The Role of the Occupational

Therapist Treatlllent of Alcoholislll

(alcoholism rehabilitation, treatment model, behavior change, use of activities)

Wanda P. Lindsay

This paper presents brief mforma­ efore examining the role of the estimate that 4 percent of the United
tion on the incidence of alcohol­ B occupational therapist in the States population over age 20 suffer
ism, its effects on physiological treatment of alcoholism, it is im­ from alcoholism, or 9 million of 2
and psychosocial dysfunction, and portant to understand the incidenCf billion people (2-4). These figures
the disease concept. j\![ ore detai led of alcoholism, its impact on health do not reflect nonalcoholics who
information is provided on a care, and some basic concepts about abuse alcohol or the growing num­
treatment program designed to the disease. Alcoholism is a disease bers of teenagers with the disease. In
meet the special needs of the alco­ of considerable magnitude. In 1973, addition, at least 36 million Ameri­
holiC pallent, and the integral role there were 9,500,000 people with cans are affected by their relation­
of the occupational therapist In alcoholism on the North American shi ps wi th active a Icololics (2-4).
this program IS explained. continent, of which 90 percent or Children of female alcoholics who
Patients are given support to more represen t a cross section of the may be suffering from fetal alcohol
accept the chronic disease of population (I). Recent studies syndrome or fetal alcohol effects as
alcoholism, are taught skills a result of maternal alcohol con­
needed to maintain sobrzety, have sumption during gestation must
opportunities to beg·in utilizmg also be considered (5, 6). (Fetal
resources for sobriety, and are IVanda P. Lmdsay, OTR, IS staff alcohol syndrome is a pattern of
assisted m regainzng a sense of therapist, A lcoholism Treatment altered growth, morphogenesis, and
self-worth. Unit, Mercy Hospital and Medical behavioral impairment manifested
Center, Chicago, and an Occupa­ in a wide range of a bnormal charac­
tIOnal Therapy Consultant spe­ teristics (7).)
clalizmg in alcoholism. Alcohol also has a significant

January 1983,onVolume
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 impact on health care. In the United creates a defense system that makes work performance, addiction to
States 20 percent of all hospitalized alcoholic persons unwilling or un­ other drugs, increased physical
persons have an alcohol problem in able to look at their lives and the problems, and morning drinking.
addition to the presenting problem problems drinking has caused. The progression through these
(2). In several countries alcoholism Antisocial or isolative behavior re­ stages may last a few months to sev­
is the third leading cause of death sults and the person may begin to eral years, and is different for each
(after heart disease and cancer), and view alcohol as a best friend. Alco­ person. By the late stages of the
in France, 48 percen t of the ind ustri­ holism destroys self-respect because disease the family unit has often
al accidents are attributed to alco­ its victims have tried to stop drink­ deteriorated, the job may have been
hol abuse (8). ing and failed, not knowing the lost, and the person's life revolves
Effects of A lcohoL. Alcohol use ina bil ity to stop is part of the disease around drinking. Symptoms mani·
affects many organs and systems of process and requires professional fest at this time are an inability to
the body. In the digestive system it help. Specific maladaptive behav­ abstain, decreased tolerance to
acts as an irritant, increasing acid iors may be seen in the alcoholic alcohol, tremors, hallucinations,
flow, and at times impeding diges­ person: inability to tOlerate pres­ and delerium tremens (a life-threat­
tion. In the circulatory system alco­ sure and stress, dependency, failure ening part of withdra wall (1,2, 12)
hol acts as a \'asodilator, aggravat­ to express one's self, feelings of Treatment and the beginning of
ing high blood pressure and contrib­ being "put down" by others, and a the recovery process can be initiated
uting to hean problems. A kidney­ lashing out at people and circum­ at any stage but often realization of
controlling hormone is inhibited stances through drinkll1g. It is im­ the need for help is not recognized
by alcohol, causing the kidneys to portant for professionals who work until the late stages. All symptOms
produce too much urine. Alcohol with alcoholic patients to accept the may not appear in every patient and
also has marked effects on the liver, effects of alcoholism on the person are nOl necessary for the diagnosis
preventing maintenance of proper or their work will be hindered by a of alcoholism. Impaired life ad­
sugar levels in the body, depriving lack of understanding and poor jus tmenl in terms of heal th, per­
the brain and other organs of ade­ communication (10, II). sonal and social relationships, and
quate nourishment. Long-term use Examining various stages and occupational functioning identify
damages the liver permanently (1,2, specific symptOms of the disease alcoholism (12, 13). figure I further
9) will enhance the professional's un­ illustrates the symptoms of the
The central nervous system, par­ derstanding of the patient. In the disease and their progression.
ticularly the brain, is most sensitive ea I' j Ystages of the disease there is an
to alcohol. Alcohol interferes with increased tolerance to alcohol, Literature Review
brain activity by acting as a depres­ blackouts (memory impairment), No current literature is available on
sant. Behavioral changes that make gulpIng and sneaking drinks, and the specific role of the occupational
alcohol appear to be a stimulant are some guilt feelings about drinking. therapist in alcoholism treatment.
due to the suspension of inhibitions The onset of the early-stage symp­ Although a 1952 occupationalther­
in several areas of the brain. Judg­ toms can occur at any age and there apy article referred to alcoholism as
ment, muscle coordination, comrol is no specific time one crosses from a disease rather than a social dis­
of emotions, and sensory percep­ "social drinking" into the early grace, it did not discuss approaches
tion are all affected. Large amounts stages of the disease. I n the middle to the alcoholic patient that would
of alcohol anesthetize the brain cen­ stages of the disease, other symp­ differ from those used with patienls
ters that control heart rate and tOms become apparent including having a variety of psychiatric dis­
breathing to the degree that coma or loss of control, use of alibis for orders (14). Alcoholic patients have
even death can occur (1, 2, 9). abnormal behavior, geographic traditionally been lreated in mental
Alcoholism is classified as a escape, change in drinking patterns, health settings with no attention
disease because it is predictable, and periods of abstinence. Other gi ven to their special needs, or the
exhibits symptOms, and is progres­ symptoms that may be apparent at different approaches necessary to
sive if not arrested. In addition to this time are the appearance of a meet those needs (14- I9). Detoxifi­
the physical effects described, the "Dr. JekyIJ/Mr. Hyde" personality, cation centers have specialized in
disease affects the emotional and Monday morning absenteeism, tak­ "dryi ng out" alcoholic persons, bu t
spiritual aspects of a person (2). It ing long lunch hours, inconsistent patients usually returned to their

The American JournaL of OccupationaL Therapy 37

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 former lifestyle without the skills
and resources needed to maintain
Figure 1
sobriety. This treatment approach Disease of Alcoholism
was consistent with views of alco­
holism at that time, as seen in classi­
fications of alcoholism by the Progression of the Disease
American Psychiatric Association.
~ Drinking to calm nerves

In 1952 alcoholism was classified as

Ol Increase in alcohol tolerance

a sociopathic per onality disorder ~ Relief drinking commences

(20). In 1968 alcoholism was classI­ :.., Discomfort when alcohol unavailable
't:
fied as a personality disorder and a &J Occasional memory lapses

Preoccupation with alcohol

psychological disorder was implied Lying about drinking

-----------~
(21). The most recen t ( 1980) classifi­
cation of alcoholism as a substance
use disorder does not assume the ~ Loss of control
involvement of emotional disorder, g> Rationalization begins
but does outline the basis on which (i) Increased relief drinking
.! Hiding liquor
a diagnosis can be formed (22). Re­ ~ Tremors, morning drinking
classification of alcoholism from i More frequent memory lapses (blackouts)
psychiatric or pvschoJogical dis­ Grandiose and aggressive behavior
Family, money, and job problems
order into addiction and disease Efforts to control fail
process categories has a significant Neglect of food
impact on the treatment approach Drinking alone
Family and friends avoided
used with the patient, and has been Loss of job

\--------~
helpful in improving patient's atti­
tudes and outlook for recovery (23).
o occupational therapy literature ::: Now thinks-"responsibilities
exists which reflects a change in Ol
~
interfere with my drinking"
(J) Physical deterioration
classification or approach. Some
CIl Urgent need for morning drink
publications on alcoholism have 3 I mpaired thinking and memory loss
referred to the benefit of activities Inability to abstain
Decrease in alcohol tolerance ~
therapy programs(l, 23). Blum and CIl
~
Unable to work o
Blum (12) discuss the therapeutic Increasing hospitalizations C.l
CIl
value of an occupational therapy Loss of family ll:

program for alcoholic patients, in­ Persistent remorse or

All alibis exhausted .... Insanity Death
cluding positive reinforcement for
socially acceptable behavior; in­ -----~
creased self-esteem; learning safe,
structured expression of emotions;
and corrected patient attitudes and
perceptions. The treatment pro­
gram and occupational therapy ser­ variety of eth nic and socioeconomic the occupation;)1 therapist, a physi­

vices that reflect the reclassification groups. Most patients are young cian, and at times, occupational

of alcoholism as a disease and which through middle-aged adults and the therapy and counseling students.

emphasizes an approach of learn­ length of stay is 28 days. (When Each patient is assigned a counse­

ing new skills is described next. third-party pavers reimburse for lor, a primary nurse, and is referred

only 20 days of hospitalization, the to occupational therapy. In addi­

The Alcoholism Treatment Unit full program is adapted to fit the tion, a psycho-drama consultant

The 12-bed alcoholism treatment shorter period.) The treatment team and yoga instructor provide services

unit at Mercy Hospital admits both consists of trained alcoholism once weekly.

male and female patients from a counselors and technicians, nurses, The unit's philosophy recognizes

38 January 1983,
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 alcoholism as a chronic illness with improved physiological and emo­ viding opportunities for experi­
its own symptomatology that affects tional state (24). menting with socially acceptable
all aspects of a person's lifeand also To achieve these objectives, a ways of expressing feelings are also
as a treatable illness of a complexity wide variet y of treatment modalities emphasized.
that requires a multidisciplinary are provided. Movies, seminars, and Evaluation. A self-image collage,
team for effective treatment. The discussion groups educate patients combined with an interview and
philosophy maintains that internal and family members about the goal-setting session, is the founda­
patient's motivation is essential to disease. Group and individual tion of the occupational therapy
recovery and that a therapeutic counseling sessions provide oppor­ program. Although similar to other
mil iell of staff a nd pat ien ts provides tunities for the discussion of prob­ collage techniques (25-27), it is used
the best climate for learning the lems that occurred as a result of and interpreted differently. Patients
new behaviors that are necessary for dri nking and for deal ing with issues are instructed to use magazine pic­
sobriety. Within this milieu, group­ that arise during treatment. The tures to describe themselves, focus­
oriented experiences are utilized as opportunity to meet with former Ing on three are3S: personal
major facilitators of change. Sup­ patients and Alcoholics Anony­ strengths, personal weaknesses, and
port and involvement of significant mous volunteers and to attend the effect of drinking on their lives.
others is also considered necessary. Alcoholics Anonymous meetings l:pon completion, the collage is
The ongoing process of recovery helps to link what is learned in discussed individually, giving the
from alcoholism is best maintained, treatment with life outside the hos­ therapist an opportunity to get to
after treatment, through active par­ pital setting. know the patient, and to assist him
ticipation in the Alcoholics Anon­ The occupational therapist con­ or her in gaining self-awareness.
ymous program (24). tributes to the o\'erall treatment Patients who say "1 have no
The first objective of treatment is program by working with patients strengths" may be revealing low
to interrupt the drinking pattern to ach ieve specific obj eCI ives such as self-esteem. Some palil"nts do not
and facilitate commitment to per­ increasing socialization, im provi ng represent any of the three areas spec­
manent sobriety. The second is to iIllerpersonaJ relations, and decreas­ ified and fill the collage with pic­
surround the person \\lith the reality ing isolation. The therapist also lures of things they like or pictures
of the effects of his or her drinking. assists the patient to improve plan­ of 110\1" they would like their lives to
Family members, employers, and ningand problem solving, fine eye­ be Others select pictnres that do not
significant others are used to assist hand coordination, and memory. accurately reflect current life expe­
\"'Ith this. The third objective is to (Tremulousness and memory loss riences. These patients may be hav­
provide a therapeutic milieu to are exhibited primarily during ing difficulty looking at their lives,
develop greater ego strength detoxification but persist in some and at their alcoholism, so that
through the practice of new behav­ patients.) Occupational therapy breaking through denial will beone
iors and to improve confidence groups provide support and oppor­ of the first treatment goals. Thecol­
through positive peer relation­ tunities for growth through facili­ lage elicits much useful informa­
ships. Additional objectives include tating realistic perceptions of one's tion and stimulates meaningful dis­
involving patients in group experi­ assets and limitations. Group ob­ cussion about the patient's prob­
ences where they can learn about jectives include increasing self­ lems. It also provides useful infor­
themselves and how they relate to esteem and learning frustration tol­ mation in planning treatment for
others, assisting patients and their erance and appropriate tension re­ that patient.
families to improve their commun­ lease. Developingan understanding After discussing the collage, the
ication, and assisting them in ob­ of how to plan and use leisure time patient and therapist set behavioral
taining a deeper understanding of is also addressed. For most patients goals for the hospitalization period.
the disease. Other objectives are to this time was previously spent The patient's participation in goal
help the person learn to identify drinking or in drinking-related ac­ setting helps to ensure an invest­
daily problems and develop al terna­ tivities. Planning and use of spare ment in working on goals and pro­
tive coping behaviors, to evaluate time is important for establishing vicks insight into what the patient
children of female patients for fetal permanent sobriety. Creating an expects to accomplish during treat­
alcohol syndrome or fetal alcohol awareness In patients that new ment. If the only goal identified is
effects, and to facilitate return to all behaviors can be learned and pro­ "tu stay sober forever," the patient

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 Figure 2
Alcoholism Treatment Unit: Treatment Team

Nursing Coordinator: Physician:

Administrative supervi­ Medical and clinical
sion of nursing staff and responsibility. Assess­
responsibility for delivery ment of alcoholism, moti­
of nursing care. vation, and physical sta­
Nurse: tus; patient education,
Addresses physiological individual sessions, and
and psychosocial needs medical management. Unit Director:
from a nursing ·view­ Administrative and clini­
point, coordinates daily cal responsibility for the
activities, supervises treatment team, staff
detoxification, individual training and support,
and milieu discussions, community and industry
and patient education. liaison.

Occupational Therapist: Counselor:

Addresses alcoholism Guides patients through
and associated problems structured interviews
from an activity, behav­ including family and
ior, and goal-oriented employer sessions,
viewpoint, assesses coordinates team efforts,
patient's ideas and atti­ milieu activities, patient
tudes through activity, education, primary after­
patient education and care planning and outpa­
milieu activities. tient treatment linkage.
Yoga Instructor Technician
Psychodramatlst Relates with patients on
Each lead a patient a milieu level, assists
session once weekly. with patient care.

needs to learn that staying sober is sessmen ts are also part of the eval ua­ with the employer's assistance.) Un­
an immense task that has to be tion process. Observing the patient employed patients who appear to
broken down into smaller steps. during recreational periods, and need assistance in finding work or
This could be achieved by working discussing avocational interests who need further training are re­
with the patient on other tasks that with the aid of an Interest Checklist ferred to a vocational rehabilitation
have to be done step by step. The (28) give information about use of agency.
goal-selling exercise also indicates leisure time and the need for inter­ Therapeutic Use of Crafl Aclivi­
the patient's motivation for work­ vention in this area. A leisure plan­ ties. Patients have many opportuni­
ing in the treatment program. A ning assignment may be given to ties to demonstrate their willing­
patient may set many goals for patients who demonstrate particu­ ness to participate in the treatment
treatment but if most of them are to lar difficulties in this area. For program. Resistance to one treat­
be accomplished by staff, the pa­ unemployed patients, informal ob­ ment modality, which may indicate
tient may have an unrealistic view servation and interview are used to underlying resistance to the entire
of the personal effort required. Goal gain information about previous program, can surface when patients
selling helps patients to see that the work experience, task skills, social are asked to perform specific tasks.
treatment process is something the skills, dress and grooming, and While the patient works on craft
team assists them with, but that motivation for seeking employ­ activities, the therapeutic focus is
they have the responsibility for the ment (28). (Job problems related to on dealing with behaviors and atti­
final outcome. drinking are dealt with by thecoun­ tudes that relate to the person's
Vocational and avocational as­ selor of employed patients, often alcoholism and sobriety program

40 January 1983, Volume 37, Number 1

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 (24,29). Patients are encouraged to charge. Patients are also encour­ ilar in theory to one described by
choose an interest area that they do aged to select projects for them­ Fidler (30), but the emphasis is on
not associate with drinking. One selves to aid in rebuilding seJf­ learning alternative ways of dealing
patient had done much of his drink­ esteem, and to reinforce the fact that with problems and issues related to
ing in his woodworking shop. It they are in treatment to improve the the recovery process. For example,
was recommended that he pursue quality of their own life. impaired communication skills of
a n alternate interest for 6 months to Recreation. A recreational pro­ the alcoholic person can be im­
a year during the first year of sobrie­ gram, including a weekly outing, proved through communication
ty in order to firmly establish new provides funher oppOrt un ity for exercises, role-playing, and discus­
behaviors that are necessary for so­ socialization, development of inter­ sion. The experiential activities are
briety. Choosing new activities not personal relationships, group inter­ used as discussion starters (3 I, 32).
associated with drinking is consist­ action, and a decrease in isolation. In addition, patients learn how to
ent with a philosophy of doing The alcoholic person has frequent­ express their feelings, begin to share
things differently. ly had little experience relating to a about their alcoholism, and to clar­
High expectations are held for group of people. The positive group ify values (31,33-36). Value clarifi­
the quality of work, which provides recreational experiences are partic­ cation activities usually promote a
patients with a sense of achieve­ ularly beneficial to those who have great deal of discussion because,
ment they have seldom experienced. difficulty interacting in structured, with a change in life style, a change
It also provides opportunities to formal group settings. Also, partic­ in val LIes is predictable and proba­
work on frustration level, tolerance, ipation and enjoyment of recrea­ bly necessary. Patients are helped to
and patience. Those patients who tional activities without drinking is recognize that some of the things
expect an overnight cure are given a a new behavior for most patients. they value have to change in order
complex task, are taught to break They realize that they can expe­ for them to maintain sobriety. Also
the task into several steps, and to rience fun without drinking. Pa­ used are activities to build group
measure progress within each step. tients comment with much surprise cohesiveness, to experience risk tak­
This is then related directly to the on this new experience during a ing, to improve self-esteem, and to
recovery process from alcoholism, game or outing. In providing op­ Ifarn to give and receive positive
and seems to reduce anxiety a pa­ portunities for practicing new be­ and negative feedback (31,33,36).
tient may have about coping with a haviors, the recreational program The task-oriented group is used at
chronic illness. offers constructive outlets for anx­ rimes specifically as a way to raise
Time spent in the occupational iety, anger, and other unexpressed issues and to get people to talk
therapy clinic can reveal other feelings. Planning the weekly out­ hefore a group counseling session
things about pa tients. For example, ing aids in making decisions with that focuses on the issue more
patients who display an "I don't others and further development of deeply.
care" attitude about their work may skills for enjoyment of leisure time Team Approach. The occupa­
have the same attitude toward treat­ without drinking. tional therapist implements these
ment, sobriety, or dealing with their Group Process. In the task-ori­ specific aspects of the treatment
alcoholism. Isolative behavior may ented group, patients meet with program and also works with other
predict future difficulty in partici­ the occupational therapist to dis­ team memhers to achieve previous­
pating in Alcoholics Anonymous cuss issues or problems related to ly stated objectives for each patient.
or an outpatient group. The earlier alcoholism. The group deals with a Acting as a co-therapist in group
patients become aware of these be­ single issue or problem through a counseling sessions, interacting
haviors, the easier they are to mod­ variety of experiential activities. with patients in informal discus­
ify. The occupational therapy clinic The therapist may choose the activ­ sions, processing fiJ ms and lectures,
also provides patients with oppor­ ity based on group needs or the and speaking in the Family Lecture
tunities to explore leisure time needs of certain patients. The treat­ sfries are examples of roles the oc­
interests and to develop planr-ing ment team has the opportunity to cupational therapist share with
skills. Patients are encouraged to have input if desired, and the other team members. The treatment
make specific leisure time plans patients may be asked whether they team meers formally a minimum of
during hospitalization to increase have a specific problem they would three ti mes a week for pa tient eva lu­
successful follow through after dis­ like to work on. The group is sim­ ation sessions. All staff members

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The American. Journal of Occupalzonal Therapy 41
 provide input on behavior observed are also shared with the outpatient disease. The treatment experiences
and information gained from the counselor who will cOnlinue to see that the occupational therapist of­
patielll, and together the team that patient after termination of the fers enrich the inpatient treatment
decides upon treatmelll plans and inpatient program. program at Mercy Hospital and
approaches for each pa tient. In addi­ promote the recovery process from
tion to formal sessions, the team Outcome alcoholism. Providing patients op­
meets in formal] yonce or twice dail y Alcoholics Anonymous estimates portunities while in treatmenl to
to review patients' progress. This that alcoholic persons have a recov­ practice the new behaviors that will
supplements routine communica­ ery rate of between 50 and 85 percent help them stay sober generates con­
tion through the medical chart. No (due to the confidential nature of fidence in their ability to cope with
decision regarding a patient is made this self-help group, permanent problems after treatment. A review
without input from all available records are not kept) (23). The vari­ of patient charts for a 6-month
team members and the consistent ety of definitions used for the term period revea led tha t 37 percen t of
approach by all team members is recovery may account for the wide patients who completed treatmenl
significant in assisting patients to variance in this estimate. Mercy stated upon dischClrge that they felt
make behavioral changes. Figure 2 Hospital defines recovery from al­ beller about themselves and that
illustrates the team approach and coholism as I ~i years of uninler­ they learned some things in occupa­
responsibilities of team members. rupted sobriety. Based on Ihis defi­ tional therapy sessions they feel will
The input of the occupationalther­ nition, a study done by the director help them to stay sober. Patients
apist is integral due to the variety of of Mercy Hospital's Alcoholism have increased the amount of shar­
situations available to the therapist Treatment Unit indicated that the ing personal incidents and feelings,
during which to observe patient program recovery rate is 43 percent both in groups and on a one-to-one
behavior. Occupational therapy (D. Stamas, Evaluation Question­ basis. LeClrning to ask for help,
programs also afford the treatment na ire, J976,24). The ra te of recovery learning how to handle frustration
team a wider selection of treatment increased dramatically for patients and tension, and increased aware­
modalities for dealing wIth specific from Mercy Hospital who lived in ness of personal strengths a nd weak­
problems a patient may be having. an after-care residence following nesses are other areas in which many
In some cases, presence of the occu­ inpatient treatment. An afler-care patients have shown dramatic im­
pational therapist on the unit per­ residence is a home staffed by provement. Even subtle changes Me
mitted treatment for patients who Irained alcoholism counselors, seen as a vinory for the alcholic per­
would have otherwise been more where recovering alcoholic persons son. A review of a program evalua­
difficult to treat. Examples of these live together for an average of 3 tion patients complete before dis­
include a patient with recently ac­ months. Alcoholics Anonymous chClrge, using a five-pointscale(five
quired blindness, a mentally im­ and other group-orienled experi­ meaning "most helpful," four
paired young adult, and a patient ences are used to assist pCltients to meClning "very helpful," and so on)
with an CI bove-the-knee amputation. firmly establish their sobriety. Stay indicated thCl t96 out of 154 pa tients
Re-evalualion and Closure. A in an after-care residence, poten­ rated occupational therapy as CI five
final part of the occupational ther­ liCllly helpful to any recovering or four. Examples of comments that
apy program is to re-evaluate treat­ alcoholic person, is recommended accompanied ratings of five or four
ment: to assess patients' perceptions to patienls who would otherwise be included: "This helped me sort out
of what they have accomplished, to returning to an unstable or particu­ priorities," "You learn with your
let them know the therapist's per­ larly difficult Jiving situation (i.e., a mind and your hands," and "It
ceptions of progress in treatment, drinking spouse), or to patienls who showed me I can do things." It
and to give patienls feedback on have been in Ireatment programs seems that learning may be en­
areas in need of continued ".fork previously. chanced if patients have such a pos­
during the ongoing recovery proc­ itive attitude about a particular
ess. As a sharing of successes Clnd Discussion treatmelll modality.
continued concerns, this wrap-up Because of the complex nature of The responsibility for working
session with each patienl is impor­ the disease of alcoholism, it seems on goals throughout Ireatmelll con­
tant and occurs just before dis­ that a multidisciplinary approach tri bu tes to a smoother tra nsi tion for
charge. The therapist's impressions is the most effective way to treat the return to the community, rather

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Acknowledgments versity Press, 1981 CA: University Associates, Volumes l­
Appreciation IS expressed to the 14 Hossack JR Clinical trial of occupa­ VIII,1969-1980
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Philadelphia, Pennsylvania. The Williams and Wilkins Co. Publishing Co., 1978

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