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Psychogenic factors in Sydenham's chorea among children : the social work aspects of a sample group of… Staghall, Hattie Ransom 1951

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L £ t> 6 7 PSYCHOGENIC FACTORS IN SYDENHAM'S CHOREA  AMONG CHILDREN The Social Work Aspeets of a Sample Group of Cases. by HATTIE RANSOM STAGHALL Thesis Submitted in Part ia l Fulfilment of the Requirements for the Degree ef MASTER OF SOCIAL WORK i n the Department of Social Work 1951 The University of Br i t i sh Columbia ABSTRACT During i t s f i r s t nirse years of operation, the Eastern Washington Rheumatic Fever Program has served twenty-f i v e children who had rheumatic chorea, and throughout t h i s period members of the medical team have been puzzled concern-ing the etiology of choreic symptoms i n th i s small but out-standing group. This study explores psychogenic aspects of t h i s special group of cases, and views the Implications of s o c i a l casework r e s p o n s i b i l i t i e s as related to t o t a l t reat-ment plans f o r such children. The study i s based mainly on a careful analy-si s of the twenty-five case h i s t o r i e s , and i n t h i s regard a detailed schddule was used as guide. In "following up" cases where i t was possible to do soy dir e c t contacts with patients or t h e i r families were made, as well as i n i t i a t i o n of correspondence with some of the other s o c i a l agencies par-t i c u l a r l y involved i n c e r t a i n case sit u a t i o n s . H i s t o r i c a l and s t a t i s t i c a l research material was included i n the pre-sentation of background factors of the i l l n e s s i n general, and In the outline of the rheumatic fever program. The primary objective of the study was to em-phasize the importance of s o c i a l and emotional factors i n chorea as a sample i l l n e s s , and to c l a r i f y the urgency of the need f o r s o c i a l casework treatment concerning these f a c t -ors. In growing children where such psychological problems exist, remedial therapy i s p a r t i c u l a r l y e s s e n t i a l , and f o r th i s reason alone the study serves a useful purpose. Probably the most important s p e c i f i c findings of the survey were that these children seemed unusually con-forming and submissive, so that t h e i r symptomatic behaviour appeared to indicate a need f o r permissable expression of pent-up, forbidden impulses. They seemed singularly de-prived of adequate dependency upon parents or parent surro-gates, and overly repressed, confirming, and masochistic, they found t h i s abnormal means of v e n t i l a t i n g i n s t i n c t i v e aggressions and h o s t i l i t i e s ; t h i s way of regressing to a more comfortable, dependent condition. Although the group studied was small, i t never-theless represented a complete survey of cases of rheumatic chorea appearing i n the defindd area during a nine year per-iod. Therefore the conclusions presented are valuable i n providing tentative bases f o r consideration i n of f e r i n g so-c i a l casework assistance with the t o t a l treatment f o r the choreic c h i l d . ACKNOWLEDGMENTS Research material i n t h i s study was colle c t e d with the cooperation of the Washington State Services f o r Crippled Children, Eastern Area. Dr. Frederick Fischer, Medical Director of the Rheumatic Fever Program endorsed the survey and was h e l p f u l i n contributing medical research data and advice. I would l i k e to express grateful appreciation to Miss V i r g i n i a Anderson, Social Service Department, fo r her u n f a i l i n g i n t e r e s t and support, as well as her generaus assistance i n supplying case material. Mrs. Gretchen Schlecht was most h e l p f u l i n securing s t a t i s t i c a l information per-taining to the study. Special mention should be made of Mrs. Dorothy Livingston f o r her assistance i n contributing toithe case material used. I wish to thank Dr. L.C. Marsh, University of B r i t i s h Columbia School of Social Work, f o r h i s valuable suggestions and advice throughout the writing of the study, and Miss Margaret Johnson, University of B r i t i s h Columbia School of Social Work, f o r her encouragement and c r i t i c a l i n t e r e s t . TABLE OF CONTENTS Chapter 1. Childhood Rheumatism and Chorea. Approach to the study. Scope and l i m i t a t i o n s . Methods and techniques employed. Sources of material. Rheumatic fever described. Is i t inherited? Rheumatic fever and heart damage. Childhood mortality and the disease. Diagnostic d i f f i c u l t i e s . C l i n i c a l features. General treat-ment and routine care, Sydenham's chorea described. The etiology of chorea and a casework approach to the problem. Chorea and heart damage. Emotional components of the i l l -ness. Medical treatment. Chapter 2 . A State (Regional) Program. The p i l o t project. I n i t i a t i o n of the Eastern Washington State Program. Subsidization of the regional program. E l i g i b i l i t y f o r program care. Administration of the program. Location. Services provided by the program. Au x i l i a r y services. C o l l a t e r a l services. Chapter 3. Parental Problems and Reactions. Inadequacies i n parenthood. Overwhelming parental demands. Rejecting parents. Emotionally dis-turbed parents. Breaks and gaps i n marital and f a m i l i a l s o l i d a r i t y . Economic stress and s t r a i n . Chapter 4. Childhood C o n f l i c t s and Defences. Manifestation of increased unrest just p r i o r to i l l n e s s . Developmental phase. Chronological age. Emotional phase and i t s components. Matriarchal family pattern. Homosescual tendencies, overt or not. Further, psychosexual c o n f l i c t s concerning parents. S i b l i n g r i v a l r y . Frustrations regarding medical care. Additional physical handicaps. Chapter 5. The Social Worker and the Choreic Child. Findings and t h e i r i n t e r p r e t a t i o n . I n s u f f i c -ient dependency i n childhood. The rejected c h i l d . Emo-t i o n a l l y deprived parents. I n s u f f i c i e n t marital and famil-i a l security. S i b l i n g r i v a l r i e s and other childhood con-f l i c t s . Developmental phase and psychosexual d i f f i c u l t i e s . The escape from heart damage. Secondary physical handicaps. Treatment suggestions. Supportive therapy. Treatment of repression. The patient and h i s family. D i f f e r e n t i a l diag-nosis. Casework and p s y c h i a t r i c consultations. C o l l a t e r a l s . The r e h a b i l i t a t i v e team. Implications of the study. Appendices; A. Sample Report Forms Used i n the Rheumatic Fever Program. B. Statement of Program Policy and Service, as Out-l i n e d by the Washington State Department 6T Health. C. Schedule Used i n Analysis of Individual Cases. D. Some Definitions of Social Casework Terms. E. Bibliography. TABLES AND CHARTS IN THE TEXT (a) Tables Page Table 1. Di s t r i b u t i o n by age i n years of rheumatic fever cases (including "possible" and "In-active" cases) f o r the years 1941 to 1948, i n the Eastern Area of the State of Wash-ington 10 Table 2. A sample of the routine convalescent re-gime prescribed by the physician. This p a r t i c u l a r one had been adapted to the needs of Jessie K 13 Table 3. Sample Annual Budget, Rheumatic Fever Program, Eastern Area State of Washing-ton Services f o r Crippled Children 24 (b) Charts F i g . 1. The twenty-nine counties of the State of Washington 26 Fig. 2. Organization chart of the State of Wash-ington Department of Health 28 PSYCHOGENIC FACTORS IN SYDENHAM'S CHOREA  AMONG CHILDREN The Social Work Aspects of a Sample Group of Cases. " ... we perpetuate the term 'St. Vitus dance', under the I l l u s i o n that i t s writhing young victims are a special concern of the miracle-working St. Vitus. But St. Vitus was no dancing maniac. He was a serious, saint-l y boy who was martyred f o r h i s f a i t h i n the year 303 A.D.. The feast of St. Vitus f a l l s on June 15th.. At midsummer, the ancient Slavs used to worship with dance t h e i r heathen god Swantevit, whose name was corrupted to Sanct V i t . Dancing to St. Vitus (chorea St. V i t i ) as-sumed h i s t o r i c a l importance i n Germany. About a quarter of a century a f t e r the Children's Crusade of 1212, i n the wake of the plague c a l l e d 'The Black Death,' andendemic psy-chosis, which took the form of a mania f o r dancing, broke out i n E r f u r t . In 1374, a fresh outbreak of d e l i r i o u s dancing began at Aachen, and spread widely. In 1518, mad dancing started at Strasbourg, and rapidly reached epidemic proportions. Throughout the sixteenth century, t h i s s a l t a -tory mania f l a r e d up from time to time. And today i t s t i l l survives i n the jumping procession at Echternach, and per-haps i n the.national goose-step. This peculiar motor manifestation of mass men-t a l disorder was termed St. Vitus chorea. It was an ex-c l u s i v e l y German habit, and was not seen i n England. The great English c l i n i c i a n , Thomas Sydenham, probably never heard of Swantevit, and apparently was unfamiliar with character and h i s t o r y of the German dancing psychosis which took i t s name from the heathen god. Nevertheless, i n the year 1686, i n hi s t r e a t i s e Schedule Monitoria. to designate a disease which he was the f i r s t to recognize, Sydenham picked the name 'chorea St. V i t i . ' n l 000000000000000000000 1 Leopold Llchtwitz, M.D., Pathology and Therapy of  Rheumatic Fever. New York, Grune and Stratton, 1944, p. 124. CHAPTER I. CHILDHOOD RHEUMATISM AND CHOREA. For the past several years, a doctor In charge of the Rheumatic Fever Program i n Spokane, and so c i a l service workers there, have been b a f f l e d by the appearance of Sydenham's chorea as an accompanying symp-tom, seemingly, of rheumatic fever,- but concerning which no l o g i c a l physical basis could be found. A keen inter e s t was expressed i n sponsoring a survey of a l l such cases, with the objective of revealing some psychological factors which might be considered bases, or at least a n c i l l a r y contribu-tory factors, of such a physical manifestation. The op-portunity eft making such an exploratory study was grasped with the hope of attempting to demonstrate the importance of the s o c i a l and emotional conponents of a sample i l l n e s s , with some consideration of casework treatment which might be re-medial or at least ameliatory i n e f f e c t . Therefore t h i s i s a survey of the psychogenic factors which seemed to play a part i n the appearance of Sydenham's chorea as a psychoso-matic manifestation, endeavouring to reveal the importance of these i n rheumatic fever and chorea, as i n a l l i l l n e s s e s which invariably have t h e i r psychic and t h e i r somatic aspects. The organismal theory provides the fundamental con-cept, or way of looking at the subject, i n what i s c a l l e d psychosomatic medicine. Once we have grasped the idea that the psychic and somatic are not two di f f e r e n t universes, but the same one viewed from di f f e r e n t approaches, i t may be possible to present -2-the s c i e n t i f i c problem attacked by our research i n somewhat more rigorous and clear-cut terms. 1 Approach to the Studyt In order that t h i s sort of study, which i s exploratory rather than pragmatic i n nature, may have r e a l value, some appreciation of the basis of case-work and casework methods i s e s s e n t i a l . Its v a l i d i t y de-pends upon weighing and assessing of the re s u l t s of these methods as applied In the twenty-five cases thus empirically observed, rather than reviewing the methods themselves. In other words, a certain acceptance as well as understanding of s o c i a l casework, i t s l o g i c , reasoning, and importance, i s required of the reader i n i t i a l l y , as the thesis i s p r i -2 marily esoteric and spec i a l i z e d i n nature. Scope and Limitations: This study was based on material compiled from s o c i a l service and medical records of the 739 patients served by the Rheumatic Fever Program, Eastern Area of the State of Washington, since i t was organized i n October, 1941, and covering the f i r s t nine years of i t s operation u n t i l October, 1950. The survey was l i m i t e d to those patients among t h i s group who were diagnosed as having had the symptoms of Sydenham's chorea at any time. There were twenty-five of these, representing 3.4$ of the t o t a l group of rheumatic fever patients served under the aegis of the program.- Although t h i s comprised a complete survey of 1 Flanders Dunbar, Psychosomatic Diagnosis. New York, Harper's (Medical Book Department;, 1948, p. 649. 2 For some casework d e f i n i t i o n s , see Appendix D. -3-t h i s category of patient, the group i t s e l f was small, and material on a few of the cases rather s l i g h t . Methods and Techniques Employed: Although the p r i n c i p a l method used i n the survey was that of the case study, sta-t i s t i c a l and h i s t o r i c a l methods were also adopted to some extent. A schedule was u t i l i z e d i n t h i s study of twenty-f i v e cases, but i n some of them i t was not possible to com-plete i t i n e n t i r i t y . The schedule served mainly as a guide, and helped give point and d i r e c t i o n to general anal-1 y s i s of the co l l e c t e d material. Sources of Material: Most of the material used was drawn from the s o c i a l service records of the program, but some other important sources were used aleo. There were s i x main sources, as follows: (1) . Case records of the e o c i a l service department, State Services f o r Crippled Children, at the Eastern Area headquarters i n Spokane. (2) . Medical records, notes of public health nurses, hos-p i t a l charts and c l i n i c a l records of the out-patient service of the program. (3) . Direct contacts with patients and/or t h e i r families i n "follow-up" of eight of the cases, and correspond-ence with s o c i a l agencies concerning two other cases. 1 See Appendix C. -4-(4) . Consultation with medical, nursing, s o c i a l service, and c l e r i c a l s t a f f connected with the State Services for Crippled Children. (5) . S t a t i s t i c a l material from unpublished records among the program's f i l e s . (6) . Background information drawn from reference books, most of which appear i n the attached bibliography. A further note must be added as to the i n -estimable value of being able to observe over a considerable period of time, even though without having actual contact with them, four of the patients among the group of twenty-f i v e studied. Direct contacts were not possible i n these cases because of the very nature of the casework services currently being u t i l i z e d by the patients. Quotations from Case Records; Quotations from actual cases appear from time to time throughout the study, and without footnotes as to t h e i r source. However, as indicated i n the bibliography, these extracts are a l l taken from the material gathered from case records, h o s p i t a l charts, and reports both written and verbal concerning the s p e c i f i c group of cases used i n the survey, and accumulated through the f a -c i l i t i e s of the Rheumatic Fever Program i n Spokane. Ex-tra c t s areeedited and summarized to suit the purpose of the study, except where direct quotations are indicated. Rheumatic Fever: In the days of Hippocrates, the c r i p p l i n g dhildhood disease that i s known now as rheumatic fever, was described under the heading of acute a r t h r i t i s , and the f i r s t -5 accurate c l i n i c a l description was made in 1676 by the Eng-l i s h doctor, Thomas Sydenham (who also gave St. Vitus dance i t s technical name of "Sydenham's chorea"). Dr. May Wilson, a contemporary authority on rheumatic fever, states that from an et iological stand-point, " . . . rheumatic fever i s a systemic disease, probab-ly an infection producing lesions throughout the body. Most important of these are the lesions found In the car-1 diovascular structures." However, there are two main schools of thought concerning the cause of rheumatic fever. Pirst jy , that i t results from an infection by streptococcal microorganisms; and secondly, that, "It i s not caused by a .4 specific microorganism or virus, but by a sensitization to antigens, protein in nature, which in most cases are pro-2 ducts of microorganisms." In other words, the second theory i s that the disease results from an al lergic reac-tion to invasion of the bodily defenses against disease by microorganisms. Dr. Leopold Lichwitz advocates this theory and expands i t as follows: Rheumatic sensitization infrequently develops into complete and f ina l immunity. Commonly, the sensitization tends to persist indef initely , and in this chronic stage i t may be either continuous-l y or intermittently evident. When the sensitiza-1 May Wilson, M.D., Rheumatic Fever. New York, The Commonwealth Fund,-1940, p. 5. 2 Lichtwltg, op/ c i t . , p. 1. -6-t i o n f a l l s below the threshhold of c l i n i c a l a c t i v i -ty, the disease has i n intermission. Reactivation i s brought about nbt only by the s p e c i f i c antigen which i n i t i a t e d the disease, but also by a number of nonspecific factors, any one of iti i c h w i l l a f f e c t the morbidly sensitized defence mechanisms of the patient i n a c h a r a c t e r i s t i c a l l y rheumatic manner. Thus, fatigue, a c h i l l , an adventitious i n f e c t i o n , a mental upset, or increased bodily a c t i v i t y may cause the rheumatic to relapse from a quiescent i n -to an acute f e b r i l e state." 1 Is Rheumatic Fever Inherited? Rheumatic fever i s often said to be hereditary, but simply i n t h i s way: a predisposition to the disease apparently may be passed from parent to c h i l d . In four of the cases of the present study, a de-f i n i t e record of rheumatic fever (not necessarily compli-cated by choreic symptoms), was found i n the family h i s -tory. The disease Is not generally conceded to be con-tagious, however, although frequently more than one c h i l d i n a family may contract the i l l n e s s . S i b l i n g studies have been and are being maSe, as are those concerning f a -m i l i a l epidemiology, but i t i s always d i f f i c u l t to assess with any degree of certainty how f a r the s u s c e p t i b i l i t y can be considered causal, or how f a r immediate and surround-ing factors i n a case may bo judged to be of primary im-portance. Dr. Wilson suggests that, i n view of present lack of d e f i n i t e knowledge: "ffiiere possible, families of known rheumatic background should be under observation dur-ing the early years of the l i f e of the s i b l i n g s to ensure 1 Loc. c i t more accurate recognition of the onset and course of rheumat-1 i c fever." Upper respiratory Infections are the most frequent forerunners of rheumatic fever, and surrounding circumstantial factors involved may range from economic un-rest and emotional i n s e c u r i t y to lack of adequate housing and malnutrition. It Is also generally thought that: "The incidence of rheumatic fever has a c o r r e l a t i o n with poverty, poor n u t r i t i o n , and poor housing conditions which appear to predispose the i n d i v i d u a l to the disease. In Boston, school children from crowded d i s t r i c t s were found to have twice as high a rheumatic fever rate as those from the r e s i d e n t i a l 2 areas." Certainly physical and psychological resistance are both undermined by the tensions and r e s t r i c t i o n s of im-poverishment. Economic d i s t r e s s was d e f i n i t e l y an impor-tant factor i n the cases studied i n t h i s survey. Rheumatic Fever and Heart Damage: Jenner, P i t c a i r n , and Bouillaud, recognized the close association of rheumatic fever and heart disease, and about the year 1840, (some twenty years following the invention of the stethescope by Laennec), M. Bouillaud declared the v e r i t y ofalaw famous to medicine — the "Law of Coincidence." Dr. May Wilson c i t e s t h i s law as follows: "•In the great majority of cases 1 Wilson, op. c i t . , p. 58. 2 Frances Uphaip, A Dynamic Approach to I l l n e s s , New York, Family Association of America, 1949, p. 56. - 8 -of diffuse acute a r t i c u l a r rheumatism with fever, there ex-i s t s i n variable degree a rheumatism of the serd-fibrous tissue of the heart. The coincidence i s the rule, and the 1 non-coincidence the exception." About t h i s time, too, rheumatic c a r d i t i s was noted to be more common among c h i l d -ren, and S i r Thomas V/at son remarked that the younger the patient who contracted acute rheumatic fever was the more l i k e l y was he to suffer from rheumatic heart disease. Rheumatic Fever and Childhood Mortality: Rheumatic fever i s a primary cause of childhood mortality, and youngsters between the ages of f i v e and nineteen are p a r t i c u l a r l y prone to the&isease. The Children's Bureau of the Federal Security Administration, United States of America, states that rheumatic fever plus heart disease, disregarding ac-cidents, " ... has become the leading cause (of death) a-mong a l l diseases for white boys and g i r l s 1 0 — 1 4 years of age, and f o r white boys 1 5 — 1 9 . In spite of these f a c t s , i t i s g r a t i f y i n g to know that i n the l a s t decades the mortality rates show a d i s t i n c t decrease. However, the decrease i s consistent only f o r white children; f o r non-white children the downward trend i s not so consistent 2 and l e s s marked." This p u b l i c a t i o n (printed i n 1 9 4 8 ) also notes that death rates i n rheumatic fever and heart disease 1 Wilson, op_. c i t . , p. 4 . 2 George Wolff, M.D., Childhood Mortality from Rheumatic  Fever and Heart Diseases, 1 9 4 8 , Children's Bureau Publica-t i o n No. 322, p.. 2. -9-increase with increasing age of the c h i l d from f i v e years and older, and are higher f o r the non-white than the white c h i l d population. Prom the point of view of t h i s study of a P a c i f i c Northwest geographical area, i t i s int e r e s t i n g to note that death r@ites f o r t h i s disease are low on the P a c i f i c coast i n comparison with other areas of the United States such as the Middle A t l a n t i c states where they are 1 quite high. In the eastern portion of the State of Wash-ington, between 1941 and 1948, there wasea markedly pre-ponderant number of nine-year-old patients, and also most of the children i n t h i s group suffered t h e i r I n i t i a l at-tack of the i l l n e s s when they were between the ages of f i v e and f i f t e e n . (See Table 1). During t h i s period of 1941 to 1948, there were eighteen deaths among cases served through the Rheumatic Fever Prcg ram, including four i n 1944, six i n 1945. Diagnostic D i f f i c u l t i e s Concerning the I l l n e s s ; There i s considerable filfficulty diagnosing rheumatic fever In mild or beginning manifestations, and i t i s contended that part of the decline i n numbers recorded of those children having the i l l n e s s may be an outcome of greater understanding of the disease, more accurate tests and examination procedures, and thus more v a l i d diagnoses. In other words, present 1 Loc. c i t . . , D i s t r i b u t i o n by age i n years Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Total 1941 - — 1 2 2 2 2 2 11 2 4 3 3 5 1 — 2 - ~ 2 44 1942 - — 1 3 1 2 4 1 3 5 6 3 2 5 3 4 2 1 - - - 46 1943 — — 1 — 4 6 6 6 7 4 5 4 4 3 4 2 2 1 ^ - 59 1944 - 2 2 8 14 7 9 9 16 9 13 7 11 9 10 9 5 5 3 2 150 1945 - — 4 7 6 4 15 9 6 8 11 6 3 4 12 3 4 _ - - 103 1946 — - 4 3 7 6 4 3 9 7 3 6 4 4 3 7 2 4 - ~ 76 1947 - 2 9 3 6 7 3 7 3 7 8 7 6 , 3 1 - - 2 74 1948 • — 2 3 2 8 8 3 8 5 3 7 2 6 3 1 1 2 - - 64 Total* 2 15 28 45 38 55 40 63 47 48 43 37 43 42 29 19 13 3 6 616 Table 1 • D i s t r i b u t i o n by age in years of rheumatic fever cases (including "possible II and "inactive" cases) for the years 1941 to 1948, in the Eastern Area of the State of Washington. -11-s t a t i s t i c s are more/accurate, and more representative of the actual extent and frequency of those rheumatic fever cases diagnosed authentically as such, rather than included as possible or probable cases of the i l l n e s s . Treatment has of course improved, as have preventive measures. C l i n i c a l Features of the I l l n e s s ; The systemic phenomena of rheumatic fever are usually fever, increased blood sedi-mentation rate, leukocytosis, loss of weight, anaemia, a general f e e l i n g of malaise and fatigue, followed by growing pains and swollen, p a i n f u l j o i n t s . Eventually, heart damage may ensue, and the patient then faces a l i f e of c u r t a i l e d physical a c t i v i t y , f o r he has become a member of the league of s i m i l a r l y stricken persons often c a l l e d "the c r i p p l e s who do not limp." When observing a group of rheumatic fever pa-t i e n t s , one i s f o r c i b l y struck by the pallmr of these c h i l d -ren, and also a certain ennui and placidness that can vanish with miraculous r a p i d i t y , but s t i l l return with f a i t h f u l consistency. Besides the physical r e a l i t y factor that anemia i s a frequent accompaniment of rheumatic fever, the s o c i a l worker i s always aware that these are t r u l y sick children; that these are more than usually deprived c h i l d -ren. Many youngsters have underlying fears and misgivings about the nature of t h e i r i l l n e s s , and the reasons why i t has attacked them as i n d i v i d u a l s . S e n s i t i v i t y and under-standing of such factors when the c l i n i c a l features of rheumatic fever are discussed are the bases of medical -12-s o c i a l casework and the I l l n e s s . General Treatment and Routine Care: Methods of actual treat' ment i n rheumatic fever are changing constantly. The i l l -ness generally has alternating phases of acute and quiescent nature. Certain drugs are used to modify or control these manifestations, and the s a l i c y l a t e s have been i n most common usage. Amidopyrin and cineophen are also used to r e l i e v e ' pain, fever, and malaise. With acute p o l y a r t h r i t i s , s a l i -cylates seem to be almost a s p e c i f i c . General routine care of the rheumatic fever patient (either with or without chorea) Includes s t r i c t adherence to n u t r i t i o n a l requirements (such asjthe usual ones of low c a l o r i e , high protein diet and adequate vitamin intake); rest and curtailment of physical a c t i v i t i e s as i n -dicated i n each i n d i v i d u a l case; and careful watch f o r i n -sidious beginning symptoms of a recurrence of the sickness. From the s o c i a l worker(s point of view, environmental man-ip u l a t i o n may be advisable i n working out plans with the doctor and nursing s t a f f , and also supportive casework or other suitable therapy with the patient and h i s family to comply with Individual needs. A sample of the/routine order sheet compiling written instructions f o r parents or others who w i l l be re-sponsible f o r the patient's convalescent, post-hospital care, i s ind i c a t i v e (Table 2) of routine program advice. These directions were prescribed i n the case of "Jessie K.", -13-1. She i s to remain i n bed except f o r 1^ hours during the morning and l | r hours during the afternoon. 2. She may walk to the t o i l e t providing t h i s i s on the same f l o o r l e v e l . 3. She i s not to sleep i n the second storey l e v e l and have to walk up and down s t a i r s . 4. Not to go outdoors yet. Not u n t i l further N o t i f i e d by s o c i a l worker. 5. A l l sugars and sweets such as honey, jam, j e l l y , canned f r u i t s , candy, and syrup are to be very l i m i t e d . She i s not to have chocolate i n any form. No nuts and peanut butter. 6. Drink up to 1 quart of milk d a i l y but not more. 7. Limit a l l r i c h foods such as pork, greasy gravies, pastry, etc., to very small amounts. 8. Limit starches such as potato, r i c e , macaroni and spaghetti to once d a i l y . 9. Stress the whole wheat breads and cereals, an abun-dance of vegetables, cheese, eggs and meats. 10. She i s not to do any physical work excepting that which can be done i n the r e c l i n i n g or s i t t i n g p o s i t i o n . 11. Not to run or play physical games. 12. In bed and go to sleep not l a t e r than 8:30 at night. Following her time up i n the morning between 9:30 and 11:00 she should be i n bed f o r lunch and then may be up between 2:00 and 3:30 p. m. and In bed f o r the b a l -ance of the time. The above program i s not to be altered ex-cepting at the parent's and chil d ' s r i s k . We can not be with you andfcnust depend upon your honesty, s i n c e r i t y , and i n t e g r i t y to follow these d i r e c t i o n s . Signed: ..... (doctor). Table 2. A sample of the routine convalescent regime pre-scribed by the physician. This p a r t i c u l a r one had been adapted to the needs of Jessie K.. -14-one of the choreic patients i n the present survey, whose diagnosis was "rheumatic fever and chorea." The doctors also noted that she had a d e f i n i t e heart murmur. In prophylactic therapy, sulfanilimide and p e n i c i l l i n have been used, and the l a t t e r has been supplied when necessary through the cooperation of the Spokane County Welfare and County Health Department to many of the c h i l d -ren served by the Rheumatic Fever Program at Spokane. Sydenham1s Chorea: The c l i n i c a l features of Sydenham's chorea were described and named by S i r Thomas Sydenham la t e i n the seventeenth century. It i s "A disorder of the nervous system characterized mainly by involuntary jerking movements of the muscles throughout almost the entire body 1 ...". Further, regarding the o r i g i n of the name, St. Vitus dance: This name was o r i g i n a l l y applied to epidemic outbursts of mental and physical excitement which occurred among the inhabitaaits of some parts of Germany i n the middle ages. Sufferers from th i s dancing mania were wont to resort to the chapels of St. Vitus (more than one i n Swabia), the saint being believed to possess the power of curing them. Fright, i l l - u s a g e , i n -s u f f i c i e n t feeding, overwork or anxiety, are among the most common exciting causes es p e c i a l l y when associated with family tendency to nervous disease; occasionally i t complicates pregnancy. 2 Etiology of Chorea and Casework Approach to the Problem: Although doctors speak of ehorea as being either of physi-1 Encyclopaedia B r i t t a n i c a , Volume 19, Chicago, Ency-clopaedia B r i t t a n i c a , Inc., p. 863. 2 Loc. c i t . . -15-c a l or of psychogenic o r i g i n , such a dichotomy i n diagnostic thinking i s erroneous i n i t s l o g i c . It i s more correct simply.to describe every case of chorea as having both i t s physical and i t s psychogenic factors i n e t i o l o g i c a l consid-erations, although one or the other of these may be primary. Physicians are apt to recognize a l l i l l n e s s as of physical o r i g i n , and when no physical basis i s apparent, to presume that i t must therefore be of psychogenic o r i g i n . Thus, such a case may be referred to a p s y c h i a t r i s t , and i f the p s y c h i a t r i s t cannot explain the i l l n e s s on a psychological basis, thejtwo experts of d i f f e r e n t f i e l d s reach an impasse. This was so i n the case of Marlie P. , which i s related i n considerable d e t a i l i n a l a t e r chapter. However, as was clear i n t h i s case, s t a t i c psychiatry does not appreciate the f u l l y rounded picture of psychosomatic reactions that i s revealed through dynamic or psychoanalytical theories of the t o t a l personality. The solution to such an impasse, and basis f o r constructive treatment of such cases, l i e s i n the dynamic approach, both i n psychiatry and i n casework. Sydenham's chorea, popularly known as St. V i t -us dance, has come to be recognized more and more as having d i s t i n c t psychogenic aspects and d e f i n i t e psychological components as to i t s o r i g i n . Although i t sometimes occurs as an apparent entity, Hnd without other detectable mani-festations of i l l n e s s , chorea i s generally recognized as one of the symptoms of rheumatic fever, even when i t i s but one of other symptoms of t h i s disease present at the time -16-of diagnosis. Sometimes, however, a contrary opinion i s ex-pressed, and i t i s i n t h i s connection that Kagan and Mirman state: Chorea associated with an increased erythro-cyte sedimentation rate i s i n most instances a manifestation of active rheumatic fever. Pat-ients, on the other haild, who have t h e i r f i r s t episode of chorea with a normal sedimentation rate (in the absence of cardiac f a i l u r e ) do not have rheumatic fever and are no more sub-ject to i t s sequelae than are other members of the population. 1 Although Kagan andJMirman do not attempt to est a b l i s h the etiology of the nonrheumatic chorea they delineate, they do state that psychogenic factors appear to be much more prominent i n t h i s form of chorea than i n that of decided rheumatic a f f i l i a t i o n . Sydenham's Chorea and Heart Damage: Sydenham's chorea seems to act as a sort of safety-valve as f a r as rheumatic c a r d i t i s i s concerned, f o r f a r l e s s heart damage occurs i n children with chorea than does i n those who have other symptoms of rheumatic fever, such as p o l y a r t h r i t i s . Jones and Bland, i n r e l a t i n g the incidence of heart disease to the manifestations of rheumatic fever, compared the incidence of heart disease with subjects i n whom the only recognizable manifestation of rheumatic fever was chorea with the incidence of heart d i s -ease i n a series of patients who exhibited 1 B.M. Kagan, and B. Mirman, "Sydenham's Chorea, a Syndrome f o r D i f f e r e n t i a l Diagnosis," Journal of Ped- i a t r i c s , v o l . 36 (June to December), 1947, p. 330. -17-any of i t s other manifestations. The low In-cidence of heart disease (3 per cent) i n the subjects experiencing chorea alone i s s t r i k i n g . " £ Emotional Components of the I l l n e s s : The very physical violence of Sydenham's chorea seems to indicate a r a d i c a l need of the patient f o r emotional and physical release. It i s a permissable expression of forbidden impulses, and through t h i s medium the c h i l d can strifce out, unchastised, at those who have been the source of h i s denial, and craving love and dependence, can frighten h i s parents into s e r v i l i t y and protectiveness through h i s drooling, foolish-seeming grim-aces. The submissive, repressed c h i l d may reach such a state of being unable to tolerate repression any longer, but what may appear as a tantrum i n a les s repressed c h i l d , may be found through a more s o c i a l l y acceptable expression such as hyster i a , convulsions, or a reaction such as Syd-enham's chorea, i n another. Psychosomatic symptoms i n c h i l d -hood may d r a s t i c a l l y and traumatically modify the environ-s' ment i t s e l f . Medical Treatment of Chorea: With chorea, sedation i s im-portant so that the patient w i l l be relaxed as much as pos-si b l e from the exhausting movements which are symptomatic of the disorder. Phenobarbital i s frequently employed, and i f so, so c i a l workers may often help parents by explaining 1 Wilson, op_. c i t . , pp. 248, 249. 2 Lester W. Sontag, "The Genetics of Differences i n Psy chosomatic Patterns i n Childhood," American Journal of Or- thopsychiatry, v o l . 20, no. 3, (July, 1950), p. 480. -18-that the drug does usually slow down and temper a l l actions and reactions, so that the c h i l d may seem sluggish, d u l l , and even stupid. Alarm as to an apparent mental retard-ation by the effects of the i l l n e s s (which parents fear i n any case with the f a c i a l contortions of chorea) may thus be prevented and fears allayed. A r t i f i c i a l fever therapy, by intravenous i n -jections of t r i p l e typhoid waccine, has been adopted i n the treatment of chorea. One of the cases i n t h i s study, that of Marlie F., was treated by t h i s method, and at the most viol e n t periods ether was administered i n order to arrest or modify muscular writhings. Death through sheer exr haustion from involuntary movements i s not unprecedented. Summary of the Chapter; The objective of t h i s chapter has been primarily that of presenting some idea of the stimulus that gave the study impetus and ways i n which material was assembled, together with a general background survey of the subject i n general, and e s p e c i a l l y including both h i s t o r i c a l and contemporary medical aspects of rheumatic fever and chorea. Focus was maintained on the fa c t that t h i s i s a study of psychogenic features with regard to a medical prob-lem, and following this, the s o c i a l work components of rheumatic fever and chorea were brought out from time to time. The caseworker, f a r from attempting pseudo-psychiatry, works from the same dynamic bases as the psy-c h i a t r i s t i n understanding the human personality and re--19-actions, and casework methods should be i n s t i t u t e d upon sound, ever-reevaluated d i f f e r e n t i a l diagnoses, with the guidance of the p s y c h i a t r i s t where necessary. The present study was undertaken with t h i s point of view i n mind. Thus, the s o c i a l worker must recognize the s o c i a l and emotional, the psychogenic aspects of chorea, and relate these to the physical symptoms, then work out treatment plans according-l y , c a l l i n g f o r p s y c h i a t r i c consultation and aid as i t i s needed. This i s her function i n the partnership of the r e h a b i l i t a t i v e team. -20-CHAPTER I I . A STATE (REGIONAL) PRQGBAM. Because of i t s magnitude as a ravaging c h i l d -hood disease, and because of i t s force as an economic threat to the families whose children contract the i l l n e s s , the problem of rheumatic fever has been given nation wide study and consideration i n the United States of America, with a view to i n s t i t u t i n g comprehensive preventive and r e h a b i l i -t a t i v e measures. The P i l o t Projects: After a survey had been undertaken by the American Association of Paediatricians, the Children's Bureau of the Federal Department of Labour and Industry administering crippled children's services, decided to es-t a b l i s h rheumatic fever programs at strategic points through-out the United States of America. Twenty such programs now exist, and since the State of Washington showed a high per-centage of Rheumatic fever cases existent at the time the projects were i n i t i a t e d , one was centred there. O r i g i n a l l y planned for l o c a t i o n somewhere along the coastal area of the state, the program i s said to have been moved to Spokane and i t s environs when an exploratory survey revealed the fa c t that there was a f a r higher incidence of the i l l n e s s i n the eastern part of the state than i n any other region. Although i t has existed since 1941, t h i s program i s s t i l l c o r r e c t l y termed a "demonstration project." The case i n favour of the p i l o t project per -21-se i s indisputable, but i t i s an experiment rather than a measure. In th i s case i t i s an experiment i n protection rather than a protective measure, so that somewhat c u r t a i l -ed coverage i s in e v i t a b l e . Actually, i t i s e a s i l y surmised that the program would have proven well located anywhere else i n the state a f t e r ten years' t r i a l , and because of l i m i t e d funds and scope necessary i n a t r i a l project, naturally many active cases of the i l l n e s s had to be refused t h i s p a r t i c u l a r f a c i l i t y . It i s a sound, practicable program i n many ways, and the p o s s i b i l i t i e s 6or u t i l i z a t i o n are l i m i t l e s s , but present economic d i s t r i b u t i o n prohibits a state or federal provision of such a program on a t o t a l scale. I n i t i a t i o n of the Eastern Washington State Program: Thus services for crippled children i n eastern Washington were o r i g i n a l l y i nstigated through the federal enactment of the Social Security Act of 1935, and under the aegis and spon-sorship of the state services f o r crippled children, a number of rheumatic fever programs were begun i n the United States of Amerlcal about 1940. The Social Security Act authorized grants-in-aid to be provided by the federal government f o r the states, which were i n turn to develop both sftate and l o c a l services f o r ; (a) c h i l d welfare, (b) maternal and c h i l d health, and (c) crippled children. In 1946, an amendraBnt to the Social Security Act provided for an annual federal appropriation of $7,500,000 f o r the -22-extension and iigprovement of the state services f o r crippled children. These services are now available i n every state of the Union, as well as i n the D i s t r i c t of Columbia, Alas-ka, and Hawaii. They are primarily to provide medical, sur g i c a l , and corrective services to children who are c r i p -pled, or suffering from i l l n e s s e s that lead to c r i p p l i n g , and also to o f f e r such children diagnostic, therapeutic, h o s p i t a l i z a t i o n , and convalescent f a c i l i t i e s . The pre-ventive aspects of these c r i p p l i n g disorders are also re-ceiving increasing emphasis and attention. S p e c i f i c a l l y , the rheumatic fever program i s one of four such organized plans sponsored by the state services f o r crippled c h i l d -1 ren. Subsidization of the Regional Rrogram; F i n a n c i a l l y , the State Services for Crippled Children are subsidized through funds made available by federal and state departments, and in:.mat;chedup.ro^ortions. However, the county, and even the municipality, p a r t i c i p a t e i n the Eastern Area Rheumatic Fever Program, but mainly through the maintenance of a nursing s t a f f . The public health nurses supplied by the county are extremely aetive i n a teaching and p r a c t i c a l nursing capacity, and the v i s i t i n g nurses association of 1 Those f o r cerebral palsy, conservation of hearing, and orthopaedics, comprise the other three. 2 During the f i s c a l year Julyjl, 1948 to June 30, 1949, the municipality contributed $16,000 s p e c i f i c a l l y to the rheumatic fever program, but t h i s i s a casual rather than regular donation, actually betokening l o c a l awareness of advantages of t h i s state-federal project centred i n Spokane. -23-Spokane municipality, together with the school nurses, work cl o s e l y with those patients within t h e i r p a r t i c u l a r areas. A f u l l time n u t r i t i o n i s t i s employed by the county, also, and supplies a valuable function i n remedial and preventive care f o r the rheumatic fever patient. A careful budget i s maintained with state d i r e c t i o n as to a l l o c a t i o n and allotment of funds. The cost of t o t a l care f o r the rheumatic fever patient i s v i -t a l l y important to the family involved, and also to the community, county, state, and country as a vhole. Actual 1 per diem cost of h o s p i t a l eare alone i s $17.20, and since the average length of stay f o r the rheumatic fever patient has been conservatively estimated at ninety days, t h i s cost would usually be about f i f t e e n hundred do l l a r s per person f o r each attack of the i l l n e s s . Many youngsters remain i n h o s p i t a l f o r s i x months or a year. A sample budget (see Table 3) reveals that state and l o c a l f i n a n c i a l p a r t i c i p a t i o n i s only about two-f i f t h s that of the t o t a l expenditure anticipated f o r the f i s c a l year, so that greater p a r t i c i p a t i o n on t h e i r behalf may be expected i n other programs In order that " f i f t y -f i f t y " sharing of state and federal f i n a n c i a l r e s p o n s i b i l i t y may be maintained. As i n a l l other ramifications of the program, s t a t e - l o c a l cooperation i s also of the utmost im-portance. 1 i . e . In October, 1950, at St. Luke's Hospital, Spokane. -24-Item D e s c r i p t i o n Amount o f r u n d s Kee-e s s a r y S s a t e and L o c a l A l l o -c a t i o n o f Funds F e d e r a l A l -l o c a t i o n of Funds P a e d i a t r i c i a n ( P a r t t i n e ) •$ 3,600 — • I P 3,600 P a e d i a t r i c i a n ( F a r t t i m e ) & 1,800 $ 1,K)0 — S e n i o r M e d i c a l S o c i a l Worker | 4,080 $ 4,080 P r i n c i p a l C l e r k $ 2,820 5 2,820 J u n i o r C l e r k S t e n -o g r a p h e r $ 2,280 -- .* 2,280 S a l a r y I n c r e m e n t s 1 375 -- § 375 M e d i c a l and S u r g i c a l C o n s u l t a t i o n $ 250 : i ? 250 C l i n i c Fees . $ 150 * 150 T r a v e l F e e s 1 150 -- $ 150 H o s p i t a l i z a t i o n $54,730 $20,135 $34,645 ; S u n d r y M e d i c a l $ 1,500 — $ 1,500 O f f i c e F u r n i t u r e & E q u i p m e n t $ 150 — _ $ 150 T o t a l s • $71,935 #21,935 •1?50,000 Table 3. Sample Annual Budget, Rheumatic Fever Pro-gram, Eastern Area State of Washington Services f o r Crippled Children. 1 1 Taken from unpublished monthly s t a t i s t i c s of Eastern Area, State of Washington Maternal and C h i l d Health and Services f o r Crippled Children Section, Rheumatic Fever Program, for the twelve-month period of July 1, 1950, to June 30, 1951. E l i g i b i l i t y f o r Program Care; Because i t Is yet a demon-st r a t i o n project, and because f i n a n c i a l support i s minimal, the program services are l i m i t e d to those children who are 1 residents of either Spokane or Whitman counties. Any c h i l d from the approved area, who i s un-der the age of twenty-one and suspected of having rheumtic fever or any of i t s sequelae, regardless of f i n a n c i a l s tat-us, may have an i n i t i a l examination under the auspices of the program. Those requiring further care are offered the f u l l service of the program, and make f i n a n c i a l contribu-t i o n according to t h e i r a b i l i t y . As already indicated, few persons can afford the expense of long h o s p i t a l sojourns f o r t h e i r children, yet long term care i s frequently i n e v i -table i n the treatment of childhood rheumatism and i t s accomanying manifestations. Physicians' services, electro-cardiogram reports, laboratory reports, are but a few of the necessary expenditures f o r the family while t h i s i l l n e s s runs i t s course. The program i s not geared to the needs of the indigent only; i t i s a health measure primarily, rather than an economic one. Administration of the Program: The Director, State of Washington Department of Health, with h i s assistant, i s responsible f o r administering and enforcing the public health provisions of the state. Thus, the Health Department i s governed by a single executive who may have been selected 1 See Fig. 2, p. 26 -26-•2B-either by the Governor of the State or the State Board of Health. The State Board of Health, i n turn, has as i t s chairman the State Director of Health, and i t includes four other members who are appointed by the Gov ernor, with the cogsent of the Senate. Locally, health units In the State of Wash-ington function autonomously, but take advantage of the ad-visory and consultative service of the state department. However, certa i n services are c a r r i e d out more d i r e c t l y through the state o f f i c e , and among these are public health s t a t i s t i c s , tuberculosis diagnostic c l i n i c s , h o s p i t a l plan-ning and develppment, l i c e n s i n g of maternity homes and hos-p i t a l s and private p s y c h i a t r i c h o s p i t a l s , i n d u s t r i a l hy-giene, public health services f o r crippled children, cere-bral palsy, and the rheumatic fever control purogram. (See Fig . 2). Location of Offices: The main administrative o f f i c e s f o r the Eastern Area, State Services f o r Crippled Children, are located i n the County Health Unit Building, which i s ac-t u a l l y an appendage of the County of Spokane Court House. Here the rheumatic fever program, under state j u r i s d i c t i o n , i s created and administered; and here the l i n k between the federal s o c i a l security plansefor the general populace and actual i n d i v i d u a l service to e l i g i b l e persons i s forged. St. Luke's Hospital, a private i n s t i t u t i o n which contracts to care f o r those rheumatic fever patients who require h o s p i t a l i z a t i o n , i s situated two miles from the -28-t i o t-Ij u tt 0 r*~T ii o C o Z • 7 f- « " it o 0 2 ; It r 5 HOURS' H4.-)V3H "TWI iJ-A-S r>a Nl V i v s H a n u s ^ ~>bN\s*d.*t4 NO I ^ ,3*3 noyXNo_j 3S**3S'a 3ifMPbMB Q 4 ft c I T x V 4 « to x V-z u T v-<c tl. u o -29-town, i n quiet and pleasant surroundings. There i s also a six-bed convalescent wing i n the paediatric ward of thi s h o s p i t a l which i s reserved for rheumatic fever patients. 1 The Rheumatic Fever C l i n i c meets i n the nurses' t r a i n i n g quarters adjoining the h o s p i t a l . The e i t y of Spokane, and community which formed a background f o r t h i s study, i s the foc a l point not only f o r the county, but also f o r the whole Eastern Area of the State of Washington. It i s the c a p i t a l of the so-called "Inland Empire," an i n d u s t r i a l and p o l i t i c a l d i v i s i o n including Eastern Washington, Idaho, and Montana. The main industry i s farming, but there are several t h r i v i n g subsidiary i n -dustries. Many mining v i l l a g e s are nearby, also a large aluminum reduction plant and a substantial naval supply depot, as well as many small f a c o t r i e s . Religious i n -fluence i s strong i n t h i s c i t y and i t s environs, and the larger i n s t i t u t i o n s are sponsored by r e l i g i o u s organizations, 2 such as a l l three of the h o s p i t a l s , many of the schools, and the three colleges. Services of the Program: The services offered by the pro-gram, which are many and varied, may be c l a s s i f i e d under eight general headings. (1). S k i l l e d paediatric care. Each year a salary of $5,600 1 i . e . Out-patient service. 2 One being Roman Catholic, one Methodist, and the other Presbyterian. -30-i s expended f o r the part time services of a chief p a e d i a t r i -cian. He has an assistant, also employed on a part time basis. These two doctors are responsible to the program f o r the medical care of the children i t serves. They make "ward rounds", or v i s i t the h o s p i t a l i z e d patients, on one morning weekly four times every month, and on other occa-sions as the need arises. During these scheduled mornings, the doctors also serve i n the Rheumatic Fever C l i n i c . Patients are usually referred by t h e i r own l o c a l physicians, by public health, v i s i t i n g , or school nurses, or by the county health doctor.-~ {2), Nursing care. Complete p r a c t i c a l nursing f a c i l i t i e s are afforded through hospital care, and the services of v i s i t i n g , school, and public health nurses are at a l l times available to patients of the program fo r advice, actual p r a c t i c a l service, and general follow-up care. The nurse active i n each case r e f e r r a l also completes a Referral and C l i n i c Report Form, which provides a b r i e f medical hi s t o r y of the patient referred for the convenience of the medical 1 s t a f f and i n order to f a c i l i t a t e treatment. ( 3 ) . N u t r i t i o n a l advice. Both i n the hospital and as an out-patient v i s i t i n g the c l i n i c , the rheumatic fever pat-ient i s given extensive advice and consultative service 1 See Appendix A. -31-by a n u t r i t i o n i s t . This i l l n e s s oftentimes necessitates such a r a d i c a l l y c u r t a i l e d program of physical a c t i v i t y f o r i t s subjects, that a high-protein, low-caloric diet i s es-s e n t i a l , and n u t r i t i o n a l t r a i n i n g and r e - t r a i n i n g of the patient and h i s family i s frequently necessary. (4) . Hospitalization.- H o s p i t a l i z a t i o n i s available to every patient e l i g i b l e under the program requiring i t , and of course includes a l l h o s p i t a l f a c i l i t i e s , and those medi-cines generally supplied as a part of such care. ( 5 ) . Out-patient c l i n i c service. The out-patient c l i n i c meets once each week, and provides valuable diagnostic and follow-up service to the patients. Again paediatric, nurs-ing, s o c i a l service, and n u t r i t i o n a l advice i s available, as well as electrocardiograms, laboratory work, and X-rays. Medicine such as p e n i c i l l i n , ferous compounds, s u l p h a n i l i -mides, and so on, as ordered by the paediatrician, may be provided according to f i n a n c i a l need through the County Welfare Department. Special diet requirements also ne-cessitate application f o r f i n a n c i a l help from t h i s agency on occasion. Deserving fringe cases may be deprived be-cause of borderline f i n a n c i a l i n e l i g i b i l i t y , but such i s often the ease i n modern embryonic s o c i a l security measures. (6) . Medical Social service. In accordance with the p o l -i c i e s set by the administrators of the program, the med-i c a l s o c i a l worker i s generally requested to enter a case s i t u a t i o n whenever f i n a n c i a l , s o c i a l , or emotional problems -32-arise with regard to a patient. This includes both the h o s p i t a l i z e d in-patient and the out-patient. Thus, medi-cal s o c i a l service i s available to those who require and wish i t , and where the service needed exceeds the province of the medical s o c i a l worker attached to the program, re-f e r r a l to other appropriate agencies i s negotiated. This service promotes cohesion of the program with i t s sertices to the patient as well as those of c o l l a t e r a l professional or lay groups of the communities.concerned. In t h i s program, the medical s o c i a l worker i s expected to complete the Agreement of Parents or Guardians for Care of Crippled Child form, and also to est a b l i s h 1 e l i g i b i l i t y f o r treatment. As with other parts of the program, there i s state supervision of the socialsservice department by an i t i n e r a n t representative of the state o f f i c e s c e n t r a l l y located i n Seattle. (7). S t a t i s t i c s . Although not a d i r e c t service to the rheumatic fever patient and h i s family, s t a t i s t i c s are nonetheless important i n general program planning f o r the present and the future. One example of these s t a t i s t i c a l records i s the r e g i s t r a t i o n of a l l crippled children, where-i n every crippled child's name, together with h i s age, sex, race, residence, diagnosis and date of r e g i s t r a t i o n , i s re-1 Ibid.. -33-1 corded on a Crippled Children's Registration Card. Thus geographical and climatological frequency d i s t r i b u t i o n of an i l l n e s s , age d i s t r i b u t i o n , r a c i a l d i s t r i b u t i o n , and other pertinent material may be compiled i n the journals of the state and federal departments of health. ( 8 ) . Mental health. A l l members of the program endeavour to encourage good mental health attitudes concerning rheum-a t i c fever and i t s victims. A newly organized group meeting of a l l the parents and guardians attending rheumatic fever c l i n i c with t h e i r children has been formed, and various members of the program outline t h e i r p a r t i c u l a r functions to the meeting, answering any questions that may arise at th i s tiime. This i s an outstanding method of extending both prophylactic and therapeutic services, and c e r t a i n l y con-ducive to improved emotional adjustment to i l l n e s s among rheumatic fever f a m i l i e s . A fellow s o c i a l worker was ex-tremely active i n the i n s t i g a t i o n and formation of t h i s group-work experiment, and i t i s good that such stimulation i s forthcoming farom the s o c i a l service department. Au x i l i a r y Services: Special services such as consultations with other doctors, including p s y c h i a t r i s t s and surgeons, (and treatment services of these doctors i f necessary), e-lectrocardiograms; transfusions; dental and o p t i c a l work; and any other service v i t a l to the recovery of the patient, may be included i n the general care provided by the prqg ram. 1 Loc. c i t . . -34-C o l l a t e r a l Services U t i l i z e d : There are also a group of c o l l a t e r a l services frequently requested by the program. The municipal school teacher, supplied by the l o c a l depart-ment, offers part time services tolelementary and some high school grades f o r a l l h o s p i t a l i z e d children, as well as those who may be convalescing or i n a state of chronicity at home. Thus rheumatic fever patients are served along with a l l other p h y s i c a l l y handicapped children i n the munici-p a l i t y . In order that active minds i n enforcedly inactive bodies may be kept interested and animated, and i n order that school work may be maintained at a standard as nearly possible commensurate with the patient's age l e v e l , t h i s teacher i s a c t i v e l y employed every morning of the school-day week. Other s o c i a l agencies are also c a l l e d upon f o r l i a i s o n work with members of the program. The Family Society, a family casework agency, offers a valuable f a -c i l i t y to both patients and t h e i r fan H i e s i n follow-up and preventive treatment not possible through the program s o c i a l service department; and the value of assistance from the County Welfare Department i n placement and f i -nancial capacities has already been recognized. Many other agencies, such as the Young Men's Chri s t i a n Association, Young Women's Christian Association, Traveller's Aid, Central Referral Bureau, Spokane Children's Home, Washing-ton Children's Home, and so on, may also render assistance as a part of t h e i r own special services and functions. - 3 5 -A single volunteer also donates her serviees to the program as a p a r t i a l l y trained occupational thera-p i s t or recreational leader. This i s a part of the t o t a l service she offers to the ho s p i t a l as a whole about one f u l l day per week, however, so that i t i s minimal, and only an attempt to i n i t i a t e some occupations f o r those most i n -terested i n her of f e r of assistance, and those best able to u t i l i z e the p a r t i c u l a r s k i l l s that she makes available. Summary of the Chapter: In summarizing the chapter, and commenting ofl the e f f i c a c y of program services, several general suggestions can be made, although i t i s beyond the purpose of the thesis to present a conclusively c r i t i c a l and detailed analysis of the project. Actually the fore-going description has stressed i t s p o s i t i v e values and a-vai l a b l e advantages, so that some i n d i c a t i o n of negative aspects with constructive recommendations f o r strengthening program service should properly be included. (An o f f i c i a l statement of program p o l i c y and service i s attached to the 1 appendix). This nation-wide pain for the care of patients suffering from childhood rheumatism i s sound and far-reaching i n many ways, and being a jbilot project, s t i l l f l e x i b l e and capable of adjustment. The emphasis i s consistently main-tained on the medical features, and more/eonsideration of 1 See Appendix B. -36-s o c i a l and emotional components would be wise. This would be i n l i n e with the greater recognition i n contemporary medical thinking of the psychosomatic appaoach to I l l n e s s . Appreciable strengthening of the s o c i a l service function would be one way of achieving t h i s objective; and extension of home care f a c i l i t i e s another. Carefully chosen Volunteers could f i l l an im-portant need f o r someone to read to the children, play games with them, perhaps, and just v i s i t . Such volunteers should be selected with care and understanding, however, and after gradual induction into program p o l i c i e s and objectives. A trained occupational therapist could also f u l f i l a valuable function, for she, too, provides the children with an out-l e t f o r pent-up physical and emotional aggression. No home v i s i t s are made by the paediatricians, so that the patient occasionally suffers some hardship i n making the journey to the c l i n i c f o r medical advice. In fact the nurse i s usually the only one who sees the c h i l d i n h i s home, and with an extension of services i t i s hoped that the so c i a l worker would make more home v i s i t s a part of departmental function. In the case of an acutely i l l c h i l d not yet admitted to the care of the program, a private physician must be engaged by the family i n order that the i n i t i a l diagnosis may be made and treatment begun before r e f e r r a l i s possible. Thus, as occurred i n feome 4»f the cases studied here, an acutely i l l c h i l d may be ho s p i t a l i z e d by a private -37-physician i n the i n s t i t u t i o n of h i s choice, then of necessi-ty transferred to St. Luke's Hospital f o r treatment under the rheumatic fever program when diagnosis i s confirmed and the family r e a l i z e s that expense of complete medical care would be p r o h i b i t i v e f o r them. From a monetary point of view alone, and be-cause the numbers of children attending c l i n i c s are i n -creasing so rapidly, the suggestion i s made that i t might prove advantageous f o r the one part-time physician to per-form ward rounds and c l i n i c duties on two separate days each week, instead of crowding many v i t a l duties into one morning. Anxious parents, and some rather sick and anxious children, would thus receive a more accomodating and ex-peditious service. The substantial salary would seem ade-quate f o r t h i s expected extension of service. Theu use of a u x i l i a r y f a c i l i t i e s i s not i d e a l , (and one case was observed of a choreic c h i l d who had to await approval of an o f f i c e secretary before orthodontia work could be approved as a necessary part of program ser-v i c e ) , but i t i s a beginning, and with better organization and extension should be quite e f f e c t i v e . The provision of good ps y c h i a t r i c consultation f o r doctors, and p a r t i c u l a r l y f o r the s o c i a l service department, i s strongly recommended. 1 (Such consultation i s r e a d i l y available i n t h i s community). 1 i . e . At time of writing, v i z . , December, 1950. -38-F i n a l l y , concerning the medical s o c i a l service department, with ever-Increasing demands, the s o c i a l worker who serves t h i s program (which i t must be remembered i s only one of four services f o r c r i p p l e d children i n thi s area), i s compelled to o f f e r s o c i a l service to the extent of the time available, rather than to the extent of the need f o r service. Actually, t h i s has been a most d i f f i c u l t charge to f u l f i l , and the Spokane Rheumatic Fever Program medical s o c i a l ser-vice department i s indeed weak i n comparison with medical services available to i t s patients. One way of r e l i e v i n g the department f o r provision of more s k i l l e d professional duties, would be the transfer of administration of routine procedures such as completion of special report forms and the e l i c i t i n g of information regarding w l i g i b i l i t y of pa-tie n t s f o r treatment, to an admitting o f f i c e r . I f con-sidered necessary, supervision and special assistance from the s o c i a l service department could be afforded t h i s admis-sion clerk. Some s p e c i f i c comments regarding foster home placement of sick children are necessary, as i t was ob-served that t h i s service was not always well administered by the program. Unfortunately, a l l too often a physician a r b i t r a r i l y "orders", or prescribes, a fos t e r home f o r a c h i l d because s u p e r f i c i a l observation of h i s patient's home setting leads the doctor to conclude that i t i s unsuitable, (usually mainly from a physical point of view). A case was witnessed i n which a doctor made such an order rather -39-casually while doing h i s routine ward rounds, and while examining another patient a few rooms distant from the c h i l d i n question. Such lack of consideration obviously can destroy the well-intentioned thought behind the recommen-dation, and a c h i l d beset with sudden consternation and anxiety may overtax an already weakened heart when h i s pre-paration f o r a change, i f i t were necessary, could have been ca r e f u l l y and sympathetically executed. The medical s o c i a l service department of the program i s overshadowed by medieal aspects of care f o r the patients. Strength of s k i l l and purpose i s never so essential as i n a minority d i v i s i o n a l department of a t o t a l program or i n s t i t u t i o n , and as a comparatively new f i e l d , medical s o c i a l service must be reckoned a minority as related to the program as a whole. -40-CHAPTER I I I . PARENTAL PROBLEMS AND REACTIONS. Every c h i l d f a l l s h e i r to influences i n h i s developing psyche that Dr. Irene Jocelyn has termed a "so-1 c l a l heritage," and she uses the word " s o c i a l " i n a spe-c i a l sense. That Is to say that formative factors i n the child's s o c i a l and emotional l i f e include the sort of people h i s parents are, psychologically speaking, the sort of peo-ple the other members of h i s family c o n s t e l l a t i o n are; i n fa c t , a l l those persons with whom he comes into contact. Parents and parental surrogates are of course primary i n im-portance among these. Parents who are inadequate, emotion-a l l y , those who have excessive dependency needs, those who are extremely r i g i d , those who taay be deemed oversolicitous, as well as those who may have an emotional disturbance of major order; a l l , may promote subsequent emotional c o n f l i c t s i n t h e i r children. A child ' s reactions are i n d i v i d u a l , and predetermined by co n s t i t u t i o n a l and environmental factors also. The reaction may a-ppear i n mainly psychological form, such as a phobia or a psychosis, or i t may appear as a con-version or somatic symptom, such as a duodenal u l c e r or an asthmatic attack. Further, the emotional c o n f l i c t s suffer-1 Irene M. Jocelyn, M.D., Psychological Devel opment  of Children. New York, Family Service Association of A-merica, 1949, p. 15. -41-ed by the c h i l d may be Wholly, or more l i k e l y p a r t i a l l y , responsible f o r setting inmmotion an organic deterioration or disorder of some sort, such as Sydenham's chorea. The s o c i a l worker, recognizing such c o n f l i c t s , endeavours to a s s i s t the i n d i v i d u a l i n resolving them to a maximum degree, thus r e l i e v i n g somatic as well as psychological pressures. Inadequacies i n Parenthood: Some adults and children who become organically i l l , modern ps y c h i a t r i c insights have revealed, have been seeking a s o c i a l l y acceptable means of regressing to a condition of greater dependency. This i s , of course, i n no way a conscious or deliberate motivation. Time and time again i n studying these case h i s t o r i e s , the writer observed that a c h i l d was seeking a refuge, a more sheltered and comfortable environment, a place where fewer and le s s stringent emotional and physical demands would be made upon him. Time and time again i n contemplating the ramifications of the s i t u a t i o n , i t was found that the c h i l d had a r e l a t i v e l y weak ego, andunduly r i g i d superego, a much repressed i d , or i n s t i n c t i v e , drive. He or she was often a submissive c h i l d , eager to please, p l a c i d , i n f a c t the small "major domo" who oftentimes f i l l e d the mother's place i n the home, the youngster whoWas usually a favor!tp when i n hospital because of t h i s very submissiveness, t h i s a b i l i t y to be a "model c h i l d . " Parents frequently remarked about t h e i r c h i l d , "She was always so grown-up f o r her age," or, "She was my right arm," "I never had to worry about her be-fore ... I knew I could always count on her," and, "She was - 4 2 -never any trouble ... she was a good baby; a good c h i l d . " Seventeen of the twenty-five children intthe present study could be said, f o r one reason or another, to have been deprived of adequate feel i n g s of dependency upon t h e i r parents. The c r i t e r i a used i n determining the ade-quacy of such dependency were such factors as: fearfulness i n facing a new situ a t i o n ; apparent wish to be unusually dependent; a need to "be t o l d what to do" that was dispro-portionate to age and emotional l e v e l of development; more than usual uncertainty and over-anxiousness to please. The apparent basis of one c h i l d ' s need may of course be traced to several sources such as these; but allowing f o r t h i s , an endeavour has been made to c l a s s i f y the main beginnings of t h i s childhood problem, a l l of which stem from oparental i n -adequacies. Thorough understanding of parental reactions Is a prerequisite i n understanding those of t h e i r children. (1). Overwhelming parental demands. F i r s t among outstand-ing c h a r a c t e r i s t i c s i s the pattern of the c h i l d who appears i n h i s parents' eyes as t h e i r embodiment of a l l the a t t a i n -ments they had hoped to possess themselves — beauty, b r i l -l i a n c e , altruism, and so on. To some parents, the possession or production of a "successful," well-accepted c h i l d means more to them than t h e i r own ease and comfort, and any un-conscious feelings of g u i l t that they may have f o r expecting t h e i r c h i l d to be a model of perfection are assuaged by the masochism of s e l f - s a c r i f i c e . This i s shown, f o r example, i n the case of Marlene F.. - 4 3 -Marlene was the f i r s t - b o r n c h i l d of* a charm-ing, easy-going father, and t a l l , rangy, rather tense mother, who drove h e r s e l f and her family to meet at least some of the high standards that she set f o r them a l l . Marlene evidently spent an uneventful c h i l d -hood, and was always a "good" c h i l d . As a baby she suffered some a l l e r g i c reactions and had impetigo at three and a h a l f , but Mrs. P. said that efcen during childhood i l l n e s s e s such as measles and whooping-cough, "Marlie" seemed to suffer less than most youngsters. She was never a problem i n feeding or t r a i n i n g , and grew up a clean, ti d y , well-mannered l i t t l e g i r l . Already the picture grows of a baby g i r l brought up to s t r i c t requirements of rearing with l i t t l e lavishment of tenderness and protection i n return. The road that Marlie was to follow was straight and narrow, and con-formity was essential or her mother's displeasure would be a clear i n d i c a t i o n that she was an unsatisfactory, unaccept-able c h i l d . This i s the story of a l i t t l e g i r l wao was a l -ways searching f o r a loving, accepting mother; who was a l -ways endeavouring to earn such a mother through s e l f - d e n i a l and r e s t r a i n t unnatural to a c h i l d . Patty was the only other c h i l d i n the F. family, and she was f i v e years younger than Marlie. Mrs. F. described with considerable •{.-•"'id-pride the s e l f - s u f f i c i e n c y of Marlie before Patty was old enough to play with her — i n entertaining h e r s e l f , t a l k i n g to h e r s e l f , making up games by h e r s e l f . Mrs. F. said that she and her husband both worked, as Mr. F. did.not earn s u f f i c i e n t money to support them, and i n any case was "quite feckless and irresponsible." She remarked once that she was fond of Mr. F., and that f o r the sake of the children she had managed to l i v e with him.-For years she had begged him to f i n d a job, keep i ; . i t , and s t a r t buying a home i n the country, but she had found that instead, any money that she -44-saved was "wasted," Now they had two l i t t l e g i r l s f o r whom to provide, and a l l l i v e d i n housekeeping rooms i n a rather poor section of town. MMrlie's mother more than once t o l d the s o c i a l worker with some bitterness that she did not enjoy working, and i n f a c t much preferred to stay at home with her children, but she could not "permit her family to starve." Mrs. P. (interviewed by the writer i n November, 1$50), was an a t t r a c t i v e woman, but raw-boned and tense, and seeming to have tremendous drive and well-concealed h o s t i l i t i e s . Marlie's story was requested, but the r e c i t a l , r e a d i l y related, was rather of Mrs. P. and her l i f e , i nclud-ing Marlie simply as a small part of i t . She t o l d of her l i f e on a lonely homestead with two e l d e r l y parents whose three other children, a l l boys, were grown up and married when Mrs. P. was but s i x years of age. "I was my mother's change of l i f e , " she said, and c l e a r l y she f e l t that her l i f e had been narrow and lonely. This must, i n f a c t , have been the case. Mrs. F.'s mother had been a cr i p p l e as long as she could remember, but even though she walked with crutches she was always active, always working. It was t h i s maternal grandmother who l i v e d with the P.'s f o r some years, dying when Marlie was nine years old. Mrs. F. also described with considerable drama every d e t a i l of her mother's l a s t hours of l i f e . She made l i t t l e mention of her father. Young Marlie assumed f a n i l y r e s p o n s i b i l i -t i e s barly i n l i f e , taking over the rearing of her younger s i s t e r and doing many of the household chores. When the grandmother came to stay with them, Marlie became quite devoted to the rather domineering old lady. Less than a year af t e r her death, the l i t t l e g i r l devel-- 4 5 -oped infected t o n s i l s , although her family was not aware of her condition f o r about three months, as she was (as usual) uncomplaining and d o c i l e . Eventually, however, they observed that Marlie be-came more and more nervous, began to twitch with the oncoming attack of chorea, and at the same time was experiencing the p a i n f u l , swollen joints symptomatic of rheumatic fever. Mrs. F. became f r a n t i c with apprehension, both concerning the f i n a n c i a l burden of i l l n e s s and special d i e t , and concerning the necessity of nursing Marlie. F i n a l l y , the c h i l d was h o s p i t a l i z e d , and a f t e r some weeks recovered from the choreic attack suf-f i c i e n t l y to resume most of her former a c t i v i t i e s . (In h o s pital one of her chief solaces had been a radio which she had bought with a l i t t l e money l e f t to her by her grandmother. She had chosen i t with some care, and said once that she f e l t i t was almost l i k e having her grandmother to know that the radio was beside her). This case h i s t o r y i s recorded at some length because i t reveals more c l e a r l y than some how much a c h i l d requires some dependency, some firm knowledge that he or she i s loved and approved of by a warm, understanding mother. This i s the case h i s t o r y of a dominant mother who set high standards of conformity f o r h e r s e l f and her children, and evidenced considerable r i g i d i t y under a mask of casual ease of manner. Marlie showed a great attachment f o r her grand-mother, who was also a s t r i c t , dominant person, but one on whom she could count, nevertheless, and one who was i n the home to give her strength, guidance, and essential security. The father was fond of h i s fan i l y , but disapproved of by the mother, and so the children were not free to love him openly as i n s t i n c t i v e l y they must have wished to do, -46-Mrs P. described a l i f e i n which she was s t r i c t l y reared, and one i n which she had f e l t consistently deprived, both before and a f t e r her marriage. A person who experiences t h i s sort of reaction cannot have the abundafct love and acceptance to give to others. It was not hers to give. In July, 1947, one and a h a l f years a f t e r Marlie*s f i r s t choreic attack, Mrs. P. t e l e -phoned the s o c i a l worker i n great consternation. She thought that Marlie was developing choreic movements again, and wished her to be checked by the doctor immediately. The doctor examined her, diagnosed beginning chorea, and advised h o s p i t a l i z a t i o n . Marlie accepted the verdict i n an "adult" fashion, her one fear seeming to be that she might lose the d o l l a r b i l l that her mother had given her to buy groceries. Mrs. F., on the other hand, was again extremely worried, as her husband was out of work and had recent-l y squandered a l l of t h e i r savings i n a venture into the.restaurant business. She said wearily to the s o c i a l worker that she had always t r i e d to present a united front to the l i t t l e g i r l s , had never c r i t i c i z e d Mr. F. before them, and was as cheerful as she could be about prospects when she was talking to her daughters, but Marlie was an i n t e l l i g e n t l i t t l e g i r l who assumed r e s p o n s i b i l i t y r e a d i l y and she f e l t that the chil d ' s i l l n e s s was the res u l t of the past s i x months of inse c u r i t y . It i s elucidating but appalling, from the child ' s point of view, to read how Mrs. F. described the onset of Marlie's second attack of Sydenham's chorea. That the s o c i a l worker did not recognize that the l i t t l e g i r l was expendable i n the drive of t h i s maladjusted mother to get what she wanted i n order to compensate f o r her own deprivations, was unfortunate, f o r interpretation to Mrs. F. of Marlie's f e e l i n g of being pushed too f a r i n attempting to meet parental expectations, and provision of understanding -47-support to the youngster, might well have staved o f f sub-sequent i l l n e s s and accompanying c o n f l i c t s . Mrs. P. said that a f t e r the restaurant venture i n Lewiston, and the return to Spokane, she had had to work f u l l time, and thas was forced to ask Marlie to assume complete r e s p o n s i b i l i t y f o r Patty. Marlie was, she said, "an excellent l i t t l e mother," but the task of watching h e r s e l f and Patty had been too much. Mrs. P. watched her becoming more nervous from day to day, u n t i l f i n a l l y she began the dread-ed, uncontrolled, jerky movements that were the be-ginning symptoms of chorea. Then Mrs. P. b i t t e r l y made the following re-mark to the s o c i a l worker: She hoped that Marlie's i l l n e s s "would be a lesson to Mr. P., but thought that ' he would just shrug i t o f f . " Thus Marlie's mother seemed to i n v i t e the chil d ' s i l l n e s s (N.B.. she "watched her becoming more ner-vous from day to day"), so that she could use i t as a whip to her weak and useless husband, then became alarmed as she r e a l i z e d that the c h i l d would perforee become dependent, thrusting upon her mother s a c r i f i c e s that she could i l l afford to spare. Probably there i s also the element here of Mrs. P.'s f e e l i n g of g u i l t regarding the fact that she had been f a i l i n g Marlie i n her need f o r a "good" mother-person, and projection of t h i s f a i l u r e to her husband. In other words, i t was a l l h i s f a u l t , i n her estimation. At t h i s juncture, Mrs. F. made the following comments regarding her husband: About two years ago she had l e f t him f o r three months, hoping that t h i s would force him to gib-e h i s family more security, "as -48-he seemed to be fond of her and the c h i l d -ren." He was upset, but remained unchanged, and he was "such a d e l i g h t f u l companion," she decided that she and the children missed him a great deal and "for the children's sake" she returned to him. The c o l d l y planned machinations of t h i s wife and mother to mold everyone to her design are clear-l y indicated. The children were c h i e f l y useful to her as pawns i n the cmmpletion of her own behaviour pattern. For a second time the Rheumatic Fever Program came to the rescue, and Mrs. F. said that she was quite w i l l i n g that Marlie should be i n hospital and a convalescent home as long as necessary. She continued working, and when Marlie returned home the youngster maintained contact with the s o c i a l worker, telephoning quite frequently for advice as to what she should wear, f o r example, or perhaps just to chat. Once more she was caring f o r both Patty and h e r s e l f . She said w i s t f u l l y to the work-er on one occasion that she enjoyed her mother, and "Qid wish that they could be together more." By May, 1948, Mrs. F. found that Marlie was showing signs of a t h i r d attack" of chorea, so she f i n a l l y l e f t work to take charge of her children. She said that Marlie was becoming increasingly nervous and somewhat re b e l l i o u s , and although she could understand i t and " r e a l l y wanted to be a good mother ... she f e l t that there was very l i t t l e that she could do." She thought that the children had missed her companionship f o r a long time, but re-marked that "sometimes she found i t a l i t t l e hard to spread her mothering as f a r as they expected i t to go." Marlie seemed to be getting out of hand, was too active, and moreover, was always worrying. These exerpts again Indicate Marlie's wish to be mothered — to be t o l d what to do — and also Mrs. F.'s r e b e l l i o n against assuming these charges of motherhood. Knowing well the implications of, Marlie's oncoming symptoms of a t h i r d attack of chorea, however, she f i n a l l y l e f t work and rel u c t a n t l y decided to take over supervision of her - 4 9 -daughters. Children r e a d i l y sense the difference between the f e e l i n g of duty and that of desire of t h e i r parents to help them. The mother then asked the s o c i a l worker to intervene and give Marlie some advice aoncerning the f a c t that she must obey the rules set to safeguard her mealth. The worker i d e n t i f i e d with the mother and did as she wish-ed forthwith. In response to the worker's telephone c a l l , Marlie apologised meekly fo r not having checked -with her l a t e l y , saying that she thought that since her mother was home she would do so i n -stead. "Did the worker think that she would be put back i n the h o s p i t a l when she came to c l i n i c next time?" "The worker reminded her that she had never had heart damage, and i f she was t i r e d i t was of her own v o l i t i o n , as she knew very well what she was supposed to do. The worker thought i t very u n l i k e l y , " she said, "that Marlie would return to h o s p i t a l , but I f she was not more careful about a c t i v i t i e s she had earned through being c a r e f u l , they would be c u r t a i l e d . She must assume more r e s p o n s i b i l i -ty f o r her own actions." Marlie, Wwas i n agreement." Mrs. P. l a t e r said that she thought that the i n -terview she had had with the worker and that sub-sequently shared by the worker and Marlie, "had cleared things b e a u t i f u l l y . " She also added that the doctor had helped, too, "as he had substan-t i a t e d what both Mrs. P. and the worker had been saying, that Marlie must assume r e s p o n s i b i l i t y f o r her own rest periods and a c t i v i t i e s . " At t h i s time Marlie was just thirteen. After t h i s , apparently Mrs. F. and the worker f e l t that the s i t u a t i o n was well under control, f o r ^ t Is recorded that: Mrs. F. "always assumed that Marlie would ac£ l i k e a reasonable person, quite capable of manag-ing her own l i f e , and t h i s seemed to have worked o -50-out n i c e l y . Mother and daughter smiled at each' other, and the worker f e l t that everything had worked out to a f a i r l y sound conclusion." By July, 1948, however, Marlie was becoming highly nervous, and already the uncontrolled, choreic movementsfarere involving her l e f t should-er, arm, and leg, as well as her face. She did not want to go to h o s p i t a l , and Mrs. F. resolved to nurse her at home. They had moved to a large house beyond t h e i r means, but i n a good d i s t r i c t , and they now took i n boarders. (Soon aft e r t h i s , Marlie had reportedly said to her mother, "My, I'm glad you're home, Mother, now you can t e l l me what to do.") This c h i l d was so "good", so conforming, took on such great r e s p o n s i b i l i t y , t r i e d so hard to please her mother, i n order that i n turn she could be dependent accord-ing to her needs on a loving mother. Mrs. F. never r e a l l y met t h i s need because of her own s t r i v i n g s , and the s o c i a l worker was unconsciously enmeshed by t h i s woman's tenseness, drive, and attr a c t i o n , so that she was aiding a strong woman i n becoming stronger rather than a s s i s t i n g the struggling c h i l d who was i n such dire c o n f l i c t . Marlie thus was to l d , one by one, and with r e l e n t l e s s persistence, by the three people whose opinion meant most to her her mother, the worker, the doctor — that she was not doing well enough, she simply must look a f t e r h e r s e l f . A recurrence of the I l l -ness at t h i s point seemed in e v i t a b l e , and within a few months the c h i l d was again a grimacing, h o r r i b l y dependent young-ster. During t h i s t h i r d i l l n e s s , Marlie spoke of i t s onset, saying that shortly before she had been at a p i c n i c , and an e l d e r l y aunt of hers had been there. "While I was playing I began to f e e l funny. - 5 1 -My aunt made me think of my grandmother, and i t was then that I thought I might be getting chorea again." The sight of t h i s aunt seemed to remind her that she had onee had a grandmother on whom she had de-pended, but now the grandmother was no longer there, and so she had to be sick i n order to force her mother to care for her. That i s , the unconscious wish to become a more helpless, dependent c h i l d i s evident. Actually, Mrs. P. probably came closest to meeting Marlie's expecta-tions when she nursed her during t h i s i l l n e s s , but she did i t from a sense of duty and g u i l t because of her r e j e c t i o n of the c h i l d , and Marlie sensed that t h i s was so. The husband and father , who could have h e l p f u l l y been brought into more prominence i n the s i t u a t i o n apparently was i g -nored by everyone, although h i s p a r t i c i p a t i o n was sorely needed, both by h i s daughter and for h i s own salvation. Mrs. P. said that i t had been a chore caring f o r Marlie, as she fought her i l l n e s s v i o l e n t l y , was t e r r i b l y upset when she s p i l l e d things, and cri e d b i t t e r l y when her mother had to clean up. The l i t t l e g i r l thought that the i l l n e s s made her ugly, and that she would be i l l forever. Marlie f e l t that her present condition of ugliness and dependency would make forever hopeless the fulf i l m e n t of her wish f o r a loving, accepting mother. Evidently the doctor f i n a l l y considered that the violence of t h i s attack could not be substantiated by any discernible physical factors, and finding that the youngster did not re-spond to treatment normally, he advised that p s y c h i a t r i c - 5 2 -help should be s o l i c i t e d . In the f a l l of that year a p s y c h i a t r i s t was consulted, but from a b r i e f and apparently super-f i c i a l survey of the s i t u a t i o n , he advised that he found the family relationships unusually good, and could see no emotional problems to explain t h i s as a psychosomatic i l l n e s s . Soon afterward a fourth attack of chorea sent Marlie to hospital and once or twice her movements were so uncontrolled and violent that she almost died of exhaustion and ether had to be administered i n pharmaceutical treatment. At the same time increasing emotional d i s -turbance became evident. During t h i s year she had often seemed to be with-drawn, vague, sometimes over-conscientious and re-pressed. She was more apprehensive about her own condition, and less able to cope with day to day re-s p o n s i b i l i t i e s . Her mother had always confided i n her, discussing the family f i n a n c i a l involvements, and Marlie had shown fear over some of the problems that the family was encountering. Occasionally she discussed these In turn with the worker i n a "gossipy, old-woman fashion." When she was l a s t i n hospital she showed a marked attachment f o r her radio, cuddling i t close to her and becoming very agitated, even to the point of having a temper tantrum, when she was asked to turn i t o f f . Sometimes she lay twisting and jerking, and sobbing i n a heart-broken way f o r her mother. The need f o r expression of i n s t i n c t i v e im-pulses i s very clear i n t h i s case h i s t o r y . Undue parent-a l expectations cause the c h i l d to t h r o t t l e h i s need f o r t h i s i n order to gain the acceptance and approval, somehow, of those who mean so much to him. The s o c i a l worker must recognize t h i s need and help the c h i l d f i n d healthy out-l e t for such expression of impulsive actions, as, f o r ex-ample, provided through the play s i t u a t i o n . At the same -53-time interpretive and supportive help must be provided f o r parents and family involved. No c h i l d can be unceasingly something he i s not. Marlie was expected to be adult, to mother her l i t t l e s i s t e r (her mother's f a v o r i t e ) , when she had been deprived of t h i s sort of care h e r s e l f . A small c h i l d can no more tolerate adult food p h y s i c a l l y , than he can tolerate adult (emotional) food psychologically. "Emo-ti o n a l 'bowlegs' develop when emotional n u t r i t i o n has been 1 inadequate." This i s p a r t i c u l a r l y evident i n a c h i l d ' s need f o r dependent love which i s immature as compared with h i s chronological age. Extenuating circumstances must be appreciated i n t h i s case nevertheless. R e a l i s t i c a l l y , Mrs. P. certain-l y was obliged to work from time to time to keep the family fed, but t h i s was mainly because of her cwn i n a b i l i t y to be s u f f i c i e n t l y supportive rather than disparaging and de-preciatory with Mr. F., and also because of her need to see that her family met high standards of l i v i n g . When the writer waw her i n November, 195u, Mrs. F. had borrowed suf-f i c i e n t money (without her husband's knowledge) to pay a down payment on t h e i r present dwelling, a pleasant, comfort-able, and respectable home i n a "better" d i s t r i c t than that they had known previously. The most important therapy i n t h i s case would 1 Jocelyn, op_. c i t . , p. 22. -54-be supportive. Marlie c r i e d out f o r someone to d i r e c t her, to give her warmth and tenderness, and long-term therapy would no doubt be necessary i n a long-standing c o n f l i c t such as t h i s . Work with the c h i l d should be accompanied by i n t e r -pretive help, support, and insight afforded not just the mother, but the father, too, slowly and as indicated, so that the l i t t l e g i r l could be helped to f i n d the strength of ego and the encouragement to grow and develop more normally. The chil d ' s need f o r help i n expressing,without g u i l t , i d or i n s t i n c t i v e impulses such as anger and h o s t i l i t y , i s also of paramount importance. Of l a t e ( i . e . December, 1950), this c h i l d has had no recurrence of i l l n e s s , her mother and father were both working again, and no further d i f f i c u l t i e s had been reported. This, however, does not, as may be sur-mised, indicate that t h i s c h i l d ' s emotional c o n f l i c t could not have been so serious, since she worked through i t with-out apparent damage, for the i l l n e s s simply acted as a sort of psychological safety-valve. This case has been described and analysed i n considerable d e t a i l as i t served admirably to i l l u s t r a t e the succombing of a c h i l d to adult pressures, and her turn-ing to a normally unwarranted sate of complete dependency and demanding of lavished attention i n the form of i l l n e s s . This case of Sydenham's chorea seems v i r t u a l l y to have been caused by a child's emotional needs, so that s o c i a l work diagnosis and treatment of the c o n f l i c t s involved, as the -55-professional caseworker i s trained to see them, were par-t i c u l a r l y v i t a l . There were many other cases of children i n th i s group who seemed to have shown considerable reaction to the overwhelming demands of t h e i r parents. Eleven of the seventeen showing d e f i n i t e deficiency i n feelings of dependency would f a l l into t h i s special category. ( 2 ) . Rejecting parents. To a greater or l e s s e r degree sixteen of the children whose cases were studied i n the present survey could be considered rejected. There/are three general manifestations of parental r e j e c t i o n : (i) conscious rejection; ( i i ) un-conscious rejection, such as that of over-protective, over-s o l i c i t o u s parents; and ( i i i ) r e j e c t i o n through indifference of parents i n t h e i r attitude towards a c h i l d . Often, clear-cut examples of these three categories may not be seen, but rather one or other to a s l i g h t or p a r t i a l extent. These children, too, are deprived of adequate dependency upon t h e i r parents. The case of Sara D. exemplifies the conscious-l y rejected c h i l d . Sara D. was known to several agencies, and i n p a r t i c u l a r to the Child Placing Agency. She was l i v i n g i n a foster home when f i r s t referred to the Rheumatic Fever Program, and i t was reported that she had not made a good adjustment there. Her fo s t e r parents were asking that she be removed, i n f a c t , and t h i s was not her f i r s t placement. Sara's father had been k i l l e d i n an automobile accident i n 1946, and her mother was a r e l i g i o u s eccentric who l e f t her children alone and d i r t y -56-while she attended gatherings of the sect to which she belonged. F i n a l l y , Sara and her s i b l i n g s were apprehended and made wards of the Juvenile Court. Sara was fourteen at t h i s time, and her only consistent i n t e r e s t seemed to be her school l i f e . In December, 1947, just before her f i f t e e n t h birthday, Sara developed chorea. She was upset when she learned the diagnosis, and her doctor wisely advised that h o s p i t a l i z a t i o n might aggra-vate her condition, and suggested instead that every e f f o r t be made to give her the security of understanding and accepting fo s t e r parents. Sara was an a t t r a c t i v e , sturdy g i r l , with consideralb&e bravado disguising her i n s e c u r i t y . She t o l d the s o c i a l worker that she had t r i e d several f o s t e r homes but none had been e n t i r e l y satisfactory, and she was s t i l l looking, she added, f o r the "per-fe c t " one. She also said that she doubted that she would ever f i n d i t . This c h i l d was very insecure, d i s t r u s t f u l of well-meaning adults, and clung to her school and contempor-ary friendships as the only ones on which she could depend. It i s not surprising that, neglected by her own parents, deserted i n a very f i n a l manner by f i r s t one and then the 1 other, and not accepted by successive fo s t e r parents, t h i s youngster was d i s t r u s t f u l of most adults, hiding her hurt and desolation beneath a cover of defiance and bravado. The worker prepared Sara f o r her v i s i t to the Rheumatic Fever C l i n i c , explaining the program to her. When the c h i l d expressed fear of h o s p i t a l , the s o c i a l worker t o l d her that she must take some r e s p o n s i b i l i t y f o r her own i l l n e s s , and that hos-p i t a l i z a t i o n might spare her future i l l n e s s . Sara agreed then that i t was "easier to do i t he r s e l f than have someone picking at her." 1 i . e . Loss of father through death, the most f i n a l of a l l desertions to the c h i l d ; and loss of the mother through open re j e c t i o n and desertion. - 5 7 -Sara required reassurance and support, so that i t must have been discouraging to have someone t e l l her that she would have to look out f o r her s e l f , as t h i s implied a further reje c t i o n , confirming her fears about adults i n general. The s o c i a l worker was anxious that the c h i l d should accept hospital care i f i t was deemed necessary from a medical point of view, and i n her wish to ensure good care f o r Sara, she l o s t sight of the young g i r l ' s emotional needs. The long-term building up of a warm, motherly relationship with t h i s g i r l , and the o f f e r of stimulating encouragement so that she might gradually develop her own strengths and be-come able to accept r e s p o n s i b i l i t i e s n a t u r a l l y as they came, would have been valuable casework therapy. Sara required complete bed rest, and was placed i n a nursing home where she remained u n t i l the spring of 1949. Her choreic move-ments had been minimal, and there was no heart damage reported. The youngster did not make a good adjustment, and evidently l i t t l e t i e was formed with her new foster parents. She was disinterested i n her home, demanded baby-ing, and disobeyed dietary rules by indulging i n sweets. She frequently complained of aches and pains. In October, 1949, Sara married, and since then her health has Improved tremendously, so that recovery from chorea seems almost complete. This case h i s t o r y demonstrates especially the rejected chi l d ' s need f o r love and acceptance. In her s t u f f i n g of sweets, symbolic of giving h e r s e l f s a t i s f a c t i o n s that she craved and could not obtain from others; need of babying, or need f o r regression to a state of greater de-pendency; and many complaints, or need f o r attention; she -58-presented a picture of great emotional deprivation. Mar-riage to a boy who must have been unusually protective and giving, apparently provided f o r her the emotional s a t i s f a c -tions for which she had been starved. Some of the cases i n the study showed the re-jection of over-protective and over-indulgent parents. Marlie's case presented a mother who from s e l f i s h motives was over-protective to some extent. She did not want Marlie to go out as something might happen to her, and then she would be held respongible and her own burdens would be correspondingly increased. This defence of a mother a-gainst reflective feelings concerning her c h i l d promotes h o s t i l i t y i n the youngster f o r such deprivation of love. Marlie's i l l n e s s was not without i t s components of h o s t i l i -ty, f o r through i t she forced her mother to give her care and attention, and i n the throes of chorea she lashed out with every limb, and t e r r i f i e d her mother with her dreadful grimaces and mouthings. This does not imply that the c h i l d consciously assumed the i l l n e s s , but that unconscious drives had much to do with p r e c i p i t a t i n g i t . Another case, that of Verne I., shows rather p l a i n l y the rej e c t i o n of parental indifference i n t h i s group of choreic children, among whom many were obviously rejected by t h e i r parents. Verne I. was the i l l e g i t i m a t e c h i l d of a lean, hard-faced woman who l e f t him wi th her parents or took him about to the di f f e r e n t hotels where she worked as cook. She fed him well and he was -59-always well dressed, but when he developed chorea and was admitted to the c l i n i c , the s o c i a l worker was soon aware that Mrs. I. could spare no i n t e r -est f o r her son, but talked instead of her own problems. The doctor advised that Verne had a s l i g h t heart murmur, but h i s mother remained casual and relaxed concerning the news. The l i t t l e boy, then fourteen, seemed anxious and a f r a i d , trying to c l i n g to h i s mother. The s o c i a l worker handled the s i t u a t i o n with great understanding, working with Vern^s school teacher so that the boy might be provided with the inter e s t and en-couragement of one of the male teachers, and helped guide the lad's interests away from a t h l e t i c s but rather towards mechanical projects, which appealed to him without necessi-tating undue physical a c t i v i t y . The patient responded well both p h y s i c a l l y and emotionally, and seemed much happier and more secure aft e r s i x months' time. (3). Emotionally disturbed parents. In seven of the cases of the present study, one or both of the patient's parents proved to be (or have been), emotionally disturbed to a substantial degree. This sort of parental pattern appeared most 1 prominently i n the case of Sidney G.. Sidney was unusually young (five years old) when she suffered her f i r s t diagnosed attack of chorea. Prom the time of her b i r t h she seemed destined to hatee a 1 The writer was able to observe t h i s case d i r e c t l y , having several lengthy interviews with Mrs. G., as well as a psychiatric consultation regarding future casework treatment (the l a t t e r i n November, 1950). -60-turbulent, uncertain l i f e , f o r her mother grew up i n the most insecure of environments her s e l f , so that a residue of unmet needs l e f t her i l l equipped f o r both wifehood and motherhood. Mrs. G,'s parents were divorced when she was an infant, and she was placed with a paternal aunt who was married and had a l i t t l e g i r l just Mrs. G. ; s age. The neighbours, as well as Mrs. G., r e c a l l that t h i s aunt and uncle showed considerable prefer-ence f o r t h e i r own c h i l d , and the uncle was openly unkind to h i s wife's niece. When Mrs. G. was ten, her cousin developed mastoiditis,aarid Mrs. G. was then banished that the aunt and uncle might l a v i s h f u l l attention on the cousin. By this time, Mrs. O.'s mother had remarried, and was l i v i n g i n Nevada, so that the c h i l d , when sent there, went to a mother who had grown s t i l l further away from her. In any case, Mrs. G. had been brought up to regard her mother as a "loose woman", and undesirable. However, Mrs. G. formed formed a very warm r e l a -tionship with her new step-father and his parents, and grew to love them very much. It was a great shock to her to arrive home one day and discover that there was a strange man l i v i n g with her mother, the step-father having vanished. Even-t u a l l y , she learned that her mother and step-father had been divorced unknown to her. A few years l a t e r this well-loved step-father died very suddenly. Thus the story unfolds of repeated rejections i n the l i f e of Mrs. G., interleaved with one or two warm, meaningful relationships. Serious emotional disturbance i s inevitable i n a case s i t u a t i o n such as t h i s , being con-s i s t e n t l y adverse f o r the c h i l d from e a r l i e s t infancy. When her mother and step-father were divorced, Mrs. G.'s own father, who did l i t t l e f o r her and whom she did not l i k e , took her back to her patern-a l aunt and uncle. Mrs. G. r e c a l l e d vaguely an unpleasant time connected with the juvenile court at t h i s period of her l i f e . Her existence was not -61-happy, and she used to retreat to the h i l l s of the nearby country i n order to read and be by her-s e l f . When she grew into girlhood, she was H o r r i -f i e d to f i n d that her uncle would follow her, mak-ing sexual advances. At nineteen, Mrs. G. married a boy she had known f o r two years, and radiantly happy to at l a s t have a l i f e a l l her own, she said that " a l l the world seemed suddenly wonderful." Mrs. G. did not want to have any children, but did not try to prevent h e r s e l f from having them, and almost immediately she became pregnant. Her husband joined the services, and they began an iti n e r a n t existence of moving from base to base. Mrs. G. did not take proper care of herse l f , and had a miscarriage. Soon she was again pregnant, and i n 1943, Sidney was born. In marriage., Mrs. G. Immediately possessed her husband, moving with him wherever he went, undergoing a l l sorts of hardships just to be with him. He was the f i r s t person who was a l l hers, the f i r s t one to give her consistent love and protection. A woman so starved f o r emotional s a t i s f a c t i o n s did not want a c h i l d who would demand a share of such s a t i s f a c t i o n s , and the fact that she neglected h e r s e l f andpmffered a miscarriage i s not surprising. Into t h i s background, Sidney wasjborn. When Sidney was six months old her father was sent overseas, and Mrs. G. immediately took her to l i v e with a paternal aunt. "Poor Sidney," she said candidly, 'll r e a l l y did not want her. A l l that I could think of was how l o s t I f e l t without my husband." Six months l a t e r the husband was k i l l e d . Mrs. G., desolated by the lo s s , went off to the eastern states f o r a month by herself, but f e l t l i t t l e better and when she returned to her home town, she t r i e d unsuccessfully to k i l l h e r s e l f by driving into a r i v e r . This was i n 1944. - 6 2 -Thus Sidney, too, i s i r r e v o c a b l y d e s e r t e d by h e r p a r e n t s , d e s p i t e the f a c t t h a t h e r mother subsequently made a semblance of c a r i n g f o r her. In about e i g h t months time, Mrs. G. m a r r i e d again, but s a i d t h at she found h e r s e l f i l l p re-pared f o r another marriage and l i f e was f a r from smooth. She d e s c r i b e d h e r second husband as being l i k e her f i r s t i n the a b i l i t y to a f f o r d h e r a f e e l i n g of protectionjand support, but e v i d e n t l y he c o u l d not understand h e r f r e -quent f e e l i n g s of panic and d e s p e r a t i o n and f i t s o f t e a r s . C aptain G. was a l s o i n the a c t i v e s e r v i c e s , and again Mrs. G. and Sidney were moving fimm base to base. Almost immediately Captain G. adopted Sidney. The second l i t t l e g i r l , A l i x , was born ten months l a t e r , and a year a f t e r t h a t , Brent, the l i t t l e boy, a r r i v e d . In view of Mrs. G.'s l a c k of mothering and one good c h i l d h o o d r e l a t i o n s h i p with a f a t h e r - p e r s o n , her choice of names f o r h e r daughters t h a t u s u a l l y are g i v e n to boys, i s r a t h e r s i g n i f i c a n t . She no doubt wished t h a t they had been boys. Once, soon a f t e r h e r second marriage, Mrs. G. t r i e d to k i l l h e r s e l f by t u r n i n g on the gas j e t , but h e r husband saved h e r . L a t e r , when Captain G. was posted to overseas s e r v i c e on the war f r o n t , the whole f a m i l y was almost k i l l e d and t h e i r c a r completely den o l i s h e d when Mrs. G. " f e l l a s l e e p " at the wheel. Since her husband l e f t i n the f a l l of 1950, Mrs. G. has f e l t more and more desperate, begging him to r e t u r n . She s a i d t h at i f he d i d not come she knew she would "do something", and o n l y the c o n s i s t e n t h elp of f r i e n d s and s o c i a l workers have enabled her to c a r r y on. The three c h i l d r e n were simply a burden to her, although Mrs. G. en-deavoured to compensate f o r t h i s and be a good mother to them. She o f t e n i d e n t i f i e d w i t h Sidney, p a r t i c u l a r l y , wanting to "make e v e r y t h i n g r i g h t " f o r the c h i l d asjLt had never been f o r her. This s t o r y r e l a t e s the background of a very much d e p r i v e d woman, who b e l i e v e d that she had had rheumatic -63-fever herself as a g i r l . A psychoanalyst was consulted about this case, and he diagnosed It as one of a woman who had never completely l e f t the womb, symbolically speaking, as l i f e had been so threatnning f o r her from the outset. She was cb served to be very dependent and with d e f i n i t e s u i c i d a l tendencies, and warm, supportive casework seemed advisable f o r an i n d e f i n i t e period. Treatment by analysis was not recommended because of the woman's lack of ego strength. Meanwhile, the children were a l l showing marked reactions to t h e i r i n s e c u r i t i e s . In 1949, Sidneys parents had f i r s t noticed that she began to drop things, l o s t her appetite, jerked her face, arms, legs, and complained of pain i n the l e f t side of her body and i n her feet. She was ta-ken to several s p e c i a l i s t s , and f i n a l l y placed i n ho s p i t a l . A d e f i n i t e s y s t o l i c murmur was noted, and t h i s has since become worse. A diagnosis of rheumatic heart disease with Sydenham's chorea was pronounced. 1 In hospital the youngster was d i f f i c u l t to man-age, would not eat, and her mother was d i s s a t i s f i e d with a l l medical advice, i n s i s t i n g that Sidney was fa r sicker than anyone knew. She took her to a c h i l d guidance c l i n i c , and was t o l d there that she was over-protective and l a r g e l y to blame f o r her child's complaints. This blunt advice from the c h i l d guidance c l i n i c , i f as blunt as described by Mrs. G., was true i n a measure, but not calculated to reassure t h i s mother who seemed determined to have something r a d i c a l l y wrong with her c h i l d . Sidney's case was observed cl o s e l y i n t h i s study, and several times the c h i l d was seen i n h o s p i t a l . She was a thin l i t t l e g i r l with long brown h a i r , and she - 6 4 -used to l i e i n bed r e s t l e s s l y and rather unhappily. Con-currently, the mother was being interviewed at the family agency (by the writer), and close contact was maintained with the soc i a l worker who saw Sidney, and helped her with her d i f f i c u l t i e s . It was observed that Sidney's choreic symptoms became much aggravated at the times when Mrs. G. was undergoing periods of greatest emotional stress and st r a i n , and receded when the mother became more stable. Sidney was s t i l l i n hospital when l a s t seen i n December, 1950, and already Mrs. was beginning to complain that i t seemed that no nne could help her c h i l d so that she had better take her to another h o s p i t a l . Irreconcilable hos-t i l i t i e s between the mother and c h i l d and the doctor further complicated the si t u a t i o n . At t h i s time, A l i x , the second c h i l d , who also had been taken to many doctors during the past s i x months, was brought to c l i n i c by her mother, and Mrs. G. seemed almost s a t i s f i e d to learn that A l i x had a heart murmur boo. She said that f o r some time she had been pos-i t i v e that there was something wrong with the c h i l d . The following week Brent eame to c l i n i c , and af t e r his exami-nation the doctor advised that the l i t t l e boy had a heart murmur also. This case i l l u s t r a t e s with some force the im-portance of emotional factors i n i l l n e s s , and the part played by the so c i a l worker i n recognizing these and r e l i e v i n g or modifying the si t u a t i o n wherever possible. Consistent - 6 5 -support afforded Mrs. G. a t l l e a s t the strength to r e s i s t s u i c i d a l impulses, a and reassurance with some interpreta-t i o n through play and conversation to Sidney seemed to give the youngster considerable r e l i e f from her anxiety. Such relationships would have to be car r i e d over a long period of time, and possibly these children would require placement away from t h e i r mother, before l a s t i n g improvement could be expected. Mrs. G. had an obvious need to f i n d her c h i l d -ren sick. In part, t h i s was no doubt based on her wish to have them i n hospital where they could be dependent upon someone other than her s e l f , and i n part, too, i t was a need to have, through i d e n t i f i c a t i o n with them, attention and protection. Further, wishing to reject her children, Mrs. G. f e l t g u i l t y , therefore insisiting that everyone else was neglecting them and refusing them proper care. The s o c i a l worker would havejfco exercise great care i n assuaging r e s u l t -ant g u i l t feelings of the mother i f placement of the children did ensue, but i f c a r e f u l l y done such a plan would r e l i e v e both mother and children i n t h i s p a r t i c u l a r case s i t u a t i o n . This was the most pronounced case of c h i l d -hood emotional c o n f l i c t following an emotionally d i s -turbed parental background, but there were others observed among the *wenty-five studied altogether. ( 4 ) . Breaks and gaps i n marital and f a m i l i a l s o l i d a r i t y . Broken homes, or p o t e n t i a l l y broken homes have long been considered prominent factors i n s o c i a l studies of rheumatic fever cases, Such breaks and gaps were d e f i n i t e l y common to -66-many of these particular cases of rheumatic fever and chorea Twelve, or almost half , of the group seemed especially to evidence such factors. Marital discord was quite plain in Marlie P.'s case history, and other of the cases revealed even more con-crete marital and famil ial breaks such as separation and divorce. The death of a parent leaves many conflicts in i t s wake, and can be part icularly traumatic to children who are in a crucial stage of development as far as parent-al relationships are concerned. Three of the patients were i l legit imate, and thus deprived of ever having a truly normal family unit , thus creating a considerable gap in famil ial sol idarity. Parental confl icts , too, whether individual or mutual, have a far-reaching bearing on the development of a chi ld , for he feels very much the uncertainty and unhappiness of his parents, reflecting in his own behaviour and reactions the insecurity betrayed by them. ( 5 ) . Economic stress and strain. Another factor prominent in social studies of the causes of rheumatic fever i s that of economic insecurity. It was important in at least eight-een of the cases in the present study. Further, i t may not have been wholloy responsible, but certainly i t was partly responsible for the fact that in wight of the cases both parents were working f u l l time. In any case financial strai as emotional strain, usually affects the whole family equi-librium. -67-S p e c i a l h i g h p r o t e i n d i e t s a r e p a r t o f t h e t r e a t m e n t r e q u i r e d f o r r h e u m a t i c f e v e r p a t i e n t s , a n d t h i s , p l u s t h e p r o h i b i t i v e c o s t o f p o s s i b l e l o n g t e r m m e d i c a l , i n c l u d i n g h o s p i t a l , t r e a t m e n t , a r e t e r r i f y i n g t o s u c h f i -n a n c i a l l y i n s e c u r e f a m i l i e s . S o m e t i m e s , t o o , i t b e c o m e s n e c e s s a r y f o r a f a n i l y t o m i g E a t e f r o m p l a c e t o p l a c e i n s e a r c h o f s e a s o n a l o r s p o r a d i c e m p l o y m e n t . S u c h n o m a d i c e n v i r o n m e n t s a r e l i k e l y t o r o b y o u n g s t e r s o f s e c u r i t y ; p r o -d u c e m a n y a n x i e t i e s a n d u n c e r t a i n t i e s i n y o u n g c h i l d r e n . S u m m a r y o f t h e C h a p t e r : T h i s c h a p t e r h a s b r o u g h t o u t t h e m o s t s i g n i f i c a n t o f t h e f a c t o r s c o n c e r n i n g p a r e n t a l d i f f i -c u l t i e s a n d i n a d e q u a c i e s a s r e l a t e d t o t h e p a t i e n t s s t u d -i e d i n t h e p r e s e n t s u r v e y . M o s t o u t s t a n d i n g w a s t h e r e -v e l a t i o n o f t h e c h i l d ' s n e e d o f s u f f i c i e n t f e e l i n g o f d e -p e n d e n c y u p o n h i s p a r e n t s , a n d t h e w a y s i n w h i c h t h i s w a s ' f o u n d t o b e l a c k i n g i n a p r e p o n d e r a n t n u m b e r o f t h e c a s e s . W e l l a d j u s t e d c h i l d r e n a r e t h e o f f s p r i n g o f w e l l a d j u s t e d p a r e n t s , a n d p a r e n t s h a v i n g t h e i r o w n n e e d s , a n d d r i v e s , c a n o n l y g i v e t o t h e i r c h i l d r e n a c c o r d i n g t o t h e i r o w n p a s t s a t i s f a c t i o n s a n d d g g r e e o f f l e x i b i l i t y . I n t h i s p a r t i c u l a r g r o u p o f c h i l d r e n i t w a s o b s e r v e d t h a t p a r e n t s w e r e e s p e c i a l l y d e m a n d i n g a n d e x a c t i n g , a n d t h e c h i l d r e n w e r e e x p e c t e d t o p l a y a n a d u l t ' s r o l e w i t h a c h i l d ' s d o c i l i t y . T h e e a r n e s t e n d e a v o u r o f p a r e n t s t o b r i n g u p t h e i r y o u n g s t e r s fis r e a s o n i n g a d u l t s f r o m e a r l i e s t i n f a n c y h a s b e e n a c h i l d - t r a i n i n g m e t h o d p r e v a l e n t t o a l a r g e e x t e n t i n c o n t e m p o r a r y t i m e s . H o w e v e r , a l t h o u g h -68-r e s p e c t f o r a c h i l d ' s f e e l i n g s and need t o grow and emanci-p a t e i n t o a d u l t h o o d i s e s s e n t i a l , a l i t t l e c h i l d d e s e r v e s t o be eased i n t o m a t u r i t y , n o t t h r u s t i n t o i t . B o t h o v e r t and c o n c e a l e d p a r e n t a l r e j e c t i o n was m a n i f e s t i n many o f the ease s t u d i e s , and i n d i v i d u a l r e a c t i o n s t o i t g e n e r a l i z e d by the h o s t i l i t y e x p r e s s e d t h r o u g h i l l n e s s and c h o r e i c symptoms, t o g e t h e r w i t h a h u r t s e e k i n g f o r g r e a t e r p r o t e c t i o n . Some o f the p a r e n t s p r o v e d t o be i n a d e q u a t e because o f a s e r i o u s e m o t i o n a l d i s t u r b a n c e o f t h e i r own, and one case s i t u a t i o n was r e l a t e d i n w h i c h pronounced p s y c h o s o m a t i c f e a c t i o n s t o such a p a r e n t a l p a t t e r n were e v i d e n t e v e n t u a l l y i n a l l t h r e e o f the c h i l d r e n . ' Above a l l , an attempt has been made t o i n d i -c a t e why these p s y c h o g e n i c f a c t o r s were i m p o r t a n t t o t h e s o c i a l worker, w i t h some d e s c r i p t i o n o f how casework methods might be employed t o the b e s t advantage. - 6 9 -GHAPTER IV. CHILDHOOD CONFLICTS AND DEFENCES. From the consideration of some defici e n c i e s i n parental relationships regarding t h i s special group o£ patients, a study of resultant c o n f l i c t s , defences and es-capes concerning the patients themselves was made. Parental and other influences of the s o c i a l m i l i e u surrounding the c h i l d , and the c o n f l i c t s and reactions of the child,are quite interwoven, so that parental problems and childhood d i f f i c u l t i e s cannot be completely divorced and analysed separately. However, the #wo viewpoints ( i . e . parent — child) were maintained as focus each i n turn during the compiling and analysis of the case material. Manifestation of Increasing Unrest Immediately Prior to  I l l n e s s : Almost without exception, the parents of these choreic patients remarked that t h e i r children behaved with increasing nervousness, and seemed p a r t i c u l a r l y upset and uncertain just before the onset of overt choreic symptoms. This factor emphasizes the importance of psychogenic aspects of i l l n e s s , and urgency f o r early r e f e r r a l of such cases to a medical s o c i a l service department for psychotherapy and c o l l a t e r a l consultation. Accumulating pressures on a child's developing psyche can re s u l t i n a sort of d i s i n t e -gration of controls, a point at which the i n s t i n c t i v e drives seem to burst through the yet unhardened wall of the super-ego, or conscience. Writhing, jerking, muscular flexions -70-resililt, as well as emotional regression through i l l n e s s to a more sheltered and comfortable environment. Just be-fore t h i s climactic reaction, the emotional c o n f l i c t to which a c h i l d i s subject may be manifestly evident i n un-certainty, apparent insecurity, teagueness, and sometimes withdrawal. The f i n a l b attle of i d versus superego i s being gought, and early awareness of beginning loss of control i s signalled by t h i s appr§hensiveness of the c h i l d . Relief of t h i s emotional c o n f l i c t i s e s s e n t i a l , and prompt psycho-therapy may spare the patient and h i s family countless days of anxiety and di s t r e s s , as well as damaging sequelae of the i l l n e s s . At l e a s t twenty-one of the wwenty-five cases observed, showed to a marked degree t h i s restiveness and insec u r i t y p r i o r to the onset of Sydenham's chorea. Some of the c o n f l i c t s that seemed uppermost i n these sick or po-t e n t i a l l y sick children concerned psychosexual c o n f l i c t s , s i b l i n g r i v a l r i e s , and feelings of inadequacy r e s u l t i n g from the physical r e s t r i c t i o n s necessitated by a serious d e b i l i t a t i n g i l l n e s s such as rheumatic fever. Developmental Phase; In considering casework therapy with the sick c h i l d , i t i s h e l p f u l In a general way to assess as f a r as possible the stage of develppment most commonly found among those patients contracting a s p e c i f i c I l l n e s s . The interplay of family c o n f l i c t s must be appreciated i n psychotherapy with the patient, and assistance i n modifi-cation of c o n f l i c t s among various members of the family i s -71-1 Implicit i n casework plans for the patient. The focus of therapy, however, remains d i r e c t l y on the sick c h i l d , and a l l considerations are postulated i n relationship to the developmental process of t h i s c h i l d , including chronological and' psychological phases of the growth process. Chronological Age; Chronologically, the bulk of the pa-t i e n t s i n the present study were between the ages of ten and f i f t e e n at the time of t h e i r i n i t i a l attack of Syden-ham's chorea. Fifteen of the twenty-five f a l l within the bounds of t h i s age group. Of the remaining ten, two — one four years of age, one three — were subsequently discharged from care, as nothing other than c h o r e i c - l i k e symptoms could be discovered that could be considdred i n d i c a t i v e of the pre-sence of rheumatic fever. The other eight children were the following ages: two ninepyear-old's, two eight, one seven, two f i v e , and one four. Average age of the children at i n i -t i a l onset of the i l l n e s s was 10.9 years. Compared with Dr. May Vi/ilson's studies, t h i s group of children was older than average at i n i t i a l attack of the i l l n e s s , but&s she indicates, frequently choreic manifestations are not recog-2 nized as early as other symptoms of childhood rheumatism. Emotional Phase and Its Components: Psychologically, the bulk of the cases studied were children of latency, puber-1 Henry B. Richardson, ct. Patients Have Families, New York, The Commonwealth Fund, 1948. 2 Wilson, op_. c i t . . -72-ty, pre-adolescent, and adolescent l e v e l s of development. However, one of the most important factors made evident by the survey was the fact that many of these patients were sexually confused aid could not be said to have adequately resolved the so-called oedigpal, or "family romance", con-f l i c t . The c r i t e r i a used i n t h i s consideration of the psy-chosexual phase of patients observed included such factors as: patient's confusion about h i s sexual rdle and drives; patient's remarks which might indicate over-protectiveness or o v e r - i d e n t i f i c a t i o n with the parent of the opposite sex; patient's exhibiting behaviour more suitable f o r one of the opposite sex ( i . e . the g i r l patient seeming to be a "tom-boy", the boy patient seeming to be a "sissy']). Matriarchal Family Pattern: Exploration of some bases f o r t h i s psychosexual ins e c u r i t y revealed that i n ateleast fourteen of the twenty-five cases the mother appeared to be the dominant member of the family. When t h i s factor was related to the f a c t that eighteen of the t o t a l number of cases were g i r l s , other implications became evident, i f not conclusive i n a single rather cursory study such as t h i s . A substantial number of the mothers i n these case situations had reasonably pronounced p h a l l i c tendencies, and to pos-tulate from a projection of t h i s observation to i t s s i g -nificance regarding the children concerned, one might ex-pect the daughters of such mothers to f i n d them rather f r i g h t ening and threatening emotionally, ofeen even overpowering. The sons, too, would f i n d t h e i r Hery masculinity i n question, -73-and a l l kinds of doubts, fears, and p e r p l e x i t i e s would plague t h e i r conscious and unconscious thoughts. Such anxieties i n childhood cannot be con-sidered l i g h t l y , t h e i r e f f e c t s are l a s t i n g and c r i p p l i n g to the degree that the c h i l d i s susceptible and vulnerable, and the weighing of every aspect of a given ease s i t u a t i o n with constant re-evaluation i n terms of treatment i s the special concern and r e s p o n s i b i l i t y of the s o c i a l worker. Homosexual Tendencies; Following t h i s recognition of the fa c t that most of these patients' f a m i l i e s evidenced a "dominant mother —• weak father" pattern, some suggestions i n explanation of the f a c t that there was an overwhelming preponderance of g i r l s subject to the i l l n e s s (and t h i s 1 has been c h a r a c t e r i s t i c of most studies concerning chorea), may be made. One of the premises of t h i s thesis has been that Sydenham's chorea provides a c h i l d with a legitimate outlet f o r greater expression of i n s t i n c t i v e impulses such as aggression, h o s t i l i t y , and so on. The l i t t l e g i r l i s very often brought up to be a " l i t t l e lady", to repress "torn-boy", unladylike impulses, and to behave sedately, d a i n t i l y , unobtrusively. The l i t t l e boy, on the other hand, i s approved and encouraged for boyish, more rowdy, 1 Wilson, op_. c i t . , c f . pp. 18, 19, 236. Also see Flanders Dunbar, Psychosomatic Diagnosis, New York, B. Hoeber, Inc., 1948. -74-active behaviouw. In other words, the boy i s not required to repress outgoing, untrammelled behaviour to such a degree. Further, the boys i n t h i s study who did contract Sydenham's chorea were not preponderantly masculine, aggressive boys, but rather were i n c l i n e d to be effeminate. This require-ment of repression, then, which i s c u l t u r a l l y more prevalent i n the rearing of g i r l s than i n that of boys, may re s u l t i n a reaction which i n some children takes the form of an i l l n e s s such as Sydenham's chorea. The soc i a l worker, recognizing t h i s , should attempt to a s s i s t the c h i l d with the expression through s o c i a l l y acceptable channels, of otherwise repressed aggressive f e e l i n g s , and at the same time afford capeful i n t e r p r e t a t i o n to the parents of c h i l d -hood emotional growth and requirements. The implications of th i s childhood manifestation are that these boys and g i r l s have tended, not necessarily overtly, to form a homosexual rather than heterosexual adjustment. Further Psychosexual C o n f l i c t s Concerning Parents: Normal children must experience, i n growing, a c e r t a i n amount of c o n f l i c t concerning t h i e r parents, but with adequate s a t i s -f a c t i o n of emotional needs, the resolution of such c o n f l i c t s and achieving of a newer, more mature outlook on l i f e (as well as a more secure knowledge of how i n t r i n s i c s a t i s f a c -tions may safely and acceptably be found) may be expected. Those who do not work through the phases of development successfully are l e f t floundering with a residue of un-certainty and i l l - m e t wishes and desires t h a t . w i l l retard -75-t h e i r psychosexual progress and growth i n the future. Caroline E. was one of those whose personal-i t y did not grow and develop normally because of early de-privations and unsolved c o n f l i c t s such as these. Caroline f i r s t became known to the Rheumatic Fever Program i n the spring of 1950. She was then thirteen years old, and the elder of two children born to parents who were divorced f i v e years before. The divorce was obtained at the request of Mr. E., who wished to remarry, and had already chosen f o r h i s second wife a widow with three children. This second marriage proved unhappy also, and Mr. E. spent more and more of his time with h i s f i r s t family, although without the acknowledged approval of Mrs. E.. He wanted then to divorce h i s second wife and remarry h i s f i r s t , but Mrs. E. refused to accede to h i s wish-es, saying that he had always shirked responsi-b i l i t y i n marriage. She to l d the worker that she had talked the si t u a t i o n through with Caroline, and f e l t that her daughter understood her point of view, although "she did not say too much." As was c h a r a c t e r i s t i c of many of the cases, th i s h i s t o r y again presented the dominant mother — weak father pattern, with the children i d e n t i f y i n g with t h e i r aggressive mother f o r fear of doing otherwise and i n c i t i n g further he? h o s t i l i i t y and r e j e c t i o n . Mr. E. escaped h i s domineering wife to of f e r succour to a widow and three children, but was soon drawn afresh to the f i r s t mate, whose independent ways and a b i l i t y to control those about her appealed more to him as a dependent person. Caroline was immediately c a l l e d upon to a l l y h e r s e l f with her mo-ther i n her point of view, although her parental c o n f l i c t was obvious •— "she did not say too much." Caroline was a thin l i t t l e g i r l with very -76-bad teeth which spoiled her smile, and she had the p a l l o r which so often i s c h a r a c t e r i s t i c of rheumatic fever. She was a somewhat apprehensive c h i l d , with a shy, i n g r a t i a t i n g manner. Mrs. E., on the contrary, was small, a t t r a t i v e , and vivacious, and presently taking a business course wi i c h occupied every daytime hour. Even during the week-end, she went out to work. Express-ing her views about leaving the children so much, she said that she "...had always thought her c h i l d -ren should not be too sheltered, but learn what l i f e was l i k e . " Caroline had apparently spent rather an un-eventful childhood. She was used to helping her mother a l l she could with household r e s p o n s i b i l i -t i e s as well as with the care of her young brother. She had always had enuresis, but i t was halted for a time a f t e r she had had a tonsillectomy i n May, 1950. Her f i r s t choreic symptoms became evident a f t e r her f i r s t menstrual period i n A p r i l , 1950. When she was admitted to h o s p i t a l , the enuresis returned (to the chagrin of her mother). Enuresis often s i g n i f i e s a c h i l d ' s wish to regress, coupled with feelings of anger towards parents. Bed-wetting can be a r e t a l i a t i o n against rejecting parents. This f i r s t attack of chorea kept Caroline h o s p i t a l i z e d f o r about two months, and a f t e r an apparent recovery which l a s t e d f o r a month, the symptoms began to return. In a few days she had to return to h o s p i t a l . During subse-quent weeks i t became apparent that the choreic symptoms were greatly aggravated at the time of her menstrual periods. Her menstrual flow was s l i g h t , and her mother thought that she should be given hormones. Caroline talked f r e e l y with the s o c i a l worker (who saw her regularly at the hospital) concerning menstruation, saying that she did not want i t as i t was uncomfortable, meant growing up, going out with boys, and eventually getting married and bearing children. This c h i l d showed considerable uncertainty and confusion concerning sexual drives, and the fact that choreic movements began with v i o l e n t spasms of her right -77-arm' and hand together with her half-expressed psychosexual fears and background h i s t o r y , gave some basis to the idea that Caroline might have had considerable g u i l t feelings about her own sexual drives and possible masturbatory wish-es. When Mrs. E. v i s i t e d her l i t t l e g i r l i n hospi-t a l , she frequently giggled and chatted about current escorts i n a way that seemed expressive of open competition with Caroline as a potential r i v a l . S i g n i f i c a n t l y , Mrs. E's own menstnual periods were always p a i n f u l , she did not approve of Caroline's learning to dance, and she stated that the youngster would not be permitted to go out alone with boys f o r some time. Caroline's case h i s t o r y indicates her need f o r a warm, maternal love, her c o n f l i c t i n g feelings about sex, (probably connected with her father's leaving, accom-panied by her mother's scorn and disapproval of him), and her need to be a l i t t l e g i r l to her mother rather than a sister-person and contemporary r i v a l . The c h i l d was placed i n the intole r a b l e p o s i t i o n of not being permitted to be aliLittle g i r l , nor Jjet being allowed to-emancipate into adolescence. Menstruation i s one of the mile-posts of the maturation process f o r a g i r l , and p a r t i c u l a r l y im-portant because of i t s connotation of femininity. Mrs. E. suffered a pa i n f u l menstrual period, and dysmenorrhoea i s frequently an in d i c a t i o n of r e b e l l i o n against assuming the feminine ro l e , so that t h i s time of l i f e stood out i n par-t i c u l a r r e l i e f i n th i s mother and daughter case s i t u a t i o n . -78-Caroline i d e n t i f i e d with the aggressive mother i n not want-ing' to menstruate and thinking i t p a i n f u l , and also showed her fear of growing up and becoming a woman as t h i s was d e f i n i t e l y undesirable to her mother. Caroline had returned home from h o s p i t a l , but was s t i l l f a r from well, when l a s t observed by the writer i n December, 1950. Her caseworker, who also l e f t i n December, did her utmost to see that follow-up casework treatment was made available to t h i s patient and her family, but the mother seemed to f i n d s u f f i c i e n t sublimation and reassurance regarding her g u i l t feelings about unconscious-l y rejecting her c h i l d and other emotional c o n f l i c t s , through p a r t i c i p a t i o n i n a rather r i g i d , self-punishing r e l i g i o u s sect. She was not ready to accept casework a s s i s t -ance at that time, but had the assurance that i t was a v a i l -able to her at any time. The case s i t u a t i o n of Athenia B., who was p a r t i c u l a r l y pathetic i n her struggle to f i n d a comfort-able and s o c i a l l y acceptable means of achieving sexual ad-justment, i s another example of a child's confusion regard-ing sexual drives and i d e n t i f i c a t i o n s . She was the oldest patient i n the study found to suffer from an i n i t i a l attack of Sydenham's chorea, being sixteen when she f i r s t became seriously i l l . Athenia B., a large, gauche, slow-moving g i r l , who was the eldest g i r l anong four c h i l d -ren born to a capable, masculine sort of mother, -79-and f r a i l , delicate father, was a self-conscious but sweetly dispositioned g i r l . She was known i n the family to be her father's "pet". Her parents were always qua r r e l l i n g and threatening to leave each other, and f i n a l l y , a year a f t e r Athenia f i r s t developed chorea, they were sep-arated. When Mrs. B. was interviewed by the writer i n December, 1950, she remarked that Athenialbrooded about her father a great deal, and " f e l t bad" that he was away from home. Mrs. B. added that Athenia "wished he would leave her alone." Thus Mrs. B. seemed to be unconsciously sensitive to Athenia's f e e l i n g of g u i l t f o r loving her father, thus incurring the displeasure of her mother,who had spurned him, and also because love of one's father that extends beyond the reaches of f i l i a l a f f e c t i o n i s taboo i n our culture. Then he had been taken, from her, banished from h i s home, and thoughts of him plagued and haunted her, reminding her of her f e e l i n g of g u i l t and resultant punish-ment. This c o n f l i c t was a r e s u l t of Athenia's f e e l i n g of threat concerning her powerful, dominant mother, and the c r i s i s was reached at the time of her i l l n e s s . Her choreic attack wasjparticularly v i o l e n t , and she was i n hospital f o r a considerable length of time. Afte r her father had l e f t home, Athenia refused to see her "boy f r i e n d " any more, as "she did not want to get mixed up i n anything l i k e that." Thus, although she was an adolescent, and should normally have experienced a resurge of inte r e s t irAthe opposite sex, Athenia seemed to f e e l more comfortable -80-rejecting her femininity. Instead, she withdrew to a more sheltered l i f e with her mother and s i b l i n g s , revealing her inward feelings of inadequacy and i n f e r i o r i t y by a - s e l f -conscious awkwardness of manner. A case of a younger c h i l d facing t h i s uncer-tainty about sexual drives and r3les i s that of Sidney G,, whose background has already been described. In h o s p i t a l , Sidney appeared nervous, insecure, often resentful. She had great d i f f i c u l t y i n accepting one of the doctors, who was' indeed brusque and somewhat patronizing, although a highly s k i l l e d p r a c t i t i o n e r . His reaction tqjher resent-ment of him (she was seven at the time) was to d i s l i k e her h e a r t i l y and with open hauteur and h o s t i l i t y . This render-ed the t o t a l emotional problem of a sick c h i l d , emotionally sick mother, and intolerant medical advisor, p a r t i c u l a r l y d i f f i c u l t f o r the caseworkers who were active i n the case. Concerning t h i s c h i l d ' s sexual confusion, i t i s important to note that one of the doctors had observed once that Sidney's symptoms seemed to begin aft e r she was placed i n a school where there were boys as well as g i r l s . Boys appeared to be a threat to the youngster, and In th i s connection i t i s s i g n i f i c a n t to note several.facts i n the child's h i s t o r y . Sidney was sent from home as a small c h i l d to stay with r e l a t i v e s , so that her mother could be with her father. Later, her father was taken from her irrevocab-l y through death. She then became fond of a step-father, -81-but again was sent to r e l a t i v e s so that her mother could be with him alone. Whan he l e f t to go overseas, she was once more rejected through desertion by a father-person. In addition she experienced consistent rejections by her mother, but her mother did return to her eventually. The men that she had known a l l l e f t her, despite her love f o r them, so that she f e l t unsure of h e r s e l f , a f r a i d , i n future relationships with men. Moreover, the chil d ' s mother had taken her from doctor to doctor, i n s i s t i n g that she was a seriously sick c h i l d . To Sidney, t h i s could only mean that no matter what happened, she was unsatisfactory, both as a daughter and as an i n d i v i d u a l . The fact that she had d i f f i -c ulty i n accepting the doctor (symbolically a father f i g u r e ) , who probed her and found her wanting, actually i s not very surprising i n the l i g h t of s i g n i f i c a n t background h i s t o r y . The l i t t l e g i r l ' s uncertainty i s evident i n the following exerpt from an Interview with her caseworker. (This and subsequent interviews present some ways i n which the use of play material as well as actual play therapy can be valuable to the caseworker i n diagnosis and treatment of childhood problems). Sidney was playing with d o l l s and a d o l l house. She put the grandmother d o l l i n one room, and the mother d o l l and a d o l l dressed as a nurse vhich probably represented h e r s e l f together i n another room. She picked up the father d o l l then, and wondered where he should go. The caseworker suggested with the mother, and Sidney said bright-l y that mama and daddy used to be together, but now daddy was i n Korea. She did not know what to do with the nurse d o l l , but f i n a l l y put her on the -82-f l o o r beside the mother d o l l and father d o l l ' s bed. Later, Sidney spoke of Sier father i n Korea. She did not know whether he was i n the war of not, she said — hastening to add that the war "was much better now." Sidney had not worked through the oedipal con-f l i c t s a t i s f a c t o r i l y , f o r at one point i n t h i s interview she seemed jubilant that at l e a s t her mother did not have father, even i f she h e r s e l f did not have him either. Later, she thought of him f a r away from home, and near war (and to t h i s c h i l d who had already l o s t one father through death i n war, war would d e f i n i t e l y be synonymous with death i n her understanding of i t ) and she seemed to f e e l immediately, even though unconsciously, that h i s death would be the r e t r i b u t i o n that she must suffer f o r wishing him away from her mother and a l l her own. Thus she quickly reassured h e r s e l f that the war was much better now, and death not so imminent for her father. Further study of Sidney's problems through the use of play equipment indicated that i n her use of finger paintts she seemed to exhibit a great need f o r ag-gression. She unhesitatingly used red f i r s t of a l l , out-l i n i n g the red with green. Her next drawing showed a pre-dominant use of red again, t h i s time i n the shape of a tree or fountain. Symbolically, a need f o r aggressive sex-ual expression i s indicated, with some confusion as to male and female i n the p h a l l i c symbols used. The s o c i a l worker encouraged her to use t h i s medium of expression f o r r -83-her inward, hitherto repressed, needs, guiding her and i n -terpreting gently to the extent of the child' s a b i l i t y to accept such therapy. In subsequent pictures, Sidney showed a pre-occupation with drawing doors and windows, perhaps s i g n i -fying her f e e l i n g of emotional repression; of seeking a way out, and escape, from an int o l e r a b l e s i t u a t i o n . Frequent-l y she drew d e f i n i t e borders around her pictures, again s i g n i f y i n g repression. (See Fi g . 1). Fig. 1. Sidney's Drawing of a Door, Which She Coloured Brown. - 8 4 -Regarding her drawing of the door, i t i s i n -teresting to note that the door i s ajar, so that perhaps she f e l t help was at hand and escape from her dilemma not hopeless; also to note the concentration on the drawing of the lock. Most of Sidney's drawings, l i k e t h i s one, were smeared oVer i n brown to a cert a i n extent, i n d i c a t i n g the residue of anal needs that remained u n s a t i s f i e d . Pos-s i b l y t h i s i s explained by the f a c t that her mother was a p a r t i c u l a r l y clean, f a s t i d i o u s person, who i n s i s t e d on Cleanliness to a rather r i g i d degree. Most of Sidney's other pictures, drawn at thi s time, were drawings of what she called"houses." There were countless of these on small scraps of paper, and a l l of them had her name (the only word that she could s p e l l j crudely printed above. (See F i g . 2). F i g . 2. Sidney's Drawing of a House i n Red and Purple. -85-Again, besides her probable wish f o r a home of her own, ( i . e . a permanent home, l i k e those other children posses, with parents a l l of t h e i r own, too, and a l l the other connotations that the word "house" may imply) the l i t t l e g i r i ' s aggressive use of red may be observed, es-p e c i a l l y i n the pointed eaves of the house. Once more, as with the picture of the tree, the aggression i s i n the form of a p h a l l i c symbol. The chil d ' s narcissism i n learning only how to s p e l l her own name, and p r i n t i t , i s not sur-p r i s i n g i n a deprived youngster such as t h i s . That she placed her name above a l l the "homes" that she dremvsigni-f i e s that these wished-for, fantasied, places were a l l ex-c l u s i v e l y hers, and made to order f o r her. Oral depriva-ti o n i s p l a i n i n these examples. During succeeding interviews with the s o c i a l worker, Sidney continued to show confusion as to which sex-ual r3le she should play, but consistently indicated a re-pressed wish to act out sexual drives. The caseworker helped her to f e e l comfortable i n expressing these sexual drives, and assisted her i n making proper sexual i d e n t i -f i c a t i o n . When the s o c i a l worker f i n a l l y had to t e l l Sidney that she would be leaving before long, the young-ster's only rejoinder was s i g n i f i c a n t -- "What w i l l Mummy do then?" At t h i s time the same worker was seeing her mo-ther, and the c h i l d was very aware of Mrs. G.'s desperation and need f o r support, as well as having an underlying - 8 6 -awareness of her own p l i g h t should her mother be without assistance. These selected examples of childhood confusion regarding parental and sexual i d e n t i f i c a t i o n were outstand-ing i n t h e i r i l a r i t y among cases studied, but others e v i -denced similar c o n f l i c t behind the physical and emotional reactions of i l l n e s s and i t s accompaniments. Si b l i n g Rivalry; S i b l i n g r i v a l r y was the basis of emotion-al b o n f l i c t evident i n several of the case h i s t o r i e s . Of-ten, p o s i t i o n i n the family, such as the eldest c h i l d , or eldest gi i S - c h i l d , seemed p a r t i c u l a r l y i n f l u e n t i a l i n these childhood c o n f l i c t s . Several cases involved children who were not as successful s c h o l a s t i c a l l y as other s i b l i n g s , with resultant feelings of i n f e r i o r i t y and inadequacy add-ing to other emotional d i f f i c u l t i e s . This sort of problem 1 complicated the s i t u a t i o n of Marlie P . , f o r example. The caseworker observed more than once that Marlie's s i s t e r , Patty, was a f r i g h t c h i l d with a c o l o u r f u l personality, and that there was l i t t l e doubt that t h i s younger c h i l d was her mother's f a v o r i t e . Another case of s i b l i n g r i v a l r y was that of Dorothy W., a l i t t l e g i r l who never seemed to get along with her brothers, e s p e c i a l l y her twin. Dorothy's mother was born i n Scotland, and came to Canada when she was twenty-one. Her 1 See Chapter III -87-father was a plasterer, and the family sought by coming to Canada to "improve t h e i r condi-t i o n . " Following t h i s pattern, Mrs. N. show-ed a continued wish to l i v e up to high stan-dards, and she imposed r i g i d ways upon her family a f t e r marriage. Drinking, smoking, and card playing, were s t r i c t l y forbidden, and new friends were not encouraged "because of the mixed types at construction towns" where her husband found employment. The father was easy going, fond of h i s fam-i l y , and inordinately proud of h i s eldest son. He was i n c l i n e d to be gentler, more relenting, than h i s wife. Dorothy was a "tom-boy" and extremely active, but a bashful g i r l , unattractive p h y s i c a l l y , and slow at school. She had trouble with her eyes and wore thick, unbecoming glasses. Her mother thought her backward, and said that; "Dorothy would make a better boy than her twin, as he was the quiet, studious type. Dorothy often engaged i n f i s t - f i g h t s with him, and usually got the better of the deal." Dorothy, the eldest g i r l i n thi s family, f e l t very rivalrous towards her brothers, p a r t i c u l a r l y her twin, who so pleased her mother by h i s conformity and: scholastic ambition. The only thing that she could do was prove through her physical prowess that she r e a l l y was superior to him. When she was eleven, Dorothy contracted rheuma-t i c fever and chorea, and was taken to h o s p i t a l . There she did not seem unhappy, but became very de-pendent and would not help h e r s e l f . She read the comics a good deal, and superman was her favorite character. At home she had l i k e d to sew and make paper d o l l s , but she no longer wished to do so when she reached h o s p i t a l . When asked to sign her name on a r e q u i s i t i o n , she refused, saying that she had "forgotten" how to write. This l i t t l e g i r l showed considerable wish to regress to a younger, more comfortable, stage of develop-ment. An unattractive g i r l , and with no apparent help from -88-her mother i n adapting to her d i f f i c u l t i e s and wishing to grow up into a waman l i k e her, Dorothy was surrounded by brothers who were p l a i n l y more acceptable to her parents than she. Her pre-occupation with "superman" i s character-i s t i c of latency, and c h a r a c t e r i s t i c of the frustrated, hampered c h i l d who wishes f o r an escape from her ordeals by magical, all-powerful, means. These were i n t e l l i g e n t , cooperative parents, and the s o c i a l worker attempted to interpret for them some of the needs of t h e i r c h i l d . As a r e s u l t , some modifica-ti o n of the mother's i n f l e x i b i l i t y , at l e a s t , was achieved, and t h i s afforded considerable r e l i e f to the patient and her family. Frustrations Accompanying Medical Care; The physical hand! cap of i l l n e s s has both p o s i t i v e and negative aspects i n a child's emotional development. Lester W. Sontag has re-cognized this,and states that although reversion to a more i n f a n t i l e , dependent l e v e l i s often possible i n i l l n e s s , this does frustrate the need f o r independence also, causing 1 fresh anxiety. He states, however, that psychosomatic symptoms i n children do d i f f e r from those i n the adult, be-2 cause they " d r a s t i c a l l y and traumatically" modify the en-vironment i t s e l f . "This i s because i n childhood the most 1 Lester W. Sontag, M.D., "The Genetics of Differences i n Psychosomatic Patterns i n Childhood," American Journal of Orthopsychiatry. v o l . 2 0(July, 1950), p. 480. 2 Loc. c i t . . - 8 9 -important components of environment are father, mother, 1 and s i b l i n g s . " This need f o r a modification of the en-vironment i s quite evident i n many of these cases, as a l -ready exemplified through those observed and described. Additional Physical Handicaps; In three of the cases stud-ied, the patients had physical handicaps other than rheuma-t i c fever, and i n addition to i t . A fourth case showed that a recurrence of the symptoms of Sydenham's chorea seemed to be p r e c i p i t a t e d by the e f f e c t on the patient of a car a c c i -dent. Ada S. developed choreic symptoms with rheuma-t i c fever when she had already suffered a severe physical handicap, f o r she had l o s t her l e f t eye following an i n -fec t i o n which was a sequelum of scarlet fever. The addi-t i o n a l physical handicap was i n f l u e n t i a l i n p r e c i p i t a t i n g an attack of chorea, no doubt, but probably wqs not the basic actuating factor, as t h i s c h i l d , too"£ was a submissive and re pressed youngster of whom too much was expected by parents. S i b l i n g r i v a l r y also appeared to increase her emotional c o n f l i c t as associated with the i l l n e s s . The case of Lois M. was one i n which a c h i l d c e r t a i n l y evidenced emotional c o n f l i c t concerning a second-ary physical handicap that could be related to choreic at-1 Loc. c i t . . -90-tacks, but she actually had had her f i r s t symptoms of chorea some years previously. The chorea seemed primarily to f o l -low i n the wake of general family problems such as economic s t r a i n , n u t r i t i o n a l neglect, and i t i n e r a n t moving fuom town to town i n search of a l i v e l i h o o d . Added to t h i s Lois's mother contracted spinal meningitis when the c h i l d was three, and the disease was followed by rheumatoid a r t h r i t i s . Lois was remembered as a "hihli-strung", nervous c h i l d who c r i e d e a s i l y , according to her mother, and a f t e r the i n i t i a l at-tack of chorea at seven she had several recurrences. When she was thirteen, Lois had to have a breast removed because of a swelling diagnosed as undulent chronic ulcer, and about a year l a t e r her other breast was also removed. The l i t t l e g i r l showed increased nervousness and anxiety.as she greww older, and great s e n s i t i v i t y concerning her deformity. How-ever the choreic symptoms appeared to cease following her family's achievement of greater emotional and economic se-c u r i t y . Parents who had been on the verge of separation a few years ago ( i . e . 1949; had apparently worked through t h e i r marital c o n f l i c t to a more sat i s f a c t o r y adjustment, and Lois seemed to reap the benefit of considerable reassurance and encouragement i n surmounting her own handicaps. Con-firming t h i s , Mrs. M. remarked to the writer on one occa-sion that Lois had always been her "daddy's g i r l " , and " t e r r i b l y distressed" by the one-time r i f t i n marital re-l a t i o n s . Thus, although additional physical handicaps - 9 1 -were present i n only a few of the cases studied i n the pres-ent survey, i n those where they did exi s t , they appeared to add to emotional c o n f l i c t s associated with the choreic epi-sodes, but probably were not basic factors i n initiating them. Possibly some of the secondary disorders had con-t r i b u t i n g factors i n common with those i n f l u e n t i a l i n pre-c i p i t a t i n g the chorea. Summary of the Chapter; This section has continued the analysis of emotional factors related to chorea i n the cases studied with a consideration of psychogenic aspects of the i l l n e s s . Following the chapter regarding some parental problems contributing to the onset of such an i l l n e s s i n children, i t has been a survey of actual resultant emotion-a l c o n f l i c t s i n the patients themselves. The developmental phase of a c h i l d during i n i t i a l onset of Sydenham's chorea can be important i n understanding certain p a r t i c u l a r emotional c o n f l i c t s that seem to be associated with a c e r t a i n accompanying i l l n e s s , and i n planning f o r immediate casework assistance f o r sim-i l a r patients, and attempting future prevention of re-currences and ensuing psychological problems. These were mostly children of latency or adolescent psychosexual l e v e l s , but many of t h e i r problems could be traced to a pre-oedipal phase of development,and many residual manifestations of uns a t i s f i e d e a r l i e r stages could be observed i n t h e i r be-haviour. Even the messiness with eating that i s unavoid-able f o r the choreic c h i l d , may give him some precarious - 9 2 -s a t i s f a c t i o n denied heretofore by a p a r t i c u l a r and over-meticulous mother and father. The s a t i s f a c t i o n l i e s i n finding both a way to be d i r t y through s o c i a l l y compatible means, and at the same time discovering a way of s t r i k i n g back at the parents who have forbidden t h i s and other sat-i s f a c t i o n s e a r l i e r . The formation of conscience or super-ego goes back to anal aggressive, t o i l e t t r a i n i n g days, so that i t seems a natural concomitant of the overthrow of the superego i n onset of the choreic outburst, that these anal drives should return with such prominence. This group of choreic children exhibited i n -creasing uneasiness and i n s e c u r i t y just p r i o r to i l l n e s s , and parental c o n f l i c t s — p a r t i c u l a r l y unresolved oedipal situations, sexual confusion and insecurity, s i b l i n g r i v a l r y , and general feelings of inadequacy seemed to form the bases of such uncertainty that was climaxed by involuntary move-ments of chorea. In confirmation of the premise enunciated i n an e a r l i e r chapter to the e f f e c t that parental demands were over-great, these children seemed singularly hyper-active, on the whole. This childhood drive to work and play tofche l i m i t of endurance i s often an expression of underlying pressures and s i g n i f i c a n t repressions. To the s o c i a l worker, these are the s o c i a l and emotional factors to search f o r and weigh i n terms of d i f f e r -e n t i a l diagnosis i n psychotherapy. They must be evaluated i n r e l a t i o n to the physical symptoms of I l l n e s s , and con-stantly re-evaluated as therapy with the patient and h i s -93-family continues. These psychogenic aspects of i l l n e s s provide the key f o r constructive casework treatment i n t o t a l r e h a b i l i t a i o n of the patient. - 9 4 -CHAPTER V. THE SOCIAL WORKER AND THE CHOREIC CHILD. In t h i s study of psychogenic factors surround-ing the physical swmptoms of Sydenham's chorea asirelated to the rheumatic fever syndrome, the most s i g n i f i c a n t general fi n d i n g i s that the I l l n e s s apparently permits an expression of hitherto repressed impulses and reactions. Thus sudden, uncontrolled, and involuntary muscular movements/are allowed free a c t i v i t y as psychological pressures that have been held dormant by the conscience or superego become s u f f i c i e n t l y powerful that they burst through the dyke of conscious i n -h i b i t i o n and control, but i n a mode that through the name of i l l n e s s i s yet s o c i a l l y acceptable, and thus necessarily peiamissable. In other language i t i s an unconsciously form-ed attention-getting and dependency-seeking device of those who have been starved f o r c e r t a i n emotional s a t i s f a c t i o n s . Probing beyond th i s cause and e f f e c t , c h i l d -hood needs that prompted such requirement of emotional re-lease must be pondered i n pursuing s o c i a l work aspects of the problem. How has natural expression of impulsive f e e l -ings been thwarted? Why has i t been denied? Are there any general conclusions to be drawn from such considerations? What casework methods should be employed In t o t a l r e h a b i l i -t a t i o n plans for the choreic child? Findings and Their Interpretation: Childhood deprivations and c o n f l i c t s (with subsequent resiiilts) that appeared to be - 9 5 -responsible f o r the onset of choreic symptoms i n t h i s special group of twenty-five cases may be c l a s s i f i e d under eight general headings. (1) . I n s u f f i c i e n t dependency i n early childhood. A p e r s i s t -ent lack of s u f f i c i e n t dependency was observed i n at l e a s t seventeen of the twenty-five cases studied. 1. The need of a c h i l d to be as a l i t t l e c h i l d nanraot be over-emphasized, and the mistaken b e l i e f common to many contemporary parents that a c h i l d should be approached as an equal i n age and emotion-a l development from the days of h i s infancy — that "baby tal k , " c h i l d i s h myths and fancies, must a l l t o l e r a n t l y be revealed as unbecoming the young adult — i s shown to reap i l l r e s u l t s i n the course of the survey. Parental i n s i s t -ence on a c h i l d ' s assuming overly r i g i d superego controls early i n l i f e i s apt to r e s u l t i n two main disorders: (a) c h i l d i s h depression or other psychosis or neurosis; (b) conversional or psychosomatic symptoms of some kind. With the choreic c h i l d , the l a t t e r disorder has taken place. An impressive f a c t revealed i n the study was that considerably fewer rheumatic fever patients with chor-eic symptoms suffered cardiac involvement thahnthose without choreic symptoms. This strengthens the premise that chorea affords the c h i l d a merciful release of pressures and over-l y powerful demands placed upon him that exert undue s t r a i n upon the heart. (2) . The rejected c h i l d . Parental r e j e c t i o n was observed to a greater or l e s s e r deg&ee i n sixteen of the twenty-five - 9 6 -cases, and further s i g n i f i e s deprivation of adequate depend-ency. Overly protective and overly s o l i c i t o u s parental attitudes were discerned i n many of the cases, in d i c a t i n g compensation of the parents f o r r e j e c t i v e feelings toward t h e i r children, whereas others were openly unaccepting of t h e i r youngsters and s t i l l others quite i n d i f f e r e n t . (3) . Emotionally deprived parents. In seven cases i t was recognized that one ot both parents of the choreic c h i l d showed considerable emotional c o n f l i c t themselves. Some were on the verge of a psychosis. One p a r t i c u l a r l y reveal-ing h i s t o r y of a mother who had decided s u i c i d a l tendencies depicted the onset of chorea with rheumatic endocarditis i n the eldest c h i l d , then the appearance of heart disease i n the second c h i l d , and f i n a l l y i n the t h i r d of the three children. Emotionally disturbed parents are deprived per-sons themselves, so that t h e i r children are inev i t a b l y re-jected, whether openly or not, and i n l i k e manner deprived of s u f f i c i e n t dependency g r a t i f i c a t i o n , (4) . I n s u f f i c i e n t marital and f a m i l i a l security. In twelve of the cases lack of marital and f a m i l i a l strength and s o l i -d arity was prominent i n causing ensuing c o n f l i c t i n c h i l d -ren, and these include three case situations involving patients who were i l l e g i t i m a t e children. Essential security i s i nvariably denied the c h i l d of a broken, incomplete, or unhappy home, and results i n emotionally c r i p p l i n g handicaps that are p o t e n t i a l l y physical handicaps also i n many cases. Again the exertion of too many pressures and anxieties up--97-on the c h i l d , and permission f o r too l i t t l e dependency, follows i n the wake of such handicaps. (5) . S i b l i n g r i v a l r i e s and other childhood c o n f l i c t s . Other i n s e c u r i t i e s were sponsored by s i b l i n g r i v a l r i e s , feelings of inadequacy stemming from i l l n e s s , f r u s t r a t i o n s because of physical r e s t r i c t i o n s i n medical treatment, and r i v a l -rous feelings concerning parents (or of parents concerning ch i l d r e n ) . Such anxieties ean b u i l d up into intolerable emotional c o n f l i c t f o r the c h i l d , so that abnormal release may become inescapable. ( 6 ) . Developmental phase and psychosexual d i f f i c u l t i e s . The bulk of the cases observed i n the present study experienced i n i t i a l choreic symptoms between the ages of ten and f i f t e e n . This chronological age-group usually comprises children of the latency, pre-adolescent, pre-pubertal, and adolescent stages of psychosexual development. However, the study re-vealed that fourteen of the patients had not achieved proper resolution of the oedipal c o n f l i c t , and they appeared i n consequence sexually confused and insecure. The fa c t that many ichoreic children seemed to show f i r s t symptoms during latency i s s i g n i f i c a n t , as t h i s i s the phase of some i n t r o -spection, r e s t r a i n t , and repression of oedipal s t r i v i n g s and sexual drives. In fourteen instances, i t was noted that the mother was the dominant member of the family, and t h i s fact may be related to d i f f i c u l t i e s i n resolution of the oedipus observed i n so many of the patients. The domineering mother -98-i s a threat to both boy and g i r l , frequently r e s u l t i n g i n homosexual manifestations which may or may not be overt. Invariably, increased c o n f l i c t w i l l r e s u l t , and i n t h i s study the fac t o r was recognized as adding to reactions that t h i s group of children repressed u n t i l the breaking point was reached and choreic behaviour became evident. Uncertainties and i n s e c u r i t i e s ensuing from such parental inconsistencie s and lack of emotional balance were witnessed i n the case studies reviewed, together with some ef f e c t i v e use of casework therapies. Deprivation of early needs i n childhood included such factqrs as oral de-pendency needs, inadequate n a r c i s s i s t i c s a t i s f a c t i o n s , and uns a t i s f i e d anal aggressive expression i n residual unmet emotional requirements preceding and complicating oedipal d i f f i c u l t i e s and resultant confusions. (V). The escape from heart damage. It was indicated i n the survey that extremely l i t t l e serious heart damage was contracted by thi s group of choreic patients. Thus i t was postulated that r e l i e f through expression of hitherto re-pressed feelings through the medium of choreic symptoms spared the heart. Rheumatic fever patients who do not have Sydenham's chorea are usually not so fortunate, and i t i s a f a m i l i a r saying that rheumatic fever " l i c k s the joint s but bites the heart." (8). Secondary physical handicaps. Additional physical handicaps i n the cases studied seemed to be secondary rather than primary causes of the central emotional c o n f l i c t ob--99-served i n the children. Only three actually showed addition-a l physical handicaps, and although i n these patients such factors were d e f i n i t e l y i n f l u e n t i a l i n promoting further C o n f l i c t and unrest, they did not appear b a s i c a l l y responsi-ble f o r psychogenic stimuli i n onset of Sydenham's chorea. Although one might suspect that such further handicaps should have already provided these three children with suf-f i c i e n t protection and dependency, th i s apparently was not the case. One of the three children had l o s t an eye, and another had had both breasts removed, but the parents of these l i t t l e g i r l s had p e r s i s t e n t l y endeavoured not to per-mit these handicaps make them any d i f f e r e n t from other mem-bers of the family. This theory was good, i f not overdone (for the trauma of such daastic experiences i n young c h i l d -hood needs careful working through), but i t does explain, perhaps, how the children did not achieve a s u r f e i t of pro-tection and dependency. Treatment Suggestions: P r a c t i c a l suggestions i n i n t e l l i g e n t r e h a b i l i t a t i v e planning with the patient and h i s family must be accompanied by the enjoinder that a l l such planning should be a cooperative outcome of cooperative working with a l l members of the therapeutic team. Proper r e h a b i l i t a t i o n should provide maximum prophylactic measures i n addition to remedial care. The real importance and significance of re-vealing s o c i a l and emotional components of I l l n e s s l i e s not i n proving i t to be of psychogenic o r i g i n or of physical o r i g i n , but i n recognizing and treating both the emotional -100-and the p h y s i c a l . In th i s way the s o c i a l worker takes a pos i t i o n i n the r e h a b i l i t a t i v e team, and t r u l y a s s i s t s the patient i n regaining h i s most desirable state of s o c i a l , emotional, and physical adjustment — h i s r i g h t f u l f e e l i n g of an optimum degree of homeostasis i n a world of hetero-genious c o n f l i c t s . $1). Supportive therapy. The rewards of growing up should always exceed the deprivations imposed upon the c h i l d , and s i a l l a r l y , the rewards of progressing from the over-depend-ency and regression enjoyed i n i l l n e s s must be greater than the urge to remain i n such a sheltered environment. Support, encouragement, and warmth of understanding must be given to the i l l c h i l d , and must be the basis of a l l other therapies i n helping the youngster with Sydenham's chorea as observed i n t h i s study. Following t h i s , and accompanying i t grad-u a l l y , consistent stimulating encouragement to meet new situations with confidence and enthusiasm must be the tool of the caseworker and i f possible of the parents, too. The group of children studied here i n general had r e l a t i v e l y weak ego's, so that support would be t h e i r primary need with possi-bly some environmental manipulation, but l i t t l e insight ther-apy as t h i s would be too threatening f o r them. The regression of i l l n e s s w i l l not be abandoned without s u f f i c i e n t growth of ego strength. (2). Treatment of repression. Since i t has been concluded that choreic symptoms appear to manifest a s o c i a l l y accept-able means of expressing forbidden, pent up h o s t i l i t i e s and -101-aggressions, dher avenues f o r such expression should be sought for the c h i l d . Play therapy, wisely used, can be an id e a l medium of such expression, and games of darts ( i f not too strenuous f o r the in d i v i d u a l p a t i e n t ) , f i n g e r painting, clay modelling, and so on, supply excellent means for the caseworker to help the c h i l d express g u i l t , h o s i t l i -ty, and anger, with support and proper int e r p r e t a t i o n as i n d i v i d u a l l y indicated. Thus some permissiveness i n ex-pression of i d drives otherwise released only through chor-eic symptoms, and bolstering of ego with r e l i e f of too r i g i d controls without unwise removal of the routine l i m i t a t i o n s necessary f o r security, w i l l encourage the c h i l d to progress and grow without fear or apprehension. Then with reinforced ego strength he w i l l be able to leave the regressive pro-tection afforded through sickness and convalescence. (3). The patient and his family. The necessity of consid-erable interpretation and modification of the patient's family si t u a t i o n i s evident i n t h i s study. Discussion of i l l n e s s and i t s e f f e c t s , with p r a c t i c a l recognition of the r e a l i t y s i t u a t i o n as each member of the patient's family experiences i t , w i l l usually be necessary. The c h i l d ' s own parents are always best f o r him i f there i s a way of adjust-ing the needs of each s u f f i c i e n t l y , even i f not i d e a l l y sat-i s f a c t o r y . In some cases, however, remedial therapy with the family w i l l not be possible, so that plans f o r a c h i l d to return home and be i n a po s i t i o n to grow and develop normally may not be 'feasible. Then, and only i f the child' s -102-chances f o r normal development, when c a r e f u l l y and sensi-t i v e l y weighed from every point of view, seem more possible away from h i s parents than with them, foster home placement may be deemed necessary and suitable. Wise selection of the new home i s never so important as i n cases of placement i n v o l t i n g children who are disturbed physieally and emotion-a l l y . In the case of Sidney G., for example (described i n Chapter IV), i t was recognized that with such a sorely disturbed mother fos t e r home placement f o r the children was not only advisable but es s e n t i a l , as t h e i r emotional milieu at home seemed p a r t i c u l a r l y damaging and d i r e c t l y responsible f o r psychosomatic heart disease i n a l l three of the youngsters. Special mention should be made of the fac t that St. Vitus dance i s a disorganizing i l l n e s s p h y s i c a l l y , and parents frequently voice the fear that t h e i r children are, or w i l l be, affected mentally by i t . In i t s most severe manifestations i t i s t e r r i b l e f o r parents to behold c e r t a i n l y . The parents i n t h i s study were found i n many cases to be already resentgul of the dependency of t h e i r children, and the threat of complete dependency should the children suffer mental deterioration, together with possible g u i l t feelings concerning rejection, alarmed them the more. The s o c i a l worker can o f f e r r e a l assistance to parents by helping them express t h e i r fears and h o s t i l i t i e s , reassuring them, and providing support and p r a c t i c a l sugges-tions with interpretation of t h e i r feelings and objective presentation of the r e a l i t y s i t u a t i o n they face. -103-(4). D i f f e r e n t i a l diagnosis. The s o c i a l worker's s k i l l l i e s i n h i s recognition and awareness of the dynamics of human personality, and i n h i s f l e x i b i l i t y and s e n s i t i v i t y to every nuance of f e e l i n g expressed (or indeed repressed) by the c l i e n t . Due cognizance of a l l these reactions from an objective and constructive point of view must be achieved so that gradually a t o t a l picture of t h i s person's psyche may be b u i l t up and tentative conclusions drawn as to why t h i s p a r t i c u l a r i n d i v i d u a l behaves the way he does i n a given s i t u a t i o n . Treatment plans are evolved from t h i s basis. Never can diagnoses be conclusive, but rather should they be changed and adapted as further knowledge of the c l i e n t i s gleaned, or even as the c l i e n t changes himself. A d i f f e r -e n t i a l diagnosis should be sought. Although such f l e x i b i l i t y and s e n s i t i v i t y i s necessary i n a l l psychotherapy, t h i s does not indicate that the caseworker v a c i l l a t e s with the c l i e n t , f e e l i n g with him every sensation and reaction, f o r t h i s would be an over-i d e n t i f i c a t i o n destroying good treatment p o s s i b i l i t i e s , and doing the c l i e n t more harm than good. The caseworker must remain f l e x i b l e i n diagnosing and treating the i n d i v i d u a l i n the most e f f e c t i v e way dt a p a r t i c u l a r time, varying diagnoses and therapy as indicated by the c l i a n t ' s behaviour and reactions, but at the same time having empathetic but unbiased, uninvolved a b i l i t y to a s s i s t him i n working through h i s emotional d i f f i c u l t i e s . Firm, objective help i s extreme--104-l y important In casework with choreic children as observed i n the present study, f o r the security of a firm, warm and understanding relationship provides them with the strength and comfort they require i n order to grow and progress more normally. (5) . Casework consultation. The value of good psy c h i a t r i c consultation cannot be over estimated, and i t s a v a i l a b i l i t y to the so c i a l work department of t h i s rheumatic fever pro-gram would have strengthened and enriched the service o f f e r -ed appreciably. In communities where i t i s possible to ob-ta i n suitable p s y c h i a t r i c consultation, necessary guidance i n recognizing and evaluating deep l y i n g emotional problems and assistance i n handling c o n f l i c t s may be secured. Casework conferences with other s k i l l e d work-ers are very important, e s p e c i a l l y i f psyhhiatric consulta-tion i s not possible, f o r a caseworker can unintentionally become emotionally involved i n a case s i t u a t i o n himself, or otherwise f a i l to appreciate valuable or s i g n i f i c a n t factors i n a case situation, so\that he can no longer be he l p f u l or objective to a maximum degree. (6) . Use of c o l l a t e r a l s . I n t e l l i g e n t u t i l i z a t i o n of special ized agencies, a u x i l i a r y services and other c o l l a t e r a l s i s p a r t i c u l a r l y valuable i n convalescent and follow-up service to the choreic c h i l d and h i s family. Methods of r e f e r r a l must be sound, and achieved with care, f o r transfer of the c l i e n t to another agency or department can e a s i l y appear to him a re j e c t i o n . -105-(7). She r e h a b i l i t a t i v e team. Essentials of remedial and preventive service to the patient involve cooperative work-ing together of a l l members of the treatment and r e h a b i l i -t a t i v e team. The respect of each member of t h i s team f o r the work and s k i l l of the others, and working towards a mutual understanding, i s necessary. Unfortunately t h i s i s an ideal that i s by no means universal i n practice as yet, and arrant lack of consideration of one professional f o r the other i s p a r t i c u l a r l y apparent i n the hospital setting. The welfare of the patient must be the f i r s t consideration, rather than personal prejudices and opinions. Summary of the Chapter: This study has been important i n three main ways. F i r s t l y , i t concerns a group of maladjusted children, who, being children, are yet at a p a r t i c u l a r l y malleable, formative stage of l i f e . They are amenable to change, and thus opportunity f o r remedial casework i s great-er than with the adult, and chances of s t i l l progressing to more normal adulthood favourable. Secondly, i t concerns a disease which i s re-sponsible f o r ninety per cent of the heart disease found i n children. It i s a prime cause of childhood mortality. Thus every means of r e h a b i l i t a t i o n and prevention must be sought, then strengthened. Thirdly, i t concerns s o c i a l and emotional f a c t -ors of t h i s i l l n e s s , t h e i r influence and t h e i r treatment. It gives some ind i c a t i o n of the implications of psychogenic factors i n i l l n e s s , and some in d i c a t i o n of remedial therapy -106-Uhat may be employed i n modifying these factors. ?he f a l l a c y of a dichotomy of thought i n considering the sick i n d i v i d u a l as either a physical problem or a psychological one i s c l a r i f i e d , and s o c i a l work aspects of childhood rheumatic chorea as a sample i l l n e s s emphasized. The group of cases studied was indeed numeri-c a l l y small, and to t h i s degree conclusions drawn must re-main tentative, but i t i s nevertheless a complete survey of a l l cases of Sydenham's chorea, as associated with the rheumatic fever syndrome, served by the Rheumatic Fever Program during i t s f i r s t nine years of a c t i v i t y . It i s hoped that comparative studies may be made of si milar groups i n other areas, and also surveys undertaken with the use of a control group i n comparative analysis. Such research has great value i n the evolution of sound s o c i a l service methods and casework practices, as well as extending the knowledge of the s o c i a l work f i e l d . The psychosomatic approach i s more than what has been c a l l e d bedside manner or medical art, more than the magnetic influence of the physi-cian's personality on the patient, imbuing him with trust and confidence. It i s based on spe-c i f i c knowledge of the E m o t i o n a l factors operat-ing i n every case and of those physiological mechanisms hy which emotional factors influence the disease process. Only with t h i s knowledge can the psychotherapy be i n t e l l i g e n t l y co-ordin-ated with somatic measures. A general knowledge of pathology — both psychological and somatic — i s the f i r s t basic requirement. 1 1 Franz Alexander, M.D., Psychosomatic Medicine, W.W.Norton & Company, Inc., New York, 1950, p. 263. APPENDICES APPENDIX A. Sample Report Forms Used i n the Rheumatic Fever Program. S. F . N o . 7838—5-49—5M. 21991. S T A T E O F W A S H I N G T O N — D E P A R T M E N T O F H E A L T H R H E U M A T I C F E V E R P R O G R A M Referral and Clinic Report Form R E F E R R A L date.. Name (Last) School-Address Parents or guardian-Address Occupation of parent-Referred by.. CLINIC date.. Birthdate. Sex.. Race.. (First) (Middle) Grade.. Phone.. Address... No. children in home.. Phone (Private physician or health officer) Reason for referral m , . . . , . . • Consultation only. Type of service referring physician requests: g Treatment BRIEF REPORT OF H O M E VISIT (Including Social Findings) DEVELOPMENTAL HISTORY Br. wt Term Mo. premature.. Fam. hist.—Asthma Allergies Hay fever Appetite Eating habits COMMUNICABLE DISEASE HISTORY—DATE Scarlet Fever Measles Upper resp Frequent Colds.. Tonsillitis T&A Other IMMUNIZATION AND T E S T S -DATE Smallpox Diphtheria Toxoid.. Whooping Cough.— Tick Others Signed. (Public health nurse) (Agency) CLINIC REPORT Date. T P R Sr Ht In. Wt Lbs. Family history of significance: Past patient history: R H E U M A T I C HISTORY: (Rheumatic Fever, Chorea, Tonsillitis, Tonsillectomy, Growing Pains, Sore Throat) PRESENT ILLNESS: (Fever, Sore Throats, Colds, Joint Pains, Swollen Joints, Muscle Pains, Epistaxis, Appetite, Twitching, Rash, Nodules, Dyspnoea, Nausea and Vomiting, Abdominal Pain, Precordial Pain, and Fatigue) Findings: i Heart: (Precordial Pulsation, Bulge, Friction Rub, Shock, Thrills, Position of Apex Impulse, Rhythm, Mur-murs) Clinic Impression and Diagnosis: Recommendations: (Return to referring physician, admit to hospital, convalescent home, return to clinic, and other) Return to clinic in cc: State Office. (Signed) (Examining pediatrician) , M . D. STATE DEPARTMENT. OF HEALTH Services f o r Crippled Children LABORATORY FINDINGS Name Address URINALYSIS D A T E CHARACTER 'AJID ...p C O L O R • . T S P E . C , GRAV, AC I D , » O R • 4 L K . • A L B . S U G A R ACE-T O N E D l -A C E T I C O C C . 8L. 8ILI. MUCOUS A M P H . U R A T E S P U S C E L L S E P I T H . C E L L S S E O I M E N T - C E f ' T S R3C ' • • C A S T S " .'• '. ;' • •• .• • -'.". . * *' ,. BLOOD. DATE Hgb. R B C t W B C d i f f e r e n t i a l Co)or Index srrear Signa-ture lymph Mono, 8 i s . •:~"V -•• •—-i " " " *• "— *' i „ * .' *. * » ' ; 1 ....... t 1 T , - w T ' p r " * " " " ' ' s ' ' - - - — •. ••«. t : . ... . v * ''l • " • ~ . *" * 4'-* * r . . .... * •! "', * l 1 - UjU v * . ... 11 .Ml. » v ^ v. '1 , i I I T • .• >.»ii'* .. SEDIMENTATION RATE SEROLOGY X-RAYS DATE "V5~Min. 30 Min. 45 Min. >,.< ' M 60 Min, Corrected s'ed. R a t e (', Hour)' Sate- Kahn » Etc. War 4Si<, Tuoercu1 in - i*8 Hrs. strength Suit sCMiC'l*~ ELECTRO CARDIOGRAMS Date Rhythm Rate ' P»R Description MISCELLANEOUS LABORATORY TESTS Date' Findings Signature -* • •• 1 ' ''-"V'r , •' -1 " ' » f 1 * ' v •. ... - 1 - U « « ? ' A • R F 1 5-46 STATE OF WASH INGTON DEPARTMENT OF HEALTH S e r v i c e s f o r C r i p p l e d C h i l d r e n AGREEMENT OF PARENTS OR GUARD IM FOR CARE OF.CRIPPLED CHILD We h e r e b y make a p p l i c a t i o n f o r t h e a d m i s s i o n o f o u r c h i l d f o r c a r e u r d e r t h e S t a t e D e p a r t m e n t o f H e a l t h S e r v i c e s f o r C r i p p l e d C h i l d r e n . ; We a r e m a k i n g a p p l i c a t i o n f o r t h e s e r v i c e s i n b e h a l f o f .because we f e e l t h a t t h r o u g h t h e s e s e r v i c e s and e f f o r t s , • m a d e p o s s i b l e b y t h e S e r v i c e s f o r C r i p p l e d C h i l d r e n , o u r c i * i I d may hnve o p p o r t u n i t y f o r a more n o r m a l p h y s i c a l c o n d i t i o n . ; We t h e r e f o r e r e q u e s t t h e a b o v e s t a t e d d e p a r t m e n t t o e m p l o y s u r g i c a l o r m e d i c a l a i d f o r t h e c h i l d os recommended by t h e O r t h o p e d i c (Med i c a 1 •) S t a f f o f t h e D e p a r t m e n t o f H e a l t h . We a l s o ' < u t ! o r i z e and r e q u e s t t h o s e d e s i g n a t e d by t h e O r t h o p e d i c ; ( M e d i c a l ) S t * f f t o p e r f o r m on s a i d c h i ! d «ny o p e r a t i o n t h e y deem n e c e s s a r y , i n c l u d i n g t h e R i v i n g o f e n a e s t h e t i c s * We ; f u r t h e r a g r e e , i n c o n s i d e r a t i o n o f t h e a d m i s s i o n o f o u r c h i l d f o r c a r e , t o r e l e a s e t h e D e p a r t merit o f H e a l t h , Sc r v J c*<; f o r C r i p p l e d C h i l d r e n , i t is . a g e n t s » e m p l o y e e s * and o t h e r p e r s o n s n o t i n g i n i t s b e h a l f , f r om a n y and a l l c l a i m s f o r d a m a g e s , e x c e p t f o r w i l f u l i n j u r y , w h i c h moy be s u s t a i n e d b y u s , o r e i t h e r o f Us, arid s a i d c h i I d j a r i s i n g b u t o f , i n t h e c o u r s e o f , o r i n c o n n e c t i o n w i t h t h e t r e a t m e n t , c a r e , • t r a n s p o r l o t i o n and e n t e r t a i n m e n t o f s a i d c h i l d . (Name o f F a t h e r o r G u a r d i a n ) (Name o f M o t h e r ) S u b s c r i b e d a n d s w o r n t o b e f o r e me t h i s d a y o f , 19 . ( N o t a r y P u b l i c i n and f o r t h e S t a t e o f W a s h i n g t o n r p s i d i ;i t? n t . , ) (SEAL) CHAPTER 129 LAWS OF 1941 No : Name (Birthdate) (Sex) (Race) Address County Parents : Reported by Date .-—. Under Care by From To Reg. Date Reason Not Under Care Date DIAGNOSIS Physician -CRIPPLED CHILDREN'S REGISTRATION C A R D Washington State Department of Health S. F. No. 4753 SERVICES FOB CRIPPLED CHILDREN APPENDIX B. Statement of Program Policy and Service, as Outlined by the Washington State Department of Health. WASHINGTON STATE DEPARTMENT OF HEALTH Section of Maternal and Child Health and Crippled Children* s Services Objectives and Programs of Service The broad objectives in the field of Child Health are to assure that inso-far as possible every child shall have opportunity to be born healthy and to develop to his fullest physical, mental, and emotional capacity, so that he can take his place in society as a healthy and well integrated personality. Thus this program begins with the mother as soon as pregnancy is suspected and continues through infancy and the pre-school and school years. To achieve these broad objectives Requires provision of various health services such as good prenatal and obstetric care for the expectant mother\ and good health supervision and good medical and dental care for the infant, pre-school and school child; also cooperation and team work on the part of a l l organized groups, official and non-official, interested in the health of ohildren. Logically the State Department of Health is expected to provide guidanoe and' leadership in this Program. Hence, one of its primary functions is to promote, extend and improve services in the interest of conserving the health of mothers and children. The major responsibility for administering this Program is centered in the State Health Department, section of Maternal and Child Health and Crippled Children's Services. This is a large and comprehensive Program and includes as a major activity the provision or promotion of health services for mothers and childraa and the care of handicapped and crippled children, and the integration and coordina-tion of these services with related services in the Health Department and the com-munity. However, practically a l l other section programs in the State Department of Health contribute materially to the health of mothers and children, i.e., dental health, tuberculosis control, venereal disease control, public health laboratory and epidemiology. Some of the more important activities of the Section of Maternal and Child Health and Crippled Children's Services in carrying i t s responsibility are described belowj (1) Educational programs for physicians, nurses and the general public as • to what constitutes good prenatal and obstetric care for the expectant mother and good health supervision for children from birth through adolescence, (a) This is accomplished for physicians and nurses through refresher and post graduate courses, in-service training and demonstration programs} for the general public and especially parents, through special classes, home visits of public health nurses, maternal and child health clinics, films, radio, distribution of l i t -erature, etc. (2) Financial assistance and professional advisory and consultation ser-vices to local health departments. (3) Advisory and consultation services, through specialists in the various fields, to physicians, hospitals, schools and various other agencies and groups interested in the health of mothers and children. 1 -2-(4.) Promotion of the establishment of maternal and c h i l d health c l i n i c s through l o c a l health departments f o r mothers and c h i l d r e n who are medically indigent, and i n those areas where health supervision i s not a v a i l a b l e through the pr i v a t e physician, (a) Funds are a v a i l a b l e by the State Health Department through which l o c a l health departments may employ on a fee basis l o c a l physicians to conduct these c l i n i c s . Also,.consultation, guidance and l i m i t e d supervision, r e l a t i v e to these c l i n i c s service are ava i l a b l e through the section of Maternal and C h i l d Health of the State Health Department 4 (5) Promotion and pro v i s i o n of home visit's by pu b l i c health nurses during prenatal and postnatal periods as a supplement to and under supervision of the attending physician; also periodic home v i s i t s by the nurse as a follow-up i n the health supervision of chi l d r e n ; (6) Inspection, l i c e n s i n g and supervision of maternity homes and hospital s to insure proper standards f o r safety and health of mother's and c h i l d r e n ; also the promotion of p r o v i s i o n f o r more adequate f a c i l i t i e s i n t h i s connection i n various areas of the State, (7) Promotion of more adequate f a c i l i t i e s and provision of consultation services to physicians and ho s p i t a l s i n the i n t e r e s t of reducing m o r t a l i t y of pre-mature infants; also the supply of incubators to p u b l i c and non-profit h o s p i t a l s i n t h i s connection. (8) Promotion of better n u t r i t i o n f or mothers and children through ser-v i c e s of a n u t r i t i o n consultant, p u b l i c health nurses, and maternal and c h i l d health c l i n i c s . (9) Analysis and study of a l l maternal deaths i n the State of Washington i n order to determine i f the deaths were preventable and what steps might po s s i b l y be taken to prevent such deaths. (10) Promotion of school health programs through; (a) J o i n t committee of State Departments of Health and Public I n s t r u c t i o n . (b) . Advisory and consultation service to school administrators and teachers. (c) Workshops, seminars, i n - s e r v i c e t r a i n i n g , other educational a c t i v i t i e s . (d) Promotion and pr o v i s i o n of p e r i o d i c p h y s i c a l examinations of school children by health o f f i c e r s , school physicians or or i v a t e physicians employed on a fee basis. PROGRAMS FOR HANDICAPPED CHILDREN: C PROGRAM: Orthopedic-Plastic Surgery OBJECTIVE: To provide for the l o c a t i o n , diagnosis, treatment, and p h y s i c a l r e s t o r a -t i o n of ch i l d r e n under twenty-one years of age who are c r i p p l e d or who are s u f f e r i n g from a p h y s i c a l condition leading to c r i p p l i n g , and are f i n a n c i a l l y unable to provide necessary care i n order that these children may i n s o f a r as possible assume a normal p o s i t i o n i n l i f e . PLAN FOR ACHIEVING OBJECTIVES R e g i s t r a t i o n — A State r e g i s t e r i s maintained for recording.the name, address, and medical h i s t o r y of c h i l d r e n r e s i d i n g within the State of Washington who come Within the d e f i n i t i o n of a drippled c h i l d . Referrals may originate from numerous sources, o r i g i n a t i n g p r i n c i p a l l y from family physicians, ' parents, f r i e n d s , or interest e d agencies; Although r e g i s t r a t i o n .i's handled as a State function, the program i s j o i n t l y administered by both State and l o c a l health departments, . Diagnostic S e r v i c e s — D i a g n o s t i c services are av a i l a b l e without charge to every c h i l d r e s i d i n g i n the State, who has or i s believed to have a c r i p p l i n g condi-t i o n . C l i n i c s are conducted by a team' of s p e c i a l i s t s employed by the Washington State Department of Health i n s i x areas throughout the State, The c l i n i c team i s composed of a p e d i a t r i c consultant, orthopedic p h y s i -c a l therapy consultant, medical s o c i a l worker, and n u t r i t i o n i s t , with a q u a l i f i e d orthopedic surgeon p a r t i c i p a t i n g i n the program on a per diem basis as examining physician. C l i n i c s are conducted on a qu a r t e r l y basis i n the c i t i e s of S e a t t l e , Olympia, Vancouver, Yakima, and Pasco, and i n Spokane on a bi-monthly b a s i s . Treatment— Treatment, including h o s p i t a l i z a t i o n and surgery, out-patient orthopedic supervision, out-patient p h y s i c a l therapy, braces and appliances, i s arranged on the basis of the examining physician's recommendations, f o r patients whose f a m i l i e s are able to meet only a part or none of the costs of care. The examining physician's recommendations are c a r e f u l l y reviewed by the medical d i r e c t o r of the program and may be r e f e r r e d to a te c h n i c a l advisory committee of q u a l i f i e d orthopedic s p e c i a l i s t s p a r t i -c i p a t i n g i n the program. H o s p i t a l i z a t i o n may be arranged at Swedish Ho s p i t a l , S e a t t l e , or at St. Luke's H o s p i t a l , Spokane. Casework service • i n planning f o r care i s ava i l a b l e to the family as a part of c l i n i c ser-vice or by appointment with a medical s o c i a l worker i n the State Depart-ment of Health. Medical s o c i a l service i s also offered to a l l patients h o s p i t a l i z e d to a s s i s t them i n working through s o c i a l and emotional problems which might i n t e r f e r e with t h e i r e f f e c t i v e use of treatment f a c i l i t i e s or t h e i r r o l e as well-adjusted, contributing members of the community. Occupational therapy i s a v a i l a b l e to chi l d r e n during t h e i r period of h o s p i t a l i z a t i o n . Services of the l o c a l p u b l i c health departments are av a i l a b l e to a l l c h i l d r e n under care from the time of the i n i t i a l examination through the period of follow-up care to in t e r p r e t medical recommendations, a s s i s t f a m i l i e s i n securing care and i n carrying cut the physician's recommenda-tio n s f o r the c h i l d ' s care at home. PROGRAMS FOR HANDICAPPED CHILDREN PROGRAM: RHEUMATIC FEVER OBJECTIVE: A demonstration program l i m i t e d to Spokane and Whitman Counties, pro-v i d i n g f or the l o c a t i o n , diagnosis, treatment, and ph y s i c a l r e s t o r a t i o n of c h i l d r e n under twenty-one. years of age with, or suspected of having, rheumatic fever or any of i t s sequelae, to demonstrate the advantages of and b e n e f i t s to be derived from a complete program of care f o r rheumatic fever. PLAN FOR ACHIEVING OBJECTIVE: R e g i s t r a t i o n — C h i l d r e n having or suspected of having rheumatic fever or i t s sequelae and r e s i d i n g within the State of Washington are registered as cr i p p l e d c h i l d r e n . Referrals may originate'from numerous sources, p r i n c i p a l l y from family or school physicians, parents, f r i e n d s , or interest e d agencies. Although r e g i s t r a t i o n i s handled as a State function, the program i s j o i n t l y administered by the State Health Department, Spokane County and Whitman County Health Departments. Diagnostic S e r v i c e s — D i a g n o s t i c services are ava i l a b l e to any c h i l d r e s i d i n g within Spokane or Whitman Counties who has or i s believed to have rheumatic fever or one of i t s sequelae. C l i n i c s are conducted four times monthly i n the C i t y of Spokane by p e d i a t r i c i a n s employed by the State Health Department on a part—time b a s i s . Treatment—Treatment, including h o s p i t a l i z a t i o n , convalescent care and. out-patient supervision i s arranged on the basis of the examining p e d i a t r i c i a n ' s recommendations, for patients'whose f a m i l i e s are able to meet only a part or none of the costs of care. The examining physician's recommenda-tions are c a r e f u l l y reviewed by the medical d i r e c t o r of the program p r i o r to h o s p i t a l i z a t i o n . H o s p i t a l i z a t i o n i s arranged at S t . Luke's Hos p i t a l i n Spokane. Casework service i n planning f o r care i s ava i l a b l e to the family as a part of c l i n i c service or by appointment with a medi-c a l s o c i a l worker i n the State Department of Health. Medical s o c i a l service i s also offered to a l l patients .hospitalized to a s s i s t them i n working through s o c i a l and emotional problems which might i n t e r f e r e with t h e i r e f f e c t i v e use of treatment f a c i l i t i e s or t h e i r r o l e as w e l l -adjusted, contributing members of the community. Services of the l o c a l p u b l i c health department are av a i l a b l e to a l l c h i l d r e n under care from the time of the i n i t i a l examination through the period of follow-up care to i n t e r p r e t medical recommendations, a s s i s t f a m i l i e s i n securing care and i n carrying out the physician's recom-mendations f o r the c h i l d ' s care at home. PROGRAMS FOR HANDICAPPED CHILDRENi PROGRAM: CEREBRAL PALSY OBJECTIVE: To provide for the location, treatment, hospitalization, education and training of educable children afflicted with cerebral palsy, and to pro-vide in connection therewith nursing, modical, surgical and corrective care with academic, occupational and related training, in order that these children may insofar as possible lead independent, well-adjusted lives. PLAN FOR ACHIEVING OBJECTIVE1 Registration—Children hrving cerebral palsy and residing within the State of Wash-ington are registered as drippled children. Referrals may originate from numerous sources^ principally from family or school physicians, parents, friends, or interested agencies. Although registration is handled as a State Health Department function, the program is a joint responsibility of both the State Health Department and the State Depart-ment of Public Instruction, carried on locally by county health depart-ment and school district administrators. Diagnostic Services—Diagnostic services are available to any child residing within the State of Washington who has or is believed to have cerebral palsy. Examinations may be conducted In a special day school at the time of the supervisory visit of an orthopedist employed on a fee basisj in one of the regularly scheduled orthopedic-plastic clinics, in an orthopedist's office; or in a special cerebral palsy screening clinic. Psychometric testing is done by a psychologist employed by the State Health Department to determine the educability of children afflicted with cerebral palsy. Treatment—Treatment, including hospitalization, medical, surgical and corrective care, as well as special academic work, occupational, speech and physical therapy, is arranged on the basis of the examining clinic team's recom-mendations, for patients whose families are able to meet only a part or none of the costs of care. Children who are less severely handicapped physically and who are determined to be educable may attend special day school classes in their school district where the various therapies are provided. After October 1, 1949, hospitalization may be arranged at the Washington State Cerebral Palsy Center located on the grounds of the Firland Sanatorium, Seattle, for children too severely handicapped physically to attend special day school classes. This center will have facilities for providing intensive physical, speech and occupational therapy for a maximum of twenty children. The center staff will be composed of the following personnel employed by the State Department of Health: academic supervisor, nurse.supervisor, nurse, two teachers, speech therapist, two occupational therapists (one full-time and one part-time), clerk, and thirteen attendants. Casework service in planning for care is available to the family as a part of clinic service or by appointment with a medical social worker in the State Department of Health, Medical Social Service is also offered to a l l patients hospitalized to assist them in working through social and emotional problems which might interfere with their effective use of treatment facilities or their roles as well«*ad justed, contributing mem-bers of the community. Services of the local public health department are available to a l l children under care from the time of the i n i t i a l examination through the period of follow-up care to interpret medical recommendations, assist families in securing care and in carrying out the physician's recommendations for the child's care at home. -6-PROGRAMS FOR HANDICAPPED CHILDREN: PROGRAM: COKSFRVATIOK OF HEARING OBJECTIVE: To bring optimum hearing health to every preschool and school age child in the State; to prevent hearing loss by early discovery of impairment, proper medical examination and follow-up; or to compensate through medical and educational provision for a loss of hearing when such loss cannot be remedied, PLAN FOR ACHIEVING OBJECTIVE: Registration—A State register is maintained for recording the name, address, medioal history, diagnosis, recommendations made by an examining otologist, as well as a record of treatment rendered and a notation of the results of such treatment, for a l l acoustically handicapped children in the twenty-nine counties which participate in the program to date. Case finding is the responsibility of the schools in participating counties and is accomplished by means of periodic audiometer tests given to school children. Diagnostic Services—These are available without charge to every hearing handicapped child residing in the twenty-nine counties which participate in the program whose hearing loss on a pure tone audiometer averages 15 decibels or more for either ear. Clinics are conducted by an otologist approved by the Otological Advisory Committee in cooperation with a local health department in a health department office, school or public building. The number of clinics per year allotted to a county and paid for out of program funds depends in pert on the school population of the area. The frequency at which clinics thus allotted to any one county are conducted, depends on the rate at which cases are found. Ten acoustically handi-capped children are needed for a half-day otological diagnostic clinic and twenty children for a full-day clinic. Treatment—Treatment, including hospitalization, surgery, radium therapy or hearing aid, is arranged on the basis of the examining otologist*s recommenda-tions for the patients whose families are able to meet only a part or none of the costs of care, as program funds permit. The examining otologist's recommendations are carefully reviewed by the consultant otologist to the Conservation of Hearing Program to evaluate the need for medical care, and a financial summary of the family's resources is reviewed by the Section Head to evaluate the family* s ability to meet a l l or part of the costs of core. In most instances the family is financially able to provide the prescribed medical care. In a l l cases, where the examining otologist has made recommendations, the local health department personnel assists in interpreting the find-ings to the parents, in helping the parents make arrangements for the care, and in giving follow-up audlometric tests after treatment has been rendered to evaluate the effectiveness of such treatment. Although i t is obvious that the programs of health servioes described above go a long way toward the achievement of our goal of opportunity for optimum health of al l children, i t must not be assumed that these services are entirely adequate. Certainly there is much room for expansion and improvement. APPENDIX C. Schedule Used i n Analysis of Individual Gases. SCHEDULE USED IN ANALYSIS OF INDIVIDUAL CASES. 1. Name: 2. Date of b i r t h : 3. Parents: (a) Mother: (b) Father: 4. Parents' dates of b i r t h : (a) Mother: (bj Father: 5. Religion: (a) Mother: (b) Father: 6. Economic status: 7. Financial assistance received at any time: 8. Occupations of parents: (a) Mother: (b) Father: 9. Health of p a r e i t s : 10. Relatives (If e s p e c i a l l y concerned with p a t i e n t ) : 11. Home and neighbourhood: 12. Education of parents: 13. Personal case h i s t o r y , with p a r t i c u l a r regard to the following points: (1) Mother or father more dominant of marital partners. (2j One or both parents seemed over-protective of patient, (3) One or both parents seemed emo-t i o n a l l y disturbed. (4) Position of c h i l d i n family as to age and sex — eg. only c h i l d , eldest g i r l , and so on. (5) Patient had to assume more re-s p o n s i b i l i t y than usual f o r age. (6) Child seemed deprived of adequate dependency. (7) Both parents employed. (8) Parents separated or divorced, or one or both dead (including pa-ti e n t s who are i l l e g i t i m a t e child' ren. (9) Additional physical handicaps suffered by patient. Schedule, Continued: (10) Child seemed rejected by one or both parents, (11) Child seemed unusually conforming, submissive. (12) Developmental phase of c h i l d during i n i t i a l attack of chorea. (13) Child-parent r e l a t i o n s . (14) Tendency of c h i l d to-wards some degree of homosexuality — to be correlated with (12); (15) Child seemed insecure, nervous, uncertain, just p r i o r to choreic attack. (16) Other symptoms of emo-ti o n a l c o n f l i c t such as enuresis, nightmares, and so on, (XH Child's reaction to school, (18) Child worked and play-ed to l i m i t of endur-ance. (19) Effects of physical re-s t r i c t i o n s , i f any. (20) Economic s t r a i n . (21) Marital c o n f l i c t suf-fered by parents. (22) Child seemed repressed; r i g i d i t y of parents; lack of s u f f i c i e n t out-l e t for aggression and h o s t i l i t y . (23) Parents made v i s i b l e e f f o r t to bring up c h i l d always as an a-dult, s e l f - s u f f i c i e n t , and independent. (24) Child f e l t inadequate, i n f e r i o r . 14, Psychiatric consultation: 15, Medical case h i s t o r y : 16, Hospital record: 17, Some evaluation of s o c i a l work done i n the case: APPENDIX D. Some Definitions of Social Casework Terms. DEFINITIONS OF SOME SPECIAL TERMS USED IN THE TEXT. 1. Conversion symptom. "In conversions, symptomatic chang-es 6f physical functions occur which, unconsciously, and i n a distorted form, give expression to i n s t i n c t u a l impulses 1 that previously had been repressed." Thus, f o r example, the man who l i f t e d h i s gun unlawfully to shoot someone, might f i n d afterwards that h i s arm was suddenly paralysed from purely psychologically reasons. Although of psycholog-i c a l o r i g i n , t h i s p a r a l y t i c symptom i s just as re a l and actual as that recognized to be mainly of physical o r i g i n . 2. Psychogenic. The term "psychogenic" i s used throughout the study as being the antithesis of "organic", but i t s connotation includes factors that are s o c i a l , emotional, and psychological. L i t e r a l l y the word means "originating i n the psyche." This i s not to say that psychogenic symp-toms are only imaginary, f o r they are just as r e a l whether sponsored mainly by emotional stimuli or mainly by organic stim u l i ; and every symptom has i t s psychogenic as well as i t s physical components. 3. I d e n t i f i c a t i o n . To i d e n t i f y with someone, a term used considerably In dynamic psychiatry and casework, means to a l l y oneself with another as being s i m i l a r or an exemplary model to follow i n one's own actions and behaviour. The 1 Otto Fenichel, M.D., The Psychoanalytic Theory of  Neurosis, New York, W.W.Norton & Co., 1945, p. 216. Definitions, Continued: small g i r l , a f t e r s a t i s f a c t o r y resolution of the oedipal c o n f l i c t , i d e n t i f i e s with her mother. I f her adjustment i s not s a t i s f a c t o r y , she may reject the feminine r o l e , and i d e n t i f y with her father. 4. Dynamics, dynamic approach. The dynamic approach (as opposed to s t a t i c approach) Is based on the psychoanalytical theories of personality, which postulate that i t i s t r i p a r -t i t e , being made up of ego, superego, and i d ; the balance of these three components constantly threatened by the uncon-scious s t r i v i n g s of i d and superego f o r supremacy, and with the ego acting as a r b i t e r . Dynamics are r e a l l y the uncon-scious mechanisms constantly at work i n the i n d i v i d u a l . 5. Ego, i d , superego. The i d drives are the a s o c i a l , amoral, impulsive wishes of the human personality; the superego controls exerted as the conscience, the d i s c i p l i n -ary factor. The ego i s the executive that governs and reas-ons, maintaining i n the normal, well-adjusted i n d i v i d u a l a good balance between the i d and the superego. 6. Empathy. This i s actually p a r t i a l , or controlled iden-t i f i c a t i o n , and i s one of the main attributes of casework. In other words, one must f e e l with the person that one i s treating through casework methods, but at the same time re-main separate from him or her. Over-identification destroys the objective capacity to a s s i s t an i n d i v i d u a l i n h i s best i n t e r e s t s . Definitions, Concluded; 7. Ambivalence. The swaying, u n s a t i s f i e d , from one f e e l i n g to another. The c h i l d just beginning to develop superego, or just f e e l i n g the brunt of parental authority, f i r s t laves, then hates, and i s torn between the two fee l i n g s . Parents, too, suffer from t h i s ambivalence towards t h e i r children, and are often h o r r i f i e d when they r e a l i z e that they have "bad" wishes concerning t h e i r youngsters as well as "good." 8. Casework. Casework i s a professional s k i l l i n which a knowledge of the science of human relations and the t o t a l personality, and a dynamic understanding and use of r e l a t i o n -ship i n interviewing, are u t i l i z e d i n mobilizing capacities i n the Individual and resources i n the community appropriate f o r better adjustment between the c l i e n t and a l l or any part 1 of h i s t o t a l environment. It i s a very technical method of interviewing with the objective of enabling the i n d i v i d -ual to achieve the best possible adjustment i n h i s p a r t i c u -l a r environment, or both. 1 Swithun Bowers, O.M.I., "The Nature and D e f i n i t i o n of Social Casework: Part III',1 Journal of Social Casework, ¥oi. XXX. No. 10 (December, 1949;, p. 417. APPENDIX E. Bibliography. BIBLIOGRAPHY Alexander, Franz, The Medlaal Value of Psychoanalysis, New York, W.W.Norton & Co,, Inc., 1932. , Psychosomatic Medicine, New York, W.W. Norton & Co., Inc., 1950. Ba l l , Georgia, "Casework With Crippled Children," (Reprint-ed ar t i c le , Children's Bureau of United States), The Family, (Apri l , 1939). Bettelheim, Bruno, "Somatic Symptoms in Superego Formation," American Journal of Orthopsychiatry, VoT: XVIII, No. 4, (October, 1948). Bowers, Swithun, "The Nature and Definition of Social Case-work: Part III ," Social Casework, Vol . XXX, No. 10, (December, 1949), p. 412, Cleesattel, Mary E . , "Rheumatic Heart Disease," (Reprinted ar t i c le , U.S. Children's Bureau), Modern Hospital, Chicago, Vo l . 64, (Apri l , 1945), pp/ 63, 64. Cohen, Ethel, "What Rheumatic Fever May Mean to a Ch i ld , " (Reprinted a r t i c l e , U.S. Children's Bureau), The Child, Vol . 11, No. 10, (Apri l , 1947). Coughlin, Ellen Whelan, "Some Parental Attitudes Toward Handicapped Children," (Reprinted a r t i c l e , U.S. Children's Bureau), The Child . Vo l . 6, No. 2, (Aug-ust, 1941). Daily, Edwin F . , "To Restore Crippled Children," (Reprinted ar t ic le , U.S. Children's Bureau), The Child. (August, 1949). D i l l , Ethel L . , and Jordan, Isabelle M. , "Convalescent Care of Children," (Reprinted ar t i c le , U.S. Children's Bureau), American Journal of  Nursing. Vo l . 45, No\" 12, (December, 1945). Dunbar, Flanders, Psychosomatic Diagnosis. New York, Harper and Brothers, (Medical Book Department), 1948. Encyclopoedla Brittanica, Chicago, The University of Chicago, Encyclopoedia Brittanica, Inc. . Bibliography, Continued: Penichel, Otto, The Psychoanalytic Theory of Neurosis, New York, W.W.Norton & Co., Inc., 1945. Preud, Anna, The Ego and Mechanisms of Defense, New York, International U n i v e r s i t i e s Press, 1946. Galvin, Louise Pry, "Preventive and Public Health Aspects of Rheumatic Fever in-Children," (Reprinted a r t i c l e , U.S. Children's Bureau), South-ern Medical Journal, Vol. 36, No. 3, (February, 1943), pp. 116 - 121. "The Rheumatic Fever Program i n V i r g i n i a , " — > (Reprinted a r t i c l e , U.S. Children's Bur-eau), Journal of Pediatrics, St. Louis, Vol. 26, No. #, (March, 1945). Greenberg, Harold A., "The Management of the Emotional Prob-lems of Crippled Children i n a New Type of I n s t i t u t i o n , " American Journal  of Orthopsychiatry, Vol. XIX, No. 2, (A p r i l , 1949), p. 253. Guide for Local Rheumatic Fever Programs, New York State Department of Health, Pamphlet, 1949. H a l l , Clark, H., "The Rheumatic Fever Program i n Oklahoma," (Reprinted a r t i c l e , U.S. Children's Bureau), Journal of Pediatrics. St. Louis, Vol. 26, No. 3, (March, 1945), pp/ 259 - 261. Henske, J.A., "State Rheumatic Fever Program f o r Children," (Reprinted a r t i c l e , U.S. Children's Bureau), Nebraska State Medical Journal. Vol. 30, (May, 1945), pp. 160 - 164. H o l l i s , Florence, Women i n Marital C o n f l i c t . New York, Fam-i l y Service Association of America, 1949. Huse, Betty, " B r i t i s h Recommendations With Regard to Child-ren With Rheumatic Fever," (Reprinted a r t i c l e , U.S. Children's Bureau), The Child. Vol. 9, pp. 5 7 - 6 1 . "Rheumatic Fever i n Children," (Reprinted a r t i -c l e , U.S. Children's Bureau), The Child, tfol. 7, No. 11, (May, 1943), pp. 158 - 161. B i b l i o g r a p h y , Continued: Jean, S a l l y Lucas, "Mental Windows f o r H o s p i t a l i z e d C h i l d r e n , " ( R e p r i n t e d a r t i c l e , U.S. C h i l d r e n ' s Bur-eau), The C h i l d , (June, 1949). J e t t e r , L u c i l l e E., "Some Emotional Aspects o f Prolonged I l l -ness i n C h i l d r e n , " ( R e p r i n t e d a r t i c l e , U.S. C h i l d r e n ' s Bureau), P u b l i c H e a l t h  N u r s i n g . V o l . 40, No. 5, (May, 1948). J o s s e l y n , Irene M., P s y c h o l o g i c a l Development o f C h i l d r e n , New York, Family S e r v i c e A s s o c i a t i o n o f America, 1949. , "Emotional I m p l i c a t i o n s o f Rheumatic Heart Disease i n C h i l d r e n , " American  J o u r n a l o f O r t h o p s y c h i a t r y , V o l . XIX, No. 1, (January, 1949), p. 87. Kagan, B.M., and Mirman, B., "Sydenham's Chorea, A Syndrome f o r D i f f e r e n t i a l D i a g n o s i s , " The J o u r n a l o f P a e d i a t r i c s , S t . L o u i s , V o l . 51, (June — December, 1947), p. 322. Lampron, Edna M,, " S o c i a l Worker Helps Handicapped Adolescents With Emotional Problems," (Reprinted a r t i c l e , U.S. C h i l d r e n ' s Bureau), The C h i l d , (May, 1946). L i c h t w i t z , Leopold, Pathology and Therapy of Rheumatic Fever, New York, Grune & S t r a t t o n , Inc., 1944. Lobsenz, Norman and Amelia, "Rheumatic Fever," Today's Woman, V o l . 22, No. 132, (October, 1950), p. 48. M i l l e r , Hyman, and Baruch, Dorothy W., "Psychosomatic Stud-i e s o f C h i l d r e n With A l l e r g i c M a n i f e s t a t i o n s , " Psychosomatic Medicine, V o l . X, No, 5, (September — October, 1948), p. 275. Ogren E l l e n E., "Connecticut Sends Handicapped C h i l d r e n to Camp," (Repr i n t e d a r t i c l e , U.S. C h i l d r e n ' s Bureau), The C h i l d , (June, 1949), Richardson, Henry B., P a t i e n t s Have F a m i l i e s , New York, Commonwealth Fund, 1945. S a d l e r , Sabra S., Rheumatic Fever, P h i l a d e l p h i a , J.B. L i p p i n -c o t t Co., 1949. Bibliography, Continued? Senn, Milton J .E. , "Emotional Aspects of Convalescence," (Reprinted article, U.S. Children's Bureau), The Child. Vol. 10, (August, 1945), pp. 24 - 28. Sherman, Robert L . , and Kaiser, I.Howard, "Two Factors in the Differentiation of Rheumatic and Non-rheumatic Types of Sydenham's Chorea," Archives of Pediatrics. Vol. LXVI, (January — December, 1949), p. 173. Smillle, Wilson G,, Public Health Administration in the United States, New York, The MacMillan Co., 1947. Sontag, Lester W., "The Genetics of Differences in Psycho-somatic Patterns in Childhood," American  Journal of Orthopsychiatry, Vol. XX, No. 3, (July, 1950), p. 479. Studies in Rheumatic Fever, Metropolitan Life Insurance Company, (no date). Tarah, Leo M., and Hodson, A. Edith, "Social and Psychologic Problems Associated With Prolonged Institu-tional Care for Rheumatic Children," (Re-printed from ) The Journal of Pediatrics, Vol. 35, No. 5, (November, 1949), pp. 648 to 661. Terry, Edith M., "Rheumatic Fever and the Nurse," (Reprinted article, U.S. Children's Bureau), American  Journal of Nursing, Vol. 43, No. 12, (December, 1943;. Upham, Frances, A Dynamic Approach to Illness, New York, Family Service Association of America, 1949. Wallace, Mildred, and Feinauer, Violet, "Understanding a Sick Child's Behaviour," (Reprinted article, U.S. Children's Bureau), The American Journ- al of Nursing. (August, 1948). Wilson, May G., Rheumatic Fever. New York, The Commonwealth Fund, 1940. Wolff, George, Childhood Mortality from Rheumatic Fever and Heart Di seases, Children's Bureau Pub. 322, 1948. Bibliography, Concluded: Case material and s t a t i s t i c a l information from unpublished records of the Eastern Washington State Services f o r Crip-pled Children (Rheumatic Fever Program), Some di r e c t interviews with members of the Rheumatic Fever Program concerning the program and patients served by i t ; and some interviews with patients and t h e i r f a m i l i e s i n follow-up of case situations presented i n the study. 

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