Social Work; Essays on the Meeting Ground of Doctor and Social Worker

Just here the individuality of fatigue, which I have been trying to make clear all along, becomes obvious. We are rested by making a success of something. If we have been making what seems to us a failure of something, it is amazing how it rests us to make a success of something. The boat crew that wins is almost never tired at the finish; the crew that loses is almost always dead tired. That is why it is so refreshing to go home, to have a home to go to, and somebody to go to in that home, because there you have a tiny success. You have built up that home; it represents your savings, perhaps, if you are a working-man, or your success in winning somebody's affections. That success is linked up with joy. Recreation re-creates us because it enables us to succeed when we have felt ourselves failures, or at any rate postponers. We are working for some "far-off divine event to which" (we hope) "creation moves," but moves very slowly. In recreation, in art, in beauty, in going to the theatre, dancing, music, we get at something where we can succeed, success by performance or by enjoyment and so be refreshed. One of the things that is always exasperating to students of industrial fatigue is that a girl who is nearly dead from working in a factory is sometimes made totally fresh by dancing. After being tired out by standing, she gets rested by dancing. It is certainly puzzling but not inconceivable if we take into account the psychical factors, which we are so apt to ignore because they are invisible.

One of the things we want in rest is success where we have felt ourselves failures, achievement where we have felt we were postponing, trying to make goods which we never see finished, of which we do only a little piece. To balance all that, we want achievement, success, finish, the present delivery of something that is enjoyed now, of home, affection, or beauty.

From another point of view, a test of rest is forgetfulness. Forgetfulness ought to be achieved in our recreation and our time off. When people ask, "What form of exercise shall I take?" we have to bear in mind that the form of exercise which is most valuable is that which makes us forget. The easiest form of exercise, and the least valuable, usually, is walking. Many people carry on while walking just the same train of thought that has tired them. If so the walk is nearly useless. For other people the act of walking is different enough from what they do, so that it will break the continuity of thought and achieve forgetfulness and rest. Well-to-do people who can run an automobile usually can forget. That has been a little good that has come out of the many evils of the automobile.

One of the good signs in modern education is that our old-fashioned gymnasiums are being stripped bare, the apparatus "scrapped," in order to give place to play a game. Playing a game gives us present joy, the first thing we want in recreation; and in the second place, it makes us forget.

I have spoken of rest through change of work. But the change ought to be such as sets free imprisoned, unused faculties that find no outlet in our daily work. It may be that marriages are made in heaven, but the marriage of a man to his job is very seldom made in heaven, and so mismating is common. The whole human race is too big for its jobs. The industrial system is altogether too small to fit us; – a large part of our powers remain unused. Therefore, the purpose of our time for rest and recreation, our evenings and our Sundays, should be to even up that balance, to use the part of us that is not used at other times. Sunday ought to be a family day, just because in the working world people do not see much of their families during the week; it ought to be a day in the country because we have organized these things called cities and live in them during the week. It ought to be a day of worship because we forget our religion so much in the week's work. Everything that we do on Sundays ought to be an evening-up of what gets crowded out of our week-day lives.

Tests of fatigue

The English tests of fatigue are nowhere near being applied yet in America or anywhere else as we hope some day they will be, to solve this tremendous problem of industrial fatigue and industrial disease. In some of the ammunition works in England3 they took a body of people of approximately the same age and sex, living under the same conditions approximately, doing the same work. They changed the working hours of one set and left the other set unchanged as a "control." In any scientific test we have to have what we call a "control," something that enables us to compare the changes that we bring about experimentally with the unchanged state of things.

(a) In one room the hours of labor were left unmodified, in the other modified, first increased, then decreased. They made interesting experiments to see whether a man produced as much output, in eight hours as he could in ten; they showed that he could produce as much in the shorter time as he could in the longer time, presumably because he was less tired, less bored, less strained. They made a further cut and found that then he did not produce as much. There is a limit, therefore. He could not probably produce as much in four as in eight hours.

Then they experimented on continuity and discontinuity of work – whether a person could produce as much or more in five continuous hours as in two batches of two and a half hours with rest in between. They found that the shorter periods did distinctly better.

Output, then, was the first rough, but still serviceable, test that they used in relation to fatigue.

(b) Next they recorded the general look and feeling of the men as the foreman and other interested people could size it up – the look of listlessness, of boredness, of fatigue in the working-man when they varied the hours and continuity of work in the ways that I have spoken of.

(c) Next they took the amount of illness, of time off, away from work, as a measure of fatigue, and it was very definitely shown that with a diminished number of hours the number of sicknesses of all kinds, such as colds, were diminished, illustrating the point that I made a moment ago, – that accumulated fatigue diminishes our resistance to infection.

(d) Finally, they made some physiological tests of powers of sight, quickness of answer, etc., after fatigue, and showed that a man was less keen in his senses, less capable of accurate response, after a certain number of hours' work than before, and that fatigue could to a certain extent be measured in that way.

All these tests of fatigue can be applied in our lives and in the lives of people we are trying to help in social work. We have to take account of the number of hours, the possible breaks, intervals, that can be made in otherwise continuous labor. Many people can get on very well if they break the day into manageable fragments. We must also take account of the effect of fatigue in producing infectious disease, of the general look of the person, and of such little physiological lapses as I have spoken of, weakened attention, the capacity for forgetting names, and mental numbness or the sense that things are unreal.

In dispensary work, when we try to give up the use of particular medicines which are useless (as contrasted with the medicines that are useful), one of the chief things to put in their place is the study of fatigue and of the methods for resting our patients. We cannot make the social work of a medical-social clinic successful unless, whenever we take away something which we know to be a fraud and an untruth, we put something else in its place. It is for that reason that I have devoted so much space to the subject of fatigue and rest.

CHAPTER VII

THE SOCIAL WORKER'S BEST ALLY – NATURE'S CURE OF DISEASE

Fatigue is a matter that seems to me of particular importance in social work for two reasons: first, because it concerns the visitor's own work and the way she does it; and second, because it concerns the troubles of a large proportion of all patients. The ultimate diagnosis, if we could make it, in probably half of all the people who come to a general clinic, is fatigue of some form, falling upon the weakest organ or function.

I want to connect this subject of fatigue with one of the policies which should govern medical-social work, namely, that we should be honest both in diagnosis and in treatment. That is a policy for which I have struggled and fought for a long time, but which we are still far from attaining. We have not yet an honest practice of medicine on any large scale, a frank declaration to patients of what ails them, how they may avoid its recurrence and so avoid coming to the doctor again. In the American Red Cross Dispensaries in France we tried to pursue the policy of honesty in diagnosis and treatment. We were told by wise people at the beginning that it would not work there, that with French patients it would not do to explain carefully and honestly what was the matter or to refuse to give them drugs when we knew that drugs were no use. But one of the pleasantest experiences of our war work was to find that this warning was not true. We used the truth exclusively and successfully. Our success seemed to me natural because on the whole the French are the most intelligent race that I have ever come in contact with. Hence they took to this particular part of our policy even better than people take to it in America.

That policy links itself up with the management of diseased states due to fatigue and with the explanation of how to prevent getting into poor condition again. In newspaper advertisements and advertisements in the street-cars, it is the fashion to state that a given remedy, a given panacea, "will cure you in spite of yourself." That is exactly what the patient wants. He wants to be put in perfect condition by the first of March, we will say. Inquiring into his present distress we almost always find that he has been violating in some obvious way some hygienic law. But he wants to be cured without reform, in spite of persisting in his bad habits of eating, drinking, sleeping, working, worrying – to be cured by means of miraculous interference which he thinks a drug will produce. He wants a tonic, and he often does not take it well when you tell him that there is no such thing as a tonic. There never was and presumably there never will be such a thing. A tonic is a thing which does nature's work, which gives us in a moment artificially what food and sleep and air and rest and recreation slowly and naturally give us. There is no such thing. The nearest thing we have to a tonic – a thing which we sometimes give when people ask for a tonic – is an appetizer. There are drugs which will help a little in giving an appetite. But only to that extent can we give a tonic. But this is not what people want to be told. They want something to take away "that tired feeling." There is one thing (as unfortunately people discover only too soon) which will take away the feeling of fatigue – alcohol. That is why people take it, because alcohol, a narcotic as it always is, dulls the sense of fatigue, and allows people to go ahead straining themselves, when they ought to have been compelled by nature's warnings to stop. Perhaps it is because so many "tonics" contain alcohol that people have not got over the idea that there is any such thing as a real tonic, which abolishes, not the awareness of fatigue, but the fatigue itself.

The promise to "cure you in spite of yourself," then, is the bait by which the quack attempts to tempt us, and his lie shows exactly the line in which we, as social workers or as physicians in a dispensary, ought to labor. We must try to show people that fatigue, strain, worry, and other natural causes have brought them where they are, and that there is no possible getting out of their troubles without following the line of common sense. No drug, no tonic, can take the place of obedience to common sense.

We see people who have varicose veins, for instance, and whose work forces them to stand a great deal on their feet. They often come to us hoping to get cured in spite of the fact that they are standing all the time, and inviting the force of gravity to produce stagnation of blood in their legs. In advising such people we have two courses open to us, quite characteristic of the courses which may be followed in all such matters:

1. We can say, "Well, I understand that you really cannot arrange to get off your feet. All right. The varicose veins will not get cured. But, on the other hand, they are not very dangerous; the consequences of neglecting them are not very serious. The number of cases when an over-distended vein breaks and causes a serious hemorrhage is not great. The chances of ulcer are not very great." Force the patient to face the danger and realize what will happen, in case he does not make any change in his habits; it is then perfectly proper in certain cases for a person to go on violating hygienic common sense provided he has counted the cost and faced it.

Each of us comes to some point in his life when he makes up his mind that for a good cause he will smash his health. I do not believe in the worship of health. There are many better things in the world than health. Many a man makes up his mind to do what he knows will probably cost him a number of weeks or a year of his life. That is all right; only we must face it, in peace as well as in war.

Or (2), when people come to us for the relief of skin abscesses, boils, and demand some drug which will cure these abscesses, we must ask the important questions, Whence did you get them? Why did they come? Presumably not because the patient has failed to take a drug. We must find the fault in hygiene, generally constipation or overwork, or lack of sleep, causing a lowering of the body's vital resistance, whereby the germs, the staphylococci, which are deep in our skin and never to be rubbed off by any washing or sterilization, begin to multiply. The soil has become such that they can multiply.

I have tried to suggest the importance that we ought to attribute to soil as well as to seed. Modern doctrine about the cause of disease has called our attention to the tremendous importance of seed, that is, germs, bacteria. But on the whole, if one had to say which is the most important single factor in disease, he would have to say, not the seed, but the soil. Take the tuberculosis bacillus, for instance. I do not think it is an exaggeration to say that nine tenths of all persons have had tuberculosis, usually in a harmless form, because the soil has been stony and so has killed off the bacteria. You know that the figures obtained by means of tests with the Von Pirquet reaction in almost any city or town, show that ninety per cent of the children of twelve years of age and on, have a positive reaction to this test for infection by tuberculosis. They have the tuberculosis bacillus somewhere in their bodies. That does not mean that they have the disease, but they have the bacteria in their bodies, and mostly in the process of being killed off by the tissues of the body which resist this infection.

One of the reasons why I go into detail here about the changes that take place in the body through disease, is to make social workers feel as strongly as I feel, and convey to patients as strongly as I try to convey it, what nature does in curing disease. We have read of people who were walled up in masonry by way of vengeance, and left to die in a casket of stone. That is what nature does to a bacillus, literally walls it off in stone. After death when the pathologist's knife cuts down into a lung, the knife is sometimes broken by coming upon what feels like a stone. A stone it really is, a deposit of lime salts in the tissue, around a nest of tubercle bacilli. If one cuts such a stone in two, one finds in the centre bacilli often still alive and perfectly capable of increase, but harmless to the body because nature has built this wall around them. I do not think one can get the full force of this fact until one has seen it. That is one of the long list of things that the body is constantly doing in this process of resisting disease, and doing more intelligently than we can.

Since, then, it is chiefly the soil, the vital condition of our tissues, which resists disease, we must do our part in making that soil good or bad for disease. That is why our hygiene, our obedience to the individual laws of our own experience, which show us how we can keep well and how we get sick, must be learned and taught by every one of us so far as we can in such a place as a dispensary or a patient's home.

For example: disease is often produced by lack of sleep; hence it is of central importance to teach people how to sleep. Excluding organic disease in the causation of most cases of sleeplessness – for most people suffering from insomnia do not have organic disease – one can say this: Insomnia usually depends on something wrong in the patient's day. The state of the night depends on the state of the day. If the day has been free not merely from gross sin, but free from hygienic blunder, then the night will go somewhere nearly right. If the day has been filled with concentrated work in which the mind has been wholly upon the thing it has in hand, if there have been no elements of strain through distraction or worry, causing double currents in the mind, then when night comes one can turn the mind off and go to sleep. On the other hand, the mind which has been intent half on its own job and half on its own worries, never wholly "turned on" during the day, cannot be "turned off" at night. Any physician or any patient succeeds in curing insomnia who succeeds in finding out what is wrong in the way the sleepless person lives, and how it can be corrected.

But most people want to go on living in just the same stupid way and yet to get rid of the sleeplessness "in spite of themselves." The obvious way is to take a drug that for a while will stop insomnia even when life goes on as before. There are many drugs that will give sleep, but there are no harmless drugs that give sleep – none. Physicians receive about once a year advertisements of a drug for sleep which is "wholly without ill effects," but I do not think it shows undue skepticism or dogmatism to say that those drugs never do what they say, and never will. Sleep being a natural process, anything that forces it upon us hardly can be free from ill effects. Hence the first thing in attacking a case of insomnia is to say, "Never take a drug again." Natural processes whereby fatigue accumulates and puts us to sleep do not go on rightly if we are being artificially driven into sleep by a drug.

One gives drugs for sleeplessness rightly when there is some rare and special reason for being awake, some catastrophic reason which will never occur again. This exemplifies the principle which I have tried to emphasize throughout this book. We may give money for some catastrophic cause which puts the person down and out, and will not occur again. So we give a drug for sleeplessness if there has been some special thing to interfere with sleep – if, for instance, you have been talking very hard with a friend and you know by your own feelings that your mind will not stop that night. Then you may perfectly properly take a drug to put you to sleep, knowing that there is no reason to suppose that such a talk will occur again in the near future. Knowing this, you do not need to waste that night. You take the drug. But it is only in rare catastrophic moments that one can be cured in spite of one's self, any more than one can give or take money safely.

It is the same in the matter of constipation. The first thing to make clear to a patient is that drugs must be abandoned before he can ever teach his bowels to behave as they should. But it is a great deal of trouble to do that, and because people shirk that trouble, and want to be "cured in spite of themselves," they come to a doctor to be cured by drugs. Alas, he is often weak enough to give them what they seek!

I have tried to make this drug-fearing practice one of the policies that honest medicine must always stand for, because it seems to me that when the doctor allows himself to be tempted into behaving as a considerable number of his profession do – that is, into giving people what they ask for – he very soon loses his ideals, gives things that he knows more and more clearly that he has no right to give, and goes downhill. Social assistants must help the doctor to avoid this disaster. They can do so by helping him to teach the truth.

I want to deal a little further with some examples of what nature does in the way of warding off disease. For a large part of what we call disease, and what we feel in ourselves as disease, is not the attack of the enemy, but is our defence against the enemy.

Take, for instance, inflammation. When germs are beneath the skin, one finds redness, swelling, heat, pain, as the symptoms of inflammation. What does that mean? It is all like the defences which were set up round Paris when the Germans were coming there, or that are set up anywhere when one is getting ready to repel attack. The inflamed finger gets red because a great deal of blood is going there. The blood cells, especially the white cells of the blood, are coming there to defend. The finger gets red for the same reason that the railroads get congested in time of battle, namely, because so many soldiers are being carried there for defence. The finger gets swollen because so many cells and fluids are coming to attack the enemy; it is their crowding outside the blood vessels that makes the swelling. There is heat in the finger because there is more blood in the part and therefore the part is hotter. There is pain because with the extra accumulation of defenders there is a squeezing of the little nerve terminations there. When a lot of soldiers are suddenly quartered, billeted in a town, it is a painful process. There is pain in having defence come to your city. There is pain in having defence come to your finger.

All of these symptoms, which we are apt to hate and to think of as misfortunes, we should realize are the thing which saves us from very serious illness. Suppose these things did not happen. Following out the metaphor, if it were not for these defences the enemy would penetrate into the whole body and we should have blood poisoning. It is because this local heat, redness, swelling, pain, appears at the point where bacteria are attacking us, that they do not penetrate the whole body with a septicemia, which is one of the most dangerous of all diseases. So while suffering what we must suffer, we ought to be glad of all that nature is doing, because if she neglected it the consequences would be very serious to us.

But we may ask, "If this is true, where do medicine and surgery come in? Why do they ever interfere if nature is so very wise?" Because nature overdoes the thing every now and then. Nature is first enormously wise and then a little blind. In another example I can bring this out a little better. You have sprained your knee and the knee gets very stiff. That in itself is good; it is a defencive reaction. The stiffness is like a splint. The knee ought to be kept quiet. So far so good. But nature overdoes the thing. The knee ought to be kept quiet, but for how long? We will say three days more or less, according to the severity of the injury. Then you have to fight nature which stiffens the knee too much. You have to fight it by the use of the knee, by walking or by massage, which is not, however, so good as walking. If we respect blindly what nature does in stiffening the knee even to the exclusion of nature's other functions, such as walking, then the knee will get worse. One of the greatest improvements in the modern treatment of sprains, is that we no longer keep the patient in bed and put plaster of Paris on, which makes the sprain last for months sometimes; but we let him walk at once on the sprained ankle, whereby the attempts of nature to cure by stiffening are not carried too far.

Another example of how nature overdoes things is in the formation of scar tissue. If a scar did not form to close the wound, the wound would remain open. Hence the scar is vastly better than nothing. But scar tissue is never as good as the original tissue. One of its known ill results is contraction, so that a scar on the hand or on the neck often draws the part out of place. Then we have to fight nature. We have to go against the workings of nature by surgery, in order to get the person right.