed to coincide with major quarrels with kin and friends. Hysterical temperament. Plan.—Convalescence. Restricted activity. Course.—Convalescence for 2 weeks. Disability explained to patient, family and friend. Refused hospital interference in her life, but later returned decompensated, not having followed instructions. Summary, October, 1931.—Social readjustment of a patient with moderate cardiac disability proved to be impossible because of her temperament and unwillingness to follow recommendations. Note added March 1, 1935.—Continued under care of hospital until April 26, 1934; hospital then lost track of her.

APPENDIX THE Name:

CATHARINE

Monahan,

Catharine

2

MONAHAN

Warren

CASE

Record No. 1805 (Abstract 18)

MEDICAI. SUMMARY * T h e patient, an English-born housewife and waitress, twentyeight years old (in New York City twenty-six years), came to Vanderbilt Clinic January 26, 1931, because of painful, swollen joints of about 3 months' duration. The onset occurred a week after a severe sore throat with chill and fever. Dyspnoea, orthopnoea, and palpitation were present but not marked. She had lost approximately 15 pounds. Small doses of salicylate had not relieved the joint pain. Her past history was irrelevant except for polyarthritis confining her to bed for 3 months, 4 years previously. Following this her doctor told her she had a leaking heart valve. Shortly after recovery from the acute illness she noted exertional dyspnoea and some orthopnoea but carried on her accustomed activities without undue interference. The family history was not significant except that a sister had rheumatic heart disease of 6 years' standing. She was pale and poorly nourished, not acutely ill. Temperature, pulse, respirations, and blood pressure were normal. Several teeth were carious; tonsils cleanly removed. Multiple joints were somewhat swollen and tender, notably the second phalangeal finger joints. T h e heart was moderately enlarged, classical signs of mitral stenosis and insufficiency being present. There was slight enlargement of the liver. Rest at home with larger doses of salicylate was prescribed. On her second visit 2 weeks later, however, hospitalization was advised since she had had hemoptysis and increased dyspnoea and joint pain. Physical examination was essentially as noted pre* Prepared by Dr. Lucile V. Moore, Assistant Physician, Department of Medicine.

CASE R E C O R D

347

viously except that fine râles without other changes were present at the base of the left lung. Laboratory and X-ray studies showed the following: slight secondary anemia, no leukocytosis; essentially normal urinalyses; stool negative for blood, ova, and parasites; negative blood Wassermann (twice); sterile blood culture; pure culture of streptococcus viridans from tooth socket and apex. Chest film: moderate thickening of broncho-vascular markings in upper lung fields. Two-meter film of heart: cardiac enlargement, mitral type, maximum right diameter 4.8 cm., maximum left 8.9 cm., great vessels S.S cm., total diameter of heart 13.7 cm., internal diameter of chest 24 cm. Sinus films: questionable clouding of right antrum. Film of elbows and hands: no bony changes, slight periarticular swelling along phalangeal joints. Electrocardiogram: prolonged conduction, PR interval 0.20 to 0.21 seconds, suggesting rheumatic involvement of the myocardium; and again 4 weeks later: P R interval 0.22 to 0.24 seconds, ST interval elevated in all 3 leads, suggesting further rheumatic involvement of the myocardium. She remained in the hospital 4 weeks, on bed rest 3^4 weeks. Ultraviolet regimen was instituted and she was given cod-liver oil with malt and iron. With moderately large doses of aspirin, later pyramidon, joint pains gradually subsided. Three abscessed teeth were extracted at intervals. On ear, nose, and throat consultation, no evidence of active sinusitis was found. Her weight remained stationary. She was discharged to a convalescent home for prolonged rest. After her return 6 weeks later she was much improved, had gained weight, and experienced only slight dyspnoea, occasional palpitation, and mild transient joint pain. Ultraviolet regimen and cod-liver oil were again prescribed, with continuance of rest. Appointment was made for further dental work. A month later she was having somewhat more dyspnoea and palpitation. Electrocardiogram showed persistence of prolonged conduction ( P R 0.22 seconds). She improved during the summer, gaining weight, adjusting to restricted activity, her joint discomfort lessening with physiotherapy. Aspirin was resumed in August for joint pain and she had a mild attack of hay fever in the country that month. In September she complained of weight loss, nervousness, and poor sleep (BMR —59c)· She was not seen again in the Follow-up Clinic until February, 1932, when her condition seemed satisfac-

CASE R E C O R D

348

tory though She complained of insomnia and there was slight joint discomfort. She was referred to the contraceptive clinic. In June she had a cold and sore throat which caused no trouble except for the immediate illness. During the following years, she attended a clinic for rheumatic disease at the hospital. In February and March, 1933, after respiratory infections, she experienced mild rheumatic symptoms. On follow-up, June, 1934, she was maintaining good health with only slight physical limitations. COPY

OF SOCIAL W O R K E R ' S

DAY

BY

DAY

NOTES

2-9-31 Patient referred from Medical West Clinic for admission; diagnosis of rheumatic fever with considerable joint involvement. She is to come in as soon as possible. She is an attractive and intelligent-looking young woman, who says that she will have to go home to arrange for the placement of her two children, Steven, 9y 2 , who attends P.S. " X , " and is in 4A, and Catharine, 8, who attends the same school and is in 3A. She is living with her husband, William, 29, at 133 Port Avenue, Apartment 57, fifth floor. There is no telephone through which the home can be reached. Since last November her husband, who is a taxi driver, has not had steady employment, but has worked on the average, one or two days a week, which has brought him approximately $10. She says that they have no relatives whom she can ask to take the children. Her mother, Mrs. Warren, telephone Cherry 1495, is caring for an invalid aunt who is 80 years old, and who takes most of her time, and she has no brothers or sisters to whom she can turn. Her husband's mother is living in Bloomsbury, and is not well. Patient does not like to consider institutional care for the children, since she had an unfortunate experience with the Children's Welfare last summer. They sent the two children away to camp and on a visit to them Mrs. Monahan found them dirty and undernourished. If they have to ask us later for assistance in placing the children, she will wish them to remain in the city where they can be seen frequently. Mrs. Monahan used to work at the Monarch Department Store, first in the restaurant and this past autumn at the soda fountain. She was doing three-quarter time there, earning $15 a week, but

CASE R E C O R D

349

she had to leave about six weeks ago because of her illness. The rent for their three rooms is $45. Patient was born in England and was brought to this country when she was 2 years old. Her father died when she was 14 years old and her mother has worked since then. She lived in an urban area near New York City for several years and has lived at her present address for only one year. Since patient insisted on returning to her home and since it was a very rainy day, worker took her home in a taxi. The house in which patient's apartment is located is a very attractive modern walk-up. Patient lives four flights up. The apartment, which consists of one bedroom, a fairly large sitting room, kitchen and bath, is attractively arranged with light on two sides and modernly furnished. Apparently patient has tried to make it attractive in spite of their limited means. She has colored theatrical gauze curtains and matting in the bedroom. Patient was advised to lie down. She said that her son, Steven, who was not at home, would probably be in soon, and that she could send him to the store. He would be able to peel the potatoes for the children's dinner, and she would not have to do any heavy work that evening. She will have Mr. Monahan come to the hospital the following morning to let us know what arrangements have been made for the care of the children and at what time she will be able to come into the hospital. She has already been signed in on the deferred list and a bed is being held for her for the next day. 2-10-31 Mr. Monahan came to hospital to discuss plans for care of the children. He says that his wife's mother cannot take them, as she already has an elderly relative to care for. He has no relatives of his own in this country who can help. He gives his earnings as around $22 a week and says he goes every afternoon at 3 to see if there is work. If there is work, he is on the job till 5 A.M. and sleeps in the forenoon. Regarding religious affiliation he says that his wife is High Church Episcopalian and he is Catholic. He does not attend church himself, but the children do. Mr. Monahan is quite willing for the children to be placed in a nonsectarian institution, but wishes them to be where he can see them. H e does not wish to repeat the unfortunate experience of last summer,

350

CASE R E C O R D

when he feels the children were poorly cared for at a vacation camp. If no charge is made for patient's care by the hospital, he feels he can make a small payment weekly for the children. 2-11-31 to 2-14-31 In the course of the next few days the following agencies were consulted regarding placement of the children: 1. Family Welfare Agency, which charges a minimum of $6 a week per child. Families not able to meet this minimum are referred to the Department of Public Welfare. 2. Children's Welfare Society, by agreement takes no Catholic cases. 3. Association for Child Care, Mrs. Berger, who recommends the Children's Temporary Shelter. She knows of no other suitable vacancies at present. 4. Children's Temporary Shelter, Miss Payson, Director, who says at first that she has one vacancy for a girl. The Shelter is nonsectarian and likes to keep the children long enough so that their school work will not be seriously upset by too frequent transfers. A small charge per week is made. Meanwhile daily telephone conversations were being held with Mr. Monahan. He reported that patient's mother had finally agreed to take Catherine, but was not willing to take Steven, as he was harder to manage. When questioned further he said Steven got poor marks in conduct at school, but had never caused serious trouble. On February 11 Mr. Monahan was advised to make application to the Family Welfare Agency for placement of Steven; he reported two days later that they referred him to an institution which refused his application because Steven was above their age limit. When worker reported to the Children's Temporary Shelter that relatives would take Catharine, Miss Payson offered to rearrange her beds so that she could take Steven instead. On February 14 Mr. Monahan was therefore advised to take Steven to the Children's Temporary Shelter, since Miss Payson wished to see the boy before making any decision. Patient had been admitted to the ward on February 12 and on the 14th worker assured her that every effort was being made by social service to assist her husband in finding a suitable place for Steven.

CASE RECORD

351

2-16-31

Telephoned Miss Payson to see if Steven had been admitted. She said that she had expected him to come in that morning but he had not as yet been brought. Miss Payson seemed to be very doubtful of the wisdom of taking Steven. She said the father had told her that Steven is disobedient at times, has run away several times and after school spends his time playing on the streets instead of coming home as told. Miss Payson has gathered that there is a good deal of friction at home, possibly arising from the parents' difference in religion. Mr. Monahan wished Steven to attend parochial school, rather than the public school, from the Children's Temporary Shelter. They cannot consider this, however, since they are under State control. She said that Mr. Monahan expressed displeasure that Mrs. Monahan does not take an interest in having the children go to Mass, and has them attend public school instead of the parochial. Steven has been seen by Miss Payson ; he looks to her like a bed-wetter. When Mr. Monahan was questioned directly about this he said that Steven did occasionally give them trouble. She is willing to take the child on trial, however. Shortly afterwards, phone call received from Mr. Monahan who said that he had been unable to secure a health certificate for Steven and wished to know if he could bring him to this hospital for it. Permission for this secured, Steven brought to clinic by his father. Mr. Monahan is a good-looking, burly, red-faced man with a very pleasant, rather jovial, manner, apparently anxious to cooperate with the hospital. Steven is an attractive youngster, possibly a little thin, rather pale and nervous-looking. He is well built and impressed the worker as being decidedly above the average in intelligence. Medical certificate secured. That morning on rounds Mrs. Monahan had been very much upset over the fact that she was to have a tooth pulled that afternoon. She had cried and had stated that her fear of dentists was the only reason. Mr. Monahan, before he left the clinic with Steven, asked that the boy be allowed to see his mother since he would probably not have another opportunity to do so for some time. Since Mrs. Monahan was still at the dentist's, took Steven up to the clinic to see her. She had just had the extraction —was quite calm. Steven, although he seemed well-mannered enough, was much more interested in the glimpses he could get into the dentist's office than in his farewell to his mother.

352

CASE

RECORD

Mr. Monahan expressed himself as very pleased with the Children's Temporary Shelter. Said that Miss Payson was a nice, motherly person and the place was very clean. Steven too said that he had liked it there and was apparently excited and pleased at the prospect of going. 2-18-31 Phone call received from Miss Payson, Children's Temporary Shelter, saying she could not keep Steven there. Last night he wet the bed and denied all knowledge of it. She found the wet sheets stuffed behind one of the lockers. Steven's bed was made up with dry sheets and it was only when they felt the mattress they discovered it was soaked. She says he is very unmanageable in the house, dashes around, and thinks nothing of interrupting her at meals or when she is in private conference behind closed doors. She says that she could stand the lying and the noisiness if it were not for the bed-wetting, but she asks that because of this he be taken away today. 2-18-31 Interviewed Mrs. Warren, patient's mother, during visiting hours, explained to her our difficulty, and asked her advice about getting in touch with the father. She said there was no way he could be reached by phone; she does not know the name of the taxi company for which he works, but she offered to take a message to the home and if he is not in, leave it in the mail box for him. She said Steven had always been rather disobedient in the home but that they had not been sure that he wet the bed. He and Catharine share the same bed and Mrs. Monahan had said that one or the other of them did, but was not sure which one it was. Mrs. Warren says that her aunt demands so much time that she could not take both children and at the suggestion that Catharine might go to the Children's Temporary Shelter and Steven come to her, she said that she did not feel that she could make the transfer since Steven was more difficult to manage and Catharine has already been established in the new school. Letter sent by Mrs. Warren to Mr. Monahan, asking him to communicate with worker, either at the hospital or at her home that day. 2-20-31 No reply from Mr. Monahan to letter or telegram. Wide inquiry by social worker among child welfare agencies (itemized account

CASE RECORD

353

omitted here) for a temporary boarding place suitable for this child. Placement by Public Welfare finally advised as best. Later today Mr. Monahan phoned for appointment and arrived two hours late. He has taken no step to make better provision for Steven. He is unwilling to ask help of any welfare agency because of his experience two years ago when their home was broken up because of his financial failure. He then applied to them and although they investigated four or five times in the home, always asking approximately the same questions, they never got around to finding a school for Steven. Steven was then with his father, living in a furnished room downtown, and Mrs. Monahan had gone to "some camp." Catharine was living with her maternal grandmother. Mr. Monahan was apparently unwilling to discuss the causes of their domestic break at this time more fully. He simply said that he could not make enough money to keep up the home. Mr. Monahan was worried because he had just received a letter from the real-estate agency, Mr. Alfred Landis, Manager, saying he would have to pay $25 by Wednesday night and an additional $20 by Friday night, or they would have to take drastic steps. Mr. Monahan says he lost his job last week when he had to take time off to bring Mrs. Monahan to the hospital, and three days ago he found another with a taxicab company as substitute driver. He will have a pay check in four days but it will probably not come to more than $18 or $20 since he is often not able to get a cab to take out. He says there are about four drivers there for every cab. He has driven, since he was married, almost every kind of car. In the summers he always drives sight-seeing and tourist busses, and has been accustomed to getting $50 a week. He has been with the Exchange Sight-Seeing and Metropolitan Sight-Seeing Companies. He says that on occasion now he makes $25 a week but that usually his pay averages about $20. It will be at least six weeks before he is able to get a full-time position with the cab company. Talked about Steven's difficulties. He feels that since he has been working at nights Steven has got out of hand. He said that when he was at home and around the house he used to lick the boy and that he would obey him. He has spanked him quite often for bed-wetting but since he has been out and since Mrs. Monahan has been ill she has overindulged him and Steven now makes no effort at obedience.

354

CASE R E C O R D

Explained to Mr. Monahan that it would be necessary for them to move to an apartment on the first floor as soon as Mrs. Monahan returned home, or preferably before, since her heart cannot stand stair climbing. Mr. Monahan seems to feel that her present illness is very surprising and mentions her previous rheumatic attack of four years ago as a very minor incident, from which he expected her to have no aftereffects. Suggested the possibility of Mr. Monahan's putting the furniture in storage until Mrs. Monahan is nearly ready to return home and then finding a first-floor apartment for them. Mr. Monahan says that the cost of moving, storing the furniture, and supporting himself in a furnished room will be equal to, if not greater than, the amount he spends by keeping the apartment open. Moreover, Mrs. Monahan has told him that she wishes to keep their present apartment and will leave the hospital if there is any suggestion of the home being broken up again through her illness. Mr. Monahan says that all four members of the family are insured in the Universal Life Insurance Company, and that he has to pay $2 a week in premiums. He has not paid this for some time, and he is afraid the policies will lapse. Since he has been carrying his own for 16 years, Mrs. Monahan's since their marriage, and those of the two children since their birth, he would like to avert this possibility. He owes $90 on his rent. Worker said that she would get in touch with the real-estate company, explain the present situation to them, and ask them to make some arrangement with Mr. Monahan. Also offered to write the lifeinsurance company. Mr. Monahan once more said that there were no relatives to whom he could turn at the present time, and was very anxious to have Steven remain at the Children's Temporary Shelter. He feels that Steven will resent any place that requires discipline and he was more than pleased with the Shelter. Worker said that she would try to persuade Miss Payson to keep Steven but that failing this he would have to apply to the Family Welfare for placement. 2-20-31 Phoned Miss Payson. She said that Steven was home from school today with a headache and that he is now in bed, having had his luncheon and a cup of tea sent up to him. She says that in spite of his being unmanageable she rather likes him, and apparently is beginning to feel quite sorry for him. Steven has told

CASE RECORD

35S

her that he has had frequent headaches for months, that he is accustomed to drinking tea two or three times a day and she feels that Steven's difficulty may be of physical origin. She said that she would be willing to keep him on trial for a little while longer if we could bring him into the clinic and have him examined tomorrow morning. Appointment for medical and psychological examination of boy could not be arranged because it was Saturday. 2-20-31 Interview with Mrs. Monahan in ward. She is talking about signing herself out since she has become very despondent over the fact that her joint swelling has apparently not subsided. Explained to her the necessity of complete rest. She spoke of the break-up in the family two years before, as a result of Mr. Monahan's financial failure. She said that she took a position at a children's camp as seamstress at that time. She stated that she had been very ill four years ago when she had her first attack of rheumatic fever and had had to stay in bed at her mother's for nearly three months. At the end of that time her mother found an apartment for her on the ground floor and she tried to reëstablish the home, but after the first two days had to give it up because of a recurrence of her condition. Last April she went to the Monarch Department Store and applied for work. The examining doctor told her that she had a rheumatic heart and questioned her about previous attacks of rheumatism. She replied that she had always been well and had never had any pain or anything resembling rheumatism. The doctor apparently believed her, asked her if she felt well enough to carry a heavy tray and when she said "yes" he allowed her to take a position as waitress in the dining room. When the dining room closed at the end of July she was out of work for a time but in September she was taken on again and reëxamined. The week before Thanksgiving she had a fever and sore throat and was so ill that she was sent home and told not to return until she was well. Since then she has been continually too sick to try to go back. She says that she realizes that Steven has taken advantage of her illness. He knows that she will not climb down four flights of stairs to bring him in from the street, and so has stayed out. She said that the school had asked her to bring him in to the behavior clinic but she had not been well enough to do so. They

356

CASE R E C O R D

had also suggested several times that she have his eyes examined. She says that she notices when he reads he holds the book closer than she would, and that he has also complained to her of headaches many times. She says that he spends many hours reading. She was reassured about Steven; it was explained that Miss Payson would probably be willing to keep him, and if not we would see that he had a good home and school. 2-21-31 (Saturday morning) Visited Children's Temporary Shelter and talked to Miss Payson who now says she is unwilling to keep Steven under any circumstances. She says that although he seems to behave well enough when she is around, if she leaves the house for only a few minutes she learns on her return that Steven has been making difficulty among the children and has been unruly. She says that he spends much of his time hanging halfway out of the upstairs window and that she is afraid that he will fall out. He had been sent up to his room an hour before worker arrived to wash his face and hands and apparently had not yet done so. She feels that Steven needs someone in constant attendance in order to keep him in hand. He has not wet the bed since her first complaint but she is anxious to get him out of the house as soon as possible, so that she can have her mattress cleaned before the Board discovers its condition. She had persuaded the Board to give her much more expensive beds than they had been accustomed to and the mattress which Steven had ruined was among the new ones. Tried to persuade Miss Payson to keep Steven for another period of trial but she absolutely refused. Said that he must leave today. Steven had told her that he had an aunt who had offered to take him to her home for the week end, and she felt that in view of this she should not be required to keep the child any longer. Telephoned Mrs. Warren, maternal grandmother, who said that she had not made such an offer to Steven and that she did not know of any one to whom he could go. Miss Payson still insisted that he must leave and worker said she would take Steven to the Family Welfare and make application for his placement. Miss Payson finally said that if absolutely necessary Steven could return until Monday. Pointed out to her that Monday was a holiday and that we would be unable to do anything until Tuesday. She said she would not consider keeping him over Monday night, however.

CASE RECORD

357

2-21-31 Took Steven to Family Welfare and made application for his placement. Supervisor said that they could not do anything until the case had been completely cleared. The family seemed to be a familiar one to her but she was unable to find the name listed in the office file. She said that there was no place she could send Steven temporarily. They would see the father on Tuesday morning as soon as the case had been cleared and would try to place Steven by Wednesday. Steven insisted on telephoning his aunt, Mrs. Hogan, who he said lived in Bloomsbury and had offered to keep him over the week end. Telephoned Mrs. Warren and asked her if it would be all right to phone Mrs. Hogan. She was very noncommittal but said that if Steven wanted to do it she saw no reason for not doing so. Steven phoned Mrs. Hogan (Aunt Eileen) at Surrey 1602 and asked if he could come out for the week end. Worker also talked to her and she said that although she did not feel that she could keep Steven for more than two days she would be glad to take care of the present emergency provided it would not be for long. Explained to her we were entirely dependent on the Family Welfare for the speed of placement but that in all probability it would not be longer than Wednesday. Worker said that she would bring Steven out to Mrs. Hogan's that afternoon, since there was no one there who could come into town for him. Phoned Miss Payson at Shelter that aunt accepted boy for week end. Worker took Steven home for lunch. Throughout the day his behavior was not only perfect but he showed excellent training in his manners. He was not only courteous but seemed to be entirely self-sufficient. The towel he was given to wash with was hung on the rack carefully folded. He set his place up at the table from his cafeteria tray in perfect order and there were no signs of restlessness or pettiness at all. He was rather quiet and uncommunicative and while waiting for worker seemed to be entirely satisfied to sit quietly and read. When questioned about his headaches and about having his eyes examined he said that his eyes were all right and that two years ago, when one of the boys in his class had poor eyes and had been given a front seat, he had decided he wanted a front seat too and had "made out" that he could not see very well. His eyes had been examined three times at the school, the last time in November, and they had said that they were all right. Steven said that he had an

358

CASE R E C O R D

uncle who was dying (he was probably referring to the relative who has recently died, on the father's side of the family, from cancer of the throat), and that this uncle owned a lot of property in (a near-by city). 2-21-31 Took Steven to his aunt's home. She lives at 47-24 49th Street, Bloomsbury, telephone Surrey 1602. This is a four-family apartment house in Old English style. The rooms occupied by the family are large, attractively furnished, and very pleasant and light. Mrs. Hogan is the relative whom worker met in company with Mrs. Warren when they were visiting the patient. Steven was greeted enthusiastically by his two young cousins, age 4 and 7. Mrs. Monahan, Sr., was at home. Mr. Hogan, the uncle, was at home also but did not come in during the interview. He entertained the children in a back room. Mrs. Hogan was out having a medical treatment for a skin eruption which she has been told resulted from nervousness. Had brief interview with the grandmother before Mrs. Hogan arrived. The grandmother is an attractive, intelligent-looking, rather nervous woman of about 60, with a motherly attitude toward Steven. She showed a distressing tendency to talk about him in his presence. She explained that it was very difficult for them to keep him since Mr. Hogan was already carrying more than his share of responsibility for relatives. She herself is financially dependent on him (she cried while discussing this matter). He has contributed financially to the Monahans in the past and has, through his wife, clothed the two children for many months. He has three brothers, two of whom are out of work and have families of five and seven children respectively. Although he has given them money, their children have not been cared for in his home, and Mrs. Monahan, Sr., feels that keeping Steven, who is a relative only by marriage, is a double imposition on his kindness. Mr. Hogan cannot stand Steven's disobedience and impudence, and although he says little about it, she says his dislike is evident. The situation at the present time is further complicated by the fact that the uncle in the family has just died of cancer of the throat and his funeral is being held this week end. Mrs. Hogan arrived shortly after worker. Following general history secured from Mrs. Monahan, Sr., and Mrs. Hogan. Mr. Monahan's father died when his son was only one year

CASE R E C O R D

359

old, leaving his mother with three children to bring up. She worked and kept the home together. When Mr. Monahan was 17, he was supporting his mother. Both of the other children, who were older, married. Mr. Monahan met our patient in the office where his sister worked. His sister was employed there as timekeeper and our patient as a telephone operator. One night, after Mr. Monahan had known her for only three months, he came home and announced to his mother that they were married. The family had had no intimation of this before. Mrs. Monahan, Sr., was very much upset by the news since it meant the breaking up of her home and the withdrawal of her means of support. Some time after this event she secured work in a department store and she was employed there for six years. She had to give up working altogether three years ago when she became very badly crippled with neuritis. She had managed to save a few hundred dollars. Practically all of this money has been used to pay the Monahans' rent in past years, and Mrs. Monahan, Sr., is now dependent. Ever since Mr. Monahan's marriage he has had what the family calls "plain bad luck." The mother and sister excused this by the fact that he had had little training and by the time he attained his majority already had two children and a wife to care for. They mentioned but did not explain the fact that the home had been broken up through his financial failure two years ago. Both of them seemed to like Mrs. Warren, the patient's mother, and to respect her, and I judge that there is considerable understanding and contact between the two groups of relatives. They described Steven as always having been nervous and unruly. They said that at the age of 3 he was the kind of child who would try to open the upholstered furniture with a can opener, and he had never been obedient. These relatives were distressed that Steven does not attend the parochial school. They felt that in the parochial school he might be made altar boy and that this might have a chastening effect on him as it did on his own father. During the past few months Steven has been in continual disfavor. He steals milk bottles at home and turns them in at the grocery store for money to go to the movies and then stays out until 11 and 12 o'clock at night, leaving no explanation at home. He has been "truanting" from Sunday School. They are inclined to blame Steven's conduct entirely on his mother's laxness, and say that after all his father cannot lick him all the time. Like

360

CASE R E C O R D

his mother, the aunt and the grandmother do not believe in chastising him. But they feel this is the only punishment he understands and therefore they do not wish to have charge of him. When the mother went to the hospital, the paternal grandmother went to live in her son's apartment. She planned to take care of Steven there. The first night he was out until 11 o'clock, the next night, until after 12. His grandmother became so upset that she refused to stay and took him with her to Mrs. Hogan's home. Steven was placed on a cot downstairs and in the mornings would get up early and make so much noise with the radio and in playing that the family could not rest. They were also afraid that he would run away when he was alone in the lower part of the house. He wet the bed twice while there. Interpreted the patient's disability to them, urged the necessity of her moving to a first-floor apartment, and told them that worker would try to arrange for Steven to return to the Shelter on Monday evening. They decided, however, that they would keep him until the Family Welfare could arrange placement. 2-22-31 Phone call received from Mr. Monahan in the evening. He said that he was sorry that Steven had gone to his sister's home, that he had not been on very good terms with his relatives, and that he was afraid they would consider it an imposition. Explained to him that his sister understood that worker had not been able to get in touch with him and the boy had been brought to them without his knowledge. He said that under these circumstances he felt much better about having him there. H e did not wish his wife to know that Steven was with them because he felt it would only distress her. 2-23-31 Phoned Miss Payson at the Shelter. Explained that Steven would remain with his aunt. 2-24-31 Letter received from Dr. McGowan, house physician at All Souls' Hospital, who was a medical student here last year. The letter was written after he had met Mr. Monahan at the uncle's wake. Mr. Monahan asked him to examine him and on examination Dr. McGowan had discovered two open sores which he thought might be syphilitic. I t was apparent from the letter that Dr. McGowan knew Mr. Monahan personally. He had referred

CASE RECORD

361

him to our skin clinic, had ascertained that Mr. Monahan had had recent extramarital relations, and had had intercourse with his wife since the appearance of the lesions. He stated his willingness to interview the worker. The letter was given to patient's physician, who remembered Dr. McGowan as a student. Social worker phoned All Souls' Hospital and arranged an appointment with Dr. McGowan for the following morning, February 25. 2-24-31 Phoned Family Welfare at noon to find out if they had investigated case. Supervisor said that they had sent a special-delivery letter to Mr. Monahan, asking him to come to their office the following morning. Explained to her once more that it was very difficult for Mr. Monahan to make the trip. She said that they would much rather interview him at the office. Also once more urged the necessity of immediate placement. 2-24-31 Interview with Mrs. Monahan in ward. Told her that Steven was still at the Shelter. She is still talking about leaving the hospital and going home. Phone call received from Mr. Monahan, who said that on coming home that morning he had found a large red notice pasted on his door, warning him that he would have to make payment for his furniture. Notice placed there by the Reliance Furniture Company to whom Mr. Monahan still owes $40. He said Family Welfare had not yet been to see him and worker explained to him that he would receive their letter shortly, asking him to call at the office. He said he would try to do so. He now feels that it would be better for Mrs. Monahan to be told that Steven is at the Hogans'. Interviewed Mrs. Monahan. Told her that worker had just received word that Steven had remained at the Hogans' after the week end, instead of returning to the Children's Temporary Shelter. 2-2S-31 Visited All Souls' Hospital and talked to Dr. McGowan. He went to public school with Mr. Monahan and for a time lived in the same house with the family. He has had intermittent contact with him in the past few years. Prior to entering medical school Dr. McGowan for seven years did settlement work. He feels that

362

CASE RECORD

Mr. Monahan is rather dull mentally, and inclined to be lazy and lacking in ambition. Gave the following family history. Mr. Monahan's grandfather was politically active in New York City, and at the time of his death was reputed to have amassed quite a large fortune from unknown sources. He left a large family and his fortune was divided unequally among the children. Mr. Monahan's uncle, who died this past week end, was supposed to have come in for the largest share. Regarding Mr. Monahan's father, some scandal was connected with his death. Dr. McGowan remembers rather vaguely his mother's talking about it and is under the impression that the father was either a saloonkeeper or a policeman and that he got shot. The father left a fair amount of money to his wife, and for a time at least they made their home with the uncle. Mr. Monahan left school early partly because his mother went insane and spent a year in a hospital for mental diseases and after that had to be supported by him. The uncle's fortune fluctuated greatly. About 11 or 12 years ago, Dr. McGowan remembers, his mother gave him $10 for food for the family. Ten years ago the uncle was involved in a large political scandal. At the time the story ran scareheads in the newspapers, and Dr. McGowan remembers detectives taking the uncle out of his own house. Shortly after that he purchased houses in New York City and considerable property in a near-by city, and after that time he was engaged in bootlegging. This uncle had a very large family himself. None of them seemed to have been bright enough to go farther than the first year in high school, although the father's ambition was to have them become lawyers. One of his sons now owns a large speakeasy. At the uncle's funeral a high city official was one of the pallbearers and Dr. McGowan said that the funeral was written up in most of the newspapers. Dr. McGowan has seen Mrs. Monahan only once, when he met her at the beach one summer, and aside from his talk at the uncle's wake had had no information about possible marital difficulty or upset. At first Mr. Monahan swore to him that he had had no extramarital relationships but finally said that about six weeks ago he had had. Dr. McGowan does not feel that Mr. Monahan has been spending much money outside of his home and thinks that the women he has been with have been picked up by him as a taxi driver. Dr. McGowan gave Mr. Monahan a letter to our superintendent and stressed the impor-

CASE R E C O R D

363

tance of his coming in soon for treatment. Naturally he does not wish Mr. Monahan to find out that he has communicated with us but he thinks that it might be all right to tell our doctor in the clinic about the situation and ask him to write a letter to Mr. Monahan telling him to report. About a year ago Mr. Monahan went to Dr. McGowan and asked his help in getting into the Fire Department. One of Mr. Monahan's eyes is bad and there was also a waiting list for this department. Dr. McGowan knew one of the examining physicians and felt that Mr. Monahan would probably be able to pass his physical examination but Mr. Monahan let the matter slip. Dr. McGowan thinks it strange that the uncle, with all his political influence, refused throughout to help Mr. Monahan and he has noticed that there has been general coolness on the part of relatives toward him. Dr. McGowan said that he would try to get further information from his mother and let worker hear from him later. 2-25-31 Phone call received from Mr. Monahan, saying that he had just talked to the Family Welfare Agency and they had told him they would send a worker out either the following day or on Monday. He was very much annoyed with them, said he had gone through this same sort of postponement and procrastination with them before, and asked worker if she could do anything to be sure their investigator would be out the following day. Phoned Family Welfare, asked Miss Marx what had been decided in the Monahan case. She said they were sending a worker the next day. Asked if their worker could stop in to see me on her way back since I had some information which might be of help to them. 2-2S-31 Phone call received from Mr. Landis, real estate agent, saying that in view of the circumstances in the Monahan home he would not press Mr. Monahan for payment but hoped that he would be able to pay a little toward his outstanding bill and asked worker's cooperation in securing partial payment. 2-26-31 Worker from Family Welfare called and gave result of investigation of Monahan family. Worker explained medical situation and urged the necessity of immediate action.

364

CASE

RECORD

2-27-31 Phone call received from Miss Payson, Children's Temporary Shelter, saying Mrs. Monahan, Senior, was there with Steven and a bundle of all his things, asking her to take him in. Miss Payson refused to do so, and asked us to place him. 2-27-31 Phoned Family Welfare; they could do nothing, and advised communication with Department of Public Welfare. 2-27-31 Phoned Department of Public Welfare. M r . Monahan has not applied to them. Suggested the Society for the Prevention of Cruelty to Children Shelter. M e t Mrs. Monahan, Senior, and Steven at S.P.C.C. Shelter. All arrangements made and Steven accepted by them. Steven cried, was very frightened and upset. T h e grandmother cried and finally decided to take Steven back to Mrs. Hogan's for another trial. S.P.C.C, said they would take Steven in any time the family wished to bring him. Long talk with Mrs. Monahan, Senior, about possible causes of Steven's behavior. Suggested that she try to break him of bed-wetting by having him wash out sheets whenever it occurred. T h e y have had some difficulty from this in the past week. She reports that Mr. Monahan intends to move out of present apartment and put furniture in storage till his wife is ready to come home. At her request phoned Mrs. Hogan and explained why Steven was returning. She was willing to try him again. 3-3-31 Phone call received from Mrs. Hogan. Reports Steven unmanageable again. Says that during her absence one evening when children were left in charge of girl helper, Steven went skating against orders at 11 p.m. and did not return to the house until 1 A.M. Night letter sent M r . Monahan, telling him to report to Department of Public Welfare following morning without fail. 3-4-31 Interview with patient and her mother in ward. Both very worried because patient has been told she is to go home on Friday. Patient says she is still in too much pain to go up and down stairs and care for home.

CASE R E C O R D

365

3-4-31 Phone call received from landlord, asking about Monahan situation. Explained that it would be necessary for them to move to the first floor. He said that he thought he could offer them a suitable apartment at the same rent. Said he would look over his lists and let worker know. 3-5-31 Mr. Monahan has not reported to our clinic. N o record under his name. Phone call received from Family Welfare, asking for present situation. 3-6-31 Telephone interview with Family Welfare. This case has now been recommended by them to the Department of Public Welfare for investigation. Department of Public Welfare will have their worker call at the hospital on Monday to see us. 3-6-31 Phone call received from Dr. McGowan, giving further information about the Monahans which he had secured from his mother. Mr. Monahan's father was a policeman who contracted pneumonia and died within 3 days after the onset of his illness, when William Monahan was quite young. T h e mother married a man named Albert Scott shortly after and financed him in opening a saloon. She put practically all of her money into this project, which was not successful. The mother was considered one of the saloon's best customers. About 14 or 15 years ago Mr. Monahan's mother was committed to a state hospital for mental disease, Dr. McGowan thinks perhaps for an alcoholic psychosis; she spent considerable time there. Mr. Scott either died or disappeared in this time. Dr. McGowan states that he would be willing to back Mr. Monahan if he wishes to try to get on the police force, and he is sure he could arrange for him to pass his physical examination in spite of trouble with his eyes. Dr. McGowan is willing to have us tell Mr. Monahan that he communicated with our clinic and to have us use his name in bringing him to task for not coming in. 3-6-31 Mrs. Monahan is now ready for discharge any time convalescent care can be arranged for her. Phoned the central office of the

366

CASE R E C O R D

cab company and secured phone number of Mr. Monahan's stand. Left a message asking him to communicate with worker that evening since it is essential that application be made to the Department of Public Welfare before they can send an investigator out. 3-6-31 Interviewed social worker, Psychiatric Clinic. It was decided not to bring Steven in until the home had been reestablished or until he had been permanently placed in a private family. 3-7-31 Phone call received in the morning from Mr. Monahan. He stated that he had already applied to the Department of Public Welfare and said he would come in to see worker that afternoon at 2 o'clock. Phoned Department of Public Welfare. They have a record that Mr. Monahan applied. Mr. Monahan did not keep his appointment in the afternoon. 3-8-31 (Sunday) Telephoned ward in visiting hours and asked that Mr. Monahan, who was visiting patient, communicate with worker as soon as he left the hospital. Mr. Monahan had not phoned by 6 o'clock in the evening but called later on and a message was left for worker. 3-9-31 Visit from Mr. Blank of the Department of Public Welfare, who had seen Mr. Monahan earlier in the day; seemed to be very much interested in the case, and said he would rush through his investigation so the report could go into the office on Wednesday. He said he would make special recommendations that Steven be placed in a private home rather than in an institution. 3-10-31 Phone call received from Mr. Monahan, saying that he would come in to see worker at 2 o'clock that afternoon. He has had Steven at home over the week end and his mother has been staying there caring for him. Mr. Monahan did not keep the appointment. 3-10-31 Interview with Mrs. Monahan in ward. She was very much upset that Mr. Monahan had not phoned worker the preceding afternoon, and worker had a long talk with her about her diffi-

CASE R E C O R D

367

culties in the home. She says that Mr. Monahan has always shown the same irresponsible attitude, has made repeated promises to her which he has never fulfilled and that she is coming to the point where she does not see how she can go on maintaining the home unless he changes radically. She feels that since she can no longer manage Steven it is essential for Mr. Monahan to spend some time in the home and to help her with the children. When the family went to pieces financially two years ago Mrs. Monahan had decided to go out and work since her husband's wages seemed insufficient to meet their needs. They had put the furniture in storage and she had secured a position in a boys' camp with the understanding that both she and Mr. Monahan would save a certain proportion of their wages. When she came back at the end of two months with almost all of her earnings Mr. Monahan had put aside only $35, although he was working on busses at the time, earning $50 a week or $200 a month. They had a big quarrel and she secured a position as housekeeper of a private family, and Mr. Monahan took Steven to live in a furnished room. Mrs. Monahan feels that many of Steven's difficulties date from this time, and she attributes much of his behavior to the contacts which he made in the rough neighborhood to which his father had taken him. (Mr. Monahan was brought up in this district.) After about a month Mr. Monahan phoned her, asking her to come back and reestablish the home and take care of the children, and she finally consented to do so, with the understanding that he would not return to night work. However, one month after her return he had again gone back on to night work. She does not understand why he has not been able to get on in the building trade with the aid of Mr. Hogan, and seems to have rather a resentful attitude toward the Hogans instead of blaming Mr. Monahan for the failure. She was quite emotional and seemed to be considering seriously giving up the home if she could find any other means of supporting herself and the children. She has been distressed by the fact that Mr. Monahan does not seem to be cooperating with the hospital and has failed to visit her more than a few times. She said that she would like to have the advice of her eldest sister, Anne Warren. There are three sisters now living with Mrs. Warren and helping to maintain the apartment—Anne, Lucy, and Ella. Anne is secretary to a man employed in a welfare office, Lucy is a milliner, and Ella is doing clerical work. Mrs. Monahan

368

CASE R E C O R D

says that her mother refused to discuss things with her. She says she has never understood her mother, who seems to have a very detached and impersonal attitude toward her. She has never before discussed her marital difficulties with Anne but now feels that she would like to have her advice, and suggests that worker get in touch with her. Offered to visit the home that evening, and patient apparently was delighted with suggestion. 3-10-31 Visited the Warren apartment at 1160 Wentworth Avenue that evening. The oldest sister, Anne, was at home. Little Catharine Monahan was asleep in one of the back rooms with the invalid aunt. Mrs. Warren and the two other sisters were out. The apartment occupied by the family is a very pleasant one on the third floor in a house on a bluff overlooking a large section of the city. It is attractively furnished and has the atmosphere of a longestablished home. At first Anne, who is an attractive and intelligent-looking young woman of about 30, was apparently cautious about discussing Mrs. Monahan and her troubles, saying that she had always tried to stay out of their difficulties as much as possible. She was finally quite communicative, however. She says that although at first it seemed to her that Mr. Monahan's failure to support his family was largely caused by hard luck, she has known of several opportunities he has had recently for steady employment which he has not taken. One of their neighbors living on the floor above had offered to get him a position about a year ago as conductor on the Sixth Avenue Elevated at $40 a week. Mr. Monahan had refused this, however, with the excuse that he could make more money driving busses in the summer. She feels that he is quite irresponsible and does not take their present difficulties seriously. While worker was at the Warrens' Mr. Monahan phoned and asked Anne's help in moving. He was apparently quite upset about Steven, told her about Burnside School which he said his sister had advised for Steven and reiterated to her his feeling that Steven needed a place with stiff discipline. He said he would come up later that evening to get a pass so that he could see his wife the following day. Worker discussed with Miss Warren the advisability of sending Steven to a smaller group where he could receive individual attention and understanding, also stressed the

CASE R E C O R D

369

advisability of communicating with the landlord before the family moved. Miss Warren says they do not feel they can put any more money into the Monahan family. They have paid out several hundred dollars in rent for them and they also have given them cash when they seemed to be particularly hard up. None of this seems to have done any good and now the times are hard and they are constantly afraid of losing their jobs and she feels that it is necessary for them to save money in case of emergency. Urged her to come to the hospital and talk things over with Mrs. Monahan. She said she would do so the following evening. 3-11-31 Phone call received from Mr. Monahan, apologizing for having broken his appointment the previous day and giving the excuse that his sleep had been interrupted by a Department of Public Welfare worker. He promised to come at two o'clock without fail. 3-11-31 Mr. Blank of the Department of Public Welfare came to the hospital a little later and interviewed Mrs. Monahan. Secured her permission for Steven's placement. 3-11-31 Mr. Monahan came to the office at 2:40. Worker told him that the Dermatology Clinic had received a letter saying he was coming in for treatment and that worker had been unable to locate a chart for him. He said that he had been unwilling to come here and had gone to the River Dispensary where they had told him that all he had was an infected pimple and had been giving him local treatment. They had said something about taking a blood test as soon as the sore healed. He had Steven with him and said that he would have to find some place for Steven to stay that night, since the grandmother was unwilling to care for him longer. Advised Mr. Monahan to take Steven to the Society for the Prevention of Cruelty to Children as advised the week before. Explained to him that permanent placement would probably be easier if Steven were under care there. He was given a card of introduction. Told him landlord had expressed interest in his family in talking with worker and advised that landlord be seen before moving. He promised to do so. Message given him from Mrs. Monahan

370

CASE RECORD

asking that he be sure to come to see her the following evening. Mr. Monahan has changed his job again and is now working with the Fleet Taxicab Company. He said that the last cab company did not give him work often enough and that he was given only the poorest cabs to take out. He feels his new job will be much better. Steven was called in and worker tried to help the father explain to him the necessity for sending him to the S.P.C.C. Shelter. Steven was very much upset and cried. The importance of Mr. Monahan's returning to the River Dispensary for further treatment was emphasized. He promised to go there regularly. His next appointment is tomorrow evening. 3-11-31

Later in the afternoon phone call received from Mr. Monahan, saying he had taken Steven to the S.P.C.C. and they had refused to admit him. Told Mr. Monahan to wait in the drugstore from which he was phoning until worker could communicate with the Department of Public Welfare. Phoned S.P.C.C. They said the D.P.W. had not authorized them to keep Steven and that Mr. Monahan had said he could keep him in his own home until the following Monday. Phoned D.P.W. Explained to them that Steven was left without adequate supervision at home, that Mr. Monahan had to be away afternoons and nights. They said Mr. Monahan had said he was not working. Explained to them that this was not the case and that Steven would have to have protection and shelter. They finally said that they would phone the S.P.C.C. and ask them to take Steven in, if Mr. Monahan would bring Steven to their office the following Saturday morning. Phoned Mr. Monahan. Told him to take Steven to the S.P.C.C. at once for admission. 3-12-31

Interview with Mrs. Monahan. She was willing to go to convalescent home the beginning of next week but would rather like to go home for a few days first. She was very much upset. Said she wanted to talk over with Mr. Monahan a good many things that she did not feel she could discuss freely in the ward. 3-12-31

Phoned Hill Top Convalescent Home and arranged six weeks' convalescent care for patient, starting March 17. Hospital Wei-

CASE RECORD

371

fare Fund to be drawn on if relatives cannot be persuaded to meet the amount. 3-13-31 Because there is some question of a venereal infection of the husband, doctor advised that patient be kept in hospital until time for convalescent discharge. Patient quite upset over not going home but finally admitted that with the stairs and emotional strain in the home it would be best for her to remain. Mr. Monahan had not come in to see her the night before. Phoned patient's mother, Mrs. Warren, and asked her if she would be willing to pay $5 a week for patient's convalescence. She was quite noncommittal, possibly because Mr. Monahan was present. Worker talked to Mr. Monahan on the phone—told him that Mrs. Monahan would go directly to the convalescent home. He was very anxious to have her home over the week end so that she could direct the packing. Said he would not allow her to be up and around. Told him that if he would be very careful and not let her take any chance of becoming infected worker would try to arrange matter with the doctor. Visited River Dispensary, and talked to social worker in charge of the clinic. Mr. Monahan had been receiving argyrol treatments; no Wassermann had been taken. Clinic worker said she would have the information about Mr. Monahan's extramarital relations and earlier appearance of infection reported to doctor in clinic that evening. She will phone worker Monday morning and let her know doctor's advice. 3-14-31 Interview with patient in ward. She said that Mr. Monahan had been in to see her the evening before and that she had told him that she had read a note on her chart, and he had told her about the infection and the fact that he was now under treatment. Patient read this note four days ago and hesitated to discuss it with worker since she felt that worker might not know about it. It is doubtful whether she got the full import of it. It says "Letter received from Dr. McGowan confidential. Husband has chancre—admits extraconjugal intercourse and patient has been exposed to infection since." Mrs. Monahan says that she has realized this is the reason we do not wish her to return home, but that if she can go it will be all right. Arranged for patient to be discharged that noon. Mr. Monahan came to the hospital in

372

CASE R E C O R D

visiting hours to take patient home. Arranged for him to come to the hospital following Monday to get half-fare ticket for Convalescent Home. 3-16-31 Phone call received from River Dispensary, saying Mr. Monahan's diagnosis was chancroid—Wassermann not indicated. 3-16-31 Phoned Mrs. Warren. She said that they did not feel that they could pay $30 for patient's convalescent care. Asked her if they would pay $15. Finally said they would. Hospital to pay the other $15. 3-16-31 Mr. Monahan phoned, saying he had taken Steven to the D.P.W. and then to the office of the Church Home. Steven had been sent to the Home in a bus. They told him that it might be possible to transfer him a little later to an agricultural school. Although commitment to an institution was the last thing we wished for Steven, it is probably better to let the matter rest here. Since half-fare slip had not come through from Hill Top Convalescent Home, Mr. Monahan said he would communicate with worker later on in the day. Report to Family Welfare. 3-17-31 Phone call received from Mr. Monahan. He said that Mrs. Warren had come to their house the night before and that he felt she was unwilling to meet the cost of Mrs. Monahan's convalescent care and that her doing so would make trouble in the family. He said that her attitude the previous evening had been very unpleasant. Mr. Monahan wanted us to keep his wife in the country (where she had gone today) longer than six weeks since he feels that he cannot get on his feet again in that short time. Explained to him that this would be impossible unless her condition required prolonging convalescence. 3-20-31 Letter received from Mrs. Monahan, stating that she was having severe joint pains and asking that she be sent a prescription for the capsules she had been taking in the hospital. Prescription secured from doctor and sent.

CASE

RECORD

373

3-24-31 Friendly letter sent to Mrs. Monahan. Five-dollar money order received from Mrs. Warren in part payment for two weeks' convalescent care. 3-26-31 Letter sent Mrs. Warren, acknowledging receipt of money order and explaining to her that if she found this payment too great a burden we would cancel the remaining amount. Explained to her that we had asked her to assume this for the sake of the hospital and without the knowledge of Mr. Monahan. 3-27-31 Phone call received from Family Welfare worker asking for information about Mrs. Monahan. Explained to him that she would be away for over a month and he asked that he be notified on her return so that his organization could help them in E s t a b lishing the home. 3-30-31 Postal card received from patient at Hill Top, thanking worker for medicine, saying that she is feeling much better and will write soon. 4-3-31 Letter received from Mrs. Monahan, saying that everything is going well and that she is feeling much better but is still sore when she gets up in the morning and toward evening. She is enjoying Hill Top very much and says that she hates to think of leaving. Her mother and Mr. Monahan had visited her the previous Sunday. She states that Steven is still in the Church Home. 4-4-31 Letter received from Mrs. Warren, stating that she wishes to continue to pay for half of Mrs. Monahan's convalescent care, and thanking us for our interest. She enclosed five-dollar money order which was deposited to Mrs. Monahan's account. 4-7-31 Friendly letter to patient. 4-10-31 Case discussed with Dr. Drake who made the following comments: No etiological factors in social situation. Contributory

374

CASE RECORD

factors in social situation are: four flights of stairs, too strenuous work on job, worry over husband and children. Future care— patient requires long convalescent care. This is complicated by her worries over her husband and children. Patient should be followed for some months and then Wassermann done. 4-1S-31 Letter received from patient, saying that Mr. Monahan had been up to see her the previous Sunday and had secured a steady job driving a truck. He has to pay $56 for a Union card and he is paying so much a week toward it. She says that she is upset about going back to live in a furnished room until he is able to save enough for an apartment but feels that she will have to do so since she does not think she will be able to extend her stay at Hill Top. They have suggested to her that she come back in July and August and stay for a few weeks to take sun baths. She has gained five and a half pounds. She said that Mr. Monahan was pleased with the way Steven was looking, that he seems happy and contented at the Church Home. She says that she is glad her mother has helped out but on the other hand feels that if she could have saved that money it might have enabled her to have a few weeks more of convalescent care. Letter sent to patient explaining to her that if after coming to Follow-up Clinic further country care seems advisable we will arrange it for her. Suggested she have Mr. Monahan get in touch with us. 4-20-31 Letter from patient. Mr. Monahan has told her that he is working hard and she has heard that he is always the first man in and is very well liked on the job. She says that he works eight hours a day with half of Saturday and all Sunday off. The furniture is in storage and he has taken a room near his place of work. She plans to go to Follow-up Clinic on April 28 but will return to New York on Sunday, April 26. She says that she is sunburnt and looks very well but is not feeling as she should and is therefore anxious to get back to see Dr. Drake. Mr. Monahan's address is 4 Museum Street. Phone call received from Mr. Monahan. He repeated information given by patient, but said that his working hours were from 7 in the morning until S at night with an hour off for lunch. He is employed as a truck driver for a construction company and his job involves loading and unloading bags of cement as well as

CASE R E C O R D

375

driving. He had been up to see patient the day before. He says that as long as she keeps taking pills she is all right, but as soon as she stops her pain recurs. He pays $5 a week for his room and goes out for his meals. He paid $10 the first week for his Union card and will have $5 a week taken out of his wages from now on until the full amount is paid. His wages are $41.45 a week. He did not go to see the landlord, simply moved out and put his furniture in storage. This costs him $5 a month. He is a little worried about Catharine, who has been getting B's and C's on her report card instead of A's and B's. Mrs. Warren is going around to talk to the Principal about her. He seems to be looking forward to having Mrs. Monahan with him again, and would like to have her stay with him permanently. He says there is an elevator in the house and she can go out and sit in the park during the day. He said he moved into that district with this in view. He thinks that Steven should probably stay on at the Church Home and said that he thinks Steven has improved a great deal there. He liked it very well at first but now talks to his father about coming home. When Mr. Monahan changed his job he had decided that he was not earning enough, borrowed some money and stayed out of work until he found another position. How much he borrowed or how long he was out of work is not known. 4-28-31 Patient returned to Follow-up Clinic, showing gain of 5 Λ/ι pounds, after she had returned from Convalescent Home. Dr. Drake found only slight cardiac symptoms and advised patient to continue her regimen of rest and to start a course of physiotherapy and to have dental work done. She seemed happy and satisfied with her present living arrangements. All meals were eaten in restaurants; her husband was at home in the evenings, and her rest was regular and unbroken. 4-28-31 to 5-15-31 Patient was seen at intervals in this time. She reported Steven was doing well at the Church Home and seemed to be happy there. Mr. Monahan had been working regularly. 5-15-31 Patient reported that her husband had been out of work for a week following a quarrel with his employer and that they were out

376

C A S E

R E C O R D

of funds. The following letter was sent to the Family Welfare, explaining the present situation and asking them to give further attention and aid to family. May IS, 1931 Miss Catharine Marx Family Welfare Agency 1211 West 19th Street New York, Ν. Y. M Y DEAR M I S S

In re

MONAHAN,

CATHARINE

MARX:

Mrs. Catharine Monahan has recently returned to the city. I did not communicate with you at the time sincc Mr. Monahan had secured what appeared to be a steady position as a truck driver with a construction company, at $41.50 a week. He was buying a Union card ($56) on the installment plan. He had put his furniture in storage at a cost of $5 a month and had taken a furnished room at 4 Museum Street, for $10 a week. The room, located as it is on a park, and in an elevator house, was ideal for our patient from the physical standpoint, and they are still living there. Unfortunately, two weeks ago, Mr. Monahan failed to report a quarrel between his helper and a yard assistant, and was dismissed. Although the Union attempted to reinstate him, the employer refused to reemploy him. Mrs. Monahan has just been in to see me and reports that he has been out of work for a week, and that they are again out of funds. Catharine is still staying with her grandmother, Mrs. Warren, at 1160 Wentworth Avenue, and can remain there indefinitely. Steven is in the Church Home. Mr. and Mrs. Monahan are pleased with the care the children are receiving. Mrs. Monahan is being treated in our Out Patient Department. Although she is greatly improved, she should have rest and freedom from household strain for a protracted and indefinite period. Anything you can do, either to secure employment for Mr. Monahan, or, failing this, to assist them financially through this period would be greatly appreciated by us. I have told Mrs. Monahan that I am communicating with you. She is usually at home during the day. This coming Monday, however, she will be at the hospital all day for treatment. Sincerely yours, DALE

GAY

Social Service Medical Division

5-19-31 Mrs. Monahan came to the clinic. She and her husband had 85^ between them and they owed two weeks' rent. Two dollars

C A S E

377

R E C O R D

were given to provide food until the Family Welfare could come to their aid. The Family Welfare was notified and a letter was sent, giving the present situation. May 20, 1931 Miss Catharine Marx Family Welfare Agency 1211 West 19th Street New York, Ν. Y. M Y DEAR M I S S

In

re

MONAHAN,

CATHARINE

MARX:

This letter is in confirmation of our telephone conversation yesterday. We are faced with the problem of providing adequate food for Mrs. Monahan. When she was seen in the clinic yesterday the physician in charge of her case felt that she was losing ground. On inquiry I found that she and her husband had eighty-five cents, and that in order not to go hungry Mrs. Monahan had been making daily trips to her mother's in upper Manhattan for one meal. The strain of this, and the less calculable but equally important strain involved in her worry over their financial insecurity are apparently having serious effect upon her heart. Yesterday we lent her two dollars to cover the purchase of necessary food until it would be possible for you to arrange aid for the family. We felt justified in doing so because of the medical importance of proper diet although we are not equipped to give family relief. Proper care for her now may prevent cardiac damage which would render her dependent for the rest of her life. I realize the trips to the hospital and to her mother's home may have coincided with your visits to her, and so I have just arranged for her to stay in all day Thursday and Friday morning. The apartment number I was unable to send you in my last letter is 3 E. Sincerely yours, DALE

GAY

Social Service Medical Division Medical note on May 19 states: "Has not been doing anything but gets short of breath after four or five blocks walking on the level and her heart 'thumps.' Admits that worries aggravate s y m p t o m s . . . . Some pain in knee joints." 5-22-31 The patient reported that worker from the Family Welfare had visited and given an allowance to cover rent and food. She had received a report from the school saying that Catharine's

378

CASE

R E C O R D

tonsils should be removed. The child was seen in our clinic and postponement until summer vacation was advised. 6-5-31 to 6-18-31 The patient was interviewed at clinic. She was feeling much better but was worried about Mr. Monahan's health. She stated that he had lost 60 pounds since her admission to the hospital, that his hair had been falling out, that he had a large lump on the side of his neck, and that his teeth were in bad condition. She had urged him repeatedly to come to the clinic but he said he had no time. A cousin, Lay ton Monahan (son of the uncle who died while the patient was in the hospital), had paid $175 for a membership for him in the lathers' union with the understanding that the brother-in-law, Mr. Hogan, would put him to work. Mr. Hogan had not done so as yet. Mrs. Monahan asked our help in persuading her husband to accept medical care. After talking it over, she agreed that it would be better not to let him know that she had discussed his problems with social worker. It was suggested that she tell him that social worker had sent a message through her asking him to come for an interview about his wife. If such an interview could be arranged it was believed that he might voluntarily broach the problem of his own health. [Social worker's previous experience with Mr. Monahan led her to believe that if anything could be done to influence his behavior, it would not be through direct intervention or any suggestion of authority. All action must appear to originate with him.] Two days later Mr. Monahan sent a message by his wife that any advice to him should be relayed through her. Free dental treatment was arranged for the patient. On June 18 a card was received from Steven. June 17, 1931 D E A R M I S S GAY,

I am glad to hear from you, my Mother told me you were asking for me. My Mother told me to write to you. I did not know your address. That is why I did not write to you. The Yankees are ahead. I am happy here. I hope you will come to see me on visiting Sunday. Your loving friend, STEVEN

MONAHAN

CASE

RECORD

379

6-20-31 M r s . Warren returned Catharine to the patient's care as school term was completed. T h e child had been wetting the bed. Mrs. M o n a h a n was worried a b o u t caring for her in a furnished room. H e r husband had secured temporary employment (wages $23 a week) a t night work and both the patient's and the child's sleep was disturbed when he returned from work. The Family Welfare continued supervision but had discontinued relief. An extra cot had been moved in for the child. Catharine was referred to a city hospital for tonsillectomy. 6-23-31 Patient came to Follow-up Clinic. Mr. Monahan was still on temporary employment basis, and no longer receiving relief from the Family Welfare. Reported to Dr. Drake the patient's situation and husband's symptoms. Because of continuing doubt as to nature of husband's infection, patient's blood again tested for syphilis; found negative. 6-29-31 M r . Monahan had secured full-time work, wages $45 a week. T h e Family Welfare offered to send Catharine away for two weeks to a summer camp. T h e question of patient's going for a vacation to the Blue Lake F a r m with Catharine later in the summer was discussed with her. She would like to do so. 7-1-31 T h e following letter was sent to the Family Welfare asking for the date of Catharine's going to summer camp so t h a t our Blue Lake Farm reservation will not conflict: July 1, 1931 Miss Catharine Marx Family Welfare Agency 1211 West 19th Street New

York,

Ν.

M Y DEAR M I S S

V.

In

re

MONAHAN,

CATHARINE

MARX:

I have been seeing Mrs. Monahan rather frequently lately in the clinic, and although she has been very faithful and cooperative in carrying out treatment, and although you have done so much to lighten her burden of anxiety at home, she has been having recurrences of her joint pains, and we feel it would be desirable for her to get away for at least two weeks to the country this summer. I have had in mind for her a vacancy in the party which is going to

380

CASE R E C O R D

Blue Lake Farm, and in which we have been given a certain number of vacancies. She would be able to take Catharine with her. She tells me that you are planning to send the child away for another two weeks this summer. If our plan also meets with your approval, will you let me know on what date you plan to send Catharine, so that the trip to Blue Lake Farm will not interfere? I want to thank you for the great help you have been to us in giving Mrs. Monahan the care she needs. Very sincerely, DALE

GAY

Social Service Medical Division

7-3-31 The Family Welfare telephoned, stating that Catharine could go the last two weeks in July. Reservation was made in the Blue Lake Farm party for August 11. 7-14-31 The patient was seen in clinic. She planned to take Steven out of the Church Home at the end of the summer. H e made excellent marks in his school work there, and had his name on the board as one of "Our Brightest Boys." He had grown and gained weight. She and Mr. Monahan had applied for an apartment in the model housing development near Rosedale, Long Island, opening in September. They would have three large rooms on the street level for $45 a month. Mr. Monahan was working regularly and was gaining weight. Patient believed he had been attending a clinic some place. Catharine's tonsillectomy was to be postponed until after their return from Blue Lake Farm. 8-4-31 Patient telephoned saying that she had had a recurrence of her joint pains and was as sick as she had ever been. Examination in Follow-up Clinic that day seemed to indicate that this was a brief flare-up which would probably subside under treatment. She had stopped physiotherapy a week before. Physiotherapy was continued and she was advised by the doctor to go to Blue Lake Farm if her physical condition at the time permitted. 8-8-31 Mrs. Monahan and Catharine were examined and passed for Blue Lake Farm. She stated that she had a large quantity of

CASE

381

RECORD

laundry to do before leaving. Arrangements were made for a patient, Caroline Thompson, to do four hours of laundry work for her at 50c an hour, to be paid by patient. 8-13-31 Patient sent card from Blue Lake Farm: DEAR M I S S GAY, A r r i v e d here about 4 P . M . . I t rained all night and is very

damp.

E v e r y t h i n g Ο. K . MRS. MONAHAN

8-17-31 Patient telephoned that she had left Blue Lake Farm after only a week. She had contracted a cold. It had rained almost steadily at the farm. The house had been crowded, the children, confined indoors, had been noisy and restless, and she had found the whole experience most unpleasant. She was advised to come to clinic the following day, 8-18-31. 8-18-31 Patient, in clinic, was found to have hay fever. Because of waiting lists here and in the city hospitals, the Superintendent's Office advised that Catharine be taken to the Eastview Children's Hospital for tonsillectomy. The patient was anxious to make arrangements for this. 8-26-31 The patient reported that the charge for a tonsillectomy is $10, payable in advance. Mr. Monahan had been working only three days a week. He was opposing the tonsillectomy on the grounds that he had never had his tonsils out, and that his wife had "hospital fever" anyway. In spite of his disapproval Mrs. Monahan intended to have the operation done as soon as she could get the money. It seemed wiser that Catharine should have time to recuperate before school opened. Arrangements were made with Eastview Children's Hospital to extend credit and the following letter was sent in confirmation. Miss

Thelma

Eastview New

York,

Wilson,

Children's N.

M Y DEAR M I S S

Registrar Hospital

Y.

In re MONAHAN, CATHARINE

WILSON:

T h e bearer of this letter, M r s . Catharine Monahan, is the mother of Catharine, age nine, about w h o m I telephoned you on T u e s d a y , and

382

CASE

RECORD

for whose tonsillectomy we will be willing to guarantee the payment of $10. If within a reasonable time Mr. and Mrs. Monahan are not able to meet this bill will you send the account to me? If any complications should come up in the meantime, I can be reached at Billings 5 - 6 0 0 0 Extension 010 Thank you very much for your help in arranging for this patient. Very sincerely, DALE GAY

Social Servier Medical Division

8-28-31 Mrs. Monahan came to clinic. She stated that Catharine had had her tonsils out that day; the bill was paid by her mother, Mrs. Warren. There was a scene with Mr. Monahan but she said, "He never holds a grudge." Patient hoped to reëstablish her home this coming month and to take Steven out of the Church Home. She was somewhat worried because the summer bus line for which Mr. Monahan was working would soon terminate its run and he had no prospects for the winter. Patient was informed that worker would be out of town for the month of September and she was advised to see the Family Welfare if she needed assistance. She said she did not want to go to them again. The last time she went to them (in June) they accused her of "using" them. In the month of September no problem arose. 10-12-31 The patient came to clinic and reported that Mr. Monahan was working as night taxi driver, earning an average of about $10 a week. Sometimes he brought her not even enough to provide food for the family, who were still living in the furnished room at 4 Museum Street. Steven had been taken out of the Church Home and registered in the public school nearest to Mrs. Warren's home. She provided lunch for him but he stayed with his parents in the furnished room. Catharine was living with Mrs. Warren and was being supported by her. Mrs. Monahan stated that since Steven had been in the Church Home his behavior had greatly improved, that he was now no

CASE R E C O R D

383

trouble to her. He was very polite, and could be trusted to come directly home and to take any responsibility she wished to place upon him. She was a little concerned because of his broken rest. He wakened when his father returned at night. She was also worried about their room, as rent was more than three weeks overdue and the landlady was getting impatient. No one from the Family Welfare had been to see them since the early summer. 10-16-31 Family Welfare asked by telephone for a report of the Monahan family. Report given. 10-20-31 Telephone call from patient. Her landlady had threatened to evict them the next day if the rent were not paid. Telephoned the landlady and explained that Mrs. Monahan was a patient of this hospital and that if any arrangements could be made to keep her in her present room we should like to have her stay there. An appointment was made for the following day to discuss the matter. 10-21-31 Visited the landlady, Mrs. Bonney. She is a Spanish woman, speaking little English, between SO and 60 years of age, with hair dyed red. She did not seem to have any real interest in the Monahans but was willing enough to have them stay if they could pay even a little on their room rent. She had three apartments in the house and had not been collecting enough to pay for the house. It was felt that little active cooperation could be hoped for from her. It was explained that the Family Welfare might be able to help the family, that they could not pay back rent but that with their assistance it might be possible for the Monahans to pay new obligations. She seemed satisfied with this possibility and willing to wait a few days until we could get in touch with the Family Welfare and have them come to see her. 10-22-31 Visited the Family Welfare. The worker on the case was not in but it was discussed with her supervisor who said that the

384

CASE

RECORD

worker would call the next day. Mrs. Bonney, the landlady, and patient were notified. 10-28-31 Mrs. Monahan came to the hospital. T h e situation was the same. N o one from the Family Welfare had been to see her and she had been looking for work without success. She was cautioned about doing too much since she might expect some recurrence of her difficulty in the winter months. She was advised to communicate directly with the worker from the Family Welfare about securing relief. M r . Monahan had been earning a little more the past few days and they had been able to pay Mrs. Bonney a small amount on their rent. Patient was warned to come to clinic if she should have any recurrence of joint pains. 11-5-31 Telephoned patient. She did not know whether worker from the Family Welfare had been to see Mrs. Bonney but no one had inquired for her. She had gotten in touch with the Family Welfare and they had said they would have their worker call on her. 12-1-31 Mrs. Monahan at clinic not looking well. She had been having some pain in the back of her legs but no definite joint swelling. T h e y now owed six weeks' rent, three weeks to Mrs. Bonney, and three weeks to another landlady who had bought out Mrs. Bonney. For a time M r . Monahan tried to do day taxi work so that the family could have a more regular schedule but found that it did not pay nearly so well and went back to his night j o b a few days ago. She said that his general health now seemed to be better. Steven was still behaving himself very well. He went to school from the house b y himself in the morning, to his grandmother's promptly for lunch, and home directly after school. He usually read in the afternoons and after dinner he did his homework; when that was finished his mother played cards with him or read to him until bedtime. She said that his whole manner seemed to be changed and that he was now neither disobedient nor impudent. H e had been growing very rapidly and it was a problem to keep him in clothes. Mrs. Warren had bought him one good-looking outfit, suit and leather jacket, which he

CASE R E C O R D

385

was already outgrowing. When he left the Church Home he weighed 82 pounds and he now weighed 96 pounds. No one from the Family Welfare had come to see Mrs. Monahan. She herself went down three times but was unable to talk to the worker and was requested not to come again as they preferred to send someone to the house. That had been two weeks ago. 12-15-31 to 1-15-32 In this month Mr. Monahan secured through his sister, Mrs. Hogan, and the borough political organization a position as Rapid Transit bus driver in Bloomsbury. They left Mrs. Bonney's, owing nearly two months' rent. The family's new address was 1212 Cornell Avenue, Hillsdale. Mr. Monahan's position lasted for about two weeks. 1-15-32 to 4-1-32 Mr. Monahan was successful in being reinstated in his job but again kept it for only a brief time. In March, through Mr. Monahan's sister, our patient applied to the borough political club and was referred by them to the Department of Public Welfare. They had been evicted from their apartment and had secured a furnished room and kitchenette at 9-11 Twelfth Boulevard, Hillsdale. This room was on the top floor of a three-story house; it was very crowded but cheap, and Mrs. Monahan felt that she could take the stairs slowly. This has been a period of considerable strain. Mr. Monahan's mother had complained to our patient about the treatment she received from her daughter, Mrs. Hogan, and had been asking Mrs. Monahan to make a place for her to live with them. 4-1-32 to 7-1-32 An inquiry was received from the Department of Public Welfare and answered by us. The family was found to be eligible for relief and a regular allowance was granted. Patient worried about marital adjustments and because of heart condition was referred by Dr. Drake to our contraceptive clinic. She was worried also about Steven. She felt that a boy's club would keep him interested and under supervision. Steven himself wanted to join the Scouts, but learned that he would not be old enough for a year. The Boy Scout organization suggested that he join a group of junior scouts in the neighborhood. But he

386

CASE RECORD

did not join because he did not want to be with "such young children." Suggested to Mrs. Monahan that she seek training at this time for work less tiring than that of waitress; the free business courses in night schools and other courses were mentioned. She registered for courses and during the next few months practiced shorthand and typing and business English. In May we received another letter from the Department of Public Welfare stating that they were still supporting the family. Mrs. Monahan had joined a political party and was active in the local club. In exchange for campaigning before the primaries and canvassing from door to door, she was given a paid job as watcher at the polls. 7-1-32 to 1-1-33 The patient was seen periodically in this interval. In the summer she finally persuaded Mr. Monahan to have his teeth fixed at the Dental Clinic, to which we had earlier referred him. He had secured a job for about six weeks as summer bus driver. Early in September he lost his position as bus driver again and went back to occasional night taxi driving, despite the fact that a short time before he had lost his license because of repeated trafile offenses. This fact added to Mrs. Monahan's worries. She was still concerned about his health, saying that he was underweight, was sleeping long hours, and always seemed irritable. A little later in the fall patient had secured work for one week as a demonstrator of a reducing machine in one of the department stores. This job was secured for her by Mrs. Hogan, her sister-in-law, through a friend who was putting the machine on the market. At the end of the week the friend refused to pay Mrs. Monahan anything for her services, although she felt that she had had a good deal of success in selling. She was sufficiently concerned to go to other department stores where demonstrations were being put on and found that her number of sales was higher than that of the other stores. She was very much annoyed with Mrs. Hogan and for a time connections were severed. In November she secured a job in a drapery and upholstery shop near her home, as an apprentice worker at $5 a week. She found the work pleasant although the hours were long and the workroom chilly. She had one or two rather severe "colds" but

CASE R E C O R D

387

no real rheumatic flare-up. In the course of these few months the family moved twice. 1-1-33 to 4-1-33 Patient continued to work through this period. In February, when she was seen in clinic, her weight had dropped from the maximum 1 2 7 ^ reached in her protected convalescence to 113 pounds. In this month she telephoned and asked for an appointment with the social worker. Mrs. Monahan came to worker's home and talked for several hours. She said that she did not feel that she could go on tolerating and living with Mr. Monahan any longer, that it had got to the point now where he refused even to go out and try to look for work. In the past week they had been transferred from Home Relief to Work Relief, and, although he would have received $20 per week, he worked two days and then said that the work was too hard and he had no intention of doing it. They were therefore dropped from the relief roll. Although he was home all the time, he would not help with the housework and she carried the double responsibility of working in the shop and doing the housework and all of his laundry. She said that she had become very short-tempered and that they quarreled almost constantly, which she felt was bad for the children. She wanted to consider ways of divorcing him. A good deal of marital history came out at this interview which had not previously been discussed. Their first separation had been precipitated not only by her illness but also by an illicit love affair of his. She described their courtship and early married life together. She said that she had met Mr. Monahan through his sister, Mrs. Hogan, who was employed in the office where the patient was a switchboard operator. They had gone out together for some time and she visited the Monahan home. One evening while she was there Mr. Monahan came in and announced that he had just lost his job. His mother and sister berated him for his irresponsibility and shiftlessness, and ordered him out of the house. She said that it was a very cold night and it was snowing. Despite the fact that she knew her mother disapproved of Mr. Monahan, when he accompanied her to her home she borrowed a dollar from her mother and gave it to him so he could get a room for the night. She helped him out for

388

CASE R E C O R D

several days after that, until he found another job. She said she felt so sorry for him, living alone in a furnished room with no one to do his laundry, that she married him. He took her to live in a room which she found dirty, dark, and unpleasant, in a rough neighborhood. She said to herself at that time, " I suppose that I'll have to get used to things like this because they seem all right to him." There followed a succession of furnished rooms here and in New Jersey. Finally she insisted on getting an apartment and some furniture. Mr. Monahan's procedure was to go to an installment house, stock up with furniture, pay the installments for three or four months, then say, " T h a t ' s all the furniture is worth; I won't pay any more." After several months the company would come and take it away. Several times in the past this had happened. After Steven was born and while Mrs. Monahan was pregnant for the second time, her husband became alcoholic and on one occasion came in and threatened her with a knife. He stopped excessive drinking S or 6 years ago. She said that she knew he had been unfaithful to her repeatedly but she had no evidence that would stand in court. Since their marriage he had always gambled and she felt that even now if he were persuaded to go out and get a little work, he would lose all he made playing cards. Mrs. Monahan felt that the children were fond of their father and because of this they should be allowed to stay with him. She said that the other evening Mr. Monahan was at home with Steven and said to him, "Steven, what do you think of your Daddy, anyhow?" and Steven replied, "Oh, I think you're swell, Daddy, but sometimes you're an awful pain in the neck." Patient said that she and Mr. Monahan were not attracted to each other any longer. She found it hard to understand why he stayed at home when life must be so unpleasant for him there. She believed it was largely because of the personal service she gave him—laundering, preparing meals, etc. She would like to think of some way by which she could make him desert. T h e patient said that her mother and her sisters had been helping her a little financially. She was worried because of the lack of supervision of the children since she was out of the house and Mr. Monahan was either out or sleeping all day. She had known him to sleep 18 hours without rising and she still worried lest something might be the matter with him physically. They

CASE

RECORD

389

had been evicted from their last place because Mr. Monahan had refused to pay the rent (for which she had given him money), saying that it was better to be put out than to pay more for a room than it was worth. Mrs. Monahan felt that her loss in weight over this period might have been due in large part to the continuous irritation to which she was subjected by her husband. 4-1-33 to 7-1-33 The patient continued to work in the upholstery shop. Worker had her make a couch, cover and other articles at this time and she made them very well. Mr. and Mrs. Monahan continued to live together. H e again planned to get a job driving a bus for the summer. 7-1-33 to 10-1-33 Mrs. Monahan gained a little weight and was able not only to do her work but to enjoy rather strenuous recreation without fatigue. She learned to roller skate and she and her husband would skate together in the evenings. In the latter part of September, 1933, her pay was raised to $12 a week. 10-1-33 to 2-1-34 During this time she continued to work in the shop; she also had several smaller jobs of slip-cover making and upholstering for private individuals. Steven was giving very little trouble. His marks in school were good, he still enjoyed reading. He spent a good deal of time writing a novel and he took up clay modeling with enthusiasm. He had no complaints to make of the children he played with in the neighborhood and aside from occasional expeditions which he and his friends made to the Bay he stayed around home pretty well. Worker took Mrs. Monahan to the theater several times. Although there was still a good deal of irritation at Mr. Monahan, she seemed to have decided that since they were getting along she would not let him disturb her too much. They were still living in two furnished rooms and kitchen for which they paid $8 a week. Her hope was to get some furniture and start real housekeeping again (their last furniture had been sold for nonpayment of storage charges sometime in 1932). She had registered for courses in dramatics, literature, and business. Her husband was scornful of her studies, but she enjoyed them and the

390

CASE

R E C O R D

opportunity to meet people. She did not worry about the children because Mr. Monahan was staying at home with them in the evenings. 2-1-34 to 8-1-34 In the latter part of February, Mrs. Monahan secured a Relief job as stenographer and typist at $15 per week for a Research Project. When the group on the project was disbanded, her supervisors asked that provision be made for her to stay on with them because her work was so satisfactory. She enjoyed it there, felt that if she could only stay on for a few months' experience she might be able to find even better-paying secretarial employment. She continued to say she wanted to separate from Mr. Monahan, if she could be reasonably sure that she could support the children herself. In April Patrolman Kohlman of the Crime Prevention Bureau came to see us about Steven who had been implicated in the theft of theater tickets in the neighborhood. A summary of our dealings with the family was given him. He seemed to be genuinely interested in Steven, thought they might get him an invitation to join the Boy Scouts or some organization in the neighborhood. In July when the patient was seen by the physician in the Rheumatic Heart Clinic she seemed to be holding her weight and strength quite well. She was still working. SOCIAL W O R K E R ' S

STUDY

MEDICAL

Identification

Sheet

AS P R E P A R E D

FOR

RECORD

Record

No.

1805

Age—28 Color—white Birthplace—England Address Parentage—English 133 Port Avenue, Apt. 57 Residence—New York City, 26 years Household Patient, Catharine ( W a r r e n ) Monahan, 23 Citizenship—American Husband, William Monahan, 29, taxicab Religion—Episcopalian Occupation—waitress driver and housewife Son, Steven Monahan, 9, school child Marital status—married Daughter, Catharine Monahan, 8, school child Name Monahan, Catharine Warren

CASE

RECORD

391

Kin of patient Mother, Mrs. Amy Warren, 1160 Wentworth Avenue. Sister, Anne Warren, secretary, 1160 Wentworth Avenue Sister, Lucy Warren, milliner, 1160 Wentworth Avenue Sister, Ella Warren, clerical worker, 1160 Wentworth Avenue Sister, Violet Warren, dental hygienist, c / o Dr. Scott Lancaster, Short Hüls, Ν. J. Sister-in-law, Eileen Hogan, 47-24 49th Street, Bloomsbury. Brother-in-law, Dan Hogan, builder, 47-24 49th Street, Bloomsbury. Mother-in-law, Mrs. Mary Scott, also known as Mary Monahan, 47-24 49th Street, Bloomsbury Interested individuals and groups Monarch Department Store, employer April 1929-November 1930 Mr. Alfred Landis, landlord Dr. Lewis McGowan, friend, private physician Reliance Furniture Company, creditors Taxi company, husband's employer Membership in club, lodge, etc.—none. Welfare agencies Family Welfare Agency Children's Welfare Society Children's Temporary Shelter Church Home for Children Public Unemployment Relief Department of Public Welfare 2-18-31 PRESENTING SITUATION.—The patient is referred to the social worker for assistance in arranging her affairs so that she can enter the hospital. She is an attractive young woman, with a straightforward, pleasant manner, giving the impression of intelligence and considerable refinement; poised, quiet, reserved. Her clothes are neat, conservative, and in excellent taste. She realizes that she needs medical attention but is unwilling to enter the hospital if there is any alternative. She states that for the past four months her symptoms have steadily increased and that she finds herself no longer able to do her housework, care for her children, and go up and down the four flights of stairs to her apartment in order to do her shopping. She also fears that if she leaves the home to enter the hospital relatives will not be able to care for both the children, and her husband will not be able to maintain the home during her absence. They are

392

CASE

RECORD

already far in debt, he is a poor manager, and his income is not sufficient to cover their living expenses. It is evident that she is deeply depressed by the persistence and severity of her illness and the economic insecurity of her home; she discusses her problems thoughtfully, listens to advice we offer, and shows discrimination in fitting it to her problem. The patient is assured that social worker can arrange care of the children, and she enters the hospital. STUDY OF SOCIAL SITUATION

Sources of information.—The patient, her husband, her mother, and her sister Anne, her husband's mother and sister, the patient's son, the husband's boyhood friend (now a physician in training), and the superintendent of Children's Temporary Shelter and other representatives of welfare agencies. Physical and social setting Home: Patient, her husband, and their two children occupy a three-room apartment on the fifth floor of a modern walk-up building in a clean and attractive residential district near the hospital and but a half-hour's ride on the subway from the center of town. There are good facilities for shopping in the immediate neighborhood. The house itself is well kept. The rooms are light, well ventilated, and attractively furnished, and, in spite of the patient's prolonged illness, clean and well cared for. Considerable thought and effort must have gone into making them appear homelike and attractive. The chief inconvenience aside from the obvious one of the four flights of stairs is the lack of space and privacy. The kitchen, though well equipped, is too small to be used for any purpose other than the preparation of meals; the other two rooms are separated from each other by glass doors. The two children sleep in the living room on a folding davenport, and Mr. and Mrs. Monahan in a double bed in the bedroom, the only entrance to which is through the living room. Family group: The patient's interests seem to center in her immediate family group. In the relationships of these four people there are felt to be conflicts of personality which have been a source of strain to the patient. Patient's background: The patient was born in England and was brought to this country when she was two years old. Since then she has lived within the metropolitan district of New York.

CASE RECORD

393

Her father, Miles Warren, died when the patient was fourteen. He had been the headwaiter in an exclusive hotel. His family were devoted to him. He is described as having been a pleasing, gracious person, devoted and indulgent to his family. When the father died the patient's mother went to work and, with the help of the children as they grew up, kept the home together. The mother lives in an attractive, comfortable apartment with three of her daughters, Anne, Lucy, and Ella, who support her and an aged aunt. The patient says that she has always felt that her mother was cold and unapproachable and as a child she was a little afraid of her. The patient turns for advice to her eldest sister, Anne. Anne is an attractive, well-poised young woman and is a skilled clerical worker. Lucy is a milliner, and Ella is employed in an office. A younger sister, Violet, a dental hygienist, lives out of the home. The atmosphere of the home is one of refinement and taste and this is reflected in the manners and bearing of the members of the family. The patient completed two years of high school, leaving at fifteen because of the financial pressure created by her father's death. She worked as a milliner and then as a switchboard operator until her marriage at seventeen. Since her marriage she has worked at intervals as seamstress, housekeeper, and waitress, when her husband's earnings were inadequate to the needs of the family. In her last position at a restaurant she was exposed to sudden changes of heat and cold, and she suffered fatigue from the work itself and from the long ride in crowded subway trains. Although her education was limited the patient reads with discrimination and intelligence. She is interested in current affairs. Her standards and deportment are those of her parents. Husband: William Monahan is a ruddy-faced, well-built man who appears easy-going and not overly imaginative or intelligent. He has drifted from one taxi and bus-driving job to another. In the years when business was good he made high wages, usually averaging about $50 a week, but for the past two years he has been earning less and less. His average wage is now about $20 a week; his last pay check was only $10. He has not saved and has borrowed from his relatives so often that he is now unwilling to appeal to them. He gives the impression of being a man who lets go easily under strain. As long as things go smoothly he is jovial, gen-

394

CASE RECORD

erous, easy to get along with, but in the face of difficulties he is probably inadequate and when pressed he is irritable. He was born and spent his childhood in a rough slum section of New York City. For two generations his relatives have been associated with city politics and some of the relatives have acquired considerable wealth and position in ways not above suspicion. As a group, they seem habituated to fluctuation of both economic and social status. When they are in funds they splurge. Mr. Monahan's father, a policeman, died when his son was two years old, leaving his wife and two young children a small but adequate income. Within a short time the mother married Albert Scott, an Englishman, penniless and irresponsible. She purchased a saloon which he ran and the neighbors said, when he disappeared a few years later, that "Mrs. Scott had drunk up all the profits." Certainly they were quite poor and they were provided for by a Monahan uncle who had recently come into a large amount of money; the papers at the time had hinted that he had not come by it honestly. There had been an investigation and a trial but the uncle had been exonerated. William Monahan's mother is reported to have developed an alcoholic psychosis when he was fourteen years old and was committed to a State Hospital for Mental Diseases. He and his sister were taken into the uncle's home. The uncle had had little formal schooling, but he had expected his four sons to go through college and enter the law. However, one after another they had failed in school, so that by the time William came under his authority he was violently opposed to formal education. William himself disliked school and had done none too well, so that he was willing enough to leave when his uncle demanded that he go to work at fifteen. He had reached only the sixth grade and had had no training to fit him for a vocation. At this time his mother was paroled from the State Hospital and a home was reestablished, which he and his sister supported. From the first William was not a steady worker, and lost job after job, usually because of failure to get up in time or because of minor infractions of company rulings. His relatives found new positions for him as often as needed. At eighteen, he met the patient, Catharine Warren, then switchboard operator at the office where his sister worked. They ran away and were married without the knowledge of their families. The husband's mother, who now uses the name of the hus-

CASE RECORD

395

band's father, supported herself for some time and gave substantial sums to the patient's family. She now lives with William's sister, Mrs. Dan Hogan. The interest of his mother and sister has continued. They have been called upon for help frequently and have given clothes and have sometimes cared for the children. The husband is somewhat reluctant to call on them for more help. Children: Steven Monahan, the older child, is now nine and a half years old. He is an attractive, well-built youngster, a little pale and underweight, but not strikingly so. Physically he resembles his father. His nails are bitten and he seems to be rather tense and nervous. His behavior has distressed his mother for the past few years and she is at a loss as to how to handle him. His marks in school have been fair, although he rarely does any home work, but his conduct is very poor—so poor that the principal has asked the mother to take him to a behavior clinic. His teacher feels that he is bright and could do very well if it were possible to enlist his interest. Steven has been running with a neighborhood gang. He goes on petty thieving expeditions to the five-and-ten cent stores, takes money from his father's pockets, and pilfers milk bottles from the neighbors to exchange for nickels at the stores. He cannot be counted on to return home when the school day ends, and frequently stays out until eleven and twelve o'clock at night, knowing that since the onset of her illness his mother has not found it easy to leave the house to look for him. He spends a large part of his time in the neighborhood movies. His father believes in corporal punishment, frequently administered. Although his mother disapproves on principle, she has had to resort to it occasionally. She says that Steven endures it in silence, "just stands there and looks me up and down, and then does exactly as he pleases." She has tried persuasion and cajolery with as little effect. When he is at home he is quiet, spends his time reading adventure stories. He complains of headaches and says he cannot see the blackboard at school unless he sits in the front row. He wets the bed. When he wishes, however, his behavior is above reproach. He can be far more polite and deferential than the average child of his years. He boasts about his escapades, considers them great fun. Daughter, Catharine Monahan, eight years old, gives her mother

396

CASE

RECORD

little worry. She is an active, robust child, resembling her mother. She does well in school, is reasonably obedient, and seemingly is above the average in intelligence. Their life together: Mr. and Mrs. Monahan had married before the age of eighteen and had established a home of their own. Before they were twenty, they had two children to support. We find no evidence of real discord between husband and wife during the first six years of married life. The patient assumed most of the responsibility for managing the home. That she has managed well is evidenced by the confidence, respect, and affection that her husband still gives her. From the beginning she says her husband insisted on turning over to her his pay envelope unopened. The only dissatisfaction in these early years which she mentioned was over his taxidriving at night. She disliked and distrusted his associates. There was no time for home life. She was alone during the evenings, her rest was broken, she had to keep the children quiet during the day while he slept, the children saw little of him, and usually then only when they wakened him and annoyed him. But he found fault with any other work—it did not pay enough, it was not interesting, and he continued the night driving. Four years ago her joints became very swollen and painful. Her private doctor told her that she had rheumatic fever and advised bed rest. Her husband, always robust himself, felt that she was making entirely too much fuss, and so she tried to keep on with her housework and care of the children. When it became evident to her that she could not go on any longer she insisted that the home be temporarily broken up. Mr. Monahan felt that her illness was an excuse rather than a reason for so doing and there was considerable friction between them before she finally gained her point. Their furniture was put in storage. His relatives offered to care for the five-year-old boy, Steven, and she and Catharine, three and a half years old, went to her mother's home. The patient was in bed for three months. In the meantime Steven had proved to be a more difficult problem than his aunt could handle and her feeling toward Mr. Monahan was none too friendly. After a few weeks she refused to care for the child, complaining that Steven incited her children to disobedience and was impudent and destructive. She sent him to his father who was living in a furnished room in a rough neighborhood, working at night. The father, sleeping a large

CASE RECORD

397

part of the day, allowed the child to run wild. It was this, and her husband's urging, that induced the patient to reestablish her home before she had fully recovered. A few weeks later she again became ill. During the three months that she and the little daughter had been with her mother, the husband had saved no money, and their relatives had paid for this premature attempt to reëstablish the home. She was again forced to return to her mother's home for care. She refused to consider reëstablishment until they were able to be financially independent. After she recovered she found a position as seamstress in a summer camp, taking the little daughter with her. It had been agreed upon that the husband would arrange for the care of Steven through a child placing bureau. This he failed to accomplish. She may have planned this break to be more final than either of them now admits. The husband's infidelity, later admitted, suggests a cause. The child, Steven, spent the summer largely unsupervised, living with the father in a furnished room in a cheap downtown roominghouse section. Steven now looks back with pleasure upon the freedom he enjoyed that summer. The patient, on returning to New York, found that although her husband had been earning $200 a month he had saved only $35, while she had saved more from wages of $40 a month. She decided to continue the separation and took a position as housekeeper in a suburb. Six weeks later, when nothing had been done about Steven and his father pleaded with her to return, promising to give up night work, she came back to him still doubting that it was wise for her to do so. When she tried to care for Steven again, she found that he had become for her the problem he is now, and recognized that it was her responsibility to make the best she could out of things. Within a month her husband had decided that he could not make enough money at the daytime work he was able to get so went back to night driving. Until the fall of 1929 they seemed to get along fairly uneventfully. Times were good and her husband managed to make about $40 a week with fair regularity. With the onset of the depression, however, his earnings steadily decreased. He shifted from one company to another, expecting to find better pay, and as unemployment became widespread he was able to do only substitute work, which meant inferior cabs and occasional nights of idleness. By April of 1930 they were again dangerously near

398

CASE R E C O R D

destitution, and the patient decided she would have to go to work. She found a position as a waitress in the restaurant of the Monarch Department Store from ten in the morning until three in the afternoon. This made it possible for her to send the children off to school and to be back by the time they returned. She saw practically nothing of her husband now. The trip from her home was too long and exhausting, and so they moved to their present address, nearer to her work. In the summer, for one month she sent the children to a camp through the Children's Welfare Society and her mother helped care for them the rest of the time. She felt that their camp experience was unfortunate. They came home dirty, tattered, and unkempt, and had lost weight. The work and the traveling, and the housework and the broken rest made her very tired. She noticed that she became irritable and often abrupt with the children. In September, because of overcrowding in the parochial school, the children were enrolled in the public school. Catharine adapted well, but Steven did not. His behavior became steadily worse and as it did she found herself losing self-control and failing to mete out punishment either calmly or justly. She continued to work until Thanksgiving time, however, since even with the extra money they were barely able to manage. She contracted a cold, her joints once more became swollen and painful, and she had to give up her work. Her husband was unsympathetic and when she complained of pain he was skeptical. She went to a doctor for a time and although treatments relieved her she had to stop going because of the expense. Meals had to be prepared; she was continuously apprehensive about Steven, on whom she had to rely to go on errands for her; the husband was not earning enough to cover their living expenses, the relatives offered no assistance. They fell behind in payments for rent, food, furniture, insurance. When she came to the hospital in February, she was not only physically worn out and sick, but deeply discouraged. Finances: The patient's wages while working in the restaurant of the Monarch Department Store were $15 a week. Her husband's wages vary now from $10 to $20 a week. Rent of $45 a month is two months overdue and warning has been received from the landlord. On their furniture bill $40 is still to be paid; a peremptory demand for immediate payment has

CASE R E C O R D

399

been posted on their door by the furniture company. All four members of the family are insured. The husband's policy was taken out sixteen years ago, the patient's ten years ago, and the children's shortly after birth. The premiums amount to $2 a week. The policies are now in danger of lapsing. The husband's sister has clothed the children for many months, and his mother has given over $600 towards the rent alone. Friends and relatives: Aside from his immediate family Mr. Monahan has many relatives who have "influence." The uncle previously mentioned, who had cared for him in his early boyhood, is dying of cancer of the throat. He is said to be still quite wealthy. There seems to be at present little likelihood of closing the breach between them. The uncle's sons, one of whom is a speakeasy proprietor, also do not seem to be kindly disposed toward Mr. Monahan. Group relationships: Outside the relatives no close social contacts of either the patient or her husband have been discovered. Neither belongs to clubs, lodges, or benefit societies. The patient does not have church affiliation. The husband maintains his connection with the Catholic church and has had his children attend parochial school. MEDICAL-SOCIAL DIAGNOSIS AND PROGNOSIS.—This m a r r i e d w o m a n

of twenty-eight, who through much effort has kept her home together, needs bed care and prolonged rest which the home cannot provide. She has a damaged heart which will doubtless require a permanent lessening of activity. She is hindered in deriving full benefit from care offered by the hospital by fear for her home and children. Her absence from the home places responsibility for it on her husband whom she does not trust. He is impulsive and imprudent in his judgments and actions. Without financial supplement from her, he has failed to support the home up to the standards which she demands. His failure has caused so many demands to be made on relatives that she does not expect him to be able to secure care from them for their children, especially for Steven whose bad behavior makes his supervision a burden. The emotional strain the patient has suffered over her domestic problems added to the physical strain endured at work and at home have probably contributed to her present incapacity.

400

CASE

RECORD

Classification The Patient Family life handicap Occupational handicap Activity greatly diminished

(Temporary?)

T h e Social Situation Child caring problem Child training mismanagement Marital friction Irregular and insufficient income Since this patient has a reasonably good general constitution, intelligence, insight, and a desire to get well, it is thought that if she can be relieved of the major physical strains (stairs and work), and the causes of her anxiety can be alleviated, she should be able to lead an active, normal, useful life, only very slightly handicapped by her cardiac and arthritic condition. Community resources and the relatives can provide sufficient help to meet immediate needs. With health regained, it is felt that the patient will be able to cope with some of the difficulties in the domestic situation which will probably persist. NOTE.—Progress notes and additional information were recorded chronologically in the social service pages of the hospital record. Since they are for the most part identical with the social worker's day by day notes, they are not repeated.

INDEX

INDEX Abstracts of cases, 285-345 Acute disease: outlined in cases studied, 16-18; demonstration case of, 21-23 Aftercare: adequate income for, 164; social factors affecting, 215-19; means for, 222 ; at home, 230; removal of obstacles to, 232-3S; favorable environment and, 236. See also Convalescence Age group, studied, 13 Air pollution: and ill-healtb, 122-23; and bronchiectasis, 147, 237 Alcohol, addiction to, 178-79 Anemia, in cases studied, 17 Anxiety: and fatigue, 136-37; and dissatisfaction, 188 Appreciation expressed to patient, and invalidism, 249 Arthritis: in cases studied, 17; example in demonstration of case, 62, 63-69; aftercare of, 164; selfcontrol and, 170 Asthma: emotional strain and, 6-7; and habitat, 122; removal of causes of, 234; and fear, 2S7 Bach, Allie: Demonstration IS, 95104; and lack of personal service, 132; and undue effort, 145; inadequacy of means, 159-61; habits and medical recommendations, 169; faulty mental habits, 186; dissatisfaction, 189-90; loss of prestige, 199; increased information to, 248; value of appreciation to, 249, 256; and positive routines, 259-60 Baker, Florence: Abstract 62, 323-24; faulty mental habits, 179-80; and dissatisfaction, 190-91, 197; removal to better environment, 23839; and influencing choice, 257; "standing by" to assist, 274 Barclay, Irene: Abstract 31, 304-5; inadequacy of means, 158; fault-

finding, 197; information imparted to, 246, 247; value of appreciation and, 256; and humiliation, 265, 266-67 Barks, Benjamin: Abstract 27, 302; and undue effort, 144-45 Beck, Donald: Abstract 23, 299-300; and incompatibility, 193-94; and satisfying outlets, 210 Boehack, Mary: Abstract 47, 315; undue effort for subsistence, 13637; faulty personal habits, 176; family relationships, 196; influencing choice of, 257 Booth, John: Abstract 1, 285; unfavorable habitat, 120-22; information imparted to, 244 Bronchiectasis: and air pollution, 122; and factory work, 147; postural drainage for, 172; removal to better environment, 237 Bronchitis, and work strain, 138 Business failure, see Failure, business Cabell, Norris: Abstract 8, 289-90; loss of prestige, 199 Cabot, Richard C., ix, 269η Cancer: examples in cases studied, 105-10, 110-13; and disability, 116; aftercare of, 165; and faulty personal habits, 177-78; endurance of disability caused by, 182 Cardiac disease: types of, in cases studied, 17; examples in demonstrations of cases, 54-55, 57-61, 62, 70-73, 78-79, 87, 90, 91-95, 95-104; emotional strain and, 59-61, 80-81, 95, 98-99; and disability, 117; and noise, 125; and lack of personal service, 131-32, 133; and undue effort, 137, 145-46, 147, 148; and work strain, 138; adverse social factors and, 146; and manual labor, 148; and adequacy of means, 158, 159-60; aftercare of,

404

INDEX

Cardiac disease (Cont.) 164; and self-control, 170; and habits of endurance, 182-84; and means of subsistence, 217 ; and regulation of conduct, 233; information to sufferer from, 243; and positive routines, 259-60; and fear, 2S7 Carlos, Santa: Abstract 11, 291; unfavorable habitat, 121 ; threat of further disability, 257 Carter, Grace, Abstract 14, 293; inadequate means, 155-56; causes of disability, 214 Case, complete record of, 346-400 Cases studied: selection of, 5-6; limitation of study of, 10-12; general data concerning, 13-20. See also Abstracts; names of individuals, viz. Bach, Allie; Barclay, Irene; etc. Chronic disease: in cases studied, 1618; case demonstrations of, 56-113 Chronic-terminal disease, in cases studied, 16, 18 City environment, see Environment, city Climate, unfavorable, 122 Clinic attendance, habits interfering with, 173-75 Clothing, as a subsistence need, 128 Commotion, and fatigue, 123 Conduct control: in cardiac disorder, 90-95 ; through information, 24247 Conduct of patients: necessary changes of, 223 ; defined from medical viewpoint, 240; remedial measures to influence, 240-77 Conformity, undue, faulty mental habit, 185 Control of conduct, see Conduct control Convalescence, in Abstracts, 285-345. See also Aftercare; Invalidism Cooperation: examples of lack of, 35, 40-41, 58-61, 75; of patient through education, 223; of patient in environmental control, 225-26; and influencing conduct, 242;

through elucidation, 247-50; through demonstration, 250-52 ; conditions necessary for, 260-61 ; of relatives, 265-66 Cost, social, of sickness, 114-15 Crawford, Louis: Abstract 97, 343; inadequacy of means, 156-57; faulty mental habits, 186; social status, 203 Cultural standards, differences in, 201-3 Dampness, and ill-health, 126 Daniels, Florence: Demonstration 3, 26-29; habits and medical recommendations, 174, 176; utilizing resources, 229; information imparted to, 245 Darrow, James: Demonstration 10, 70-73; and undue effort, 147; utilizing resources, 231 Death: expectancy of, and disability, 116; as source of undue effort, 136; fear of, 253 Dependency: and inadequate income, 154, 155-56; and humiliation, 158; fear of, 159, 162; and faulty mental habits, 185 ; collective aid against 220-22 ; dispelling sense of, 255 Deprivation: of satisfying outlets, 203-11; and development of disability, 213 Desertion, with relation to incompatibility, 194 Diabetes: and disability, 117; and malnutrition, 129-30; and food habits, 171 Diagnosis, scheme of, in cases, 16-18. See also the item Diagnosis in individual abstracts, 285-345 Diet: influence of, in disease, Demonstration 4, 35, Demonstration 7, 49; and duodenal ulcer, 140. See also Malnutrition; Nutrition Digestive disorder: in demonstrations of cases, 43, 46, 47-49, 49-50; and food habits, 171 ; and faulty habits, 176-77

INDEX Di Lorenzo, Pasquale: Demonstration 8, 54-61; habits and medical recommendation, 170-71; endurance of disability, 185; and restricted outlets, 204-5 ; obstacles to care of, 235; information imparted to, 244 ; influencing conduct of, 261 Disability: causes of, 3-4; defined, 115; types, degrees, and causes of, 115-17; and downward shift in economic status, 154 ; and financial anxiety, 156-57; delay in seeking care for, 162-63 ; and faulty habits, 166-86; and dissatisfaction, 187219; and family group, 188-203; and restricted outlets, 203-11; incidence of adverse social factors and, 211-19; factors affecting development of, 212-15; adjustment to, 215-16; defense against further, 216-19; control of environment and, 225-39; and social security, 220-22; similar types compared, 251-52; and dissatisfaction, 254; "standing by" to assist, 269-76. See also Invalidism; Convalescence Discipline, supplying necessary, 239 Disease: defined, 115; distinguished from disability, 115-17; as source of undue effort, 136. See also Acute disease; Recurrent disease; Chronic disease; names of diseases, as Arthritis, Cardiac disease, etc. Disfigurement: influence of, 62-70; and disability, 116 Dissatisfaction: and disability, 11819, 213, 217; and business failure, 141-42; in white-collar group, 14445; and social status, 150; and restriction of activity, 168; and overdoing, 171; adverse social factors causing, 187-219; classified, 198; and restricted outlets, 203-11; alleviation of, 222, 252-61; information imparted concerning, 242, 24546 Domestic service, undue effort in, 142, 145-48 Donato, Joseph: Abstract 28, 302-3;

40S

and undue effort, 144; faulty mental habits, 181 ; and dissatisfaction, 202-3 D'Orsay, Frank: Abstract 56, 320; lack of personal service, 131-32; and undue effort, 144 Drug addiction, 178 Duff, Elsie: Demonstration 2, 2326; sunlight necessary for, 127; and undue effort, 137; faulty personal habits, 176; utilizing resources, 229, 230; information imparted to, 244 Duodenal ulcer: and work strain, 140; and diet, 140, 193-94; and emotional tension, 170 Economic status: in cases studied, 14-16; examples of, in demonstrations of cases, 22, 23-24, 27, 30-33, 37-38, 39-40, 41, 44-46, 56, 72, 74, 76, 77-79, 92, 96, 111; income of patients studied, 152-55; as inadequate protection against adverse social factors, 133-66; of isolated persons, 158-62; and medical care, 162-65; and dissatisfaction, 198, 199-201; and spending money, 209; restoring security in, 223 ; and removal to better environment, 236. See also Employment; Income Education: amount of in cases studied, 14 ; examples of, in demonstrations of cases, 22, 50-51, 56, 59, 65, 66, 70-71, 77 Edwards, Jerome: Demonstration 14, 90-95; habits and medical recommendations, 169; and satisfying outlets, 210; and adjustment to disability, 216; and self-regulation, 262 Effort, undue: to secure subsistence, 133-51; and cardiac disease, 137, 145-46, 147, 148; incidence of, 214, 216, 218, 219 Eidelberg, Bertha: Abstract 22. 29899; inadequacy of means, 161-62 Emotional tension: as adverse social factor, 7-8; examples of, in demonstrations of cases, 30, 33-36, 66-67;

406

INDEX

Emotional tension (Cont.) and cardiac disease, 59-61, 80-81, 95, 98-99; and disability, 116-17, 232; and commotion, 123; in securing of subsistence, 133-35, 160; of piecework, 146; from insecurity, 155-58; release from, 170; and regulation of personal habits, 171; and faulty mental habits, 179-82; and dissatisfaction, 187-88; effect of aid on, 228, 229; removal of patient to relieve, 233; as wrong conduct, 240 Employment: status in cases studied, 14-16; effect in invalidism, 62, 65, 68-69, 77, 81, 82-84, 85-86, 89-90, 102-3, 167; and undue effort, 136; tedium without, 140; and income, 152; incidence of unsatisfactory, 216, 218, 219; completing psychotherapy, 231 Energy: regulation of, 164, 167, 223; faulty habits of expenditure of, 176. See also Physical strain Entrepreneur, and undue effort to secure subsistence, 139-42 Environment: control of, by removal of patient from, 74-77, 105, 109-10, 236-39; and disability, 118; city, and health, 123; control of, in aftercare, 164-66; incidence of unfavorable, 214, 216, 218, 219; control of, as remedial measure, 225-39, 241 ; influencing choice of, 254; and established habits, 264 Environment, home: in cases studied, 14; examples in demonstrations of cases, 22, 24, 27-29, 31, 32, 35, 3738, 44-46, 50, 55-56, 64, 65, 6667, 71-72, 88, 106-7 Exploitation, faulty mental habit, 180 Extrafamily association, and satisfaction, 210 Factory work, and bronchiectasis, 147 Failure, business: and undue work strain, 141-42; and dissatisfaction, 199-200

Family group: and satisfying sociable life, 209-10; incidence of lack of, 216, 218, 219; dissatisfaction and lack of, 188-203 ; hospital "standing by" to aid, 275 Family relationships: and friction, 196; and business failure, 200; explained to patient, 246-47; remedial measures in, 266-67. See also Marital relationship; Maternal relationship Fatigue: as social factor, 7; and disability, 123, 214; and work strain, 134; incidence of, 134-51; and piecework, 146; in aftercare, 167; and emotional strain, 188; removal of patient to other environment, to overcome, 233 Faulkner, Jerry; Abstract 25, 301; and lack of personal service, 13233 ; and undue effort, 148-49 ; inadequacy of means, 158-59; supplying deficiencies for, 228 Fault-finding: habit of, 179-80; and friction, 197 Fear: and sleeping arrangements, 126; of economic inadequacy, 154, 155; of dependency, 159; of disease, 183; and living alone, 189, 191; and restricted outlets, 205 ; disabling effect of, 257, 260 Financial losses, and dissatisfaction, 200-201

Fleming, Theresa: Demonstration 6, 42-49; habits and medical recommendations, 168; and satisfying outlets, 210-11; causes of disability, 214; utilizing resources, 232 ; information given to, 248; "standing by" to assist, 275 Food: insufficient, and health, 12831; change of diet, and aftercare, 171; faulty habits of, 176-78; supplying, 225; demonstration of correct use of, 250. See also Malnutrition Friction, with associates, 191-98 Habitat, examples of unfavorable, 120-28. See also Environment

INDEX Habits: faulty, and disability, 116; of worrying, 137; of eating, 14041 ; and medical recommendations, 166-75; incidence of faulty, 214, 216, 218, 219; influencing choice of, 252; fostering of good, 26269 Hart, Marianne: Abstract 36, 308; habits and medical recommendations, 175-76; and dissatisfaction, 191-93 Heart disease, see Cardiac disease Hinkelman, Carrie: Abstract 37, 3089; unfavorable habitat, 121 Hodgkin's disease, aftercare in, 165 Home environment, see Environment, home Hookworm, sanitation and, 127 Hospital: and remedial measures to control environment, 226-27; fostering good habits, 263; "standing by," 270-76 Housework: facilities for, and illhealth, 127-28; as source of fatigue, 135-39 Housing, and health, 124-25. See also Environment Hygiene, habits of, and health, 17582

Impairment, and disability, 116-17 Incidence: of fatigue, 134-51 ; of adverse factors, 211-19; of faulty habits, 214, 216, 218, 219; of lack of family group, 216, 218, 219; of social treatment undertaken, 224 Income: of patients studied, 152-55; for medical expenses, 162-65; and financial losses, 162-65, 200-201; lack of spending money, 209 Incompatibility: and dissatisfaction, 191-98; incidence of, 214, 216, 218, 219; relief of, 231 Indecision, as faulty mental habit, 181-82 Influences, social, see Social factors Insurance, disability, 220-21 Interests, narrow range of, 184-85 Invalidism: examples in demonstrations of cases, 62, 65-69, 76, 77,

407

81-86, 89-90, 93-95; learning role of, 95-104, 248; and home care, 108, 110-13; and overcrowding, 125; and fault-finding, 179-80; and restricted outlets, 205-6; frbm emotional strain, 232; status of, establishment of, 235; and approval, 249-50; and appreciation, 255-56; and good habits, 264; "standing b y " to assist, 271 Irresolution, as faulty mental habit, 181-82

Isolated persons, see Single persons Jealousy, and invalidism, 232 Jenkins, Richard: Abstract 43, 312; utilizing resources, 231 Jessup, Perry: Abstract 41, 311-12; and undue effort, 148 Kean, Etta: Abstract 44, 313; and misinformation, 245 Klein, Isaac: Demonstration 11, 7477; and undue effort, 142; habits and endurance of disability, 182; and incompatibility, 197; and restricted outlets, 204 Kovacs, Emma: Demonstration 9, 62-70; sunlight necessary, 127; habits and medical recommendations, 170; and dissatisfaction, 197, 198; obstacles to care, 235; demonstration to, of similar disability, 251-52 Labor with machines, see Machine labor Labor without machines, see Manual labor Larsen, Rita: Demonstration 13, 8690; habits and medical recommendations, 168; and satisfying outlets, 210 Larue, Verna: Abstract 55, 320; fear of marriage, 257-58 Levine, Dora: Demonstration 16, 105-10; habits and medical recommendations, 170; and endurance of disability, 183; faulty mental

408

INDEX

Levine, Dora (Coni.) habits, 186; and incompatibility, 195; obstacles to care of, 235-36 Liver therapy: examples in demonstrations of cases, 37, 39, 40, 74; neglect of, 172 Ludwig, Jacob: Abstract 52, 318; and effective occupation, 208; and adjustment to disability, 216 Machine labor, undue effort in, 142, 145-47 McKenzie, Lillian: Abstract 58, 32021 ; habit and recommendation, 174 Maggenti, Michael: Abstract 16, 294; unfavorable habitat, 122; habits and medical recommendations, 172 Mahoney, William: Abstract 64, 324-25; and undue effort, 149-50; faulty personal habits, 178-79; loss of prestige, 199; loss of satisfying outlets, 210; information imparted to, 245-46 Malnutrition: as adverse social factor, 7 ; in case of recurrent disease, 40; and disability, 117; and illhealth, 128-31; and faulty food habits, 176-78; and development of disability, 214; incidence of, 216, 219 Manual labor, undue effort and, 141, 148-51 Marital relationship: example in demonstrations of cases, 22, 24, 30, 31, 32, 33, 42-43, 45, 48, 75, 77, 88, 92, 107-9, 111; as emotional problem, 168-69; and faulty emotional habits, 170; and dissatisfaction, 193-96, 198; as obstacle to care, 234; alleviation of difficulties in, 267-68 Marital status, of cases studied, 13 Marks. Benjamin: Abstract 27, 302; lowered social status, 201 Maternal relationship: examples in demonstrations of cases, 37, 38, 39, 57, 58, 59, 60-61, 63, 67, 71, 107; and self-control, 170; and

the spoiling of children, 185; tod incompatibility, 191-93, 194, 197; and dissatisfaction, 198 ; as obstacle to care, 235 Medication, habits interfering with, 171-73 Mental disease, 16, 18 Mental strain, 144. See also Emotional tension Merman, Anna: Abstract 59, 32122; and faulty personal habits, 177-78; faulty mental habits, 180; and fault-finding, 197; and misinformation, 245 Monahan, Catharine: case history, 346-400; overcrowding and, 125; and undue effort, 137; and incompatibility, 194, 196, 197; removal of obstacles to care, 232-33 ; increased information to, 248; value of appreciation and, 249-50, 256; and humiliation, 265 Mother love, see Maternal relationship Murray, William: Demonstration 17, 110-13; and lack of personal service, 132; utilization of resources, 230, 231; "standing by" to assist, 275-76 Nationality, in cases studied, 13 Nephritis: example as chronic disease, 87; and work continuance, 168; and pregnancy, 175-76; and dissatisfaction, 192 Neurosis, aftercare, 164 Noise: and fatigue, 123; and health, 125; and work strain, 150 Norton, Mabel: Abstract 66, 326; malnutrition, 129-30 Nurture, defined, 279 Nutrition: as subsistence factor, 12831 ; and aftercare in disability, 164. See also Malnutrition Obesity, and food habits, 171 Occupation: lack of satisfying, 2068, 215, 216, 218, 219; supplied for disabled, 222, 225, 226, 229; to overcome disabling fear, 258. See

INDEX Occupation (Coni.) also Employment; Occupational therapy Occupational strain, see Work strain Occupational therapy: value of, 2078, 222; providing security and recreation, 230-31; as relief of disability, 231, 246; demonstration by, 250-51 O'Connor, John: Abstract 56, 320; and undue effort, 144 Old age, and aid, 221 Outlets: restricted, 203-11; lack of, obstacle to care, 238 Overcrowding, and health, 125 Patients, see Cases Pensions, and self-respect, 221 Personal service, see Service Petrakis, Alexander: Abstract 10, 290-91; faulty personal habits, 176; and incompatibility, 193 Physical strain: effect on chronic disease, 70-73; in securing subsistence, 133-36; and disability, 148-51, 213; and inadequacy of means, 158. 5ee also Work strain Physician: private, and patients studied, 162-63 ; relationship with patient, 242 ; responsibility of, 278 Piecework, nervous tension of, 146 Play, see Recreation Pneumonia: in cases studied, 16; aftercare of, 164 Pogany, Hilda: Demonstration 4, 29-36; and aftercare, 165; supplying deficiencies, 228; "standing by" to assist, 272-74 Poisons, as harmful habits, 178-79 Pollution, air, see Air pollution Postural drainage, for bronchiectasis, 172 Prestige: example in demonstration of case, 31, 33; and dissatisfaction, 198-201 ; remedial measures and, 227, 228; diverting attention from, 249. See also Social status Prognosis: social influences and, 5; scheme of, in cases studied, 1618

409

Protection, physical, and disability, 120-32 Psoriasis, example of, 62, 67-68 Psychotherapy, relief of physical symptoms by, 181-82 Rand, Nellie: Abstract 78, 333; and incompatibility, 197 Reali, Tony: Abstract 17, 295; unfavorable habitat, 122; faulty mental habits, 186; and incompatibility, 195; and restricted outlets, 205 ; utilizing resources, 231-32; removing obstacles to care, 234; information imparted to, 246; disabling fear, 257-58 Recreation: lack of satisfying, 2089; incidence of lack of, 214, 216, 218, 219; occupation as, 231; utilizing of resources for, 231; supplying, 239 Recurrent disease: in cases studied, 16-18; demonstrations of cases of, 23-53 Relatives: oversolicitude, 105, 107, 108-10; support of by patient, 160; interference of, 235; cooperation of, 265-66 Religion: in cases studied, 14; influence of, 44-45, 47, 89; and invalidism, 103; and prevention of disability, 149; as satisfying outlet, 210-11; opportunity for, 239 Remedial measures: to control environment, 225-39; to influence conduct, 240-77; classified, 279 Resentment, and dissatisfaction, 188 Resources: utilizing available, 22932; understanding of, 256 Rest, influences adverse to: 125-26; faulty habits of, 176. See also Fatigue Reynolds, Gladys: Abstract 100, 343-44; adverse social factors affecting, 146 ; inadequacy of means, 159; faulty mental habits, 180, 186; and incompatibility, 195; lowered cultural standards, 202 Rheumatic disease: and habitat, 12022; and temperature change, 126;

410

INDEX

Rheumatic disease (Coni.) and physical strain, 150; and inadequacy of means, 1S8; and climate, 217; removal to better environment, 236; information imparted concerning, 244; and choice of habits, 256 Ridicule, as means of influence, 257 Risks, encouragement to take, 257 Rocher, Marian: Abstract 82, 33536; inadequacy of means, 157; lowered cultural standards, 201-2 Routines, positive: defined, 259n; for disabled, 259-60 Sanitation, and ill-health, 127 Santos, Harry: Demonstration 12, 77-86; and undue effort, 146; habits and medical recommendations, 169-70; endurance of disability, 183-84; unselfishness, 185; and dissatisfaction, 199; and restricted outlets, 204 ; supplying deficiencies for, 228; utilizing resources, 230-31; information imparted to, 246, 248-49; value of appreciation of, 256 ; and disabling fear, 257-58 Satisfaction, see Dissatisfaction Self-control, and maternal indulgence, 170 Self-discipline, and medical recommendation, 167 Selfishness, habit of, 185 Self-pity, provoking invalidism, 232 Self-regulation, example of, 262-63 Selig, Mark: Abstract 89, 339; and work strain, 139-41; faulty personal habits of, 177; information imparted to, 243 Service, personal: and sleeping arrangements, 126; incidence of lack of, 131-33, 215, 216, 218, 219; supplying, 225; lack of, obstacles to care, 237 Sexual maladjustment, examples of, 45, 52-53 Shelter, supplying, 225 Single persons: and inadequacy of

means, 158-62; and dissatisfaction, 189 Sleeping arrangements, adverse, 12526 Smoking: and duodenal ulcer, 140, 243; control of, 171; as faulty habit, 179 "Social," defined, 7η Social agency: cooperation with hospital, 227; aid of, 229. See also Social workers Social factors: study of, 6-9; outlined in cases studied, 19-20; described in demonstrations of cases, 21, 23, 24, 26-42, 44-52, 54-57, 6063, 65-67, 70-75, 77-80, 86-92, 95100, 105-13; adverse, affecting subsistence, 114-86, affecting satisfaction, 187-219; incidence of adverse, 211-19; adverse, remedial measures for, 223-77; as classification, 279. See also in Abstracts, 285-345 Social security, need for, 220-22 Social status: described in demonstrations of cases, 37, 39, 56-57, 63, 79, 91, 96; and dissatisfaction, 150, 190-203; and inadequacy of means, 158; of homeless persons, 158-62; and faulty hygiene, 178; lack of satisfying contacts and, 209-11; incidence of unsatisfactory, 214, 216, 218, 219; and lowered cultural standards, 201-3 Social workers: work of, 226, 227; and patient, 242; and understanding in cases, 256; and advice, 26869; responsibility of, 278 Space, see Overcrowding Stairs: and fatigue, 124-25, 128; and housekeeping, 128; and work strain, 150; as obstacle to care, 237 "Standing by": as remedial measure, 269-76; defined, 270« Stone, Sam: Abstract 85, 337; and undue effort, 151 Subsistence, means of: defined, 119; adverse social factors affecting,

INDEX Subsistence, means of (Cont.) 119-86; essentials of, 119-20; fatigue and effort to secure, 13351 ; standard, 153n; undue effort to secure, 214, 216, 218, 219; imparting information concerning, 242, 245-46; influencing choice regarding, 252-61 Subsistence standard, for New York, 153» Sunlight, a n d ill-health, 127 Swenson, Selma: Demonstration 5, 36-42; malnutrition, 129; habits and medical recommendations, 172; faulty personal habits, 176 Symptoms: diverting attention from, 191-93, 207-8, 246; relatives and attention to, preoccupation with, 242 ; fear of, 258 Syphilis: and disability, 116; and physical strain, 149; aftercare of, 164; therapy for, 173-74; and means of subsistence, 216

411

30, 32-34, 36; and occupational strain, 138; and heart damage, 150; and inadequacy of means, 161 ; aftercare of, 164 Transportation, to work, 146, 147, 149-50 Treatment of disease, see Therapy Tuberculosis: social influences on, 5; in cases studied, 16; examples in demonstrations of cases, 23, 25, 26; and city environment, 122, 123; aftercare of, 164; removal to better environment and, 236-37; information imparted concerning, 244 Ulcer, duodenal, see Duodenal ulcer Unemployment, see Employment Ventilation, and ill-health, 126 Vocational guidance, and heart damage, 147 Volk, Isadore: Abstract 94, 341; information inparted to, 243

Temperature, change of, and health, 126

Terminal stages, care during, 215 Therapy: described, 5; examples described in demonstrations of cases, 25-26, 28-29, 31-36, 38-43, 47-49, 57-61, 72, 75-76, 81-86, 92104; habits interfering with, 16675; and home medication, 171; and adverse social factors, 224-39; itemizing, for patients, 234 ; information to patients concerning, 243-47; demonstration by occupational, 250-51; regulation of habits and, 264; rest as, 280-81. See also Abstracts, 285-345 Therapy, occupational, see Occupational therapy Threat, as means of influencing conduct, 257 Thyroid disease: social influences on, 5; in cases studied, 17; examples in demonstrations of cases, 26, 28-

Wage earners, undue effort of, 14251 Watson, Thomas: Abstract 96, 342; malnutrition, 130; endurance of disability, 182; lowered social status, 201 Weil, George: Abstract 99, 344; addictions to poisons, 197; dislike of associates, 197; dissatisfaction, 200; utilizing resources, 229; obstacles to care, 235 White-collar class, undue effort in, 142-45 Wood, Cyrus: Abstract 98, 244-45; removal of obstacles to care, 233 Work, see Occupation Work strain: and ill-health, 70-73; and disability, 77, 78; and cardiac trouble, 96-99; and noise, 150; in securing subsistence, 133-35; and fatigue, 134 ; and faulty habits, 14041 ; and business failure, 141-42