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Social and emotional problems in rheumatoid arthritis, -- a study of a group of Vancouver cases Mickelson, Harvey Paul 1949

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SOCIAL AND EMOTIONAL PROBLEMS HSf RHEDMAI.OID'ARTHRITIS. A Study of a Group of Vancouver Cases. by HARVEY PAUL MICKE1SON. Thesis .Submitted, i n P a r t i a l Fulfilment of the Requirements for the Degree of MASTER OP SOCIAL WORK i n the Department of Social Work. 1949. The University of B r i t i s h Columbia. ABSTRACT The purpose of th is study i s to examine the aspects of a r th r i t i s as a socia l welfare problem as wel l as a health problem, and to show (a) that the socia l and emotional components of the disease have a significant bearing on the " t reatabi l i ty" of the patient; (b) that casework, community organization and public welfare must be involved i n an adequate treatment programme. The broader implications of the problem are i n -dicated by s ta t i s t i c s from national surveys and other re-lated studies. But the essential material i s derived from a study of cases. These include t h i r t y hospital cases, of which twenty three were interviewed one or more times, and seven were taken from socia l his tor ies i n which sufficient data were available. Thirty re-p l ies were received from a special questionnaire sent to the homes of a second group of patients. The study shows that (1) each of the patients had an average of 3-1 socio-emotional problems s i g n i f i -cantly related to onset or recurrence^ (2) the disease created additional personal and family problems which are c lass i f ied and discussed i n de ta i l , a l l of which pre-vented the patient from getting or benefiting from ade-quate treatment; (3) there are gaps i n present treatment and rehabi l i ta t ion programmes which must be f i l l e d , and (4) medical social work has an important role to play i n assist ing disgnosis, treatment and rehabi l i ta t ion . I t i s hoped that th i s study of the socia l as-pects of rheumatoid a r th r i t i s w i l l c l a r i fy the role that social work must play i n an adequate treatment programme, indicate the kinds of further research which would be valuable i n this area and point up the need for a much broader perspective on the whole problem. ACKHOWIEDGEMEHITS I wish to express my sincere appreciation to the following persons for their invaluable as-sistance while this study was i n process: Dr. L . C. Marsh for h is many helpful sug-gestions and cri t icisms throughout the entire period of wri t ing. Miss Margaret Johnson for kind cooperation i n the work of revis ion. Miss Olive Cotsworth, Miss Eleanor Bradley and Miss Dorothy Longley of the Social Service De-partment of Vancouver General Hospital for their guidance i n the selection of eases and for reading the manuscript after the f i r s t wri t ing. Miss Mary Pack, Secretary of the B. C. D i - ' v is ion of the Canadian A r t h r i t i s and Rheumatism Socie-ty for her cooperation i n providing reference material and i n arranging to have the questionnaire used i n the study distributed to the homes of f i f t y patients re-ceiving treatment from the Society's t ravel l ing physio-therapists. Mrs. Horma Mickelson, for providing a lay-man's c r i t i c i sm of the text and for proofreading each revis ion. TABLE OF CONTENTS Ackno wl e dgemerrfc s. Chapter I . The Problem of A r t h r i t i s . The social problem. Incidence of the disease. Econom-i c and social aspects of the disease. The nature and types of the disease. Constitutional, emotional and psychic fac-tors . Chapter I I . A Case Study Approach. Aims. Approach to the study. Methods employed. Sources of case material. Chapter I I I . Problems Associated with Onset and Recurrence. Depletion of energy and strength. Disturbing exper-iences. Related Studies. Case analyses. Significance of emotional factors. Case i l l u s t r a t ions . Chapter IV. Problems Belated to Progress of the Disease. The frustration of tiredness. The importance of opt i -mism. Limitation of movement and crippling effects. Finan-c i a l and vocational problems. Loss of independence. Limita-t ion of social l i f e and recreation. Personal and family prob-lems aggravate the disease. Case i l lus t ra t ions of typ ica l problems. Chapter Y, Treatment and Rehabil i tat ion. Treatments i n common use. Evaluating the various ther-apies. Measures considered of proven value. Lacks i n pres-ent treatment programmes. Rehabil i tat ion. Chapter VI. The Role of Medical Social Work. The "real" function of the medical social worker. Long term, recurring cases constitute a special problem. The patient 's personality problem must be considered i n treat-ment. The value of v i s i t s to the patient 's home. Support-ive casework services to the semi chronic patient. The importance of casework services i n the medical setting. Appendices. A. Class i f ica t ion of A r t h r i t i s . B. Questionnaire used i n th is study. C. Summarized sample case history. -D. Bibliography. TABLES IN THE TEXT Page Table 1. Duration of A r t h r i t i s . 4 Table 2. Estimated Number of Persons with Ar th r i t i s by Age at Onset (in thousands) 7 Table 3» Socio-emotional Problems Asso-ciated with Onset and Re-currence 29 Table 4« Limitation of Movement 43 Table 5« Duration of Crippling 45 Table 6. Vocational and Financial Problems . . 46 Table 7* Loss of Independence 48 Table 8. Limitation of Social Life and Recreation 50 Table 9. Treatments Reported as Helpful . . . . 69 SOCIAL AND EMOTIONAL PROBLEMS IN RHEUMATOID ARTHRITIS. To You, 0 Goddess of Efficiency, Your happy vassals bend the reverend knee, Save when a r t h r i t i s , your benighted foe, Sulks i n the bones and slowly mumbles "No." Samuel Hoffenstein. CHAPTER I . THE PROBLEM OF ARTHRITIS. A r t h r i t i c disorders have plagued mankind since time immemorial, but never i n great epidemics l i k e those of smallpox or typhoid fever. I t does not k i l l , so i t i s not possible to point to mortality records and say, "Shis disease has caused so many deaths; we must do something about i t . " In most cases i t begins ins idiously , and the patient may be thought consumptive, neurotic or just lazy u n t i l the disease has been allowed to do much damage. The disease i s not known to be communicable, so that health de-partments have no morbidity records for i t . Hence the pub-l i c , i n general, adopts a somewhat complacent attitude to-ward the disease and attention i s turned to more dramatic 1 diseases. In recent years, however, a r th r i t i s has gradually begun to gain the attention i t deserves. Ar th r i t i s has been called Canada's "number one cr ippler ," and, as such, i t was recently described by one of the M.P. ' s i n the House of 2 Commons at Ottawa. Various newspaper and magazine ar t ic les 1»- McKevin, Kathleen. Bheumatoid A r t h r i t i s . (Essay) Chapel H i l l , N. C. November, 1945^ 2. Canada, House of commons Debates. Speech, Mrs. Gladys Strum, on "The Problem of A t t h r i t i s , delivered on February 1, 1949. "TJEtawa. King's Pr inter . have also r e f l e c t e d the growing awareness of the problem. In October, 1948, Vancouver newspapers carried the report of an overflow meeting of approximately three thousand per-sons eager to f i n d a cure f o r t h e i r common ailment. Among the. speakers were the Hon. George S. Pearson, B.C. Minister of Health and Welfare, who suggested that "the size of the crowd indicates that people are demanding an answer to a r t h r i t i s , " and Dr. Wallace Graham, president of the Cana-dian A r t h r i t i s and Bheumatism Society, who said that " t h i s meeting w i l l bring a glimmer of hope to those whose p l i g h t „1 i s unrivaled i n human suffering." INCIDENCE OP THE DISEASE. The high incidence of a r t h r i t i s makes the dis -ease a medical-social problem of major significance. So f a r as current measurements can be trusted, there are ten times as many cases of a r t h r i t i s as of tuberculosis, twice as many as heart disease, ten times as many as diabetes and seven times as many as cancer. Roughly two-thirds of 2 these a r t h r i t i s cases are of the rheumatoid type. Widely varying figures have been quoted regarding the r e l a t i v e incidence of the various groups of rheumatic diseases. The most r e l i a b l e figures on the prevalence of 1. Quotations, from report i n The Vancouver Sun.. "Three Thousand Seek Rheumatism Cure as S p e c i a l i s t s Promise Hope." October 1, 1948. Vancouver, B.C. Page 1. 2. Greater Vancouver Health League. Canada's Number  One Crippler. (pamphlet) Vancouver, B. C. 1948. a r t h r i t i c rheumatism are to he found i n those countries which have a eompulsory national insurance scheme cover-ing a substantial propor t ion of the adult population, and which have made careful surveys of the incidence of the dis-ease. From the records of the national health insurance scheme i n England and Wales, i t i s estimated that i n those two countries one out of every twenty persons suffers from some kind of rheumatic disease, and that out of the to ta l pop-ulat ion one mi l l i on are a r th r i t i c s . Scotland i s estimated to have more rheumatic victims than England and Wales combined. Important data are available for the United States for the years 1935 - 1936, as th is i s the date of the com-prehensive National Health Survey made by the U.S. Public Health Service. This survey established that rheumatic d is -eases head the l i s t of chronic diseases. Of nearly seven m i l l i o n Americans suffering from rheumatic diseases, three mi l l i on were a r th r i t i c s . Of these, 130,000 were completely disabled, and another 800,000 part ly d isabled . 1 In Canada, a sample survey on a wide* base was made i n November, 1947, by the V i t a l S ta t i s t ics Divis ion of the Dominion Buraeu of S ta t i s t i cs to determine the number of people suffering from a r th r i t i s i n Canada. This study included 65,000 persons and from the results obtained es-timates of the to ta l problem were made. I t was estimated m 1. Snyder, Dr. R. G. "Ar th r i t i s , A Neglected Dis-ease." ,.An_nals of Internal Medicine. February, 1940. Volume 1 .^. "pages 13 17 - 1376. -4-that 652,000 people were suffering from some form of arth-r i t i s at that date. The time f a c t o r i n the disease i s an aspect equal-l y as s i g n i f i c a n t as i s the high incidence rate. Table 1. btings into focus s i g n i f i c a n t findings of the Canadian Sur-vey r e l a t i n g to the duration of the disease. Table 1. Duration of A r t h r i t i s . Estimated numbers of persons who have suf-fered a r t h r i t i s f o r various periods of years. (In thousands : 1947) Years of Duration Men Women Both Percentage of Tp-t a l A r t h r i t i c s i n Each Category under 5 years 117 108 225 34 5 - 9 73 75 148 23 10 - 14 46 54 100 15 15 - 19 26 31 57 9 20 years and over 60 62 122 19 Total 322 339 652 100 Source t Dominion Bureau of S t a t i s t i c s : Preliminary Repori on the Incidence of A r t h r i t i s i n Canada, 1947. page 10. The s t a t i s t i c s of t h i s report underscore the t r a g i c f a c t that 66 per cent of the victims of a r t h r i t i s have had the disease f o r more than f i v e years. Many of these per-sons have therefore gone past the stage at which they could entertain hopes f o r a cure. Approximately 120,000 persons have had the disease twenty years or more. These long -5-sufferers have only one compensation i n that the disease tends to burn i t s e l f out a f t e r a few years so that although the v i c t i m i s deformed, he or she may be free of pain. Of course, many of these chronic sufferers may not be hopeless-l y involved. The largest single group i n terms of "years of duration" were those who had the disease l e s s than f i v e years. I t i s t h i s large group, 34 per cent of the t o t a l , who have the greatest hope of cure, or at l e a s t of a l l e v i a t i o n of pain and prevention of deformity. ECONOMIC AND SOCIAL ASPECTS OF THE DISEASE. One of the disastrous effects ofchronic a r t h r i t i s i s the great loss of earning power which i t occasions, with consequent deleterious effects on the patient, on h i s family and on society as a whole. A r t h r i t i s accounts f o r a greater number of days l o s t from work than any other chronic ailment with the exception of nervous and mental diseases. The Dominion Survey of 1947 indicated tha# during the month of October, 1947, 99,700 a r t h r i t i c sufferers l o s t a t o t a l of 1,650,300 days from t h e i r regular a c t i v i t i e s ; t h i s would amount to nearly 20,000,000 days f o r the year -a great economic and s o c i a l l o s s indeedl The Survey also showed that a r t h r i t i s accounted f o r roughly one quarter of the time l o s t by men and women i n Canada as a r e s u l t of i l l -ness of a l l kinds. Figures derived from the United States P u b l i c Health Survey (1935 - 1936) show that among the more than -6-3,000,000 a r t h r i t i c sufferers more than 100,000,000 work days were l o s t by completely and p a r t i a l l y disabled v i c -tims. Reckoning at a minimum of s i x d o l l a r s a day, a wage loss of #600,000,000 per year i s indicated. Recent national health surveys i n Canada and the United States indicate that t_a burden of chronic disease f a l l s heaviest on the part of the population which i s l e a s t able to bear the cost. D i s a b i l i t y from chronic i l l n e s s , expressed i n terms of the average number of days l o s t from work per per^son, i s almost three times as great among fa m i l i e s on r e l i e f , and twice as great among non-relief f a m i l i e s with incomes under $1,000 per year as among fami l i e s with incomes of $3,000 per year or more. I t i s i n t e r e s t i n g to note, however, that according to the Dominion Sur^vey, 7 per cent of those s u f f e r i n g from a r t h r i t i s were i n the managerial and professional occupations; 3 per cent were i n c l e r i c a l ; 2 per cent i n transport and communication occupations; 15 per cent were i n agriculture, f i s h i n g , trapping and logging; 7 per cent were i n labour arid construction occupations and 41 per cent were housekeepers. This indicates that a r t h r i t i s i s not exclusively a "poor man's disease" as i t has sometimes been c a l l e d but that i t s t r i k e s at a l l economic s t r a t a . I t does, however, tend to affect more persons i n the lower economic, s t r a t a , because the greatest percentage of the population f a l l s i n the lower income brackets and because t h i s portion of the population i s less able to finance the necessary health care than are those persons i n the higher income groups. A r t h r i t i s not only s t r i k e s most frequently among these lower income groups but i t also attacks dur-ing the period of greatest economic productivity, roughly i n the age group 2 5 - 5 4 years. This i s a c h a r a c t e r i s t i c which t h i s disease shares with other chronic diseases. I t can be seen from Table 2 that approximately 60 per cent of those su f f e r i n g from a r t h r i t i s f a l l into t h i s group. Table 2. Estimated number of persons with a r t h r i t i s , by age,"at onseT. (in thousands] Age at onset Men Women Both Percentage i n each age group under 15 12 16 28 4 15 - 24 37 37 74 11 25 - 54 191 195 386 59 5 5 - 6 4 51 56 107 17 65 and over 31 26 57 9 Total 322 330 652 100 Source: Adapted from Dominion Bureau of S t a t i s t i c s : Preliminary Report on the Incidence of Arth-r i t i s i n Canada, 1947. page 8. THE NATURE AND TYPES OF THE DISEASE. A r t h r i t i s i s simply one of a great group of d i s -eases known as the "rheumatic diseases." This term i s i n current use by the medioal profession but only as a con-venient general term f o r a large number of diseases, some -8-of which are w e l l understood while others remain a mys-tery. There i s no e l a s s i f i c a t i o n of rheumatic diseases acceptable to the whole medical profession, but there i s general agreement that the term includes three main groups. The f i r s t of these i s rheumatic fever, a disease occurring primarily i n childhood and young adults. The second group i s designated by the term non-articular rheu-matism, that i s , forms of rheumatism which affect the soft tissue around the j o i n t but not the j o i n t i t s e l f , and re-s u l t i n inflammation of the muscles (myositis), the f i b r e s ( f i b r o s i t i s ) , the protective tendon sheaths (tenosynovitis), or the protective pads around the knees and albows (bur-s i t i s ) ; along with these go some cases of lumbago, n e u r i t i s , and s c i a t i c a . I t i s t h i s second group that the layman knows as "rheumatism;" and his doctor, so as not to confuse him with the various forms of the rheumatic diseases, w i l l probably give him t h i s diagnosis. "Rheumatism" may be l i m i t e d to s l i g h t twinges, or may r e s u l t i n severe pain and the appearance of hard nodules which can be f e l t under the skin. Though i t may be very aggravating and stubbornly r e s i s t a n t to treatment, i t seldom gives r i s e to serious d i s a b i l i t y . At the outset non-articular rheumatism i n i t s various forms may show symptoms s i m i l a r to those of the diseases of the t h i r d great group of rheumatic diseases which i s referred to as " a r t h r i t i s . " The medical term f o r " a r t h r i t i s " i s " a r t i c u l a r rheumatism", that i s , the forms of rheumatism that a f f e c t the j o i n t s . The term a r t h r i t i s i t s e l f comes from the Greek word "arth" meaning joint , and " i t i s " meaning inflammation. 1 Rheumatoid a r th r i t i s i s one of several types of a r t h r i t i c diseases* of which seventy-five per cent are of unknown etiology. The cases i n the present study are con-fined to the rheumatoid type of a r t h r i t i s because i t i s th is form which causes more problems, personal and soc ia l , than any other. Rheumatoid a r th r i t i s may begin suddenly and dra-matically but usually begins insidiously with fatigue, gener-a l malaise, gradual loss of weight, vaso-motor disturb-ances, numbness and t ing l ing i n the extremities. These effects may occur weeks or months before any joint involv-ment i s noticed. After affecting one joint the disease tends to proceed symmetrically inwards towards the trunk and may involve fingers, wris ts , elbows, shoulders, ankles and knees. I t progresses with acute remissions and exacer-bations. In some persons i t does not go beyond a certain stage. Several of the patients interviewed i n th i s study reported having had "rheumatic pains" for years but they had s t i l l not yet become too seriously crippled to be be-yond hope of a l lev ia t ion or cure. On the other hand there were some examples of patients who had a r t h r i t i s only a 1. Gallager, Mary P. A r t h r i t i s as a Public Welfare  Problem i n B r i t i s h Columbia. Essay submitted to Depart-ment of Social Work, University of B r i t i s h Columbia, March, 1948. 2. See Appendix B for c lass i f i ca t ion . -10-short time and were now almost completely crippled. In extreme cases of the disease the patient's s k i n becomes transparent, the palms of the hands and the soles of the feet become hot and moist or cold and clammy, the j o i n t s s t i f f e n and the muscles weaken and eventually atrophy. Then the j o i n t s become deformed; the hands take on the c h a r a c t e r i s t i c spindle-shaped appearance, and the wri s t s become so s t i f f that the patient cannot raise h i s arms to dress himself. The feet may become so s t i f f that the v i c t i m cannot even shuffle around, and the knees may be-come swollen to two or three times t h e i r normal size and "grate l i k e nutcrackers" when the patient t r i e s to move. The jaws can become so s t i f f that chewing i s impossible. The disease may also a f f e c t the eyes and v i s i o n may become dimmed fo r months at a time. Gastric and r e c t a l complica-t i o n s may also be added to the suffering. In the extreme cases of the disease, i t i s r e a d i l y to be believed that the patients, as they have t e s t i f i e d , "pray for death." The "Marie Strumpell's" form of rheumatoid arth-r i t i s , which occurs ten times as frequently among men as among women, s t i f f e n s the spine but usually spares the j o i n t s . The v i c t i m can regain h i s general health but i s l e f t with a s t i f f e n e d spine. He may have e i t h e r a poker-s t i f f back or a hump so r i g i d that he cannot bend or turn. He may have to wear an uncomfortable brace for the rest of h i s l i f e , but he can get around a f t e r a fashion by re-educating h i s other j o i n t s to take over many of the move-ments i n normal l i v i n g . -11-Fortunately rheumatoid a r t h r i t i s does not r e -s u l t i n hopeless c r i p p l i n g i n every case. I t may arrest i t s e l f or be arrested by adequate treatment at any stage i n i t s progress. Only about f i v e per cent of cases progress to the " t o t a l immobility" stage, but even t h i s i s a large number when the great number of chronic a r t h r i t i c s i s con-sidered. Even i f the disease stopped at the ankles and w r i s t s , the degree of d i s a b i l i t y involved i n the loss of. the use of the hands and feet would s u f f i c e to make i t . a r e a l dependency problem. CONSTITUTIONALt EMOTIONAL AND PSYCHIC FACTORS. Although the cause of rheumatoid a r t h r i t i s i s not known, the theory of causation most generally accepted has been that " f o c i of i n f e c t i o n " are always present and that "nests of b a c t e r i a l (usually streptococcal) i n f e c t i o n can pr e c i p i t a t e rheumatoid a r t h r i t i i . " Dr. Margolis, w r i t i n g from long exper5*lence with a wide va r i e t y of oases, states, however, that " i n f e c t i o n must neither be ignored nor be con-sidered a sole factor. To r e a l i z e the f u l l e s t implications of t h i s disease we must also view certain more fundamental aspects of the human organism upon which the t r i g g e r (of 2 f o c a l infection) acts." Some of these more fundamental aspects are c o n s t i t u t i o n a l , emotional and psychic factors. 1. Margolis, Dr. H.M. "Care of the Patient with Rheumatoid A r t h r i t i s . " The Family. January, 1945. page 324. 2. Margolis, Dr. H.M. I b i d , page 325. -12-Constitutional vulnerabi l i ty to a r th r i t i s prob-ably depends on such factors as inherently in fe r io r joint tissues, impaired blood supply, the type of nervous system with which the potential ly a r th r i t i c patient i s endowed, per-haps abnormalities i n body bui ld and i n the form and function of various v i t a l structures, and increased suscept ib i l i ty to infection. These and probably many other influences determine i n a large measure whether a r th r i t i s w i l l occur at a l l , and they also modify the course of the disease. 1 The inherent b io logical t r a i t s of the potent ial ly a r t h r i t i c patient are not s ta t ic , but are subject to stresses of dynamic environmental influences that can mould the phy-sique and personality toward or away from development of the disease. Dr. Margolis c i tes , as an example of the effects of these "dynamic" influences, the impressive evidence of auto-nomic nervous system imbalance i n a large number of patients with rheumatoid a r t h r i t i s . Such imbalance, however, i s not simply a result of the disease; i t i s more l i k e l y a pre-cursor of i t , for the existence of such a state of auto-nomic imbalance may be observed for years before the onset of the disease. Undoubtedly i n many patients th i s abnormal-i t y dates back to childhood.^ Emotional and psychic factors are also known to exert significant influences on the function of the auto-nomic nervous system. The relationship between pal lor and 1. Margolis, Dr. H.M. Ibid, page 325. 2. Margolis, Dr. H. M. Ibid, page 325. -13-rage, muscle tension and fear, i s too commonplace to re-quire amplification; yet the emotional background of the physiological abnormalities which predispose a person to a r t h r i t i s has been almost t o t a l l y disregarded. S i m i l a r l y the "emotional involvement" of the patient who i s under-going treatment has been ignored. Studies on the psychogenic make-up of the arth-r i t i c patient have revealed certain rather c h a r a c t e r i s t i c neurotic tendencies, i n extreme cases tinged with morbid anxiety whieh existed as often before as after development of the disease. Dr. Margolis states that h i s experience "leaves no doubt about the d i r e c t e f f e c t of prolonged anx-i e t y or emotional shock, having so often seen a v i o l e n t attack of widespread a r t h r i t i s developing i n neurotic i n -dividuals i n the wake of a s t i r r i n g emotional experience, when they were seemingly bent by the loss of a partner, a c h i l d , or power around which l i f e gravitated. With the l e a s t prodding and frequently v o l u n t a r i l y , the patient i s l i k e l y to express b e l i e f i n the close r e l a t i o n s h i p between such emotional experiences and the onset of h i s a r t h r i t i s . " Drs. Cobb, Bauer, and Whiting i n a pertinent study of f i f t y patients with t y p i c a l rheumatoid a r t h r i t i s , from a s o c i a l and psychological point of view, concluded that there was a s i g n i f i c a n t r e l a t i o n s h i p between l i f e stress and the a r t h r i t i s i n over s i x t y per cent of the patients. "Environmental stress, e s p e c i a l l y poverty, g r i e f 1. Margolis, Dr. H. M. I b i d , page 325. -14-and family worry, seem to bear more than a chance r e l a t i o n -ship to the onset and exacerbations of rheumatoid a r t h r i -t i s . " The authors add, however, that "the r e l a t i v e im-portance of these factors i n the etiology of rheumatoid a r t h r i t i s can only be established by a more detailed psy-c h i a t r i c study on a large group of patients^*" One distinguished physician has stated that "the e f f e c t of emotional upsets can no longer be considered mere coincidence, however. Any investigations i n the past ten years show that anxiety and resentment are the two most con stant emotional reactions i n rheumatoid a r t h r i t i s and mal-adjusted human relationships are a r e a l (contributory) 2„ problem." I t i s these psychic, emotional and s o c i a l factors that point to the r o l e of the s o c i a l worker i n both diagno-s i s and treatment of rheumatoid a r t h r i t i s . In recent years the need to consider both body and mind as a whole and to treat the "patient as a person" as we l l as to t r e a t the d i s ease i s winning acceptance. Psychotherapy, therefore, has i t s place i n the treatment of rheu^matoid a r t h r i t i s . Psy-chiatric and medical s o c i a l workers are trained not only to practise psychotherapy d i r e c t l y , but to take account of environmental influences which may have predisposed the 1. Weiss and English. Psychosomatic Medicine. W. B. Saunders and Company. Philadelphia and London. 1943. page 507. 2. Swain, L.T. " P r e s i d e n t i a l Address to American Rheumatism Association." Annals of Internal Medicine. July, 1943. Volume 19. . pages 118 - 12JL. -15-patient to the disease or which may be hindering the progress of treatment. The s o c i a l worker thus has a r o l e i n helping the physician to see the "whole person" i n treatment and to gain i n s i g h t into the needs of the patient which are related to h i s w e l l being and "treat-a b i l i t y . " I t i s obvious that, from the very nature of the disease, the s o c i a l effects are serious. As l a t e r sections show, there are also s o c i a l implications on the caeaal side. CHAPTER I I . A CASE STUDY APPROACH. The f i r s t problem i n approaching t h i s study was to f i n d a representative group of patients, preferably one which contained men, women, and children of various ages and which would provide, on analysis, a f a i r l y accurate picture of the t y p i c a l problems and needs. Prom such a sample i t i s possible to get information to show that the s o c i a l and emotidnal problems of the patient are associated with the onset and progress of the disease irr e s p e c t i v e of age and sex, and that they must be considered i n treatment. Other aims of the study are: To determine what problems the d i s -ease creates f o r the v i c t i m and h i s family and how these are rel a t e d to the " t r e a t a b i l i t y " of the patient; to indicate what treatments are now available and to point out s i g n i f i -cant gaps i n present treatment acrib. r e h a b i l i t a t i o n programmes; to show that a r t h r i t i s i s a public welfare problem as w e l l as a public health problem which requires governmental action on national and l o c a l l e v e l s , comparable to that taken i n the control of other widespread diseases such as tuberculosis and cancer; to indicate that medical s o c i a l workers can contribute to the treatment and r e h a b i l i t a t i o n process and to emphasize the need f o r "teamwork" i n the treatment and r e h a b i l i t a t i o n of the patient. The f i n a l choice was a group of 60 cases which included: 23 patients interviewed one or more times; 7 cases -16--17-where case records only were used because s u f f i c i e n t s o c i a l data was available; and 30 additional cases which were ques-tionnaire studies. The f i r s t 23 case h i s t o r i e s were ob-tained as a r e s u l t of interviews at the weekly outpatient c l i n i c of the Vancouver General Hospital, from November, 1943, to March, 1949, i n c l u s i v e , a period of f i v e months, ighe other 7 patients were not interviewed because they were being ca r r i e d by other workers and i t was not necessary to duplicate the work being done. I t i s i n t e r e s t i n g to note i n passing that the records of the Soc i a l Service Department indicated that very few a r t h r i t i c patients were being r e f e r r e d to s o c i a l workers except f o r admission to nursing or boarding homes, to obtain appliances, crutches or some other s i m i l a r service. This made a t o t a l of 30 patients on which adequate s o c i a l and medical information was available by personal contact of the author or co-worker i n the s o c i a l service department. In addition, a questionnaire was prepared and sent to a d i f -ferent group of 50 patients known to be s u f f e r i n g from rheu-matoid a r t h r i t i s . The cooperation of the B. C. A r t h r i t i s . and Rheumatism Society greatly f a c i l i t a t e d t h i s step. Thir-t y completed questionnaires were returned, which increased the number of patients included i n the study to s i x t y . In s e l e c t i n g these cases ai* attempt was made to obtain approximately equal numbers of men and women and a v a r i e t y of age-groups from children to old age pensioners. Uo age l i m i t s were set but there were no children under fourteen available and the oldest person interviewed was seventy years of age. The patients eliminated were those -18-unavailable f o r interview and those who were considered to be permanently and t o t a l l y incapacitated. This l a s t group of patients was excluded because they could not be included i n a study concerned with treatment and r e h a b i l i t a -t i o n . Ten patients interviewed at the Glen and Grandview Hursing Homes and at the Marpole Infirmary f e l l into t h i s group. Several other avenues were explored i n the search for case material. Many ho s p i t a l case records were read, permission having been granted to examine charts of a l l the rheumatoid a r t h r i t i c patients admitted to Vancouver General Hospital i n 1948. Hospital s t a t i s t i c s were not up to date so that i t was necessary to examine a l l charts containing a r t h r i t i c diagnosis i n order to segregate the theumatoids. Moreover, only the occasional chart contained anything approaching the s o c i a l h i s t o r y required. The main r e s u l t of t h i s , indeed, i s that i t re-affirmed the need f o r a study of t h i s kind. I t became immediately obvious that the s o c i a l aspeots of the disease were not being considered i n t r e a t -ment. That i s , l i t t l e or no attempt had been made to ana-lyze each patient's personality and background to determine h i s personal problems, worries, burdens etc. and how these were related to the medical problem. Twenty nine medical case h i s t o r i e s were obtained from these charts which ap-parently included a l l or at least most of the cases having a primary diagnosis of rheumatoid a r t h r i t i s . Twenty of these had been admitted to the Vancouver General Hospital i n 1948 and nine i n the previous year. Because of the lack of s o c i a l -19-data these twenty nine cases were checked with the Social Service Index to determine whether the f a m i l i e s were known to any s o c i a l agency which might have information about the family relevant to the medical problem. I t i s i n t e r e s t i n g to note that the majority of the cases were not registered with the Index. Several were known to the C i t y Social Ser-vice or to a p r o v i n c i a l Social Welfare Branch. Four were known to the Family Welfare Bureau but only two contained s u f f i c i e n t relevant data. These 29 cases were not included i n the main body of the thesis as case studies because of the paucity of s o c i a l data. Only one patient was interviewed outside of the hospitals and nursing homes. This patient, a young man almost completely crippled, was interviewed i n h i s own home. He was the only patient who reported that he was f i n a n c i a l l y secure i n spite of years of involvement. This patient was not included as one of the 60 cases but r e f e r -ence i s made to him elsewhere i n the study for i l l u s t r a t i v e purposes. The minimum length of each interview with patients i n the outpatients department was one h a l f hour; the aver-age being longer. Several of the patients were interviewed re g u l a r l y over a period of f i v e months so that a f u l l h i s -tory could be obtained f o r i n c l u s i o n i n the study. CHAPTER I I I . PROBLEMS ASSOCIATED WITH ONSET AND PJiCIURRENCE. I t i s impossible to indicate to what extent any one factor may contribute to the cause or onset of a d i s -ease, because the various factors are bound to bear d i f -ferent weight with d i f f e r e n t i n d i v i d u a l s by v i r t u e of the f a c t that i n d i v i d u a l s d i f f e r a great: deal i n family back-ground, heredity, personality t r a i t s , and so on. Neverthe-les s one can assume that emotions of one kind or another are common to a l l human beings. I n the onset and recurrence of rheumatoid a r t h r i t i s i t i s the extent of the negative emo-tions that i s the s i g n i f i c a n t factor. Pear, anxiety, hate, resentment and kindred emotions are examples of negative emotions that have a detrimental ef f e c t on the human organism. A l l chronic a r t h r i t i c s seem to have suffered a de-p l e t i o n of energy and strength manifested i n loss of weight and a general f e e l i n g of tiredness. Tiredness and depletion of energy are generally attributed to overwork, but no study yet done, including the present one, has indicated that the a r t h r i t i c patient beeomes t i r e d and depleted because of over-work i n every ease. In those who did overwork i t might be asked what "emotional" motives were d r i v i n g them. Many peo-ple have bom witness to the t i r i n g e f f e c t of discouragement, inner emotional c o n f l i c t , worry and anxiety on t h e i r own bodies as w e l l as having seen the e f f e c t on those of t h e i r acquaint-ances at some time or other. Naturally these negative emo--21-tions would only have a severely depleting e f f e c t i f they were f e l t over a r e l a t i v e l y long period of time,and of course the effect would also depend much on the i n t e n s i t y of the s t r a i n . A severe shock can and does render some persons so i l l that they have to go to bed, p a r t i c u l a r l y i f the person i s of delicate constitution. And, i f the shock i s prolonged, the person can suffer loss of weight and strength and weak-ening of resistance to disease. Dr. G. W. Thomas states that rheumatoid a r t h r i t i s cannot be contemplated c l i n i c a l l y without gaining the con-v i c t i o n that i t i s associated with physiologic depletion. Aside from i n f e c t i o n there i s no more important cause of physiologic depletion than that of emotional and physical 1 2 trauma or s t r a i n . Dr. C e c i l goes s t i l l further i n s t a t i n g that psychic factors are more important than i n -f e c t i o n i n provoking the o r i g i n a l symptoms or i n bringing about relapses of rheumatoid a r t h r i t i s , RELATED STUDIES. Several p s y c h i a t r i c studies of groups of a r t h r i t i c patients have been made which indicate that emotional factors have a s i g n i f i c a n t r e l a t i o n to the onset and recurrence of r the disease. Some of the more pertinent examples are b r i e f l y 1. Thomas, Dr. G.W. "Psychic Factors i n Rheumatoid A r t h r i t i s . " American Journal of Psychiatry. Volume 93. November, 1936, page 694. 2. Committee of the American Rheumatism Society. "Rheumatism and A r t h r i t i s Review of American and English Literature of Recent Years. (9th Rheumatism Review)" Annals of Internal Medicine. Volume 28. January, 1948. -22-c i t e d below. Emotional factors were studied i n twenty-five cases by Drs. Patterson, Craig, Martin, Waggoner and Preyberg. A-bout one h a l f of the group of patients studied had exper-ienced prolonged emotional stress f o r periods of months pre-ceding the onset of rheumatoid a r t h r i t i s . Discussion of t h e i r emotional problems caused a f a l l i n skin temperature i n d i c a t i n g a change i n peripheral c i r c u l a t i o n . The importance of these physical changes appeared important i n producing exacerba-1 tions of the disease. Dr. Halliday discovered "a d e f i n i t e upsetting event" antecedent to the onset i n nine of twenty oases of rheumatoid a r t h r i t i s , and i n seven cases emotional o o n f l i c t s were thought to provoke recurrences. The emotional disturbances included shock following acute danger, anxiety over finances or the misbehaviour of r e l a t i v e s , fear of loss of an object, paranoid resentment concerning superiors, f r u s t r a t i o n at being j i l t e d by a fiancee, and others. 2 Although these studies were based on the findings of a r e l a t i v e l y small number of cases, the Medical Review from which they were taken considered them s c i e n t i f i c a l l y v a l i d and the implica-tions of importance. A much more comprehensive survey was made i n Mass-achusetts i n recent years by Dr. Donald Griegg which i n -volved a study of 610 insane persons and a post mortem ex-amination of 3000 other insane persons. Only one out of 1. Annals of Internal Medicine. Ib i d . January, 1948. page 123. 2. Annals of Internal Medicine. Loc. C i t . January 1948. -23-the 610 insane persons had a r t h r i t i s , and no frank evidence of a r t h r i t i s was found i n any of the 3000 autopsies. In con-t r a s t to t h i s , one out of every 36 persons i n the-general pop-u l a t i o n of Massachusetts had chronic a r t h r i t i s . The sugges-t i o n has accordingly been made that the insane persons were not facing the stresses and st r a i n s faced by the sane section of the population. In effect, they had solved t h e i r emotion-a l and s o c i a l problems by escaping from r e a l i t y i n t o insanity. Dr. Griegg suggests by way of explanation that man i s endowed with reactions which enable him to escape from harmful forces or to f i g h t them o f f by increasing h i s blood pressure, pulse, muscular a c t i v i t y , etc. These reactions are b e n e f i c i a l when appropriate and when not prolonged, but inju r i o u s when unduly extended. Through his memory and im-agination, man has lengthened the period during which the blood pressure and pulse are increased and muscles are tense. But these normal reactions when unduly prolonged can produce a l o c a l i z e d i n s u f f i c i e n t blood supply to a t i s -sue, a condition c a l l e d ischemia, which can lead to numer-ous disturbances, such as stomach ulcer, spastic c o l i t i s and a r t h r i t i s . 1 M i l l a r d Smith's study of 1 0 2 oases of rheumatoid a r t h r i t i s gave evidence that about 5 0 percent of the cases had undergone "depleting and unbalancing experiences" which were closely related to the onset of t h e i r a r t h r i t i s . 1 . Phelps, Dr. Al f r e d E. Your A r t h r i t i s : What  You Can Do About I t . William Morrow and Company. New York": 134"37 -24-Of the t h i r t y h o s p i t a l cases i n the present study, eighteen of the patients, when interviewed, were suffering from emotional c o n f l i c t of one sort or another and had cherished long standing resentment and h o s t i l i t y (usually unexpressed) towards other persons. One e l d e r l y lady was so resentful of her husband's alleged selfishness and i l l - t r e a t m e n t of her that she could scarcely t a l k of anything else. I t i s obvious that her entire blood system would be upset by the i n t e n s i t y of her negative emotion. Another patient, a young man of 36 years of age, described himself as a "moral coward." He had never faced h i s per-sonal problems i n order to work them through to a s a t i s -factory conclusion. Consequently, he always seemed to be " b o i l i n g i n s i d e " with inner c o n f l i c t s and fears. Often he projected these feelings onto persons i n h i s environ-ment which caused him to bear strong resentment towards others over long periods o f time. Another young man ex-pressed great h o s t i l i t y towards h i s physician because the doctor had allegedly made a wrong diagnosis i n h i s case two years previously. The young man had projected a l l his f e e l i n g s of f r u s t r a t i o n to his physician. Over a period of two years he had b u i l t h i s feelings into a constant attitude of h o s t i l i t y . Ten of the patients interviewed stated that they had "always been nervous and high strung." Most of these persons expressed the b e l i e f that t h e i r present poor health was d e f i n i t e l y related to a disturbed, unhappy childhood. - 2 5 -In several instances t h i s b e l i e f was mentioned without d i -rect questioning, i n d i c a t i n g that the patients themselves were conscious of the r e l a t i o n s h i p between emotional states and physical disturbances. Another group of ten patients had been disturbed over a period of years because of marital unhappiness. One woman stated that she f e l t that there was a d e f i n i t e con-nection between the onset of her a r t h r i t i s and a series of emotional upsets occurring within a four months period, a l l of which were rel a t e d to her husband leaving her for another woman. In t h i s case, the patient was being affected d e t r i -mentally; f i r s t , by the emotional upset of what had happened and, secondly, by the strong resentment and animosity which she was f e e l i n g towards her husband whom she was blaming f o r breaking up the marriage. This patient f e l t that when-ever she was most disturbed by the thought of "her misfor-tune" her a r t h r i t i c pains and swellings became much more acute• Evidence that prolonged shock had been suffered as a r e s u l t of deaths i n the family was given by ten of the patients interviewed. In some of these ten cases, the shock was d e a r l y related to the onset of a r t h r i t i s , and i n others i t was related to an exacerbation of the disease. One pa-t i e n t , f o r example, reported that she had had s l i g h t arth-r i t i c pains i n t e r m i t t e n t l y f o r years, but that her condition had not become serious u n t i l a f t e r the death of her husband upon whom she had been very dependent. This patient said that she s t i l l f e l t disturbed about the loss of her husband -26-and the d i f f i c u l t i e s involved i n l i v i n g alone. She f e l t that her anxious, disturbed state of mind was d e f i n i t e l y making her a r t h r i t i s worse, The effects of severe shock i n p r e c i p i t a t i n g an attack of a r t h r i t i s was described by another woman patient who t o l d of a disturbing experience she had undergone at the time of the onset of her a r t h r i t i s . She and her hus-band were at that time l i v i n g i n a r u r a l d i s t r i c t i n Mani-toba where there were no neighbours within several miles. During the absence of her husband, she had l i t a f i r e i n the yard to burn up some rubbish. The f i r e somehow got out of her control, caught onto the dry grass surrounding the house, and soon threatened the entire property. The woman was t e r r i f i e d , and worked f e v e r i s h l y f o r hours t r y -i n g to put out the f i r e . She dared not go to a telephone l e s t the f i r e reach the house i n the meantime. In her at-tempts to quench the flames, she pumped a l l the water out of the w e l l - some two hundred buckets - and completely ex-hausted herself i n the process. By t o i l i n g a l l day alone, she managed to save the house. When her husband f i n a l l y came home, he took her immediately to the h o s p i t a l . Shortly af t e r t h i s the woman developed d e f i n i t e symptoms of rheuma-t o i d a r t h r i t i s , and she has since suffered from the disease f o r many years. This incident, p r i o r to onset, could not be said to have caused the disease but i t most c e r t a i n l y would appear to have been a p r e c i p i t a t i n g factor, because of the severe shock, great fear, and physical depletion that the patient experienced. -27-F i f t e e n of the a r t h r i t i c patients interviewed admitted f e e l i n g f r u s t r a t i o n and resentment over a long period of time because of employment d i f f i c u l t i e s . Of these f i f t e e n , seven had been unemployed or only spasmodi-c a l l y employed at the time of onset. Five were doing work that was d i s t a s t e f u l to them, and three expressed marked feelings of f r u s t r a t i o n because of t h e i r i n a b i l i t y to achieve t h e i r occupational goals. Another group of s i x -teen of the patients indicated that they had experienced much anxiety about low and uncertain income, p a r t i c u l a r l y during the depression years of the 1930 fs. Most of these sixteen patients r e a d i l y stated that they f e l t that t h e i r prolonged anxiety about f i n a n c i a l and vocational matters was related to an increase i n t h e i r a r t h r i t i c involvement. Overwork may be a causative factor as much as emotional s t r a i n , although the psychological counterpart of the former i s usually discernible. Twelve of the pa-t i e n t s i n t h i s present sample had a h i s t o r y of overwork, to the extent that they were suffering from chronic fatigue p r i o r to the onset. The cause of t h i s overwork varied: some had to work hard to pay o f f b i l l s or to meet extra family demands; others worked hard because they feared they would lose t h e i r jobs; s t i l l others because they feared f a i l u r e . Table 3 contains some of the more outstanding s o c i a l and emotional problems that were found to be common to those interviewed. I t i s obvious that no one of these problems can be e n t i r e l y separated from the others because -28-of the fact that they were a l l i n t e r r e l a t e d . The two cate-gories "personal and family" and "vocational and economic" are broad and are intended to i l l u s t r a t e i n a general way the two main problem areas. I t i s s t a r t l i n g to r e a l i z e that the patients con-sidered i n the present study were found to have an average of 3*1 of these problems to face. As can r e a d i l y be seen, any one of the problems included i n the table i s r e l a t i v e l y v i t a l and would have marked effects on the patient. Each of these problems i n i t s e l f i s s i g n i f i c a n t enough to be a con-t r i b u t o r y f a c t o r i n p r e c i p i t a t i n g the disease or causing a recurrence, and when each of these problems i s only one of three, the patient i s faced with almost insurmountable so-c i a l and emotional d i f f i c u l t i e s . TABLE 3 on next page -29-TABLE 3 SOCIO-EMOTIONAL PROBLEMS RELATED TO ONSET AND RECURRENCE. (based on 30 case" h i s t o r i e s ) EMOTIONAL DISTURBANCE OR STRAIN Number Per Cent A. PERSONAL AND FAMILY 49 53.3 Long standing resentment or hos-t i l i t y (towards persons or s i t - 18 19.6 uations) Disturbing childhood experiences 10 10.9 (e.g. unhappiness i n the home) Persistent negative feelings about 10 10.9 divorce and separation Prolonged shock (e.g. caused by 11 11.9 a death i n the family) B. VOCATIONAL AND ECONOMIC 43 46.7 Frustration and Resentment (e.g. d i s l i k e of job) 15 16.3 Long periods of anxiety about i n -come, employment, etc. 16 17.4 Fear of unemployment, debt or f a i l -ure; causing overwork, worry, de- 12 13.0 pl e t i o n of energy. TOTAL PROBLEMS 92 100 Source - (Thirty case h i s t o r i e s ) 23 interviewed, 7 case hi s t o r y records I t should he noted that most of the patients i n t e r -viewed appeared to be of f a i r l y keen i n t e l l i g e n c e . They had thought a great deal about t h e i r ailment and some had consider-able insight into the causative factors. None of them denied that there was some connection between t h e i r emotional states and l i f e stresses, and t h e i r physical condition. Several i n d i -cated t h e i r b e l i e f i n t h i s c o r r e l a t i o n without being asked or -30-espeoially prodded to do so. I t must be made clear here that no attempt i s .. being made i n t h i s study to prove that emotional factors cause a r t h r i t i s . What i s clear i s that each patient has emotional and s o c i a l problems that are related to the d i s -ease, and that these problems may w e l l tend to predispose a person to a r t h r i t i s or to pr e c i p i t a t e an attack. The im-p l i c a t i o n i s that a l l those who are interested i n t r e a t i n g and r e h a b i l i t a t i n g the patient should have some•understand-ing of the problems which the patient i s facing, both within himself ( i n the way of c o n f l i c t s , anxieties, e t c . ) , and i n hi s environment (including h i s work, home, etc.) When a patient's "history" i s being obtained i n a ho s p i t a l or c l i n i c these aggravating problems should be uncovered i n order that they may be dealt with i n treatment, so f a r as personnel and f a c i l i t i e s permit. I t i s even clearer that t h i s i s important when the story of rheumatoid a r t h r i t i s i s reviewed i n terms of in d i v i d u a l patients l i v e s . Therefore several cases are i n -eluded i n t h i s chapter. They have been selected because they are representative of both sexes and of various age groups, and because they are t y p i c a l of the s o c i a l and emotional problems that are common to the a r t h r i t i c patients. THE PATTERN OP FRUSTRATION AND HOSTILITY OFTEN STARTS IN CHILDHOOD. During the course of several interviews with Miss I. the following data were obtained. Miss I. had always ad-mired her father more than her mother, p a r t i c u l a r l y because of h i s calmness and emotional s t a b i l i t y . Her mother was -31-"hot tempered and e a s i l y hurt. 1 1 Miss I. never got along w e l l with her mother and usually did not t r y to disguise her disagreement with her mother about how things should be done, f o r example. I t i s possible, then, that f a i l i n g to i d e n t i f y with her mother, Miss I. never learned to ac-cept the feminine r o l e , and has been le d to gain s a t i s f a c -t i o n from academic and other accomplishments. S t i l l another factor from her childhood days has influenced her: that of s i b l i n g r i v a l r y . Her younger s i s t e r was less i n c l i n e d to repress emotions, was more overt and generally adjusted more e a s i l y to l i f e s i t u a t i o n s . This s i s t e r "knew how to get around mother." Miss I.*s parents were i n c l i n e d to favour the younger daughter because she was the baby of the family and more appealing. Consequently, Miss I. has had to compete with her s i s t e r for parental at-tention and af f e c t i o n . She was always able to please them, however, by doing we l l with her studies because both parents wanted her to become a teacher. Her mother was an ex-teacher and she had supervised her two daughters through several years of regular, routine study of correspondence courses. (They l i v e d i n a remote r u r a l area.) A l l through Miss I.'s l i f e h i s t o r y the s t r i v i n g tendenoy i s evidenced. She was always at the top of her class when she attended school f o r b r i e f periods even though she was two years ahead of her age grade. She was sent to the c i t y to f i n i s h her f i n a l year of high school where she found her studies easy, but she had to " s t r i v e " to "keep up so-c i a l l y " because of her age and inexperience wife ©lt& l i f e . ' - 3 2 -At th is time Miss I . f e l t pain i n her knees; they became swollen at times and she was not able to do the physical t ra ining. This discouraged her and even at that early age she accepted the idea that her ailment was incurable. During the previous spring and summer M i s s l . ' s mother had been i n bed for nine months as a result of a major operation. During most of th is period she was i n the home and was nursed by Miss I . At the same time Miss I . was also helping her s i s te r and keeping up with her own school work. In th is si tuation Miss I . suffered ambivalent feelings toward both her mother and her s is ter . On the one hand she f e l t resentment and h o s t i l i t y towards them, and on the other hand, identifying with her father, she f e l t i t her duty to be a "good g i r l " and help a l l she could. Her host i le fee l -ings remained for the most part unexpressed. At this time her knee pain increased considerably. Another area of confl ic t entered her l i f e at uni-vers i ty . She did not want to be a teacher although she ap-peared to be heading for that goal.. She was torn between the desire to please her parents, or to please herself by working toward another occupational goal. She f i n a l l y chose to go her own way, but was now more concerned than ever to succeed because her parents were s t i l l paying her way. More-over, her mother had made i t clear to her that she wanted the money back some day, even going so far as to express a desire to have the f inancial agreement put i n writing.Miss I . resented her mother's attitude and expressed to the wri ter some h o s t i l i t y towards her mother for th i s . Miss I . finished her course i n spite of the d i s -oouraging effects of unsatisfactory boarding home r e s i -dences, recurring bouts of j o i n t pain, and general weari-ness. She continued the struggling, s t r i v i n g pattern of behaviour u n t i l the f a l l of 1946 when she suffered what she c a l l e d a "shock reaction" to Gold treatment. Since that time she has not worked at a l l . Since h o s p i t a l i z a t i o n , Miss I. has admitted f e e l -ing discouraged and resentful of her fate. There i s also an element of h o s t i l i t y and envy regarding her s i s t e r who i s married and has a c h i l d , and who i s apparently l i v i n g a happy normal l i f e . I t bothers her a great deal to f e e l that she has f a i l e d her parents and that she w i l l not be able to help them f i n a n c i a l l y i n t h e i r o l d age. The p a r a l l e l between the medical data and the. socio-emotional data i n t h i s case i s p a r t i c u l a r l y s t r i k i n g and i s presented i n summary f©rm i n Appendix p , page 117. POOR ADJUSTMENTS TO SCHOOL AND VOCATIONAL EXPERIENCES AS PREDISPOSING FACTORS. Mr. G. i s now 40 years of age and has had some form ot rheumatism o f f and on f o r the past twenty years. Mr. G. was always small, underweight, and somewhat sen-s i t i v e . However, he had "been a f a i r l y normal, active boy. Mr. G. stated that the most disturbing period of h i s l i f e was h i s school days. He described them as being "highly demoralizing" to him. His teachers were s t r i c t and a u t o -c r a t i c , e s p e c i a l l y the p r i n c i p a l of the high school he at-tended. He f e l t that he was surrounded by pedagogical -34-b u l l i e s o n t h e one h a n d , and " r a g g i n g s c h o o l k i d s " o n t h e o t h e r . ( A l l o f t h i s was by no means e v i d e n c e o f p a r a n o i a b e c a u s e t h e p r i n c i p a l o f t h e s c h o o l r e f e r r e d t o d i d have a r e p u t a t i o n as a t y r a n t and h i s s t a f f l e f t much to be d e s i B e d . ) Mr, G. l e f t s c h o o l b e f o r e f i n i s h i n g g rade n i n e . He h a s s i n c e e x p r e s s e d t h e o p i n i o n t h a t a l l s c h o o l s s h o u l d have a p s y c h i -a t r i s t f o r t h e b e n e f i t o f b o t h s t a f f and p u p i l s who a r e . n o t a d j u s t i n g w e l l . Mr. G. c o n c l u d e d t h a t he was an " a r t h r i t i c t y p e " j u s t as some p e o p l e a r e t h e t u b e r c u l o s i s t y p e , i n t h a t he was u n d e r s i z e d , s e n s i t i v e and i n t r o s p e c t i v e and t h e r e f o r e h a n d i c a p p e d t o compete w i t h more h e a l t h y men i n a v e r y com-p e t i t i v e w o r l d . He f e l t t h a t h i s d i f f i c u l t i e s i n f i n d i n g employment made h i s a d u l t l i f e m e r e l y an e x t e n s i o n of h i s s c h o o l d i f f i c u l t i e s ; h i s w o r r i e s , f e a r s and a n x i e t i e s "wore h i m down . " He h a d w o r k e d o n l y t h r e e y e a r s by t h e t i m e he was t w e n t y f i v e and t h i s was a t an u n s a t i s f a c t o r y s e l l i n g j o b w h i c h i n v o l v e d t r a m p i n g a r o u n d t h e c i t y s t r e e t s i n wet w e a t h e r c a r r y i n g h e a v y l o a d s . Mr. G. had r h e u m a t i c f e v e r when he was t w e n t y f i v e . For t h e p a s t f o u r t e e n y e a r s he h a s s u f f e r e d i n t e r m i t t e n t b o u t s of j o i n t p a i n , w e a k n e s s , w e a r i n e s s and s l e e p l e s s n e s s . One c a n only s p e c u l a t e on t h e t o t a l " e m o t i o n a l i n v o l v e m e n t " w h i c h must have b e e n p r e s e n t o v e r t h o s e y e a r s o f s t r e s s and unemployment . (Mr. G. has n o t worked s i n c e 1935.) Oan a n y -one doubt t h a t h i s e m o t i o n s h a v e r u n t h e who le gamut o f n e -g a t i o n o r t h a t t h e s e e m o t i o n a l d i s t u r b a n c e s have b e e n f u e l f o r t h e f i r e s o f a r t h r i t i c i n v o l v e m e n t ? And c a n anyone - 3 5 -doubt the importance of considering these socio-emotional problems i n the treatment plan? PERSONAL AND SOCIAL MALADJUSTMENTS ARE OFTEN FOUND IN THE PATIENT'S BACKGROUND. Mrs. C.'s mother died i n c h i l d b i r t h when Mrs. C. was s i x years old. Her father took care of her and a s i s -t e r f o r two years i n spite of the fact that he was very up-set at h i s wife's death. Then Mrs. C. was placed i n a con-vent a f t e r which she saw her father f o r b r i e f periods only each week. Hence i t can be said that Mrs. C. grew up with-out the benefit of normal parental relationships from the age of s i x . When Mrs. C. married, she chose a man o l d enough to be her father; i n f a c t he treated her l i k e a c h i l d . Both her father and her hasband were s t r i c t and were i n -cl i n e d to worry. Mrs. C. was fond of s o c i a l l i f e and "out-ings" whereas Mr. C. was a home-lover. Mrs. G. would often react l i k e a c h i l d when denied the kind of s o c i a l l i f e she wanted; sometimes she would go away; always she f e l t s ick, and got t i r e d . Sometimes she was so t i r e d i n the mornings as a r e s u l t of her f r u s t r a t i o n s that she could not t a l k . The only i n t e r e s t she and her husband had i n common were t h e i r two children, but they, too, "held her down." About ten years ago she began to suffer back pain along with chron-i c tiredness and "female trouble." By 1947 t h i s had evolved into t y p i c a l thrumatoid a r t h r i t i s , the f i n a l diagnosis being Marie Strumpell's s p o n d y l i t i s . -36-It. i s obvious that i t i s impossible f o r Mrs. C. to get w e l l with medical treatment alone. In f a c t , i t be-came quite clear to the wr i t e r that Mrs. C. did not want to get w e l l . She was not prepared p h y s i c a l l y or emotion-a l l y to cope with her home d i f f i c u l t i e s , namely that her marriage was unsatisfactory to her (emotionally she was more her husband's c h i l d than h i s wife), she had many g u i l t f e e lings about her mother r o l e and she d i s l i k e d the town to which the family had recently moved f o r f i n a n c i a l and health reasons. Mrs. C.'s case i s a t y p i c a l example of how an abnormal family l i f e , or lack of family l i f e , can lead to a poor marital adjustment, which i n turn can be a predis-posing or p r e c i p i t a t i n g f a c t o r i n a r t h r i t i s , depending on the constitution and p e r s o n a l i t y of the i n d i v i d u a l con-cerned. The physical disease becomes an expression of the f r u s t r a t i o n and h o s t i l i t y that the patient seems unable to express i n any other way. Mrs. C. l i k e a l l other chronic a r t h r i t i c s needs help with a l l her problems, not just that of her disease, i f she i s ever going to be even p a r t i a l l y r e h a b i l i t a t e d . THE RESULTS OP A PATTENT1S REACTIONS TO TRAUMATIC EXPERIENCES. Mrs. P. was one of several patients who stated that she thought her a r t h r i t i s had i t s o r i g i n i n childhood when she had "growing pains" which were r e a l l y rheumatic pains. She f e l t that i f she had received proper atten--37-t i o n then she would never have developed a r t h r i t i s l a t e r . Questioned further about her childhood, Mrs. P. explained that although her parents were w e l l meaning they were very s t r i c t , cold and unaffectionate emotionally. Mrs. P. stated that she had always been a very nervous person. Several other women patients brought out s i m i l a r data without being e s p e c i a l l y guided to do so. Mrs. P. f i r s t noticed a r t h r i t i c pain 30 years ago. She was i n a weakened state of health at the time because of overwork and the effeot of shock at the sudden death of her husband. A few months l a t e r , she suffered further shock when her only daughter died. Since then she has not been seriously troubled with a r t h r i t i s u n t i l about ten years ago. Associated with t h i s exacerbation was her increased worry about her only son who was presenting both health and be-haviour problems and her worry about the fa c t that her f i -nancial resources had been used up. Mrs. P*s case i s representative of the older age group who are l i v i n g alone and t r y i n g desperately to main-t a i n t h e i r independence. She might have been successful i n doing t h i s i f i t had not been for the f a c t that she had suf-fered the shock of two deaths i n the family, and that she had been worrying over a long period of time about her f i n a n c i a l problems and her son, a l l of which have predisposed her to the recurring attacks of a r t h r i t i s . THE EFFECTS OF SHOCK AND WORRY. Mrs. K. stated that her a r t h r i t i s "came on sudden-l y " twenty three years ago when she l o s t her mother and her - 3 8 -brother i n the same week. She had suffered a r t h r i t i c pain i n t e r m i t t e n t l y during the past seventeen years, p a r t i c u l a r l y during the depression years of the 1930»s when Mr. K. was out of work a great deal - a great source of worry to Mrs. K. She became much worse three years ago when Mr. K. became i l l sud-denly. Mr. K. has not worked since and as a r e s u l t Mrs. K. has had to care f o r him. Their savings have almost gone and she has l i t e r a l l y "worried her s e l f s i c k " about i t . Now she i s becoming crippled and thereby getting more causes for wor-r y - "a vicious c i r c l e . " She i s receiving regular treatment which i s of l i t t l e help to her, because, as i s often the case, her worries are n e u t r a l i z i n g the posi t i v e effects of the t r e a t -ment . OVERWORK THROUGH FEAR OF UNEMPLOYMENT. Mr. H. gave no hi s t o r y of family d i f f i c u l t y of any serious kind. He admitted no emotional c o n f l i c t s , worries or anxieties except fear of unemployment. He had worked several years at hard-rock mining i n damp underground conditions. To-ward the end of h i s stay i n the mines he experienced a tendency toward j o i n t pains and tiredness but be continued to work hard and long because he knew that "there were 50 more men standing by ready to take my job." (This was i n depression days). He l a t e r took on a less strenuous type of manual labour, s t i l l however, being subject to dampness. By the summer of 1945 h i s hand j o i n t s had swollen enough to prevent h i s working and he has been o f f work and under treatment of some sort ever since. Mr. H. impressed the wr i t e r as being i n t e l l i g e n t , capable and industrious. He admitted being worried and de--39-pressed about having a r t h r i t i s but a f t e r a few months he decided that i s was useless to worry and resigned himself to waiting f o r recovery. Mr. H. said that he was "not the worrying k i n d . n I t i s i n t e r e s t i n g to note that Mr. H. has almost recovered from j o i n t involvement with no sp e c i a l treatment apart from r e s t and medication. On the w r i t e r 1 s l a s t contact he asked further help i n f i n d i n g a job and was prepared to do a few hours of l i g h t work d a i l y . Mr. H.*s ease exemplifies how overwork due to fear of unemployment (or fear of any kind) can predispose a per-son to a r t h r i t i s . J&ie case also shows the s i g n i f i c a n t re-l a t i o n s h i p between lack of worry a f t e r onset and the posi t i v e response to simple treatment measures. I t i s clear, then, that persons who develop rheuma-t o i d a r t h r i t i s have personal and family problems which are as much a part of t h e i r ailment as i s the pain and c r i p p l i n g . The most constant emotional pattern i s that of f r u s t r a t i o n -resentment - h o s t i l i t y . In many cases t h i s emotional pattern has i t s source i n disturbing childhood experiences, an abnor-mal or unsatisfactory home l i f e and unhappy s o c i a l r e l a t i o n -ships. These e a r l i e r experiences become part of the person-a l i t y and character of the i n d i v i d u a l and govern h i s habitual mode of reaction to the d i f f i c u l t l i f e s i tuations which he must meet. A l l of the patients i n the present study were found to have experienced d i f f i c u l t i e s i n adjusting to l i f e and because of t h e i r i n a b i l i t y to cope with t h e i r troubles they had become intensely disturbed emotionally. This emo-- 4 0 -t i o n a l disturbance, i n turn, undermined t h e i r health and greatly increased t h e i r v u l n e r a b i l i t y to a r t h r i t i s . These patients were unable to express the h o s t i l i t y and resentment they f e l t because of t h e i r f r u s t r a t i o n - a c h a r a c t e r i s t i c shared by most a r t h r i t i c s . Consequently, t h e i r negative feelings were turned loose upon themselves to the detriment of t h e i r health. I t can be seen, then, that i f the patient i s to be treated thoroughly, h i s personality and habitual modes of re-action must be understood. His p a r t i c u l a r "environmental" d i f f i c u l t i e s must also be assessed; that i s , current family rela t i o n s h i p s , school or vocational adjustments, s o c i a l re-lati o n s h i p s , recreations, etc. I t i s necessary to know how much of the patient's trouble stems from inadequate person-a l i t y and how much from unusual environmental stresses i f ade-quate treatment i s to be introduced. Hot only does the v i c t i m of rheumatoid a r t h r i t i s have s o c i a l and emotional problems which are associated with the onset, but also, when the disease s t r i k e s , the patient and h i s family are faced with a brand new set of problems. These new problems must also be considered i n an adequate treatment programme and are f u l l y discussed i n the following chapter. CHAPTER IV. PROBLEMS RELATED TO PROGRESS OF THE DISEASE, The v i c t i m of rheumatoid a r t h r i t i s becomes h e i r to a series of problems a l l of which cry out f o r solution just as vigorously as the disease c r i e s out f o r treatment. In a l l of the oases considered i n t h i s study, these problems were added to the burdens that the patients already had and which had predisposed them to the disease or precipitated an at-tack. These other problems, personal, family, economic, vo-cational, s o c i a l etc. must be dealt with because of t h e i r d i -rect r e l a t i o n s h i p to the " t r e a t a b i l i t y " of the patient. I t has been noted that tiredness, i n many cases chronic fatigue, was experienced by the person before onset. This f e e l i n g p e r s i s t s a f t e r onset, and continues to be a source of f r u s t r a t i o n to the i n d i v i d u a l . Soon a f t e r onset, the patient faces the fa c t that he has become a v i c t i m of a dread disease f o r which there i s no sure cure. A few of the patients described t h e i r feelings as "sheer panic." However, i n most cases the onset i s so gradual that the v i c t i m i s not required to make a sudden emotional adjustment to i t . The accompanying emotion i s some form of fear, usually anxiety and worry, along with discouragement, regarding the disease and the problems i t creates. The patient may want to give i n to h i s emotions and take out h i s feelings of hopelessness on h i s family and friends. On the other hand he may learn to accept the disease and the l i m i t a t i o n s i t imposes upon him, - 4 1 --42-and consequently learn to make the most of h i s handicaps. I f he chose the former course i t would be unfortunate but under-standable . Every patient must face the tremendous problem of "What can I do with myself?" The thought of being a useless cripple depending on others and contributing nothing to the world i s devastating and depressing. The patient may wallow i n s e l f p i t y and despair f o r months or even years. One man described how a f t e r several years spent i n bed he suddenly discovered that he could type with one of the fingers of h i s deformed hands. This discovery, i n h i s own words, was more s i g n i f i c a n t to him "than the Battle of Waterloo was to Eng-land." S t i l l l a t e r , t h i s patient found to h i s delight that he could earn money by marking correspondence school papers. Although he did not p a r t i c u l a r l y need the money, t h i s discovery gave his morale the biggest boost i t had ever received. This case i l l u s t r a t e s very w e l l that the patient must never lose h i s i n t e r e s t i n l i v i n g , or hi s hope of being useful, i f he i s ever going to adjust to h i s ailment or recover from i t . A f e e l i n g of hope has ex h i l a r a t i n g effects on the body while, conversely, despair tends to disrupt the normal functioning of the body. A l l victims of rheumatoid a r t h r i t i s are unable to carry on t h e i r usual active l i f e because there i s i n each case some degree of j o i n t involvement and l i m i t a t i o n of move-ment. The patients interviewed almost i n v a r i a b l y remarked about t h e i r former active l i f e and the contrast presented by t h e i r present physical condition and r e s t r i c t e d l i f e . -43-Some in d i c a t i o n of how the body may be affected i s given i n Table 4 below. TABLE 4. LIMITATION OF MOVEMENT. (Based on 60 cases) Part of body affected Feet and knees Hands and elbows Back Shoulders Neck Other Number 42 38 24 14 10 17 per cent  of t o t a l 70 63.3 40 23.3 16.7 28.3 Average number of parts affected per person 2.41 Source: 30 case h i s t o r i e s ; 30 questionnaire r e p l i e s . Thw greatest c r i p p l i n g appears i n those limbs of the body which are most important to the patient i n terms of h i s a b i l i t y to carry on h i s normal a c t i v i t i e s , namely, arms and legs, 63.3 per cent of the cases being crippled i n the j o i n t s of the hands and arms and 70 per cent i n those of the feet and legs. When the j o i n t s of these limbs become stif f e n e d and deformed, the v i c t i m i s forced to cut down on h i s normal a c t i v i t i e s . The spine comes next i n frequency of involvement, 40 per cent of the cases of t h i s study being so affected. Here again the effect i s disastrous. When the spine i s involved usually the hips and neck are also affected, so -44-that the person becomes greatly l imited i n scope of move-ment. Although the hands are often l e f t free i n these cases, the knees usually become flexed so that crotches must be used, and i n extreme cases the patient becomes bedridden. I t can be seen, then, that for each patient to have an average of 2.41 body parts affected constitutes a serious cr ippl ing problem. Eight of the patients i n th is phase of the study were c lass i f ied as completely crippled or bedridden; t h i r t y four were p a r t i a l l y crippled and eighteen were s l i gh t ly crippled. These, of course, are broad, general categories and the d iv is ion between them i s not sharp. Those with "sl ight" cr ippl ing had no deformed joints or only s l ight deformity, whereas those who were "par t ia l ly" crippled had markedly deformed or swollen joints with definite l imi ta t ion of movement. Crippling, of course, results i n loss of employ-ment or i n a b i l i t y to follow any regular ful l-day employ-ment or normal ac t iv i ty . This i s a major problem i n most cases and also appears to be the greatest source of emotion-a l disturbance i n that i t i s related to loss of independence, loss of social status and loss of the feeling of "whole-ness." Most of the patients had been crippled over a re la t ive ly long period of time. - 4 5 -IABLE 5-DURATION OP CRIPPLING (Based on 60 cases) Duration Numher Per cent less than 2 years 12 20 2 to 5 years 15 25 5 to 10 years 17 28.3 over 10 years 16 26.7 Total 60 100 Source: 30 Hospital oases and 30 questionnaire repl ies . The fact that 55 per cent of the cases i n th i s study have been crippled for five years or more indicates that the majority of victims are not being cured at present; that many victims of a r th r i t i s would have l i t t l e hope for cure, assuming that the disease must be caught early, add that the problems caused by the disease tend to increase rather than to diminish. Apart from learning to accept the disease with i t s cr ippl ing effects and of finding something useful to do, the problem which has the most marked effects i s the f inancia l one. Roughly one th i rd of the soc ia l his tories and ques-tionnaire replies brou"*ight out the patient 's resentment and frustration because of loss of employment and consequent i n -sufficient income. Most of the patients had spent a consider-able amount of money i n vain to find a cure. Most of these indicated that thei r fai lures were very discouraging to them. Likewise the majority of the patients interviewed expressed discouragement at having to apply for assistance. They seemed -46-to f e e l badly about the f a c t of dependency a f t e r having previously taken pride i n t h e i r s e l f sufficiency. F i n a n c i a l dependency i s thus one of the most dev-astating consequences of chronic a r t h r i t i s . Many of the effects already ci t e d could have been avoided i f there had been no f i n a n c i a l problem. The most serious f i n a n c i a l and vocational problems are l i s t e d i n Table 6 below. TABLE 6. VOCATIONAL AND FINANCIAL PROBLEMS. (Based on 60 cases) Vocational and Fi n a n c i a l  Problems Forced to give up employment L i v i n g on savings, p a r t l y or e n t i r e l y Used up resources Debt created Forced to accept s o c i a l assistance Receive help from family Number 29 8 45 10 33 15 per cent 48.3 13.3 75 16.6 55 25 Average number of problems per. person 2.33 Source:30 case h i s t o r i e s and 30 questionnaire r e p l i e s . Almost a l l of the 29 persons who were forced to give up t h e i r jobs were the breadwinners of the family. Those who had been working to help i n the "breadwinning" (usually the spouse) were forced to give up t h e i r employ--47-ment i n order to stay home to look a f t e r the patient. Added to the years of l o s t earning power were thousands of do l l a r s spent i n treatment both by the patient ( u n t i l h i s savings were exhausted) and then by the govern-ment which subsidizes treatment of non-paying h o s p i t a l pa-t i e n t s . Of twenty one rheumatoid a r t h r i t i c patients admitted 1 to Vancouver General Hospital i n 1948 the t o t a l number of days spent i n h o s p i t a l was 851. The t o t a l cost of h o s p i t a l -i z a t i o n and treatment f o r these patients was #12,009.19. Each patient spent an average of 40.52 days i n h o s p i t a l at an average of #14.11 per day - a heavy drain on family r e-sources and savings. Approximately three quarters of the fam i l i e s con-sidered i n t h i s study had used up t h e i r resources; only 13.3 per cent had any savings l e f t . Host of the re s t had l i t t l e or no resources i n the f i r s t place. I t therefore became neoessary f o r almost a l l the victims to seek f i n a n c i a l help of some sort. Well over h a l f the cases had to r e l y on some form of " s o c i a l assistance" or on a pension, company or m i l i -t ary. F i f t e e n were "getting by" with the help of immediate f a m i l i e s or other r e l a t i v e s . At l e a s t ten had put them-selves i n debt i n search of a cure or because of i n e l i g i -b i l i t y f o r s o c i a l assistance or because of reluctance to "go on r e l i e f . " Added to the discouragement and resentment caused 1. This figure represents the majority of rheumatoid patients but hospi t a l s t a t i s t i c s were not up to date at time of w r i t i n g . -48-by pain and cr ippl ing and by f inancial insecurity i s the patient 's feeling about, losing his independence and status to some degree. The disease inevitably involves a great degree of dependency upon others. TABLE 7. LOSS OF INDEPENDENCE. (Based on 60 cases) PROBLEMS Humber Per cent Pamily burdened by care of 35 58.3 patient Need a housekeeper part time 33 55.0 Need a housekeeper f u l l time 27 45.0 Porced to l i v e with relat ives 20 33.3 Average number of problems per person 1.92 Source: 30 case his tor ies and 30 questionnaire repl ies . In f if teen of the th i r ty hospital cases there was clear evidence that the patient was discouraged or otherwise affected emotionally because of the fact that he had become a burden on the family. In most of the oases, loss of independence and status was related to f inancial problems. Only three of the persons who replied to the questionnaire indicated that they could afford to pay a f u l l time housekeeper and, of course, most of the hospital cases were of necessity low income cases who also oould not afford such help. However, -49-a l l of the cases including the above three indicated that they needed housekeeper services on a f u l l or part time basis. Almost a l l of the cases, then, because they could not afford help, were forced to depend on t h e i r f a m i l i e s or friends f o r help. One i n every three of the patients was forced to l i v e i n the home of some r e l a t i v e . The reason f o r t h i s was lack of finances i n almost every case. The serious-ness of the f i n a n c i a l problem would be somewhat lessened i f , a f t e r treatment, the patient were able to return to h i s former employment or at l e a s t to some form of remu-nerative a c t i v i t y . However, not one of the persons i n t h i s study who l o s t h i s (or her) job was able to go back to i t a f t e r treatment; only one of them was able to take a substitute p o s i t i o n , either f u l l or part time. There were 23 patients who were not employed at the time of onset. (These persons were for the most part housewives.) In these cases the average time l o s t from regular a c t i v i t i e s was 77.52 months or 6.46 years. That i s , each of these persons had gone through a period of over s i x years when he (or she) was not able to carry on normal a c t i v i t i e s at a l l or was not able to carry on i n the usual manner of speed or e f f i c i e n c y because of some degree of pain, s t i f f n e s s , tiredness, weakness, de-formity or lack of muscular oooridination caused by the disease. -50-dbviously any c r i p p l i n g disease such as theumatoid a r t h r i t i s would also reduce the victim's so-c i a l contacts and recreational a c t i v i t i e s to some extent. TABLE 8. LIMITATION OP SOCIAL LIFE AND RECREATION. (Based on 60 cases) AMOUNT Number ffer cent. Reduced to a great degree 28 46.6 Reduced to a s l i g h t degree 16 26.7 Reduced to zero 16 26.7 TOTAL 60 100 Source: 30 case h i s t o r i e s and 30 questionnaire r e p l i e s . Some of the r e p l i e s to the questionnaire con-cerning the effect of the disease on the patient's s o c i a l l i f e and recreation give a clear picture of the t y p i c a l r e s u l t . One husband who was himself w e l l , completed the questionnaire on behalf of h i s i n v a l i d wife and wrote the following: "Our s o c i a l l i f e and recreation have been entire-l y eliminated f o r both of us, because my wife cannot be l e f t alone. We have no s o c i a l l i f e . " A woman who was p a r t i a l l y crippled stated: "Have been confined to home due to i n a b i l i t y to remain on my legs or walk a great distance, p a r t i c u l a r -l y t h i s month/" A male patient r e p l i e d with s i g n i f i c a n t abrupt-ness: "Completely ended i t . " This bleak statement appeared on several ques-tionnaires with such variations as the following: "Social l i f e and recreation n i l . " "The only social l i f e I have i s from the kind-ness of friends who come to v i s i t me. My husband or daughter cannot entertain at home or leave me alone to go out together." "Don't go out at a l l . " "Unable to enter iirto any social l i f e or recreation whatever." "Ho socia l l i f e or recreation since 1946." "Has cut off a l l church and other ac t iv i t i e s outside the home." "Social l i f e given up." One woman reported specif ic l imi ta t ions : "Stopped lawn bowling, gardening, also going out i n the evenings." Another woman had obviously been very active before a r th r i t i s came upon her and was wis t fu l ly r e c a l l -ing happier days. "I am unable to play golf, bowl, climb mount-ains, do old time dancing, kn i t t ing , crocheting or even go for a good long walk." However, other factors besides the actual re-duction i n socia l l i f e enter the picture here. 26.7 per cent of the persons stated that their socia l l i f e had been reduced to n i l even though some of them were not seriously crippled. On the other hand, some of those -52-who are permanently bedridden have kept up their social contacts to some extent and have devised means of recrea-tion as well. In this study, 75.3 per cent of the patients managed to have some form of social contact or recreation. The effect here depends to a large extent upon the individ-ual person's reaction and upon his family conteaft. What-ever the reaction, however, a serious limitation has been imposed on the victim. Any chronic disease i s bound to have drastic effects on the victim's family and arth r i t i s i s no excep-tion. The ways i n which the disease could affect the family are many and varied depending on such factors as age, sex, family solidarity, economic standing, etc. Some of the effects not already mentioned are marital d i f f i c u l t i e s , care of dependent children and change of family plans. In eleven of the thirty hospital cases (36.6 per cent) the disease accentuated or created a marital problem within the family. In seven of the families (23.3 per cent) the problem of the care of children dependent on the ar t h r i t i c victim was created. In 29.5 per cent of the cases, family plans had been changed, postponed or thwarted because of the onset of arthritis which was i n each case the disturbing factor. Of the persons replying to the section of the questionnaire concerning the effect on the plans of the family, one man answered the question as follows: -53-"My family has heen affected, par t icular ly my wife; she has had constant worry wondering and planning how to make ends meet and th is could, were she not brave enough, affect her health materially. My young daugh-ter has had to forego the many things she should have had, par t icular ly the going around and about with Daddy. This hurts i n places which do not show and I wonder how th is may affect her i n later l i f e . We are forced to l i ve meagerly and so neither I nor my family can get the proper supply of the very necessary nourishing foods." Another person repl ied: "Our family plans had to be changed and post-poned. We have a son seven years old and would have l iked to have another chi ld about three years la ter but my arth-r i t i c condition would not allow i t . " S t i l l another reported his"plans for a new home were postponed," and another stated that she had to employ a housekeeper u n t i l her daughter arrived home from work. "She (my daughter) looks after me at night. Be-cause she has to cur ta i l her social l i f e almost entirely she i s losing normal contacts and losing her friends. Men think twice before le t t ing themselves f a l l for a g i r l with an inva l id mother, par t icular ly an a r t h r i t i c . " Many more such remarks could be quoted but enough have been given to show that the patient 's family becomes closely involved, usually to the detriment of a l l i t s mem-bers. Among the 60 cases studied, housing was a f a i r l y serious problem. 42.6 per cent had been forced to move i n -to smaller quarters and obviously resented the fact. Some of these had run into disturbing housing problems such as insufficient space or f a c i l i t i e s , no hot water or heat, uncooperative attitudes on the part of landlords or tenants, etc. 32.8 per cent of the s ixty e»e persons had either -54-been forced to move into the home of a re la t ive or were unable to move from the home of a re la t ive . This i n i t -se l f was a source of disturbance and annoyance i n most cases as can well be imagined. Two comments noted on the questionnaire give a f a i r l y graphic idea of how housing d i f f i cu l t i e s can affect the sufferer of rheumatoid a r t h r i t i s : "Had to leave a five room f u l l y modem home to l i v e i n a shack s© that my husband could care for me and the home and manage to pay expenses." "Had to l eve l a l l floors of my home and share the house with my daughter and her family." PERSONAL AND FAMILY PROBLEMS AGGRAVATE THE DISEASE AND PROLONG TREATMENT. The discouragement caused by these many problems has a definite tendency to aggravate the disease and to prolong the treatment. In replying to the questionnaire i n the section "Do you feel that personal and family prob-lems, worries, etc. tend to aggravate the disease?" s ix-teen persons replied i n the affirmative. Only two per-sons gave "no" for an answer and the remainder did not reply. The following specif ic problems and worries were mentioned as being par t icular ly discouraging: f inancia l , sickness, housing, marital , i n a b i l i t y to cope with per-sonal and family problems, death of spouse, pain and sleeplessness. Some i l l u s t r a t i v e repl ies were: -55-" I f some member of the family i s sick and I am worrying about them I usually have more pain. I f I have f i n a n c i a l worries they discourage and upset me too. I could give many examples.1' "D e f i n i t e l y , any problems, excitements or wor-r i e s tend to make the pain worse during the next few days. After an emotional upset, a f l a r e up of some days or even weeks duration has been noticed. lack of sleep through pain makes nerves ragged and makes me hard to l i v e with." "Yes, d e f i n i t e l y so, f o r always having been an active independent woman and now having become a nuisance, asking f o r help to brush my h a i r , t i e shoe laces and other t r i v i a l things, my home l i f e i s e n t i r e l y d i f f e r e n t . I f r e t f o r days i f I have to ask someone to take me to town f o r treatment." Many of these "aggravating" problems which pa-t i e n t s must face are graphically i l l u s t r a t e d i n the f o l -lowing f i v e case studies. MANY DISCOURAGEMENTS HARRASS THE ELDERLY PATIENT WHO IS LIVING ALONE. Mrs. P. was worried about her a r t h r i t i s and the l i m i t a t i o n s i t was imposing upon her, and she was also upset because of several "environmental" problems. Mrs. P. fs problems are t y p i c a l of those who are i n her age group and who are i n s i m i l a r s t r a i t s f i n a n c i a l l y . Mrs. P. stated that she worried "an awful l o t . " She has had a great deal to worry about, being the mother of fourteen children and having a husband who was too shy and backward to " s t i c k up f o r himself." She had been es-p e c i a l l y worried and nervous during the past ten years be-cause of the following reasons: she had been l i v i n g alone i n a poorly heated room; she i s unable to do a l l her own -56-housework; she i s subsisting on #40 a month, paying rent, gas, food, laundry, housekeeper, etc. ; she fears that the landlady i s going to raise the rent to #20 at any time; i n the past s ix months her hands have become further stiffened with a r t h r i t i s , and she i s unable to walk more than a biook. Besides these worry-producing factors, Mrs. F. has suffered greatly from the shock of the sudden death of her husband four years ago and of a son, s i x years ago. Her husband used to have to do the housework and take care of her and she f e l t sorry for him because of th i s . This went on for nine years u n t i l he died and since then she has had to hire help which she can i l l afford. One of her sons stayed with her for a while after re-turning from overseas but was ejected by the landlord. This greatly disturbed and worried her. Another son d i s -appears for months at a time without writ ing - another fact which worries her. A l l these things added to the weight of her years have produced an anxious, high-strung woman who finds i t impossible to relax even i n bed. Without some r e l i e f from environmental d i f f i c u l t i e s and numerous wor-r ies her disease i s more l i k e l y to increase rather than to decrease i n spite of medication and physiotherapy. SOME PATIENTS REACT NEGATIVELY TO LONELINESS AND PARTIAL CRIPPLING. Mrs. A . f s case i s i l l u s t r a t i v e of several - 5 7 -things: the ef f e c t of the death of a spouse; the kind of housing problem which often r e s u l t s from the disease, and the t y p i c a l f r u s t r a t i o n and resentment expe3<*ienced by the patient because of h i s i n a b i l i t y to be self-supporing, i n -dependent and useful. Mrs. A. has had some form of arth-r i t i s for twenty years. Her involvement became worse r e-cently after the death of her husband upon whom she was de-pendent. She l e f t her home i n the i n t e r i o r because of lone-l i n e s s , and came to Vancouver to l i v e with her, married daugh-ter . The s i t u a t i o n i s not a happy one as the. son-in-law i s out of work; there are three l i v e l y children, and the house i s small. Mrs. A. worries a great', deal about these d i f f i -c u l t i e s but does not know what to do about them. " I know I shouldn't worry but how can I help i t ? I f only I could r do something to earn a l i t t l e money so that I would f e e l more independent i t would be a great help to me and i t would give me something to think about. There should be some provision f o r people l i k e me so that we could help ourselves and t r y to become a l i t t l e self-supporting." Mrs. A., l i k e many other patients, would bene-f i t from the supportive help of a case worker. She ob-viously needs assistance i n finding suitable l i v i n g accom-modation and i n f i n d i n g something useful to do to occupy her mind. She also needs the benefit of a l l known medi-c a l treatments as do a l l the patients attending the out-patients department of Vancouver General Hospital. -58-IOSS OP EARN ING POWER AND INDEPENDENCE BR INGS V A R I E D PROBLEMS. Mrs. R . ' s case indicates the problems involved i n l i v i n g alone i n unsatisfactory rooms on inadequate i n -come. Mrs. R. was l i v i n g i n a room i n an elongated two storey hutment. She was paying 43 per cent of her income for rent and( fuel , which l e f t her $20.00 for a l l other expenses for the month. This was a source of both worry and discouragement to her. She had been an independent woman for many years and had earned f a i r wages as a cook. She i s now too crippled to work and has no relat ives i n th is c i ty to help her. To get to her room she must climb two f l igh ts of s ta i r s . Also, her soc ia l contacts have reduced almost to n i l since the disease struck her. Mrs. R . , too, would benefit from the supportive help of a case worker because of the fact that she i s lone-l y and depressed. Her main d i f f i c u l t y , however, i s finan-c i a l ; i f she had sufficient money she could find more sui t-able housing, hire a housekeeper f u l l or part time, and en-joy recreations that are at present beyond her economic reach. Patients l i k e Mrs. R. would be greatly helped i f they were able to enjoy the resources of a r t h r i t i c treat-ment "centres" which would not only provide treatment but socia l contacts, recreation, employment service, etc. This treatment need i s discussed i n greater de ta i l i n Chapter 5. -59-DNEMPLOYMENT AND FAMILY PROBLEMS COMPLICATE THE MEDICAL PROBLEM, Mr. D. f i r s t f e l t a r t h r i t i c pains nine years ago when he was convalescing a f t e r a logging accident i n which he l o s t considerable blood. He had been i n a weakened state of health f o r several weeks after t h i s accident; then he began to be troubled with a r t h r i t i s , and he subsequently suffered from knee pain almost continuously for two years. By the second year the disease had involved the spine to some extent. Mr. D. was placed i n a cast by h i s physician, and was i n t h i s f o r a year. By t h i s time he had become completely unemployable and had almost given up hope of a cure. His finances had been depleted, and he had been forced to accept help from h i s r e l a t i v e s to supplement so-c i a l assistance. During t h i s period Mr. D. »s condition was aggravated by h i s feelings of resentment, f r u s t r a t i o n and discouragement about having the.disease and l o s i n g h i s i n -dependence. After four years of involvement Mr. D. spent four months at the Banff A r t h r i t i c Hospital, but f a i l e d to get more than temporary r e l i e f from pain. He s t i l l owes a big medical b i l l f o r services received, and t h i s worries him a great deal. To further complicate the s i t u a t i o n , Mr. D. was having marital d i f f i c u l t i e s . Two years ago h i s wife l e f t him, leaving t h e i r s i x year old daughter i n h i s care. This action was precipitated by a shocking street - 6 0 -acoident which took the l i f e of t h e i r youngest c h i l d . The misfortune greatly discouraged both parents, although they reacted d i f f e r e n t l y . Mrs. D. wanted to separate from her husband and move away from the d i s t r i c t ; Mr. D.'s condition became worse causing increased pain and discomfort. Mr. D. i s at present very stooped although he i s only t h i r t y two years of age, and he gives the impression of l i t e r a l l y car-ry i n g burdens on h i s shoulders. His spine has become so s t i f f that i t forms a r i g h t angle with h i s hips as he walks. These varied personal and family problems pre-vented Mr. D. from getting adequate treatment and neutral-ized the effect of the treatments which he did have. F i r s t , he was unemployed and f e l t very badly about t h i s because he had been an active man, capable of earning a good l i v i n g as a logger. Secondly, he was for^ced to apply f o r s o c i a l assistance and learned, to h i s discouragement, that t h i s income was i n s u f f i c i e n t to maintain a decent standard of l i v i n g f o r his family. Thirdly, he was notxhappily mar-r i e d and hi s wife f i n a l l y l e f t him. This break up i n the family caused a fourth problem, namely that of caring f o r the c h i l d . So f a r Mr. p. and h i s mother have taken the r e s p o n s i b i l i t y although neither of them i s able, p h y s i c a l l y or f i n a n c i a l l y , to cope with the problem. I f Mr. D. i s to get w e l l he must get f i n a n c i a l security with adequate i n -come during treatment and convalescence. He needs help i n planning f o r the care of the c h i l d , and he should have had help with h i s marital d i f f i c u l t i e s . Without such a s s i s t --61-anoe Mr. D. w i l l never be atrle to r ea l ly relax and rest, nor w i l l he be able to obtain the best treatment and re-ceive the f u l l benefit of t h i s . MARITAL UNHAPPINESS AND FINANCIAL INSECURITY WEAKEN RECUPERATIVE POWERS Mrs. T. has experienced great anxiety during the past twelve years for two reasons, f i r s t because of finan-c i a l insecurity, and secondly because of her husband1s i n -f i d e l i t y . During the depression years Mr. T. earned only $10.00 per week and there were three children to support. Mrs. T. worried constantly about the family income and the consequent effect of this on the health and happiness of her children. Also, the experiences of the early years of Mrs. T . f s married l i f e had undermined her health. She had had a baby every year for eight years and five of these had died at b i r t h - a l l traumatic events to Mrs. TI Mr. T. joined the army and was away from home during World War I I . When he was discharged he informed Mrs. T. that he had been supporting another woman for two years and that he wanted a divorce. This was another shock and source of worry to Mrs. T. Later, Mr. T. spent a l l his army gratuities on the new woman, and bought a house i n another c i ty for her to l i v e i n . To make matters worse, Mrs. T . ' s two daughters l e f t home to get married at the ages of sixteen and seventeen respectively, much to Mrs. T . 1 -62-shock and disappointment. Mow Mrs. T. i s l i v i n g with her son i n a hotel suite and she i s struggling to earn a l i v i n g so that she can remain independent and help her son get a l l the educa-t i o n he wants. However, Mrs. T. suffers from the chronic tiredness t y p i c a l of t h i s disease and she i s unable to work more than one or two hours at a time. This worries her, and the worry, i n turn, causes more tiredness and a continuous reduction i n energy. A physician has ordered Mrs. T. to r e s t , but she cannot afford to do so. Mrs. T. has been i r r i t a t e d by these s o c i a l and emotional problems f o r years and has needed help with them f o r as many years. At present, she needs f i n a n c i a l security, complete bed re s t and freedom from worry before she can begin to benefit from medical treatment. The t y p i c a l effects of rheumatoid a r t h r i t i s on the person and hi s family, as indicated by the data de-ri v e d from the study of the t o t a l group of s i x t y oases and by consideration of the case h i s t o r i e s of f i v e of these persons may be summarized as follows: tiredness with consequent l i m i t a t i o n of the scope, number and f r e -quency of the patient's normal a c t i v i t i e s ; severe pain, coupled with loss of weight, strength and energy; some degree of c r i p p l i n g and l i m i t a t i o n of movement; f r u s t r a -t i o n , resentment and discouragement because of the above -63-e f f e c t s ; time l o s t from employment or other normal activ-i t y , creating a serious f i n a n c i a l problem; loss of the in d i v i d u a l ' s independence and s o c i a l status; s o c i a l l i f e and recreation reduced or eliminated! marital problems created or accentuated; family plans changed oxmpost-poned; some d i f f i c u l t i e s regarding housing and almost i n v a r i a b l y discouragement and depression. These multiple effects imply the need for t r e a t -ment that goes beyond medication and even the various kinds of therapy. They imply that the patient not only needs to be treated f o r a r t h r i t i s but f o r a l l of the problems created by a r t h r i t i s , because i t i s these problems that aggravate the disease and prevent successful treatment. CHAPTER V. TREATMENT AND REHABILITATION. I t has been said of rheumatoid a r t h r i t i s that probably i n no other disease have so many treatments been t r i e d without success. In order to know what treatments are needed to cure rheumatoid a r t h r i t i s and to see what lacks e x i s t i n present treatment programmes i n hospitals and c l i n i c s , i t i s h e l p f u l to examine some of the t r e a t -ment measures now i n common use. A w e l l known American magazine recently carried a long l i s t of antidotes that doctors have t r i e d out. I t included: "high calorie d i e t s , low calorie d i e t s , vitamins A, B, C and D, typhoid vac-cine, streptococcus vaccine, a r t i f i c i a l fever, blood transfusions, i n j e c t i o n s of milk and horse serum, aspi-r i n and whisky (for pain), massage, dry heat, mineral baths, metals such as gold, change of climate, psycho-therapy, exercise and rest i n bed." 1 To t h i s l i s t might be added other l e s s s c i e n t i f i c antidotes which many arth-r i t i c s have t r i e d i n hope, or i n desperation, such as ohalmoonga o i l , bee venom, snake venom, toad venom, i n -1. "Medicine - For A r t h r i t i s . " Time. Volume 53. Number 18. May 2, 1949. -64--65-jections from the blood of a pregnant woman, and many-others. In A p r i l , 1949, a new chemical, known as Com-pound E, was announced as a possible cure for a r t h r i t i s and according to reports has already proven of some value; i t s beneficial effects, however, are only temporary. In evaluating the kinds of ther^apy, one im-portant fact to note about the treatment of rheumatoid a r th r i t i s i s that, although there i s no specific cure for the disease, i t can be cured i f caught early enough. Th^ ee quarters of a l l cases can be cured or greatly im-proved i f properly diagnosed and treated during the f i r s t year of incidence. About f i f t y to s ixty per cent might be cured or materially helped when attended to during the second and th i rd year."1" Obviously, then, victims of the disease are not diagnosed and treated early enough or are not receiving the f u l l benefit of a l l known treatments. Studies indicate that i t i s not so much a lack of diag-nosis as a lack of consistent proper treatment, including treatment of a l l of the socio-emotional aspects, that has resulted i n the wide incidence of chronic cases. The importance of accurate and thorough diagno-s i s , however, must not be minimized. Dr. A. W. Bagnall, eminent Vancouver physician, states that diagnosis and treatment of a case of a r t h r i t i s requires not only a 1. Snyder, Dr. R.G. op .c i t . page 1318. -66-lengthy physical examination and h i s t o r y , but also a proper analysis of the patient's personality. Environ-mental and f a m i l i a l factors must also be known and as-sessed. He goes on to say that "without such thorough knowledge, treatment may be s u p e r f i c i a l l y appropriate to a reasonably accurate diagnosis, but at the same time b a s i c a l l y inadequate." 1 A complete h i s t o r y and accurate diagnosis, then, must be made before treatment can begin. Treatment measures considered to be of proven value are: rest, physiotherapy, good n u t r i t i o n , removal of f o c i of i n f e c t i o n , equable climate, occupational ther-apy and psychotherapy. Rest for body and mind i s considered of primary importance. Rheumatoid a r t h r i t i s i s a systemic disease and a l l the body's resources need to be mobilized to meet i t . This cannot be done i f the patient t r i e s to carry on h i s usual d a i l y l i f e at the same time. Bed r e s t may be necessary f o r weeks or months, or only part of every day. With the reduction of a l l forms of stress, the disease may be temporarily or permanently arrested at any stage short of ankylosis; but i f movement of the affected j o i n t i s not preserved, a f i x e d j o i n t may r e s u l t . Prevention of 2fixed" joi n t s involves the second 1. B i g n a l l , Dr. A.W. The Problem of Control of the  Rheumatic Diseases i n British~Columbia.""Canadian A r t h r i t i s and Rheumatism SocieTy. Vancouver, B.C. January, 1949. p . l . -67-great therapeutic measure of proved value - physiotherapy. Rest does not mean complete inac t iv i ty . Even i n cases of gross swelling, the joints must be passively moved through the fu l les t range of motion every day, and muscle setting exercises must be given i n the acute stages. As the pain subsides, massage and passive movements are followed by a graduated programme of prescribed exercises which aim at the maximum sustained effort and movement with the mini-mum of s t ra in . Warm baths and pools are used to induce greater movement without pain, and to relax muscular and psychic tension. A r t i f i c i a l heat i s applied i n the form the pa-t ient finds most soothing and tolerates best, which may be hot water bottles, e lec t r i c heating pads or short wave dia-thermy. Like massage, which i s also used, i t increases the flow of blood through the joints and stimulates the c i rcu-l a t ion . I t i s obvious that a programme such as this re-quires the assistance of trained physiotherapists, work-ing i n cooperation with the doctor, and thus able to adapt the programme' to the patient 's individual need. Careless handling or excessive exercise can do untold damage.1 Deep X-ray therapy i s a helpful therapeutic measure i n some forms of the disease. Surgical orthopedic 1. Gallagher, Mary P. op. c i t . p. 15. -68-therapy may have to be used i n advanced cases, where limbs have become r i g i d i n an abnormally f i x e d p o s i t i o n , or i n case of severe c r i p p l i n g . Cabinet-fever t h e r a p y i s often h e l p f u l i n cases of a r t h r i t i s associated with the genito-urinary t r a c t . Some idea of the time and expense involved i n one of the therapeutic measures may be gained from the description by Dr. Dean Robinson of the Banff Hospital f o r Rheumatism of the measures used there i n some cases of c r i p p l i n g : "the breaking of adhesions slowly and gently under anaesthesia followed by incasing of the limb i n a cast which i s removed every f o r t y eight hours and re-applied a f t e r treatment by the masseur." 1 There i s no special d i e t e t i c therapy i n arth-r i t i s . The patient requires a normal d i e t of nourishing food, a t t r a c t i v e l y served, with perhaps some extra i r o n i f he i s anemic, or some extra calcium during convales-cence i f h i s bone lime i s depleted. Occupational therapy, which helps to keep up the patient's morale, exercise h i s muscles and even d i -r e c t l y help to r e t r a i n him f o r a job to f i t h is reduced c a p a b i l i t i e s i s another important therapeutic measure. Once the disease i s established, no p a r t i c u l a r climate seems to benefit the patient. However, most arth-r i t i c s believe tjjey are affected by changes i n the weather, and i t i s true that they should avoid exposure to extremes of cold, heat and dampness. For t h i s reason they are some-1. Gallagher, Mary P. op. c i t . p. 16. -69-times advised to escape the vigorous northern winter i f they can. Psychologically, of course, a change i n climate may do a great deal of good. There i s s t i l l no specif ic drug therapy for the cure of a r t h r i t i s . Optimistic reports have been made con-cerning the uses of gold, but even th i s i s s t i l l of unde-termined value. The following treatments were l i s t e d as being of some help by patients replying to the questionnaire. TABLE 9- TREATMENTS REPORTED AS HELPFUL (based on 30 cases) Treatment number .of times helpful Heat 5 Massaging 4 Physiotherapy 3 Vitamin D 2 Rest 4 Gold 8 Fever therapy 1 Mineral baths 2 Deep X-ray 3 Platinum sal t 1 Exercises 3 Occupational therapy 1 Nothing helpful 3 Total 40 Source: Questionnaire replies (some mentioned more than one treatment.) - 7 0 -Although several of the patients mentioned more than one therapy as being somewhat helpful, none of them seemed to feel certain as to the extent of the benefit re-osived; the general impression being that a l l the therapies gave only temporary r e l i e f . I t i s evident that no one of the above therapies was considered to be of outstanding value, the two most popular being gold, which was mentioned by only eight of the patients (27 per cent), and heat which was mentioned only five times (17 per cent.) One other important therapy not yet discussed i s psychotherapy. As a therapeutic measure, psychotherapy i s not a separate entity or practice but should permeate a l l other aspects of treatment. Perhaps i t i s reasonable to say that those concerned with treatment, par t icular ly the physician, are giving psychotherapeutic help i f they merely show a real interest i n the patient, and convey to him a feeling of optimism. Dr. Phelps has stressed the importance of opt i -mism as opposed to discouragement and depression which usually grips the patient. He states, "The greatest help the physician can ask i s the cooperation of the patient and his continued optimism. I f the mind gives way to gloom, apprehension and panic, the body w i l l surely suffer." 1 Some interesting conclusions are given i n a re-cent professional journal regarding psychotherapy. At least one doctor has concluded that perhaps "the benefits 1. Phelps, Dr. A. E. op. c i t . p. 135. -71-from most forms of current treatments result from psy-chic effects, rather than physical effects." Another doctor states that some therapies such as vaccines are useful "only for their psychotherapeutic purposes." S t i l l another reported a study of a series of cases i n which significant improvement resulted i n 40 per cent of pa-tients given injections of s te r i le saline I The Review stressed the importance of giving the patient "a new le$se on l i f e , " so to speak, by encouraging hope and optimism and stimulating new interests for the patient. I t points out that the c l i n i c course of the disease f luc-tuates with the mental state of the patient, and that one doctor had repeatedly noted the ameliorating influence of a new interest added to the cramping l i f e s i tuat ion, thus "giving the patient something to li#e for ." 1 LAOKS IN PRESENT TREATMENT PROGRAMMES Assuming that a thorough knowledge of the per-sonal, fami l ia l and environmental factors i s necessary for adequate treatment, this study indicates clearly that the f i r s t gap i s i n meeting this diagnostic need. Physi-cians are not getting th is important data, nor are they assigning the task to any other professionsl group. In none of the eases studied, had the doctor given any i n -dication i n the case record that the patient 's personal-i t y and social relationships had been assessed or even considered. 1. Annals of Internal Medicine, op. c i t . January, 1948. pages T25 - 141. -72-From the social worker's point of view, th is i s one of the main gaps i n the treatment programme -fai lure to get this complete "history" i n diagnosis which i s so necessary. I t i s this fact of seeing "the whole person" that i s so v i t a l and yet so often neglect-ed i n treatment. I t i s v i r t u a l l y impossible for a pa-t ient to benefit from any form of treatment when h is a i l -ment i s being aggravated by his negative attitudes, by his emotional and environmental stresses and strains, a l l of which have been discussed i n considerable de ta i l i n the previous chapter. Can a person, for example, carry out one of the prime requisites of treatment - rest - when he i s troubled by an average of more than three major prob-lems at onset, coupled with the numerous other problems created by the disease i t s e l f , such as cr ippl ing i n two or more limbs, 1.92 dependency problems created and an average of 2.33 f inancial and vocational problems per person? Such social and emotional problems should be-come known to the social service department when the pa-t ient i s f i r s t admitted to the hospital . In th is way the medical social worker could throw valuable l i g h t on the patient 's needs, and by meeting these needs wherever pos-s ib le , f ac i l i t a t e the healing process. At present there are too few medical social workers i n our hospitals as well as too few physicians interested i n the treatment -73-of a r t h r i t i c patients. Related to this lack i s the great need for edu-cation of the general practi t ioner, medical social worker and those i n the a l l i e d professions, i n sound methods of diagnosis and treatment. Many physicians have no oppor-tunity at present to study the newer methods because of the fact that there are too few c l i n i c s special iz ing i n arth-r i t i s . The opportunity to study and treat i t i s rarely found even i n the best teaching hospitals; i n the United States, for example, at only s ix out of seventy medical colleges i s specialized study of rheumatic diseases pos-s ib le , and i n Canada the opportunity to study and treat a r th r i t i s i s not found even i n the large university hos-p i t a l s . A l l too often the average physician has been rather bewildered by the problems he i s confronted with i n the a r th r i t i c patient. He has had l i t t l e or no exper-ience with the treatment of these patients under ideal conditions and i s therefore pessimistic because his p i l l s and injections (which have been the only remedies readi ly available) are rather ineffective when used alone. ^ Dr. A. W. Bagnall thinks that s ix to eight months post-grad-uate course i n rheumatology for a l l doctors should enable them to provide adequate diagnostic and therapeutic ser-vice at loca l centres and hospitals. Similar ly the edu-1. Bagnall, Dr. A. W. op. c i t . page 4. -74-cational opportunities for socia l workers, physiothera-pis ts , etc. need to be greatly extended. Since bed rest i s one of the most important needs i n most cases, i t follows that, i f adequate treat-ment i s to be obtained there must be hospital beds ava i l -able. In the United States pr ior to 1942 there were less than 200 beds spec i f ica l ly available for a r t h r i t i c patients, while there were 100,000 free beds for tubercu-los i s patients. There was no hospital exclusively for a r th r i t i cs i n the United States u n t i l 1942. Today most large hospitals have c l i n i c s with some diagnostic and treatment f a c i l i t i e s but few give any free service. In the United States the patient who cannot af-ford nursing home care i s for the most part dependent on the f a c i l i t i e s of a few private hospitals. I t i s not sur-pr is ing, then, that the majority of oases of chronic arth-r i t i s receive no medical care. Most sufferers, except vet-erans, go without the benefits of adequate treatment. In 1931, Bigelow and Lombard, i n their survey of Massachu-setts, found that 70 per cent of rheumatic sufferers were getting no medical ©are at a l l , or were treating themselves! In Canada*, the 1947 National Survey indicated that 25 per cent of the a r t h r i t i c sufferers had no treat-ment whatsoever. Canada has only one special hospital for the care of the a r th r i t i c which i s looated at Banff, Alber--75-ta , and i s under the direction of Dr. Dean Robinson. Un-fortunately this hospital i s a private one and i s very small, accommodating only seventy f ive patients who can afford to pay between |150.00 and $250.00 per month. The only other people i n Canada who get adequate treatment are the veterans for whom five hospitals are available. There are only a few private nursing homes which might take arth-r i t i c s but these would hardly provide the specialized treat-ments necessary. In B r i t i s h Columbia i t i s estimated that there are 45,000 known cases of a r t h r i t i s , yet they are allocated only a small propor t ion of the available hospital beds, and are not usually kept i n the general hospitals when they become chronic. In Vancouver General Hospital there were only 103 cases of a r th r i t i s admitted during 1946 and of these, a number had only a secondary diagnosis of arth-r i t i s . Some chronics are cared for i n the Glen and Grand-view Hospitals, s ix i n the former and two i n the l a t t e r . One of the patients at the Glen Hospital i s an ex-sai lor who spent over $4,000 on nursing home care before he be-came destitute. A l l are completely bedridden. At Mar-pole Infirmary 9 per cent of the t o t a l of 121 patients 1 are a r thr i t ios . These figures obviously do not cover the whole picture. Thousands of disabled a r th r i t i c s are forced i n -1. There are no s t a t i s t i c s on a r th r i t i s i n St. Paul 's Hospital . -76-to being oared for by the i r families because of lack of hospital accommodation. Obviously th is tremendous inad-equacy i s one of the major gaps connected with the prob-lem of a r th r i t i s and one which indicates that provision of adequate hospi tal izat ion for the a r t h r i t i c must be undertaken at as early a date as i s possible. Many patients benefit i n a general way from stays at a spa where baths, rest and special treatment may pro-duce much improvement. However, from a l i s t of sanatoria and spas with f a c i l i t i e s for treating a r th r i t i s i t i s again d i f f i c u l t to find places where a person of even moderate income could afford any prolonged treatment. Oomroe 1 l i s t s the outstanding spas and sanatoria of the United States and shows that the prices at these ins t i tu t ions vary considerably both for accommodation and treatment. Board and room varies from seven dollars to one hundred nineteen dollars per week. Baths and medical fees are extra. Spa treatment to be most effective should be sup-plemented by careful supervision of rest and dietand an individual ly planned programme of massage and exercise over a period of at least several months. This sort of treatment i s , of course, denied to most because of ex-pense and even those who begin such treatment are often forced to discontinue i t before the disease i s arrested. 1. Oomroe, B. I . A r t h r i t i s and A l l i e d Disor-ders. Lea and Pebeger. Philadelphia,T9AV» page 472. -77-Apart from t h i s lack of accommodation i n hos-p i t a l s , sanatoria, etc., i s the very r e a l problem of the i n a b i l i t y of the patient to afford medical treatment. Since t h i s study was begun, free h o s p i t a l i z a t i o n has been inaugurated i n B. C. This was a very necessary step but, of course, i s r e l a t i v e l y useless to the chronic patients without the provision of h o s p i t a l beds. The B r i t i s h Columbia H o s p i t a l i z a t i o n Scheme makes no pro-v i s i o n f o r the problem of payment of medical fees and treatment expenses. I t has been indicated previously that the average expense of treatment i n 1948 was $14.11 per day including cost of h o s p i t a l i z a t i o n at $6.00 per day. Removal of the l a t t e r charge would leave $8.11 per day as the cost of treatment of "in-patients." I t can be seen from the figures already quoted regarding time l o s t from work by patients i n t h i s study and i n national sur-veys that the vast majority of patients would s t i l l not be able to finance any adequate treatment. I t follows that a system of free medical ser-vices must be introduced comparable to the system now i n operation i n Great B r i t a i n . Besides provision f o r free h o s p i t a l i z a t i o n and free medical services, such things as crutches, braces, fracture boards and a l l other necessary appliances would need to be provided. The incidence figures for a r t h r i t i s already mentioned, together with the t y p i c a l s o c i a l problems -78-which the disease has been shown to create can leave no doubt that a r t h r i t i s i s a problem of national significance and one which must be dealt with on a broad basis as a pub-l i c health and welfare problem. Any nation-wide attack on the disease must include, among othec things, an attack on poverty and f i n a n c i a l i n s e c u r i t y because inadequate d i e t , bad housing and chronic worry about income are factors contributing to the incidence of rheu""matic i n f e c t i o n s and have a bearing on the general health l e v e l and resistance of the people. Gladys Strum, M.P., stressed t h i s point when speaking on the subject of a r t h r i t i s i n the Dominion leg -i s l a t u r e recently. The w r i t e r i s i n agreement with Mrs. Strum when she urges that the Dominion Government make an a l l - o u t attack on a r t h r i t i s , as has been done i n tubercu-l o s i s , not l i m i t i n g the number to be treated. I t i s rea-sonable to believe also that "we cannot think i n terms of cost, (because) there w i l l be many cases of preventive treatment that w i l l r e s u l t eventually i n a great saving because we w i l l prevent t h i s c r i p p l i n g process which re-moves so many from the f i e l d of actual production and makes them a charge on the community, on the municipality, or on the province." 1 As has already been indicated, psychotherapy i s an invaluable adjunct to any of the treatment measures that 1. Strum, Gladys. op. c i t . page 4. -79-are considered beneficial to the arthritic patient. Ade-quate psychotherapy implies the availability of consultant psychiatric help and a trained staff of medical social work-ers and this is one of the significant treatment gaps at present. However, i t is not always necessary to have psy-chiatric service in order to do much better work in t r e a t -ing the social aspects of the patient's ailment. Well trained medical social workers can do much of this work as well as act as consultants to doctors and nurses in these "psycho-social" matters. There are instances, of course, where psychiatric consultation would be very desirable and perhaps indispensable; for example, in cases in which func-tional symptoms were superimposed on those from arthritis. (In these cases, pain may be disproportionate to the activ-ity and extent of the disease.) Some of the psychothera-peutic needs which are not being met at present are in reference to prevention of such attitudes as those of de-pendency, helplessness, frustration and self pity. Any good treatment programme must also include trained physiotherapists. In B. C. however, there is a lack of both qualified physiotherapists and of equipment for treatment. In the Vancouver General Hospital treat-ment is handicapped by lack of facilities. Present facili-ties meet only a small fraction of the need. Also the pa-tient has to be ambulant in order to attend the clinic and has to be eligible under the low outpatient department in-come limits, $90.00 per month for one person plus an ad-ditional $20.00 for each dependent. -80-This gap, however, has recently begun to be f i l l e d i n B r i t i s h Columbia due to the ac t iv i t i e s of the Canadian A r t h r i t i s and Rheumatism Society which i s now sponsoring t raining programmes and paying the salaries of several t rave l l ing physiotherapists. However, the pro-gramme designed to cover the whole province through the ins t i tu t ion of "p i lo t" diagnostic and treatment centres i n each d i s t r i c t i s barely under way and i t i s probable that many years w i l l pass before sufficient personnel and f a c i l i t i e s w i l l have teen mobilized to deal with the prob-lem on a broad comprehensive basis as i s tuberculosis con-t r o l , for example. B. C. i s the f i r s t province to under-take such a step i n connection with a r t h r i t i s , but as the Provincial Health Minister, Hon. G. S. Pearson has stated, "even this small beginning w i l l serve as a bright hope to „ 1 many." REHABILITATION. Because a r th r i t i s i s a cr ippling disease, the f i r s t kind of rehabi l i ta t ion i s obviously that of physi-cal rehabi l i ta t ion. Dr. Bagnall has pointed out that the basic programme for treatment of a r th r i t i s consists of "appropriate rest combined with physical therapy to pre-vent deformity, maintain excursion and bui ld up muscle power." 2 This physical therapy can be considered as the 1. Vancouver Sun. op. c i t . October 1, 1948. 2. Bagnall, Dr. A. W. op. c i t . page 3. -81-f i r s t step toward rehabi l i ta t ion because i t can be a great aid not only i n preventing deformity but i n helping to "loosen up" stiffened joints and t i r ed muscles. This form of therapy has not been available to the average physician because of the lack of physiotherapists trained i n the rheu-matic diseases. Also i t has been lacking for the patient because of the cost which most patients are not able to meet. 1 A programme of occupational therapy may be ad-vantageously combined with the physical therapy programme. Once the acute infection has subsided and the patient 's general physical condition i s improved, occupational ther-apy i s important from a physical and a mental standpoint. Carefully selected occupations help to t r a in muscles and increase or preserve joint motion, and may be a means of t raining the patient for a type of work more suited to his d i s a b i l i t y . Equally important, the patient i s able to oc-cupy his time usefully and cultivate new interests. Recov-ery i s a slow process, a matter of months or perhaps several years, and the occupational therapist plays a v i t a l part i n 2 maintaining the patient 's morale. After the patient has had the f u l l benefit of the necessary physical and occupational therapy he should show signs of improvement which would permit him to do some work 1. Bagnall, Dr. A.W. i b i d , page 4. 2. McNevin, Kathleen. op. c i t . page 23. -82-with a view to actual vocational rehabi l i ta t ion. The twenty nine "breadwinners" i n th is study who had los t their jobs as a result of a r th r i t i s needed the ben-ef i ts of such gradual rehabi l i ta t ion . Hone of them under present treatment f a c i l i t i e s was able to return to his (or her) job. In fact none of them has returned to any sort of employment except on a temporary basis. Because of the magnitude of the vocational prob-lem, then, which also involves finances, i t seems necessary that the provincial government i n i t i a t e some programme to meet th is need. A special placement programme i s essential before patients can be successfully rehabili tated. In th is connection, Dr. Bagnall states that many p a r t i a l l y disabled persons are now unemployed because concerted efforts to find them suitable employment do not l i e i n the domain of any existing agency. By reason of this fact the p a r t i a l l y d is -abled persons i n effect become completely disabled and, very soon, they and their families become "wards" of the state. He further suggests that job rehabi l i ta t ion and job finding for the pa r t i a l l y disabled i s not alone a problem of the Iheumatic Diseases and therefore an agency be set up for these purposes. Such an agency would consist of the var-ious organizations v i t a l l y interested, namely, Government, the Workmen's Compensation Board, the Canadian National Institute for the Bl ind , T. B. Control, B r i t i s h Columbia -83-Divis ion of the Canadian Rheumatism and Ar th r i t i s Socie-ty, etc. 1 The Swedish experience has demonstrated that a treatment programme which includes sound rehabi l i ta t ion methods can be successful. In Sweden the care of the chronic rheumatic patient has been developed to an ad-vanced stage. Figures for that country indicate that three years after discharge from hospitals s ixty per cent of the patients are working at their former occupations and a further eighteen per cent have been rehabili tated to such an extent that they require no further soc ia l a id . Another poss ib i l i t y i n the vocational r ehab i l i -tat ion of a r th r i t i c patients who are not able to leave home i s employment at pixkce work projects i n thei r own homes. This would be of immense value to many, especially perhaps to women. This type of work i s needed for sever-a l reasons, namely, to relieve the f inancia l problem, to maintain interest and boost morale and to provide some exercise to keep muscles i n shape. Vocational guidance i s another important aspect i n rehabi l i ta t ion. A part icular problem i s posed i n the case of children who suffer from rheumatoid a r th r i t i s or some related disease such as rheumatic fever which may later develop into a r t h r i t i s . This phase of the pro-1. Bagnall, Dr. A. W. op. c i t . page 6. 2. Snyder, Dr. R. G. op. c i t . page 1319. - 8 4 -gramme would probably best be handled through the school social worker or school counsellor i n cooperation with teachers, nurses and parents. Vocational guidance for adults also would be an important adjunct to any complete programme for the rehabi l i ta t ion of a r th r i t i c s . I t i s again necessary to stress here that i f the patient i s to become properly rehabili tated the provision of income for the family i s necessary to enable him to take the necessary months or even years off from work that would be involved i n adequate diagnosis, treatment, care and rehabi l i ta t ion . Present socia l allowances are i n -sufficient to supply even the barest necessities such as food, clothing, recreation, l i f e insurance, payment of mortgages, education costs, etc. With such problems fac-ing him, the worker w i l l not stop for the rest and treat-ment so badly needed. Since rheumatoid a r th r i t i s affects so many more women than men and i n the chi ld bearing and chi ld rearing age, i t seems necessary to provide some sort of homemaker services to help look after the home and family at least on a part time basis. I t has been shown i n th is study that a l l of the patients needed a service of this kind either because of the necessity of looking after ch i l d -ren or simply because the woman of the house was not able to carry on the work. Rehabili tation from the social and recreational point of view must not be neglected. The patient must not be allowed to become withdrawn and introspective as arth--85-r i t i c patients are often prone to do. The a r t h r i t i c pa-t ient needs interesting things to do and to think about and also needs company within the l imi t s of the need for rest. This implies provision of such f a c i l i t i e s as recrea-t iona l rooms, movies, hobbies (perhaps by occupational ther-apists) , reading material, etc. In order that the a r t h r i t i c w i l l not feel that he has entirely withdrawn from normal l i v i n g he needs this social and recreational contact with the outside world. Treatment and rehabi l i ta t ion measures, then, are closely related and can i n some instances be carried out simultaneously. For the most part, however, rehabi l i ta t ion measures follow successful treatment measures. From the point of view of th is study the important need i n both pro-grammes i s to focus plans on the patient as a person, so that a l l steps are taken with consideration for the pa-t i en t ' s unique needs. These needs can only be ascertained by the thorough understanding of the patient, his personal-i t y and his social relationships. The "pressures" the pa-t ient has had to bear because of his personality problems and because of environmental d i f f i c u l t i e s must be taken i n -to consideration i f treatment and rehabi l i ta t ion measures are to be successful. However, i t has been made clear that the problem of rheumatoid a r th r i t i s cannot be dealt with by considering individual problems alone, because i t i s a health and welfare problem which requires loca l and nation-a l planning, financing and research. -86-The federal and provincial governments have to-gether provided a grant to the newly created Canadian Arth-r i t i s and Rheumatism Society, which i s a voluntary organi-zation, to ins t i tute a programme of education, research and control. Unfortunately th is society was not able to use a l l the funds i t received this year; the reason for this being that there are no a r t h r i t i c centres where the fiknds can be applied. I t has been pointed out that the reason T.B. control has become so adequate i s that there were treatment centres available where the research grants could be used; that while T.B. patients were being treated and sources of infection wiped out, valuable research In-formation was being accumulated which has been of i ne s t i -mable value to the world. 1 The problem of a r t h r i t i s can and should be handled i n a similar manner. Funds for research alone w i l l not be of the greatest value u n t i l such a r th r i t i c "centres" have been established to bring together doctors with specialized training and the victims of a r th r i t i s who are so badly i n need of proper treatment. The Federal Government general health grant to the provinces i s a l l to the good. Never-theless i t seems necessary that a large proportion of the grant be especially given to the ins t i tu t ion of a com-plete a r th r i t i s control programme. The Dominion Govern-ment i s s t i l l , however, not providing nearly enough money 1. Strum, Gladys. op. c i t . page 5» -87-to the provinces for these purposes because health and welfare are s t i l l considered to be largely the concern of provincial governments. Hence i f a good beginning i s ever to be made i n providing a r th r i t i c centres with su f f i -cient beds, f a c i l i t i e s , laboratories, etc. , both the pro-v i n c i a l and federal governments w i l l have to take action. To date this has not been done, although the problem has been brought to the attention of the members of parliament. Research i n a r t h r i t i s , then, i s s t i l l scant i n comparison to that done i n connection with other diseases chief ly because of th is lack of f a c i l i t i e s , personnel and funds. Prom the point of view of th is study, there i s a great need for research i n the socia l aspects of the d is -ease. I t i s f e l t that when the relationship between the social and personal problems of the patient and his d is -ease i s f u l l y understood, much more comprehensive and basic measures of control w i l l be- undertaken. CHAPTER VI. THE ROLE OP MEDICAL SOCIAL WORK. I t has been shown i n this study that there are two main groups of problems which each rheumatoid a r thr i t -i c patient faces: those which he had before onset and those which have accrued as a result of the disease. I t i s these problems which present a challenge to the medical social caseworker. The worker obviously has a tremendous job on his hands i f he attempts to deal with a l l the social and emotional problems of the patient which need attention. He must decide on an individual basis which problem i s most i n need of attention. However, this i s the task for which he i s trained and the sooner he can prove his useful-ness to both patient and physician the sooner w i l l his pro-fession be given i t s true status i n the medical sett ing. A l l too often the social worker has been busily engaged i n doing a variety of tasks which might well be the work of a c l e r i c a l person. The posit ion of the worker i n most hospitals i n the past, and i n many at present, i s apt-l y summarized by Dr. E. P. Boas as follows: "Social work-ers i n hospitals are too often engaged i n admitting pa-t ients , i n determining how much they should pay for hospi-t a l care, acting as c l i n i c clerks for administrators, etc. _ - 8 8 --89-They give r e l i e f to families, one of whose members i s i n hospital , and they shuttle patients from hospitals to con-valescent homes or to custodial ins t i tu t ions for the chroni-ca l ly s ick ." He goes on to emphasize that their rea l func-t ion i s to work out, i n cooperation with the physician, a wel l conceived plan for the treatment and rehabi l i ta t ion of the patient, employing their knowledge of the soc ia l , economic and emotional factors that condition the disease. 1 Several hospital case histories from this study have been selected to i l l u s t r a t e the role of social work i n the medical setting. The f i r s t case i s an excellent example of what can happen to a patient when the social service department of the hospital i s not active on the case from the f i r s t contact with the patient at the hos-p i t a l , and when the socia l service department, having "entered" the case does not perform i t s "real function", working closely with the physicians and a l l of the agen-cies concerned with the treatment and rehabi l i ta t ion proc-ess. The case of Mr. E. also i l l u s t r a t e s the great (and largely unnecessary) expense that accrues to the hospital i n long term recurring cases as wel l as the great loss of earning power to the patient. LONG TERM, RECURRING CASES CONSTITUTE A SPECIAL PROBLEM. Mr. E. was admitted to hospital i n November, 1944-, 1» Boas, Dr. E .P . The Unseen Plague - Chronic Dis-ease. J . J . Augustin. New York~J T940. -90-a f t e r having consulted a doctor because of the swelling of h i s j o i n t s . Medication was given; the swelling lessen-ed after f i v e days and the patient was discharged. He was readmitted i n A p r i l , 1945, complaining of a pain i n the l e f t w r i s t , l a t e r of pain i n the ankles and i n both feet. He had l o s t twenty pounds. There was some l i m i t a t i o n of move-ment i n the l e f t ankle and knee and he suffered pain and loss of strength i n a l l j o i n t s . He received gold therapy; the pain was reduced but he f e l t s t i f f i n the j o i n t s . He was discharged to h i s home on crutches i n May, 1945* In July, 1945, he was admitted to a nursing home because he was unable to get around at home and needed bed re s t and nursing care. His condition had retrogressed to such an extent that he required an ambulance to get to the nursing home. He was placed i n a ward with older men, had no oc-cupational therapy or other a c t i v i t y to occupy h i s mind and was not happy there. Gold treatment was continued but evidently did not help. He was discharged from t h i s nurs-ing home i n A p r i l , 1946. In August, 1946, the C i t y Social Service Department reported to the h o s p i t a l that the pa-t i e n t was too much r e s p o n s i b i l i t y f o r h i s mother. Nurs-ing home placement was again arranged. He was i n the nurs-ing home u n t i l May, 1947, when he was again discharged to hi s home. Again the s i t u a t i o n was impossible and the pa-t i e n t was admitted to a ho s p i t a l annex i n which he was the -91-only young man among a number of older chronic patients. This experience was upsetting to him. Later he was read-mitted to the nursing home. During these years the pa-t i en t ' s knees became flexed. On the advice of the ortho-pedic staff of the hospital , casts were applied to his knees to straighten them. Up to this time Mr. E. had been admitted to hospital five times, involving approximately 1000 days i n hospital . He i s now classed as chronic, with l i t t l e hope for other than ins t i tu t iona l care. Several pertinent questions regarding the so-c i a l and emotional aspects of Mr. E . ' s disease, which should have been considered i n treatment, might be asked at th is point. To what extent did adverse environmental factors and the patient 's reaction to them contribute to his i l l n e s s , and once having got the disease to what ex-tent did these factors prevent his achieving a re-estab-lishment of equilibrium, in ternal ly and externally? More par t icular ly , what could the hospital socia l service depart-ments have done to help? Hot u n t i l the month i n which the patient was discharged from the hospital for the f i f t h time did the case come to the attention of a socia l worker (and th is was not i n the course of regular hospital procedure). At that time i t was learned that during the past twenty years the patient had l ived through a series of t rying experi--92-ences, some traumatic, both i n h i s personal l i f e and i n hi s family, almost any one of which could have had a serious effect on h i s physiological processes, h i s emo-tions and h i s health and "wholeness" generally. Besides these disturbing experiences he suffered a l l the emotional stress that accompanies any chronic disease as devastat-ing as a r t h r i t i s . In the f i r s t place, h i s family h i s t o r y spelled "insecurity." There were i l l n e s s e s and deaths i n the fam-i l y , poor housing and unemployment. In the patient's own words, "there was just one disappointment a f t e r another." The patient's father, a streetcar motorman, died nineteen years ago leaving s i x children, of which Mr. E. was the second youngest. At that time he was twenty one years of age. Some of the more discouraging and traumatic exper-iences from that point were: (1) l o s s of the family home through i n a b i l i t y to meet the payments; (2) application f o r s o c i a l assistance i n 1933; (3) patient's s i s t e r be-came i l l and was nursed at home by the mother; (4) pa-t i e n t unemployed and on r e l i e f at t h i s time; (5) a broth-er died of spinal meningitis; (6) an i l l e g i t i m a t e c h i l d was born to patient's s i s t e r and the patient's mother cared f o r the c h i l d ; (7) patient's s i s t e r died of tuber-culosis; (8) patient's eldest brother was k i l l e d overseas; (9) another brother returned from overseas and was admitted -93-to the hospital with pleurisy; (10) another brother re-turned from overseas, a heavy drinker, and was no help to the family; (11) the family had to move many times from one set of "rooms" to another; (12) patient 's moth-er was not well enough to look after him i n the home, and (13) patient has not worked since 1944. Since no complete socia l history was taken at anynof the admissions to hospi tal , obviously the treat-ment programme was not aimed at meeting a l l the needs of the patient that were related to his i l l n e s s . I t does not require much imagination to see that some, i f not a l l , of the above facts i n the patient 's history contributed to weakening his health and strength, so that his body was not able to withstand the encroachment of infect ion. More important, perhaps, was the fact that he was unable to face his discouraging l i f e and consequently his emo-tions were not suff ic ient ly positive to recharge the 'cat-teries" of his dynamic equilibrium. Inner and outer stress were too much for him. The patient, i t might be noted, was not an a r t h r i t i c "type;" he was not th in , or asthenic or neurasthenic. On the contrary he was (before 1944) a strong, husky male, capable of doing heavy manual labour. Even now he i s broad chested and gives the appearance of strength. Where, then, could and should social work enter -94-the picture to halp rehabil i tate Mr. E.? I t would be the responsibi l i ty of the hospital soc ia l service department to have obtained data concerning the family background i n th is case somewhere along the l i n e , preferably at the f i r s t admission. Assuming that the case had been referred early (say sometime i n 1944 or 1945) the obvious pos s ib i l i t y would be to t ry to rel ieve some of the environmental press-ures, even one of them. For example, help could have been given i n finding housing, finding employment, budgeting, arranging homemaker services or V.O.N, services for the mother when she had the responsibi l i ty of caring for one or more sick offspring besides the chi ld i n the home. Per-haps even more important would be the psychotherapeutic help. Apart from the "supportive" or "environmental" therapy involved i n the help l i s t e d above, the patient would undoubtedly have appreciated the friendly interest of a worker who could l i s t e n to his troubles, allow him to discharge the resentment and h o s t i l i t y which he would surely have (although i t would possibly be well repressed/ and help him to adjust to the various shocks and discour-agements. Lacking a social history early i n the case, the next best thing would have been to c a l l a case conference at some point. This could have been in i t i a t ed by the City Social Service Department who knew the family be-cause of thei r receiving social assistance. The family -95-was also known to the Children's Aid Society because of the i l legi t imate ch i ld and to the Family Welfare Bureau be-cause of a request for v i s i t i n g homemaker services. Such socia l agencies whose cl ients or thei r families are also hospital patients should be responsible for passing on to the hospital information about the family that has a bear-ing on the medical problem. On the other hand, the medical soc ia l worker's understanding of the meaning of i l l nes s and of the hospi-t a l experience to the patient may enable him to aid such community agencies and their c l i n i c s toward a more effect-ive use of medical f a c i l i t i e s . By presenting the medical plan with i t s social implications carefully to the agen-cies, the worker aids them to do better work for the pa-t ients i n their own area at the same time that they are furthering the medical care. When socia l problems are f i r s t discovered within the medical ins t i tu t ion the medical social worker can take the i n i t i a t i v e i n mobilizing community resources. I n t e l l i -gent selection and use of these resources i n re la t ion to the patient 's needs w i l l be essential for the success of both the medical plan and the social casework services. This implies an even broader responsibi l i ty for the medi-cal social worker - that of studying the gaps i n the com-munity programme i n terms of adequate treatment and of assuming leadership i n stimulating new resources as -96-needed. Such effort i s usually most effectively carried out through organized groups which have the community point of view; preferably professional councils of health i n social welfare, perhaps supplemented by c i t i zen groups which have indicated interest and concern i n the socia l programme. Medical social workers whose chief concern i s helping patients who enter and leave hospitals with handi-caps, such as those created by rheumatoid a r t h r i t i s , should be par t icular ly active i n connection with these other social agencies. They need to consult with nurses, teachers, agen-cy workers, vocational rehabi l i ta t ion workers, parents and others on behalf of the patient. Caroline Elledge gives a very pract ical account of some of the problems and re-sponsib i l i t ies of socia l workers i n dealing with handi-capped groups. She points out the importance of such fact-ors as the age at which the patient becomes handicapped, the severity of the handicap and the attitude of both patient and relat ives toward the patient and his handicap i n determining how casework can be best, adapted i n the various agencies to meet the needs of a l l concerned. 1 The social worker should at a l l costs avoid the 1. Elledge, Caroline H. The Rehabili tation of the  Patient. Social Casework i n Medicine. J .B . LippIiiTcott Go. Montreal, 1948. -97-indiscriminate placing of patients i n nursing homes or chronic hospital wards as was done i n the case of Mr. E. I f there was no other way of helping the family to care for Mr. E. then the community organization job outlined above i s indicated: an attempt by the socia l service de-partment and social work organizations to work together and to stimulate interest i n the mobilization of community (provincial or national) resources to meet the needs of th is type of chronic patient. THE PATIENT'S PERSONALITY PROBLEMS MUST BE CONSIDERED IN TREATMENT. 1 Miss I . had suffered some form of *heumatoid pain with remissions and exacerbations extending over a period of sixteen years. In spite of th is handicap she managed to carry on a reasonably normal l i f e and to grad-uate from university. Two years ago her minor joint i n -volvement became more serious and she has been confined to bed more or less since then. Hot u n t i l late i n 1948 did the hospital get any kind of social history on Miss I . By this time she had completely accepted the role of the chronic patient. She had been i n hospital continuously for nine months and had no plans for the future beyond getting a change of environment some time. Miss I . stated that she had thought a great deal 1. See page 30 and Appendix C. -98-about her ailment, how i t started and why i t did not im-prove. She admitted that exacerbations occurred during those times when she was most discouraged and resentful because of her condition. She also f e l t that this was true i n past years; there was a definite connection be-tween her negative emotional states and the attacks of joint pain accompanied by general tiredness. The social worker i s jus t i f ied i n assuming, i n l ine with the "biodynamic point of view" expressed by Dr. Margolis and others, that i f he can help the patient ex-press her negative emotions of anger, resentment, frus-t ra t ion and gu i l t , and replace these emotions with posi-t ive ones based on the hope of an improvement i n health and on the stimulation of taking some step, however small, toward rehabi l i ta t ion, then some progress i s being made. In th i s case, the worker f e l t that a positive step would be to prepare Miss I . for placement i n a suit-able private boarding home to offset "hosp i t a l i t i s . " This step was carried out after several interviews over a per-iod of about s ix weeks. During these weeks, the worker aimed to establish a good working relationship with Miss I . , and to encourage i n her a hopeful, expectant attitude. The boarding home with appropriate nursing care was to be the intermediate step between the hospital and the normal home environment. The next step was to be part time em-ployment. -99-In trying to decide the best was to help pa-t ients , the social worker must continually ask himself, "What does th is i l lness mean to th is patient, and why?" This may not become apparent u n t i l the worker knows the patient well enough to make an accurate estimate of the patient 's personality and character. How are the patient 's pre- i l lness needs related th ih is present needs? How ade-quately did th is person function as a member o£ society? Does she welcome her i l l ness as an escape from an envi-ronment to which she could not adjust? Does the i l l n e s s annoy and frustrate her? Did she have big ambitions? Was she competing with someone or something? What i s the pa-t i en t ' s capacity to accept the r ea l i t y of her si tuat ion, to adapt herself to i t and to make reasonable plans for the future? These and many other questions may have to be answered before the socia l worker i s prepared to give the patient the therapeutic help she needs. In trying to discover what the disease meant to Miss I . the worker concluded that, among other things, she f e l t gui l ty because of the fact that she would not be able to help her parents f inanc ia l ly i n their old age and that . she would not be able to pay back to her parents the money they had spent on her education. The worker, i n t ry ing to al leviate th is gu i l t , assured her that i t was not her fault that she had become i l l and reminded her that her i n -tentions were good; some day she might be able to earn a -100-l i v i n g again. Discussion that allows the patient to vent his h o s t i l i t y reduces emotional tension that might otherwise be going into diseased joints . When Miss I . was placed i n a boarding home, she reacted almost immediately to her new environment by finding fault with almost everything, i n -cluding the proprietor of the boarding home. This h o s t i l i -ty was to be expected after having been so long i n the at-mosphere of the hospital where a l l her needs were met and no demands were made upon her. The worker anticipated Miss I . ' s h o s t i l i t y and arranged to interview her on her f i r s t return to physiotherapy, to allow her to "talk i t out." She did have some legitimate cause for complaint and the worker said he could understand her disappointment and resentment at what appeared to her to be a move for the worse. However, the worker took the necessary action of looking into the complaints and of making some adjustments. On the second t r i p to the hospital Miss I . had quite a d i f -ferent attitude and was adjusting much better to the s i t -uation. There are also the problems of family adjustments which must be considered by the social worker. In this case the family l ived quite a distance away but the patient s t i l l needed help i n connection with her family relationships. The patient 's family reacted negatively to the patient and her i l l n e s s . They were unable to face the si tuation rea l --101-i s t i o a l l y because of the pressure of other burdens. The family needed to be convinced of the necessity of prolonged hospi tal izat ion, as i s often the case. Deprivation of es-sential income may engender feelings of deep insecurity and anxiety which the family may translate into uncooper-ativeness or open h o s t i l i t y . The s k i l l e d social worker may be able to prevent this and to prevent the family from wrecking the plans for the patient by interpreting the na-ture of the disease to them and by pointing out the s ign i -ficance of proper care. VISITS TO THE PATIENT1S HOME CAN PROVIDE GREATER INSIGHT INTO TREATMENT NEEDS. Jean; Jean was described as a small, dark, at-t ract ive, talented and "emotional" g i r l of fourteen years. She had been referred to as "always a high strung and i n -tense g i r l . " She was a poor eater, a l i g h t sleeper and she dreamed frequently. She had always been a very active chi ld u n t i l the spring of 1948 when she became lazy and nervous. She developed joint pain, rashes, fever and nod-ules under her skin. She was admitted to hospital i n the summer of 1948. After five weeks she was discharged, fee l -ing better but not cured. She went back to high school but found she could not keep up to the class; th is resulted i n increased sleeplessness and further loss of appetite. -102-The socia l worker who v i s i t ed Jean's home learned the following facts about the family. Jean was the younger by s ix years of two daughters. She was an unwanted chi ld and had never r ea l ly been accepted by her mother. Jean had been encouraged by her mother's attitude to feel that she was just a "carbon copy" of her s is ter . She f e l t that i n order to obtain her mother's love and affection she had to be just l i k e her s is ter and do every-thing the s is ter did. Hence, strong r i v a l r y had motivated Jean a l l her l i f e . She also hated her s i s ter . However, the mother never allowed the daughters to express any hos-t i l i t y i n any way. Her ambition was to make " l i t t l e l a -dies" of the g i r l s . In working with the family, the aim of the so-c i a l worker was to establish a good relationship with the mother so that eventually the real problem could be dis-cussed with her. This took several interviews spaced over a period of three months, during which time i t was learned that the mother had herself been raised very s t r i c t l y by a maiden aunt and, although she had been unhappy as a ch i ld , she used the same training methods on her own daughters. There was also a marital problem which was discussed i n some de ta i l . F ina l ly , due to the worker's continued con-tact and interest, the mother was able to see why Jean had always been so 'emotional" and intense even as an infant. -103-Gradually the mother was able to see that Jean needed to be accepted and appreciated i n her own r ight and not be-cause she was l i k e the older s i s te r . In handling this case, the worker was able to help the mother also i n that some of her own inner con-f l i c t s were somewhat c l a r i f i ed and al leviated. She had been condemning her husband for the undesirable aspects of the family si tuation for which she also was respons-i b l e . She had been feeling discouraged, too, because the family had been forced to move from a good resident ia l d i s t r i c t to a poor one because of her husband's fa i lure to do well i n business. As a result of this work i n the home, both Jean and her mother have been feeling more re-laxed and happy i n recent weeks. Another aspect of this case also points up the worker's role i n treatment. When Jean was discharged from the hospital , the family had not been to ld what the diag-nosis was and they had received no instructions as to what the treatment plan was to be. The social worfier was able to c la r i fy what the diagnosis was, what the physician had recommended and why. Thus he was able to gain the f u l l co-operation of the family. Even the father and s is ter , who' had formerly been described as "insensitive to the fee l -ings of others and not openly affectionate" began to take a new and warm interest i n Jean. Jean has made rapid pro--104-gree s^ since the change i n family attitude, par t icular ly since that on the part of the mother has been brought about. This case shows that indirect casework can be just as effective, or more so, i n some cases than direct work with the patient. I t also indicates that i t i s important that the worker be able to actually v i s i t the home to assess the family si tuation i n terms of the patient 's needs. New aspects of the case are often revealed i n this way which may provide the worker with new clues as to how to most adequate-l y help the patient. This case also points out the possible need for social casework services i n the school setting which has already been mentioned. Jean's problems might have been detected and help might have been given much ear l ie r by a school socia l worker had there been one i n the school. How-ever, th is service i s almost completely absent from the Cana-dian educational scene. Most schools are, however, f a i r l y adequately covered by public health nurses who could be ac-t ive i n referring cases to such agencies as the Health Cen-tre for Children or the Child Guidance C l in i c i n Vancouver, where help could be given by doctors, nurses, socia l workers and psychologists. A l l these services are, of course, need-ed for other health and welfare problems and need to be greatly expanded as a means of preventing social and health problems which might later ar ise. - 1 0 5 -THE SENSITIVE PATIENT BENEFITS PROM SUPPORTIVE CASEWORK SERVICES. 1 Mr. G. has been a vic t im of a r th r i t i s and con-sequent unemployment for a period of fourteen years. In spite of th i s , his hands have not been involved. This fact seemed to the worker to be a clue to a means of re-hab i l i t a t ion . The worker thought that by getting Mr. G. some suitable l igh t handwork which he could do for an hour or two each day might be the f i r s t step to eventual finan-c i a l independence. The problem of rehabi l i ta t ing Mr. G. , however, was not a simple one. In the f i r s t place, he said that he was not good at handwork and doubted that he could ever do good work of th is kind. He recalled his school manual t ra ining which had been a distasteful , unhappy experience for him and had contributed to what he described as "the horrible feeling that I was not suited for any kind of work." The suggestion was then made by the worker that perhaps Mr. G. would benefit from some correspondence course, preferably one which would introduce him to some vocation. Questioned about th i s , Mr. G. said that the only subjects which would interest him were l i tera ture and 1 . See also page 3 3 . -106-history. The worker discussed this with him pointing out that although these subjects were interesting they would probably never lead to any position i n which he could use the knowledge to earn a l i v i n g . Mr. G. agreed but seemed unable to face having to make a decision about choosing a trade or occupation for which to t r a in himself through study. The only feasible plan for the worker was to continue seeing Mr. G. regularly i n a "supportive" role so that he would be kept interested i n his own rehab i l i -ta t ion and so that he would have someone with whom to d is -cuss his feelings and plans. The worker, therefore, saw Mr. G. regularly over a period of three months. I t was obvious that Mr. G. was benefiting from the relationship. He became much more friendly while i n the outpatients department; he would speak to the various staff members who passed him, whereas previously he had been sullen and apathetic. He gained weight steadily and seemed to be i n better sp i r i t s as time went on. The worker encouraged him to ta lk about how i t f e l t to be crippled by a r t h r i t i s . In one interview Mr.. G. said he would put i n writ ing his ideas, thoughts and feelings about what factors contributed to his a r t h r i t i s , what i t meant to him to have the disease and what he thought could and should be done about i t . More recently, the worker arranged for Mr. G. to take a series of vocational guidance tests i n order to -107-get a better idea of what he might be best suited to do. Nr. G. was w i l l i n g to take these tests although he was some-what apprehensive about i t . The worker had to proceed slow-l y with this plan explaining every step, getting Mr. G.*s co operation and allaying his fears. Although the plan was s l i gh t ly premature, i t was f e l t i t would be a positive step i n giving Mr. G. the feeling that he was making definite pro gress toward a better future. The tests were not part icular l y revealing, the conelusion being that Mr. G. was best suit ed for l igh t handwork that did not involve much s k i l l . Mr. i s now at the point where he i s ready to take on a part time job of this sort and plans are under way to th is end. The fears that Mr. G. expressed throughout the worker's contact with him are typ ica l of a l l patients who have been crippled by a r th r i t i s over a period of years. The sense of inadequacy and hopeless feelings are natur-a l outcomes of the devastating effects of the cr ippl ing. Nevertheless, as this case i l l u s t r a t e s , a great deal can be accomplished i n a re la t ive ly short space of time even though the patient i s chronic and has been crippled for years. I t points out what needs to be accomplished i n a l l cases, namely, achieving i n the patient a feeling of hope and interest, the "mental equivalent" of rehabi l-i t a t i on . The role of soc ia l work i n the treatment of -108-rheumatoid a r th r i t i c patients, which has been discussed or inferred throughout this entire study, has definite basic s imi la r i t i e s to i t s role i n the treatment of any patients. This i s because of the fact that soc ia l work recognized the importance of seeing the "whole person" i n the treatment process, not just a person-with-a-disease; and th is applies also to treating persons who have prob-lems other than medical problems. s o c i a l work, general-l y speaking, has been more conscious of the need to know more about the patient, his family relationships and "to-t a l " needs i n order to help him effectively, than has the medical profession. However, i n recent years a new em-phasis i s being placed on the patient as a person as a result of the growing understanding of the emotional and social aspects of i l l n e s s . I t i s th is new emphasis on treating a patient as a person rather than treating a disease per se that has pointed up the great need to understand not only the physiology of the patient, but also the psychology; more spec i f ica l ly the "psycho-dynamics" of the individual and the dynamics of his significant relationships with other people. Physicians, for the most part, are not trained 'to consider the whole person thus conceived; and, even i f they were, there would be neither time enough nor doc--109-tors enough to deal with a l l aspects of the si tuat ion. It i s i n th is area of socia l , emotional and psychic fac-tors that social workers have special training and s k i l l s and they can join with the physician to form a treatment team, alogg with nurses and other interested persons. Many physicians and socia l workers have written to elaborate on th is new concept i n medicine. However, the principles of treating patients today used i n the most progressive hospitals are not r ea l ly new discoveries; they have been held for many years. "In certain basic respects they were expressed by Hippocrates and the physicians of ancient times. Today we are re-stating an old concept i n medicine, bearing considerable significance for socia l 1 casework practice." W. B. Cannon i n h is studies of the re la t ion between emotions and physiological processes i s one of the modern scient is ts who helped bring about the new ap-2 proach to medical problems. Dr. Margolis states that Cannon's concept of physiological equilibrium cannot be l imited to purely physical phenomena - "For the human or-ganism cannot be considered as an isolated specimen i n a hermetically sealed environment, but rather an integral 1. Margolis. Dr. H.M. "The Biodynamic Point of View i n Medicine." Journal of Social Casework. January, 1949. page 3. 2. Cannon, W.B. The Wisdom of the Body. W. W. Worton and Company. New York, 1939. -110-part of the wider mil ieu from which he stems and i n which he l i v e s . " Richarctson, too, has reminded ua that i n ad-di t ion to the physiological "organ-equilibrium" which i n -dividuals must maintain, "patients have famil ies ," and that the "family maintains.an equilibrium within i t s e l f compara-ble to homeostasis (physiological equilibrium) . , . . . The balance which i s reached, favourable or otherwise, i n -volves not only health and i l l n e s s , but also socia l re-lationships, economic support, education and other con-tacts with the outside world. Only to the extent to which the individual can fuse his physical and socia l adaptation does he succeed as an integrated person and 2 remain w e l l . " I t has been shown i n this and various other studies that persons who f a l l prey to rheumatoid arth-r i t i s have experienced considerable d i f f i c u l t y , and i n most cases insurmountable d i f f i c u l t y i n t rying to achieve th is integration and so do not remain w e l l . Dr. Margolis, i n summing up the psychosomatic concept and indicating the need for casework help i n the treatment process, says: "The streptococcus which i s prob-ably involved i n the rheumatic process becomes a patent e t io logic agent only when other conditions - climate, 1. Margolis, Dr. H.M. op. c i t . page 4. 2. Richardson, H.B. Patients Have Families. The Commonwealth Fund, 1945» page 95. - I l l -hereditary, sociologic, and emotional - favour the break-down of organismic equilibrium or resistance. I t i s l i t -t l e wonder, then, that the physician, aware of the social environmental influences that are so closely related to the maintenance of health or the breakdown of adaptation, which spells i l l ne s s , i s turning more and more to the help 1 that he can get from well applied social casework." The treatment goal, then, i s not that of v i c -tory over some demonic "attack of disease" or germ i n -vasion but rather the reinforcement of nature's own at-tempts to restore physiologic balance. The therapeutic programme, therefore, must be planned to cover a l l fac-tors including psychological and sociological . This principle i s an important one for social casework be-cause i t s services to an individual may f a i l to meet his rea l need i f the focus i s too narrowly confined to only one aspect of his problem and f a i l s to take into account hoar this i s related to the other disturbances i n adjustment which are apparent. So l i t t l e attention i s being given to the so-c i a l aspects of the disease 'that the subject cannot be over-emphasized. A great part of the physician's time and energy i s taken up seeing the same patients over and over again endlessly, and achieving no cure, and i t be-1. Margolis, Dr. H.M. op. c i t . page 4. -112-hooves researchers to look into a l l the problems of the patient to see why he i s not getting better. The personal and socia l problems loom so large i n the patient 's l i f e that i * i s impossible for him to get adequate treatment or to benefit from treatment. Un t i l these problems of f inancia l and emotional insecurity, e tc . , are dealt with, no end of time and money w i l l continue to be wasted i n fu t i l e attempts to curb the problem. The problem of Rheumatoid a r t h r i t i s , then, has been shown to be of much more significance than a physi-cian-patient relationship, on a medical basis. Medicine alone has fa i led to solve the problem of a r t h r i t i s . Ob-viously something more i s needed. I t has been shown that social work has a great deal to offer as part of a treat-ment team. Five branches of sooial work can and should be included i n the to ta l programme, namely: (1) casework ser-vices to the individual patient and his family; (2) re-search to determine what the patient 's problems are and to determine the best methods of approach to the control and treatment of the disease^ (3) community organization to meet needs indicated by casework and research findings; ( 4 ) public assistance on provincia l and federal levels to provide necessary income to the patient and his family so that he w i l l be free to obtain the necessary adequate treat--113-ment and (5) public welfare programmes on dominion and provincial levels to bui ld treatment centres, labora-tories and c l in i c s to t r a in personel and to promote re-search. . . . (ar thr i t is) cripples i n the largest number of cases and k i l l s the smallest number. This very a b i l i t y to cripple without k i l l i n g would seem to put i t i n the lead of a l l other chronic diseases as of pre-eminent soc ia l , economic and medical import-ance, " Bigelow and Lombard. APPENDICES. (114) /115) Appendix A. Class i f icat ion of A r t h r i t i s . (Developed and adopted by the American Rheumatism Association, 1942 and quoted by Dr. B. I. Comroe i n I r t h r i t i s and A l l i e d  Conditions. l ea and Febiger, Philadelphia, 1 9 4 4 , p. '51) A r t h r i t i s Rheumatoid: Takes various forms which are specified as multiple a r th r i t i s (synonyms: prol iferat ive a r th r i t i s , atrophic a r t h r i t i s , chronic infectious a r th r i t i s , S t i l l ' s disease) atypical rheumatoid a r th r i t i s (focal infection ar thr i t i s ) rheumatoid a r th r i t i s of spine (synonyms: rheu-matoid spondylitis, Marie Strumpell's disease, spondylose rhizomelique, infectious spondylit is, spondylitis ankylopo-i e t i ca , von Beckterew's disease.) The other main groups of a r th r i t i s are: Ar th r i t i s due to infection: This may be of the spine, due to tuberculosis; of the knee due to gonococcic infection; of the wrist , due to pneumococcic infection; of the hip, due ' to syphi l i s . Other sources of infection are: treponema, pa l l ida , typhoid and paratyphoid b a c i l l i , meningococci, sta-phylococci, streptococci, (and a r th r i t i s occasionally as-sociated with dengue, dysentery, chronic ulcerative c o l i -t i s , leprosy, malaria, Brucellosis , scarlet fever, yaws, and infections with B. c o l i , B. diptheriae, of B. i n f l u -enzae;) some forms of Tenosynoritis. Ar th r i t i s due to rheumatic fever: Rheumatic fever i s p r i -mary diagnosis. Ar th r i t i s due to direct trauma:Affects the knee due to con-tusion; the elbow due to habitual dislocation. This group includes traumatic forms of synorit is and tenosyn-ov i t i s , f i b r o s i t i s , burs i t i s , sprains, internal derange-ments to cartilages, etc. Neurogenic Arthropathy: (Charcot joint) (associated with Tabes dorsalis, syringomyela, cord trauma, nerve injur-ies or leprosy.) Ar th r i t i s due to gout: Gout i s primary diagnosis. Joint must be specified. New growths of joints : Joints and neoplasm are specified as: Synorioma of knee, cyst, xanthoma, hemangioma, giant c e l l tumors, synorioma. Degenerative joint disease: multiple due. to unknown cause; synonyms: osteoarthri t is , hypertrophic a r th r i t i s , de-generative a r t h r i t i s , chronic senescent a r t h r i t i s . Mixed forms of a r t h r i t i s : (especially rheumatoid a r th r i -t i s and degenerative joint disease.) Hydraathrosis: intermittent; joint must be specified. -116-Appendix B QUESTIONNAIRE USED IN THE STUDY. (Names, addresses, ages, sexes, etc. were obtained from the f i l e s of the B r i t i s h Columbia A r t h r i t i s and Rheumatism So-ciety. A br ief l e t te r was enclosed wiibh the questionnaire explaining i t s purpose.) 1. How long have you been crippled by ar thr i t i s? 2. Did you lose your job as a result of a r thr i t i s? When? 3. How has the disease affected you f inancial ly? Used up your resources? Put younin debt? Forced you to apply for assistance? Other? 4. To what extent are you crippled? Sl igh t ly P a r t i a l l y Completely (bedridden) What parts of your body are involved? Hands legs and feet Back Other 5. How has your family been affected? What adjustments became necessary, for example: Occupational: Financial : Housing: Family plans changed or postponed: Other: 6. Does your incapacity make i t necessary or advisable for you to engage a housekeeper, part or f u l l time? 7. How has your cr ippling affected your social l i f e and recreation? (Use reverse side for details) 8. What treatments have you found effective? 9. Your suggestions as to what i s needed i n the way of treatments, f a c i l i t i e s , etc. for the cure or prevention of a r t h r i t i s . (Use reverse side) 10. Your general remarks: e.g. Do you feel that your personal and family problems, worries, etc. tend to aggravate the disease? (Use reverse side) Appendix 0: -117-Summarized Oase History. Exemplifying Relationship Between Medical and Social Data i n Sequence of the Disease. Date Medical Data 1933 F i r s t sign of arth-r i t i s - aching joints . Previous spring run down, had colds; ton-s i l s and adenoids re-moved. Had rheumatic heart murmer. Social and Emotional Data Str iving hard to do well with school studies under s t r i c t supervision of mother, an ex-teacher. Competition with younger s is ter for parental love and affection. 1938 Developed knee pain. 1939 Knees became puffy and painful. Mother i l l and i n hospital two months; la ter , seven months at home i n bed. Pa-t ient looking after house, caring for mother, helping s is ter and doing her own work. Great resentment to th i s . Completing high school intra-murally at 15, s t r iv ing un-successfully to compete so-c i a l l y with older g i r l s . Couldn't do P.T. Thought she had an incurable disease. 1940-41 Tired easi ly; tend-ency to aching joints. Spring More pain i n knees; i n bed three weeks. 1941-42 Joints s t i l l trouble-some. Improved i n second term. In a poor boarding home at university; f e l t unhappy, re-sentful, disturbed. "Plunked" two exams. - her f i r s t fa i lures . Fel t badly; also not getting along with landlady. Almost l e f t uni-vers i ty . Worked very hard to make up for fai lures and passed. In same boarding home. Did not work so hard; l i ked courses better. Got more rest; did not go out much. -118-Appendix C (continued) Date Medical Data Social and Emotional Data 1942-43 1943 Summer Autumn Christ-mas 1944 Spring August 1945 1946 Summer Had sulpha treat-ments - "made me s ick . " Pe l t very-weak. Further injections. Fel t pain, some stiffness. Knees bothered her two days out of seven. Got worse. S t i l l worse; los t appetite, interest i n work. Treated at hospi-t a l . Back to hospital . Picked up; gained weight. Could ride a bicycle i n May. Got very t i red ; got cold, l a ryng i t i s . Most of her joints bothered her. Tiredness continued. Had los t 20 lbs . More gold treatments. Ch i l l s at night after-ward. Finger joints began to s t i f fen. Back at university,"don 1 t know why.11 Parents paying her way to become a teacher. She wanted something else; inner conf l ic t . Some improvement. Selected more interesting courses, got good marks. Could s t i l l get around f a i r l y we l l . This slowed her down, caused her annoyance. She was always incl ined to be active and to work hard. In a poor boarding home. "Running around" a l o t . V i s i t i n g at home with her s is ter with whom she had a poor relationship. Discouraged about her condi-t ion . Always sees worse when at home. Has no affeo-t ion for mother; they do not get along w e l l . Improved. Went home. After s ix weeks got a cold and went "down h i l l " again. Had now spent a l l her money and became a "staff" patient. Went back home again. Taking special t raining course. Walking to work i n cold and ra in , la te r went back to work but not much better i n jo in ts . Off work during July and August. -119-Appendix C (continued) Date 1946 (cont) Septem-ber Medical Data Using aspirins to k i l l pain. los t more weight. Shock reactions from gold treatments. Back to bed. Social and Emotional Data. Back to work; now doing fine copying work; very d i f f i c u l t for her. Very disappointed be-cause she could not go home for a v i s i t as planned. Mind f e l t d u l l . Christ-mas In bed most of time. Pelt d u l l , l i s t l e s s , no appetite; could not read. At home. 1947 Fingers los t nor-January mal shape. 1949 In hospital almost February continuously to date. Fel t very depressed. March Placed i n a private boarding home. -120-Appendix D. BIBLIOGRAPHY. I . General References: Bigelow, G.H. and Lombard, H.M., Cancer and Other Chronic  Diseases i n Massachusetts. Houghton M i f f l i n Company. 1933. Boas, Dr. E . P . , The Unseen Plague - Chronic Disease. J . J . Augustln^ Sew York. 1940. Cannon, Dr. W.B., The Wisdom of the Body. W.W.. Norton and Company. New YorkT 1939. Committee of American Rheumatism Association, "Review of English and American Literature for 1940." Annals  of Internal Medicine. December, 1941. Vol . 15. "Rheumatism and A r t h r i t i s Review of American and.English Literature of Recent Years." (9th Rheumatism Review) Annals of Internal -Medicine. January,1948. Dunbar, Dr. Flanders, "Emotions and Bodily Changes; a Report . of Some Recent Psychosomatic Studies." Annals of Internal Medicine. 1940. Volume 14: S29T Psychosomatic Diagnosis. Paul B. Hoeber Inc. Medical Book Department of Harper and Bros. New York and London. 1943. "Problems of Convalescence and Chronic I l lness; A Preliminary Discussion." American  Journal of Psychiatry. 92:1095. 1955^ Fremont-Smith, F . , The Influence of Emotional Factors Upon  Physiological and PatHoTogToal Processes. (Bulletin) NewTork Academy of Medicine. 15:560. 1939. -121-Margolis, Dr. H.M., Diagnosis and Treatment of Ar th r i t i s  and Allied~DisordersT Paul B. HoeHer, Inc. niw York, m n Richardson, Dr. Henry B . , Patients Have Families. New York Commonwealth Fundi 1545^ Robinson, Dr. Canby, The Patient as a Person. New York Commonwealth FuncT 153*9. Robinson, Dr. C.G. , "Relation of Emotional Strain to I l l -ness." Annals of Internal Medicine. 11:345 1937. Swain, Dr. L . T . , "President's ftddress to American Rheuma-tism Association." Annals of Internal Medicine. Volume 19. July, 1943. Weiss E . , and English, O.S., Psychosomatic Medicine. W.B. Saunders Co. Philadelphia and London. 1943• I I . Specific References: B e l l , Charlotte, and Swain, Dr. L . T . , "Occupational Ther-apy i n A r t h r i t i s . " Public Health Nurse. A p r i l , 1940. Cotrb, Dr. S., Bauer, W. and Whiting, I . , "Environmental Factors i n Rheumatoid A r t h r i t i s . " A study of the relationship between the onset and exacerba-tions of a r th r i t i s and the emotional or environ-mental factors. Journal of American Medical  Association. August 19, T$37~» Comroe, Dr. B . I . A r t h r i t i s and A l l i e d Disorders. Lea and Febiger. Philadelphia. 1944. Committee of American Rheumatism Association. "Primer on A r t h r i t i s . " Journal of the American Medical Association. August, 1942. Gordon, R .G. , "Psychological Factors i n Chronic Rheumatism." B r i t i s h Medical Journal. 1:1165 1939 -122-Graham, Wallace, and Fletcher, A.A. "Gold Therapy i n Rheumatoid A r t h r i t i s . " Canadian Medical Asso-ciat ion Journal. December, 1943. Halliday, J . L . "The Concept of Psychosomatic Rheumatism." Annals of Internal Medicine. 15:666 1941. , "The psychological Approach to Rheumatism." Proceedings of the Royal Society of Medicine. 31:167 Jinu^ry7T9T8: , "Psychological Aspects of Rheumatoid A r t h r i t i s . " Proceedings of the Royal Society of Medicine. 257435 19*427 Horder, Lord, Rheumatism: A Plan for National Action. H.K. Lewis, LimiTJed" London, 1944. Phelps, Dr. Alfred E . , Your A r t h r i t i s : What you Can Do  About I t . William Morrow and Company. New York. 1943. Rhodes, Ceci l H. "Ar th r i t i s , King of Cripplers ." Canadian  Home Journal. November, 1947• Robinson, Dr. Dean, " A r t h r i t i s . " Canadian Medical Asso-cia t ion Journal. March, 1944. Seeley, Evelyn, " A r t h r i t i s . " Survey Graphic. December, 1948. Smith, Dr. Mi l l a rd , "A Study of 102 Cases of Rheumatoid A r t h r i t i s . .Et iologic Factors." New England Journal of Medicine. 206:211 - 1552. Snyder, Dr. R.G. "Ar thr i t i s a Neglected Disease." Annals of Internal Medicine. February, 1940. Swain, Dr. L .T. "Physical Therapy i n A r t h r i t i s . " Public  Health Nurse. A p r i l , 1940. -123-Thomas, Dr. G.W., "Psychic Factors i n Rheumatoid A r t h r i t i s . " American Journal of Psychiatry. November, 1936. Weber, I . , "The Neurotic Origin of Progressive Ar th r i t i s Deformans." Journal of ffervous and Mental Dis-ease. 11:72 January- 0 c tober, "T58TT^ Whitehead, E r i c , "Arthr i t is , the Monster Crippler ." The  Vancouver Province. January 31, 1948. Wright, Dr. H.P. , "The Challenge of A r t h r i t i s . " Canadian  Medical Association Journal. September, 1944. "Rheumatoid A r t h r i t i s . " Canadian Medi  cal Association Journal. October, 1944. I I I . Social Work References; Bar t le t t , Harriet W., Some Aspects of Social Casework i n a Medical Setting. Prepared" for Committee on Functions, American Association of Medical So-c i a l Workers. Chicago, 1940. Cocker i l l , Eleanor, "New Emphasis on an Old Concept i n Medicine." Journal of Social Casework. Jan-uary, 1949. , "Widening Horizons i n Medical Educa-t ion . " Journal of Social Casework. January, 1948. Elledge, Caroline H . , The Rehabili tation of the Patient; Social Casework i n Medicine. J .B. lippencott, Col Montreal, I9"48l Margolis, Dr. H.M. "The Biodynamic Point of View i n Medicine.". Journal of Social Casework. January, 1949. -124-» "Care of the Patient with Rheumatoid A r t h r i t i s . " Journal of Social Casework, Jan-uary, 1945 Schless, Bessie, "Social Case Work Services to the A r t h r i t i c Patient." Journal of Social Case- work. January, 1945. Thornton, J . , and Khauth, M.S. Social Component i n  Medical Care. A study of 1UU cases from Presbyterian Hospital in' Hew York. Colum-bia united Press. Hew York. 1937. Essays, Reports and Pamphlets; American Association of Medical Social Workers. State- ment of Standards to be Met by Medical Social  Service Departments i n HospiTJals and C l i n i c s . Chicago, 1940. A r t h r i t i s and Rheumatism Foundation. A Hation Wide At-taok on A r t h r i t i s and other Rheumatic Diseases. Pamphlet. Issued 1948"! Bagnall, Dr. A. W., The Problem and Control of the Rheuma-t i c Diseases i n B. C7 Report published by Canadian Ar th r i t i s and Rheumatism Society, B. C. Divis ion, Vancouver. January, 1949. Canadian A r t h r i t i s and Rheumatism Society, B. C. D i v i -sion. Operations Bluebird. Circular issued March, 1949. Dominion Bureau of S ta t i s t i c s . Preliminary Report on the Incidence of A r t h r i t i s i n Canaalu 19T7-Gallagher, Mary P . , A r t h r i t i s as a Public Welfare Problem in B.C. Essay submitted To the Department of So-cTal fork, University of B.C. March, 1948. -125-Graham, Dr. Wallace, A r t h r i t i s . D.V.A. (Canada) Treat-ment Services B u l l e t i n . Issued February, 1947. McFarland, William Donald, The Care of the Chronically 111. Master of Social Work Thesis submitted to the Univeristy of B. C. 1949. McNevin, Kathleen, Rheumatoid A r t h r i t i s . Epidemiological Essay, 1975 : CiTapel H i l l , H . C. Strum, Gladys, The Problem of A r t h r i t i s . O f f i c i a l Re-port of Speech delivered i n the House of Com-mons, Canada, February 1, 1949. King's Pr in t -er, Ottawa, 1949. Time, The Weekly News Magazine. "Medicine — For Ar th r i -t i s . " Report published May 2, 1949. Volume 53, Number 18. Vancouver Sun. News Reports printed on the following dates: January 31, 1948; October 1, 1948; March 12, 1949; A p r i l 21, 1949; A p r i l 22, 1949; May 7, 1949. 

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