Books by Richard C. Cabot
PUBLISHED BY
HOUGHTON MIFFLIN COMPANY
A LAYMAN'S HANDBOOK OF MEDICINE. With Special Reference to Social
Workers.
WHAT MEN LIVE BY.
SOCIAL WORK. Essays on the Meeting-Ground of Doctor and Social Worker.
SOCIAL WORK
ESSAYS ON THE MEETING-GROUND OF DOCTOR AND SOCIAL WORKER
BY
RICHARD C. CABOT, M.D.
[Illustration: Logo]
BOSTON AND NEW YORK
HOUGHTON MIFFLIN COMPANY
The Riverside Press Cambridge
1919
COPYRIGHT, 1919, BY RICHARD C. CABOT
_All Rights Reserved_
TO
MARY E. RICHMOND
WHOSE ILLUMINATING BOOK ON "SOCIAL DIAGNOSIS"
MARKS AN EPOCH IN THE DEVELOPMENT OF SOCIAL WORK
PREFACE
Most writers who disclaim thoroughness are prone to describe their work
as an outline, a sketch, or an introduction. But the chapters of this
book are more like spot-lights intended to make a few points clear and
leaving many associated topics wholly in the dark. Possibly such
isolated glimpses may serve better than a clear outline to suggest the
interest of the whole topic. At any rate, that is my hope.
Part of the same material has been used in lectures given at the
Sorbonne in the early months of 1918 and published by Crès & Cie. under
the title of _Essais de Médecine Sociale_.
CONTENTS
INTRODUCTION: HISTORICAL DEVELOPMENT OF SOCIAL
ASSISTANCE IN MEDICAL WORK vii
PART I: _Medical-Social Diagnosis_
I. THE MEDICAL STANDING, DUTIES, AND EQUIPMENT
OF THE SOCIAL ASSISTANT 3
II. HISTORY-TAKING BY THE SOCIAL ASSISTANT 28
III. ECONOMIC INVESTIGATION BY THE SOCIAL ASSISTANT 47
IV. MENTAL INVESTIGATION BY THE SOCIAL ASSISTANT 66
V. MENTAL INVESTIGATION BY THE SOCIAL ASSISTANT, CONTINUED 96
VI. THE SOCIAL WORKER'S INVESTIGATION OF FATIGUE, REST,
AND INDUSTRIAL DISEASE 112
VII. THE SOCIAL WORKER'S BEST ALLY--NATURE'S CURE OF DISEASE 127
PART II: _Social Treatment_
VIII. SAMPLES OF SOCIAL THERAPEUTICS 151
IX. THE MOTIVE OF SOCIAL WORK 176
INTRODUCTION
HISTORICAL DEVELOPMENT OF SOCIAL ASSISTANCE IN MEDICAL WORK
I
The profession of the social worker, which is the subject of this book,
has developed in the United States mostly within the past twenty-five
years. Probably ten thousand persons are now so employed. It is known by
various titles--social worker, school nurse, home and school visitor,
welfare worker, hospital social worker, probation officer--varying
according to the particular institution--the hospital, the court, the
factory, the school--from which it has developed. But although the use
of these visitors has been developed independently by each institution,
and largely without consciousness of what was going on in the others,
yet the same fundamental motive power has been at work in each case.
Because this is so, we shall do well, at the outset of our study of home
visiting, to get a clear conception of the common trunk out of which
various types of home visitor have come like branches.
Why has such an army of new assistants been called into existence? For
this reason: In the school, in the court, in the hospital, in the
factory, it has become more and more clear, in the last quarter of a
century, that we are dealing with people in masses so great that the
individual is lost sight of. The individual becomes reduced to a type, a
case, a specimen of a class. These group features, this type of
character, of course the individual possesses. He must be paid as "a
hand," he must be enrolled in a school as "a pupil," admitted to the
dispensary as "a patient," summoned before the court as "a prisoner."
But in this necessary process of grouping there is always danger of
dehumanization. There is always danger that the individual traits, which
admittedly must be appreciated if we are to treat the individual
according to his deserts, or to get the most out of him, will be lost
sight of. We shall fail to make the necessary distinction between A and
B.
It is the recognition of this danger which has led, in the institutions
which I have mentioned, to the institution of the social worker. Above
all of her duties it is the function of the social worker to discover
and to provide for those individual needs which are otherwise in danger
of being lost sight of. How are these needs found? In schools,
hospitals, factories, courts, and in the home visiting carried out in
connection with them, one can discern the two great branches of work
which in the medical sphere we call _diagnosis and treatment_.
Thus, in the school, it is for the individualization of educational
diagnosis and of educational treatment that the home visitor exists. The
educational authorities become aware that they need to understand
certain children or all the children of a group more in detail--each
child's needs, difficulties, sources of retardation. This _educational
diagnosis_ is made possible through the home visitor's study of the
child in the home and out of school hours. There follows a greater
individualization of _educational treatment_. The teacher is enabled,
through the reports of the home visitor, to fit his educational
resources more accurately to the particular needs of the scholar, so
that they will do the most good.
In the juvenile courts the judge needs to understand more in detail the
child's individual characteristics, the circumstances, the temptations,
which preceded and accompanied the commission of the offence which now
brings the culprit before him. This is _penological diagnosis_, and the
court visitor or probation officer, sometimes simply called the social
worker, makes a study of the law-breaker in his home and in relation to
all the influences, physical or moral, which may help to explain the
commission of the particular offence which has brought him into trouble.
All this leads to the greater precision of _penological treatment_.
Understanding more in detail why this particular boy has committed this
particular theft, how he differs from other boys who have stolen, the
judge is much more likely to choose wisely those measures of treatment
which in the long run will do most to reëstablish the individual as a
healthy member of society.
In the factory the object of the employer in setting a home visitor or
welfare worker at work is to create the maximum of satisfaction and
good spirit among his employees, whereby each will do his best work and
be as little likely as possible to change his employment. In the old
days, when shops were small and the employer could know his employees
personally, no intermediary such as a home visitor was necessary. The
employer could keep human touch with his men. He could know not merely
the amount of work done by each man, but something of the circumstances
of his life, something of his personality, his adventures and
misfortunes, so that help could be extended to him from time to time
when special need occurred. It is only when the workshop has grown to
the enormous size familiar in modern industrial plants that this
relation of employer and employee has to be supplemented through the
mediating offices of the home visitor.
It is this same process of evolution, the same heaping-up of groups till
finally they become unmanageable, which has led to the employment of the
social worker in other institutions. It is because the schoolmaster must
teach so many that he can no longer know his pupils and their families
individually that he has to employ the home visitor to keep him better
in touch with them. It is because the judge tries so many prisoners that
he cannot grasp and pursue all the detailed characteristics of those who
come before him for judgment that he is compelled to get them at
second-hand from a home visitor.
So finally when we approach the reasons for which the medical home
visitor has come in the better dispensaries of the United States to be
an essential part of the institution, we find that the unmanageable
increase in the number of patients to be treated by the doctor is one of
the chief reasons why the home visitor has become necessary. In the old
days and in country practice especially, it was doubtless possible for
the doctor to follow the lives of his patients individually as
acquaintances, and through many years, to watch the growth and
development of families, to know their members as a friend and not
merely in a professional capacity. He would meet them as a neighbor, in
church, in town meetings, in agricultural fairs, in village sports and
holidays. Thus he would touch the lives of his fellow citizens on many
sides, and when he came to their aid in his narrower professional
capacity he could supplement his diagnostic findings and his therapeutic
resources out of the wealth of knowledge which years of association with
them outside the sick-room had furnished him.
II
But in the evolution of the particular type of social worker who is the
subject of this book, the home visitor connected with a dispensary,
there are other forces besides those described above, other motives
besides that common to the rise of all the types of home visitors in all
the other institutions named. For in the dispensary, not only has the
number of applicants greatly increased, but it has increased because
people realized that there was much more to be obtained by going to a
dispensary than was formerly the case. The development of medical
science and of the resources of diagnosis and treatment which can now be
put at the service of the dispensary patient, has served to attract more
patients there. But these new resources have also complicated the work
of the physician in a dispensary, and made it more difficult for him to
remember each patient and all the details about each patient as the
physical, chemical, psychological, biological facts emerge in the
complex ramifications of modern diagnosis and treatment.
In the old days the dispensary, as its name suggests, was a place to
dispense, to give out medicine in bottles or boxes. The patient
mentioned the name of his ailment, the corresponding remedy was given.
It was a quick and simple business--no individual study, no prolonged
labor was necessary. Moreover, one dealt only with a clearly defined
class, the poor. There was no danger that the numbers applying for
relief would swamp the institution or make it impossible for the
dispenser to do his work properly.
But within the past quarter of a century the dispensary, especially in
the United States, has received a new idea, an access of fresh life.
Largely because it has become associated with universities and been used
as an instrument of medical teaching, the influence of scientific
medicine has begun to be felt there. This influence has enlarged and
remodelled the dispensary in two respects. First it has compelled the
introduction of modern accurate methods of diagnosis, instruments of
precision, _time-consuming processes of examination_, specialization of
labor, and subdivision of function, for the skilful application of these
methods. The dispensary physician is no longer content to treat a
headache or a cough as an entity, to dispense this or that drug as the
remedy for such a symptom. He must discover if possible the underlying
disease, and, moreover, the individual constitution and life-history in
the course of which the patient's complaint now rises for the moment to
the surface like a fleck of white foam on an ocean wave. But how is the
physician to gain this radical and detailed knowledge of his patient's
life outside the dispensary and enveloping the particular complaints for
which he now demands relief?
His difficulties are only increased when diagnosis is complete and he
turns to the labors of treatment. For with the advance of modern medical
science there are left now but few physicians who believe that disease
can often be cured by a drug. It is recognized by the better element of
the medical profession all over the world that only in seven or eight
out of about one hundred and fifty diseases clearly distinguished in our
textbooks of medicine, have we a drug with any genuine pretensions to
cure. What is to take the place of drugs in dispensary treatment? In
hospital patients we have the hospital régime, the unrivalled
therapeutic values of rest in bed, the services of the nurses; but in
dispensary practice all this is impossible. What is to take its place?
For a good many years this question remained unanswered in American
dispensaries, and as a result thereof there developed the pernicious
habit of giving drugs no longer believed in by the physician, the custom
of giving what we call _placebos_, remedies known to be without any
genuine effect upon the disease, but believed to be justified because
the patient must be given something and because we know not what else to
do or how else to satisfy him.
III
It was at this very unfortunate and undignified stage in the development
of our dispensary work in America that we received priceless help from
France, help which I am all the more anxious to acknowledge to-day
because it has not, I think, been fully appreciated in the past. We in
America have not given to France the full expression of the gratitude
which, for her services in the field of medicine, as in even more
important phases of our national life, it is to-day particularly fitting
that we should utter. The timely contribution made by France at this
halting and unsatisfactory stage in the evolution of our dispensaries
came through the work of the great Dr. Calmette, of Lille.
Calmette's introduction of the anti-tuberculosis dispensary as a focal
centre of the fight against tuberculosis contained among other
important provisions the institution of the _visite domiciliaire_. The
functions of the person making this visit were not precisely the same as
those of the social worker whom I am describing in this book, but the
latter may truly be said to have grown out of the former, nourished by
some contributing elements from other sources. So far as I know,
Calmette was the first to see that in the struggle of the dispensary
against this particular disease, tuberculosis, it is essential to make
contact with the home, and to treat the disease there as well as at the
dispensary itself. In Calmette's view the function of the _visite
domiciliaire_ was an outgrowth of his bacteriological training and his
bactericidal plan for treating tuberculosis. The home visitor was a part
of the plan of antisepsis, a method of destroying the bacteria through
disinfection and sterilization of the premises and of the patient's
linen. In America the work of the home visitor in cases of tuberculosis
has been concerned less with the disinfection and bactericidal
procedures than with the positive measures of hygiene, such as the
better housing of the patient, better nutrition, better provision for
sunlight and fresh air, and above all instruction of the patient as to
the nature of his disease and the methods to be pursued in combating it.
But the great debt which we owe to Calmette was the linkage of the
dispensary and the home by means of the home visitor. In America we have
applied this principle, outside the field of tuberculosis, to all other
diseases, and we have broadened the field of work assigned to the social
worker. Nevertheless, the idea was primarily Calmette's.
There was another leading idea of Calmette's which we have followed
first in relation to tuberculosis, later in dealing with other diseases.
Like Calmette we have stopped wholesale drugging, and put our trust in
those scientific hygienic procedures which carry out our knowledge of
the nature of the disease which we are combating. Calmette's measures
have the tone and the point of view of preventive medicine, and of that
sound science which we have learned to associate with the Pasteur
Institute and all that development of medicine which took its rise from
Pasteur.
The focussing of interest upon a single disease which began, so far as I
know, with Calmette's anti-tuberculosis dispensaries, has been fruitful
in many ways. In the first place, it has enabled science once more to
_conquer by dividing the field_, to help humanity by devoting itself to
a single manageable task. Like others of Calmette's ideas, this
isolation of a single disease for group treatment in dispensaries has
been followed in fields with which he never concerned himself. Thus we
have had special classes for cases of heart disease, for diabetes, for
syphilis, for the digestive disturbances of infancy, and for
poliomyelitis. A valuable measure of success has come in each of these
diseases through the concentration of attention, at a special day and
special hour by a special group of physicians and assistants, upon one
disease at a time. We have even used class methods and taught the
patients in groups as scholars are grouped and taught at school.
But there has come another signal advantage in the point of view adopted
by Calmette in his dispensary campaign--the point of view, namely, of
public health and public good. It has freed us from the limitations
contained in the old idea that a dispensary is an institution concerned
solely with the poor. Tuberculosis, of course, like every other
infectious disease pays but little respect to distinctions of property.
From the point of view of the State a tuberculous individual is as
dangerous to others and a cured tuberculous patient is as valuable as a
possible asset to the State, whether his income is above or below a
certain figure, whether, in other words, he is inside or outside the
imaginary group sometimes called the poor. From the institution of
tuberculosis dispensaries with their home visitors in America, the
poverty of the individual ceased to be a necessary badge for admission.
Especially since many of our dispensaries have been instituted and
maintained by the State, and therefore are paid for by all its citizens
in their taxes, any one so unfortunate as to acquire tuberculosis, or be
suspected of it, feels himself wholly justified in seeking help at a
State-maintained tuberculosis dispensary. In this respect, as in many
others, the campaign against tuberculosis has had a value far greater
than its measure of success in checking that disease. It has introduced
methods which were applicable outside the field of tuberculosis. One of
these, as I have already said, was the utilization of the home visitor.
A second was the disregarding of property lines. A third was the frank
and confident reliance upon scientific measures and the relegation of
eclecticism and quackery to the hands of those who make no pretence at
scientific education or honest dealings with the public.
IV
I must speak at this point of another great French contribution towards
the occupation which in its fully developed state we now call social
work. I mean that which at present receives ordinarily the name of the
"OEuvre Grancher." Grancher proceeded upon the same sound
bacteriological foundations which guided Calmette. Since children are
especially susceptible to tuberculous infection (though they rarely show
alarming signs of it till later years), he planned the _separation of
children from the neighborhood of tuberculous parents_ or other
tuberculous persons as an essential measure for preventing contagion. I
am not concerned now with the enormous benefit derived by the forces
struggling against tuberculosis from this insight of Grancher's, nor
with the part which it has played in such success as that fight has
already attained in the United States and elsewhere. What interests me
particularly in connection with the topic of this book, is that the
procedures suggested by Grancher led the physicians who came in contact
with the tuberculous individual in a dispensary to extend their interest
to other persons who did not present themselves at the dispensary as
patients. It is not obvious at first sight how great a transforming
principle is thereby introduced. Hitherto the doctor had been passive in
his activities at the dispensary. He had concerned himself with such
patients as chanced to appear there. He had never taken _the active or
aggressive attitude_, searching for possible patients among those who
had made no attempt to avail themselves of his services. Now he goes to
find patients.
This is an epoch-making change. The physician becomes henceforth not
merely a person who stands ready to treat disease when the accidental
and incalculable forces of custom, hearsay, and natural propinquity
bring the patient to him. He becomes now a person who actively wars
against disease, who searches it out wherever it may be found. Thus he
approaches for the first time the possibility of truly preventive
action, the possibility of killing disease in its infancy or preventing
its birth. For it is well known that preventive action in relation to
disease is well-nigh impossible if we are forced or accustomed to wait
until the disease has made such progress that the patient himself is
aware of it and forced by its ravages to ask medical aid. Ordinarily the
patient seeks the physician only when he has broken down. From the
point of view of public health and public good, this is grievously late,
far too late. It is as if one inspected an elevator only after it had
fallen and killed or maimed its passengers, instead of inspecting it at
regular intervals so as to prevent its breaking down.
In this series of aggressive steps in the campaign against tuberculosis
whereby one seeks out possibly infected children, brings them to a
dispensary for examination, and separates them from their infected
parents or house-mates, the social worker is the all-important
executive. She finds the children, brings them or has them brought to
the dispensary, and sees that financial aid or other assistance is given
so as to carry out the isolation demanded by our bacteriological
knowledge of the disease.
V
As far back as 1895 the reforms introduced by Calmette and Grancher in
the field of tuberculosis had begun to modify and improve the treatment
given in our dispensaries, not only to tuberculosis but to all other
diseases. Especially it had favored the growth of home visiting, at
first for the specific ends for which it was designed by Calmette and
Grancher, but later for the prosecution of various related purposes
which the very process of visiting brought to light. Not only in
tuberculosis, but in other diseases, it was soon found that a knowledge
of home conditions and of the family was essential for the treatment of
the single patient who chanced to appear at the dispensary.
It was my good fortune during the ten years preceding 1905 to work as a
member of the board of directors of a private charitable society caring
for children deserted by their parents, orphaned, cruelly treated; also
for children whose parents found them unmanageable or for children who
had special difficulties in getting on at school. The work of this
society brought to me detailed knowledge of the life-histories of a good
many children. I watched the careful studies made by the paid agents of
the society into the character, disposition, antecedents, and record of
the child, his physical condition, his inheritance, his school standing.
I noticed during these years how the agents of this society, to whom the
child was first brought by its parents or by others interested in it,
utilized to the full the knowledge and resources of others outside its
own field; how, for example, they enlisted the full coöperation of the
child's school-teacher, secured facts and advice from the teacher, and
agreed with her upon a plan of action to be carried out both by her and
by the home visitor in concert. Moreover, I saw how physicians were
consulted about the child, and how their advice and expert skill
contributed something quite different from that obtained from the
teacher or that gained by the home visitor herself. The priest or
clergyman connected with the family was also asked for aid, and
sometimes could give very great help, differing essentially in kind
from that given by the teacher or by the doctor. If there were problems
involving poverty on the part of the parents, other societies concerning
themselves particularly with the problems of financial relief were asked
to aid, in order that indirectly the help given to the parents might
make itself felt in the better condition of the child. Sometimes free
legal advice was obtained from the legal aid society formed for the
purpose of giving such advice to those who were unable to pay for it.
As I watched the application of this method over a period of a good many
years and in the case of a great many children, I saw a good many
failures in addition to some most encouraging successes. But what most
of all impressed itself upon me was _the method_, the focussing of
effort on the part of many experts upon the needs of a single child, the
coöperation of many whose gifts and talents varied as widely as their
interests, to the end that a single unfortunate child might receive
benefit far beyond what the resources of any single individual, no
matter how well intentioned, could secure.
I have said that the doctor was a member of the group whose efforts were
focussed upon the needs of a single child, but he was never a very
closely connected member of this group. A few charitably inclined
physicians, personal friends of those directing the charities, were
called upon again and again to help out in individual cases by examining
a child, by giving advice over the telephone or otherwise. Through the
free hospitals and dispensaries help was also obtained for the physical
needs of persons who had come to the notice of the different charitable
associations by reason of economic need or other misfortune. But the
medical charities, the hospitals, dispensaries, convalescent homes, and
the benevolence of individual physicians were not well connected with
the group of charitable associations which I have been referring to
above.
At this period, in 1893 and 1894, I had been working for some years as a
dispensary physician, concerning myself chiefly with perfecting the
methods of diagnosis in a dispensary, so that the patient could obtain
there a diagnosis as correct and scientifically founded as he could
obtain from a private physician. But in the course of these efforts for
a complete and exact diagnosis which should do justice to the actual
needs of the patient, I found myself blocked. I needed information about
the patient which I could not secure from him as I saw him in the
dispensary--information about his home, about his lodgings, his work,
his family, his worries, his nutrition. I had no time--no dispensary
physician had time--for searching out this information through visiting
the patient's home. Yet there was no one else to do it. My diagnoses,
therefore, remained slipshod and superficial--unsatisfactory in many
cases. Both in these cases and in the others where no diagnosis was
possible from the physical examination alone, I found myself constantly
baffled and discouraged when it came to treatment. Treatment in more
than half of the cases that I studied during these years of dispensary
work involved an understanding of the patient's economic situation and
economic means, but still more of his mentality, his character, his
previous mental and industrial history, all that had brought him to his
present condition, in which sickness, fear, worry, and poverty were
found inextricably mingled. Much of the treatment which I prescribed was
obviously out of the patient's reach. I would tell a man that he needed
a vacation, or a woman that she should send her children to the country,
but it was quite obvious, if I stopped to reflect a moment, that they
could not possibly carry out my prescription, yet no other filled the
need. To give medicine was often as irrational as it would be to give
medicine to a tired horse dragging uphill a weight too great for him.
What was needed was to unload the wagon or rest the horse; or, in human
terms, to contrive methods for helping the individual to bear his own
burdens in case they could not be lightened. Detailed individual study
of the person, his history, circumstances, and character were frequently
essential if one was to cure him of a headache, a stomach-ache, a
back-ache, a cough, or any other apparently trivial ailment.
Facing my own failures day after day, seeing my diagnoses useless, not
worth the time that I had spent in making them because I could not get
the necessary treatment carried out, my work came to seem almost
intolerable. I could not any longer face the patients when I had so
little to give them. I felt like an impostor.
Then I saw that the need was for a home visitor or a social worker to
complete my diagnosis through more careful study of the patient's malady
and economic situation, to carry out my treatment through organizing the
resources of the community, the charity of the benevolent, the forces of
different agencies which I had previously seen working so harmoniously
together outside the hospital. Thus I established in 1905 a full-time,
paid social worker at the Massachusetts General Hospital, to coöperate
with me and the other physicians in the dispensary, first in deepening
and broadening our comprehensions of the patients and so improving our
diagnoses, and second in helping to meet their needs, economic, mental,
or moral, either by her own efforts, or through calling to her aid the
group of allies already organized in the city for the relief of the
unfortunate wherever found. To bring the succor of these allies into the
hospital and apply it to the needs of my patients as they were studied
jointly by doctor and home visitor, was the hope of the new work which I
established at that time.
In the thirteen years which have elapsed since this period, about two
hundred other hospitals in the United States have started social work,
some of them employing forty or fifty paid social workers for the needs
of a single hospital. Unpaid volunteer work has always been associated
with that of the paid workers in the better hospitals.
I should mention, in closing this chapter, three forms of medical-social
work which had been undertaken previous to 1905, and which were more or
less like the work which I have just described, though not identical
with it:
(1) The after-care of the patients discharged as cured or convalescent
from English hospitals for the insane (1880). The visitors employed in
this work followed the patients in their homes and reported back to the
institution which they had left. Their labors were directed chiefly to
the prevention of relapses through the continuation in the home of the
advice and régime advised by the hospital physician and previously
carried out in the institution.
(2) The work of the Lady Almoners long existing in the English hospitals
had begun about the time that I started medical-social-service work in
America, to change its character so as to be more like the latter.
Originally the purpose of the Lady Almoners was to investigate the
finances of hospital patients in order to prevent the hospital from
being imposed upon by persons who were able to pay something, but who
represented themselves as destitute and therefore fit subjects for the
aid of a charitable hospital. Gradually, however, the Lady Almoners had
begun to be interested in the patients as well as in the hospital funds,
and had begun to labor for the patients' benefit as well as for the
hospital's. This brought them near to the idea of hospital social
service as practised in this country since 1905.
(3) The visiting nurses or public health nurses, employed by a Board of
Health or by private agencies for the care of contagious diseases in the
home and also for the nursing of the sick poor whatever their malady,
have found it more and more difficult in late years to confine their
work wholly to physical aid. They have been forced to take account of
the patients' economic, mental, and moral difficulties, to extend their
work beyond the field of nursing proper, and thus to approach very
closely to the field of the social worker. It is my own belief that the
frontier separating visiting nurse and medical social worker should be
rubbed out as rapidly as possible, until the two groups are fused into
one. The visiting nurse must study the economic and mental sides of the
patients' needs, and the social worker must learn something of medicine
and nursing. Then the two groups will be fused into one, as indeed they
are fast fusing at the present time.
SOCIAL WORK
_PART_ I
MEDICAL-SOCIAL DIAGNOSIS
SOCIAL WORK
CHAPTER I
THE MEDICAL STANDING, DUTIES, AND EQUIPMENT OF THE SOCIAL ASSISTANT
I have said in the Introduction that _home visiting_ may easily and
properly spring up in connection with various institutions; for example,
in connection with the schools, courts, or factories of the city as well
as with the dispensaries. But it is essential in home visiting, no
matter what institution it is connected with, that the social assistant
should be distinctly recognized as _part of the machinery_ of that
institution, or, in other words, as one of the means by which that
institution does its work. If she is connected with the schools, she
should be a part of the school system alone, not responsible to a Board
of Health or to any other outside agency.
So in the type of home visiting which now particularly concerns us, it
is essential to make it clear from the outset that the social worker is
a part of the medical organization. She is one of the means for
diagnosis and treatment. All that she does from the moment when she
first scrapes acquaintance with the patient is to be connected with the
condition of the patient's health. She is not to pursue independent
sociological or statistical inquiries. She is not to be the agent of any
other non-medical society. It is unfortunate even if her salary should
be paid from any source other than the medical institution itself.
There are great advantages in this apparently formal and obvious point
of connection. In the first place the _medical method of approach_ to
close relations, to friendly relations, with a group of people, is
decidedly the easiest. Persons who may be suspicious or resentful of our
approach if we appear primarily as investigators, or primarily as
persons concerned with economic or moral control, will welcome the
visitor if she appears as the arm, the cordially extended hand, of the
medical institution where they have already found welcome and relief. I
know well that charity organization workers, court workers and others
may establish just as close a relation with their clients _in the end_
as is possible for the medical social worker. But the start is harder
and needs more experience. Because disease is the common enemy of
mankind, all sorts and conditions of men are instinctively drawn
together when it becomes necessary to resist the attacks of disease as
the enemy of the human family. Members of a family may disagree about
many matters, and may be far from congenial with one another in ordinary
times and upon ordinary subjects, but will draw together into the
closest kind of unity if any one attacks the family, accuses or
criticises the family. So human beings of widely different environment,
taste, economic status, heredity, may find it quite easy to begin and to
maintain friendly relations when that which brings them together is
their common interest in the struggle against disease. It is, indeed,
almost too easy to get friendly with people when they are suffering
physically and we are endeavoring, however lamely, to bring them relief.
The medical avenue of approach, then, the plan and hope of establishing
intimate relations with a person or a family while we are trying to give
them medical assistance, offers incomparable advantages. These
advantages become clearer still if we compare them with the special
difficulties which arise if one tries to begin an acquaintanceship with
financial inquiries or with moral investigations. People who will agree
on everything else will quarrel on money matters. There is nothing that
so easily leads to friction, suspicion, and unfriendliness, as the
interview in which one is trying to make out whether people are speaking
the truth, the whole truth, and nothing but the truth, in relation to
their income and expenditure. This matter very naturally seems to people
their own business. They quite naturally resent inquiries on such
matters by strangers. They feel attacked and in defence they are apt to
conceal or color the truth. And yet, if a friendly relation has first
been established through the patient's recognition of our genuine desire
to help his physical difficulties, the financial inquiries which make a
necessary part of the home visitor's work can much more easily follow.
One has to understand what money is available in order to make the best
plans for nutrition, for home hygiene, for rest and vacation--all of
which naturally form part of our medical interest. I wish to make quite
clear here my appreciation that good social workers never begin their
relationships with a client by assuming a moral fault on his part and
never push the economic questionnaire into the first interview. All I
wish to point out is that it is perhaps easier for the medical social
worker than for others to avoid these blunders.
At the outset of a relationship which aims to be friendly,
investigations which start with the assumption that there has been some
_moral fault_ or weakness in those whom we wish to help are even worse
than financial inquiries. The instant that the social worker finds
herself in the position of a moral critic, it becomes next to impossible
that a friendly relation not hitherto established, shall be built up
from the beginning. Late in the course of a friendship established long
before, moral help, even moral criticism, may be welcome. But it cannot
often or easily be one of the topics of conversation, one of the points
of investigation, in the early stages of what we hope to make a friendly
relation.
Everything stands or falls with this. We cannot even teach hygiene, we
cannot even make medical principles clear unless we have succeeded to
some extent, perhaps without any merit on our part, perhaps through
extraordinary good fortune, in acquiring a genuine liking for the person
whom we want to help. Once that is attained, we can work miracles. But
if it is wholly lacking, we cannot count upon accomplishing the simplest
interchange of accurate information; we cannot achieve the most
elemental hygienic instruction.
But there is another signal advantage in the medical point of approach
to a relationship which, as I have said, must be friendly in fact, not
merely in name, if it is to succeed in any of its ulterior objects. When
the social worker begins the difficult task of acquiring her influence
in a family, she starts with a great deal in her favor if she appears in
the home as _the agent of the physician_. He has prestige. By reason of
his profession, by reason of the institution which he represents, by
reason of confidence already established by him in the patients' friends
and neighbors, the new family is ready to have confidence in him. He is
not thought to have any axe to grind. He is assumed to be genuine in his
desire of helpfulness. Therefore any one who appears in his name, as his
assistant, has a great deal in her favor, especially when compared with
the visitors of societies which might be supposed to begin with economic
or moral suspicions about the family. If the visitor appears in the home
with the prestige of a medical institution enhancing the value of her
own personality, she has a very definite advantage.
_Light on the severity of illness_
I have said that it is essential to the success of a medical visitor's
work that she should be part of the medical machine, acknowledged as the
doctor's agent, concerned wholly with helping to carry out his plans.
But we must ask now, _what part_? And the answer is that the social
worker is an assistant to the physician both _in diagnosis and in
treatment_. I will begin with an account of what she is to do as his
assistant in diagnosis.
She is to discover, so far as she can, _what_ the disease is, _how much_
the disease is, and _why_ it is. I do not mean, of course, that she is
to ape the doctor's scientific investigations, that she is to use
instruments of precision, or to try to prescribe medicines. But she is
to help the physician in some of the following ways:
He is often very much at a loss to be sure how bad the patient's
symptoms really are, how much the patient suffers, how serious the case
is. The social worker is often able to help in discovering why the
patient really came to the dispensary, discovering, perhaps, that the
reason is such as to show that the malady is really a trifling one. She
may find, for instance, that the patient has come merely because her
husband had to come, anyway, and she thought she would get the benefit
of whatever there was to be had in the way of medical assistance at the
dispensary, even though, unless her husband had been going, anyway, it
would not have occurred to her to make the independent visit upon her
own account. Or, again, the visit may be due chiefly to curiosity,
especially if the dispensary has been newly established or has added
some new features to its methods of diagnosis and treatment. These facts
are passed along from person to person; the person hearing of them may
appear as a patient chiefly to see just what it is that her neighbors
are getting when they go to the dispensary. I have known a patient to
come merely because he was alarmed as a result of a recent conversation
with a friend. His friend had been hearing about heart trouble and had
mentioned some symptoms such as pain about the heart or cold extremities
or dizziness. Any one sick or well on hearing such symptoms may easily
remember that he has had them himself not long ago, or may even begin to
feel them as a result of suggestion. Straightway, perhaps, he will
betake himself to the dispensary, complaining of symptoms which never
would have been noticed but for his talk with the friend.
Or, again, the patient may have some definite organic disease or some
obstinate train of discomforts and physical inconveniences. But he has
adapted himself to them tolerably; he has settled down to bear or forget
them as best he may. He may know that his troubles are really incurable
and yet not serious. He may have become as accustomed to them as he is
to an uncomfortable lodging or to a modest income. Yet, as a result of
some temporary fatigue, some newspaper paragraph, some fragment of
gossip overheard, there may arise in him a crisis of alarm and worry
about his familiar discomforts or inconveniences. Thereupon he may
betake himself to a dispensary, and give the physician an account which
may be very difficult to interpret, because the physician does not
understand the train of events which appear acute and new in that they
have led the patient just now, rather than at any earlier time, to seek
advice. After nearly twenty years' experience of dispensary work I
should say that in no respect can a social worker give the doctor more
welcome help than by discovering now and then reasons such as I have
just suggested whereby the patient comes to the dispensary now rather
than at any other time, and at a season not really connected in any
special way with the nature of his disease.
Perhaps I can make this clearer by contrast with its opposite. A person
who has just developed a scarlatinal rash, who has just coughed and
raised a considerable quantity of blood, who has just lost the power to
move half of his body, who has just begun to have swelling of the face,
naturally consults a doctor at once. If he then comes to a dispensary
for treatment, he has come at a time which is the right time, the
reasonable time, considering the nature of his malady. Something new has
happened. An attack has been made which should be foiled if possible at
once. The clue for usefulness on the part of the doctor is thus fairly
clear. If, on the other hand, a person has had more or less back-ache
all his life, and has grown used to getting along and doing his work,
even enjoying life in spite of it, he may suddenly come to a dispensary
for that back-ache because he has seen in the newspaper the wholly false
statement that pain in the back means kidney trouble. Yet when he comes
to the dispensary _he may say nothing whatever about his having seen
this newspaper advertisement_. Indeed, it is very unlikely that he will
mention this at all. He will describe his back-ache as something which
demands immediate treatment, and the doctor may set in motion extensive
and probably useless activities of investigation or treatment which
never would have been undertaken had he known just what it was that
brought the patient to the dispensary that day rather than months
earlier or later.
So far I have spoken only of cases in which the visitor's studies in the
home make it clear that the case is not as bad or not as manageable as
it might have seemed if one had known only what the patient himself
could reveal in the dispensary. But occasionally on reaching the
patient's home the visitor may find reason to believe that the symptoms
are much more serious, the disease much more urgent, than could have
been realized from the story told and the facts obtained at the
dispensary. The visitor may find in the home conditions of
disorganization, dirt, disorder, serious malnutrition, discouragement
on the part of other members of the family, arguing a much more serious
condition of the patient than one would have realized from talking with
him at the dispensary. As a result of such findings the doctor, who must
spend his energies for the patients who need him most, will see that he
had better give more time and more effort to the patient than he would
otherwise have thought right.
Still, again, the visitor may find that the symptoms are neither more
serious nor less serious than he would have supposed from the dispensary
interview; yet the clinical picture is different from the doctor's
because the patient has thrust into the foreground of the clinical
picture something which further knowledge shows to be really
unimportant, while he has said almost nothing of some other feature of
the trouble which is really much more serious. For example how much does
the patient really eat, how does he do his work, are there complaints
about him from his "boss," has he _always_ had the cough which he has
only just now begun to complain of? Such questions can be better
answered after visits at the home and talks with the whole family.
Clearly the supplementary information thus secured by the social worker
will count for nothing unless clearly explained to the doctor, and is
taken up by him as part of the evidence on which he bases his diagnosis
and his treatment. It is absolutely essential that the social worker
should not merely make her visits and record them in her notebook, but
should incorporate her findings in the medical record and deliver them
not formally but effectively to the doctor's mind.
Such help is needed because she can often learn far more in the quiet of
an interview at home than would be possible for the doctor despite all
his medical skill. For at the dispensary he questions the patient when
he is confused and forgetful, alarmed, perhaps, by the sights and sounds
of the clinic, and so very unlikely to give a correct and well-balanced
account.
_Nests of contagious disease_
So far I have been describing the work of the social worker as a process
of finding out how much ails the patient and what his symptoms signify.
But it is also a part of the social worker's duty to find how much
disease is present not only in the individual who appears in the clinic,
but in his immediate environment, to discover _nests, foci or hotbeds of
disease_. In the case of a disease like smallpox, this is obvious. If a
patient presented himself at a dispensary with the pustules of smallpox
upon his body, it would be criminal negligence on the part of the
physician not to set on foot a search of that patient's home, his
industrial environment, or, in the case of a child, his school
environment, for evidence that others have been exposed to the same
contagion and possibly already infected. This sort of duty cannot be
abandoned merely because there is no health officer at hand. It is a
crying need and must be attended to at once.
Now in a minor degree this is true of many other diseases as well as
smallpox. We are beginning to realize that it is true of tuberculosis,
so that when one case of advanced and therefore contagious tuberculosis
is seen at the dispensary, machinery should automatically and invariably
be set in motion to search out possible paths of contagion from that
patient to others, just as if he had smallpox.
This principle which is well established in the case of dangerous
contagious diseases like smallpox and diphtheria, and is beginning to be
established in relation to tuberculosis, is even more important in
dealing with syphilis. Every case of syphilis means more cases of
syphilis, and the danger of still more each day that the contagious
patient is at large. No physician has done his duty unless, after seeing
a case of syphilis, he attempts, through a social worker or otherwise,
to get knowledge of others from whom this disease has been acquired, or
to whom it may be freshly spread. At the Massachusetts General Hospital
each patient with syphilis is asked to bring to the clinic for treatment
the person who infected him. The method sounds impossible _but in fact
it works_, and many cases are thus brought under treatment and prevented
from infecting others.
With contagious skin diseases such as scabies or impetigo, the principle
is obviously the same, though the dangers of disregarding it are not so
great. With typhoid fever, which not very infrequently shows itself
even at a dispensary, the duty of the social worker is not so much to
search for other persons through whom it may have been contracted or to
whom it may be spread, as to investigate the water-supply and the
milk-supply of the patient and of others in his environment. One case of
typhoid always means more cases, usually more cases acquired, not by
contact with one another, but through their share in a contaminated
water-supply or milk-supply. The social worker, therefore, should know
how to search out contaminated water-supplies, or at least to put in
motion such machinery of public health investigation in the city or town
where the case arises as may lead to good detective work in the attempt
to track down the source of the trouble. It has been well said that
every case of typhoid is some one's fault. It has even been asserted
that for every case of typhoid some one should be punished. Certainly
there are some grounds for such an assertion.
_Hotbeds of industrial disease_
Commoner and not less important than the contagious diseases that I have
just mentioned are industrial diseases, or diseases aggravated by the
conditions of industry. A physician may serve for many months in a
dispensary without seeing a case of smallpox, of trichiniasis, or of
typhoid fever, or feeling it his duty to set in motion the forces that I
have just mentioned for rooting out the sources of contagion and
preventing their further spread. But he cannot serve a month in any
well-attended dispensary without seeing cases of industrial disease in
the narrow sense, such as lead poisoning, or of independent disease
aggravated by the conditions of industry, such as the functional
neuroses of cigar-makers or of telephone operators. With such diseases,
as with the infectious and contagious diseases, the presence of one case
in the clinic should lead straight to the inference that there are
others elsewhere, out of sight but no less important from the point of
view of public good. This conclusion should lead in turn to the search
through a social worker for the cases of disease which do not present
themselves to any physician, which may be totally unknown even to the
patient himself, yet which are important to the health of the nation.
Difficult though this field of industrial disease has shown itself to
be, difficult though it is to separate out that portion of the patients'
complaints which can justly be referred to the conditions of his work,
and to distinguish it from the portions which are due to the way he
lives, to his inheritance, to his habits or to diseases like
tuberculosis and syphilis which may have been acquired without any
connection with his work,--nevertheless we must try to disentangle and
to recognize the elements in this knotty problem. And we can hardly fail
to see that the social worker is an essential and logical assistant in
the processes of investigation which we must carry out. If we can ever
unravel the tangled skein of causes and effects whereby the hours of
work, the strain of work, the patients' heredity and his home
conditions, all combine to produce the symptoms of disease, it will be
through such intimate, prolonged, detailed studies as the social worker
can carry out, especially if she becomes a friend of the family. The
doctor in his hours of consultation at the dispensary certainly can
never do it. The official agent of the Board of Health, perhaps feared,
certainly not a natural confidant for the family, may easily miss the
truth which the social worker unearths, provided always she succeeds in
differentiating herself altogether from the impersonal and professional
investigator, and gradually becomes in the mind of the family and in
truth their friend.
I said above that the social worker should try to find out what disease,
how much disease, and why this disease is present. The answers to these
three questions cannot be kept separate. If one knows how much
importance to attribute to a given symptom and whether it is as bad as
it seems or worse than it seems in the dispensary interview, one may be
steered straight to a correct diagnosis. To know _how much_ disease may
thus mean knowing _what_ disease is present. Furthermore, the
understanding of these questions, even though it be only partial and
unsatisfactory, leads us a considerable distance towards understanding
why the disease has arisen. The search for sources for contagion is an
example of a search for a _why_ in disease. The search for psychical
factors--groundless fears, misleading newspaper advertisements,
distracting rumors--all this is also a search for the cause as well as
for the nature of disease.
The social worker's investigations into the cause of disease may perhaps
be still further exemplified. I once sent a social worker to my
patient's home with the request that she try to find out what I had
failed to find out, namely, why a young girl could not sleep. Physical
examination of the girl had revealed no cause; the exploration of such
parts of her mind as she would reveal to me had thrown no light upon the
trouble. I was at a loss and asked for help through the more intimate
knowledge of the patient sometimes to be gained through a social
worker's studies. Such a search might easily have been fruitless--it
often has been fruitless in my own experience. But in this case it was
almost comically swift in reaching its goal. The visitor found that this
girl was sleeping with two other girls of about her own age, in a bed
hardly more than a metre wide. It needed only that she should acquire a
separate bed for herself, which she was able to do without any financial
assistance. She then regained her power to sleep. How often have such
cases been treated with drugs or perhaps with more complicated
physio-therapeutic or psycho-therapeutic procedures, when some simple
fact like the size of the bed, the temperature of the sleeping-room, or
the mental activities of the evening immediately preceding bedtime, are
really responsible for the whole trouble.
_Medical outfit of the social worker_
In order to carry out the particular procedures of diagnosis and
treatment which belong within the province of the social worker, a
certain amount of medical knowledge is needed. Because this is true, it
has often been assumed that the social worker must be a trained nurse,
prepared by months or years of experience in a hospital. But experience
has shown that much of the knowledge possessed by nurses who have had
this training cannot be used by the home visitor. On the other hand, the
information which the social worker needs is often quite lacking even in
well-trained nurses. Furthermore, it may be said with truth that the
training of a nurse, as we know it in America at any rate, really unfits
a woman in some respects for the work of a social worker, since it
accustoms her to habitual obedience and subordination. These habits are
very useful in their proper place, but they are antagonistic upon the
whole to the temper and mental activity which is important in the social
worker. I mean the temper of aggression in relation to disease, and the
mental attitude of the teacher and leader in relation to the patient.
But of this point it will be more in place to speak when I come to
consider the functions of the social worker as a teacher.
Let us return, then, to the question, What knowledge should the social
worker possess in order to do her part in the "team-work" of the
medical-social dispensary? Her knowledge should approximate that of the
public health officer. Like him she should be, above all, familiar with
what is known to medical science about _the causes of disease_. This is
of great importance because it is especially in this field of medical
science and medical ignorance that the public, the patients among whom
the social worker will work, is most in need both of new knowledge and
of the uprooting of old error and superstition. Medical science knows
very little of the causes of many diseases. But our patients, especially
the more ignorant of them, are very glib and confident in their
assertions as to what has caused the particular disease from which they
just now suffer. They tell us about their "torpid livers," their
"congestive chills," their "ptomaine poisonings" and the like. Their
supposed but unreal knowledge is extensive and detailed. Indeed, so
stubborn are their beliefs upon such matters that they often present a
firm wall of resistance which must be broken down by the social worker
before any truth upon these matters can be introduced into their minds.
The social worker, then, should share such knowledge as the medical
profession possesses about the causation of infectious disease, about
direct personal contagion, and also about the indirect _methods by which
disease is conveyed_ from person to person through insects or through
instruments and utensils, such as the barber's razor, the family towel,
or the public drinking-cup. She should be familiar with the small body
of knowledge which we possess upon the transmission of disease by
drinking-water, by milk, and other kinds of food. She should appreciate
our still smaller body of knowledge about the relation of disease to
climate, to weather, and to other physical agents such as the extreme
heat and cold produced by some industrial processes, and the action of
X-rays.
In addition to this definite and specific knowledge of causes, she
should know the generally accepted views of the medical profession on
the subject of _bodily resistance_, _immunity_, inheritance, the
diseases and perversions of metabolism, and the other non-bacterial
factors in the production of disease. Above all, she should realize the
_multiplicity of causes_ which science more and more clearly recognizes
in their single result. She should learn both by precept and by
experience that for a single fact such as disease or health there are
always many causes, so that any one who points confidently to a single
cause, such as cold, fatigue, bacteria, or worry as a sufficient
explanation of a person's disease, is almost certain to be wrong.
Obviously, this truth bears a close relation to what is to be said on
the "historic and catastrophic points of view." Chapter III.
The importance of teaching the social worker all that is known about the
transmission and causation of disease is due to the following fact:
whatever we succeed in accomplishing in our efforts at _preventive
medicine_, whatever we do to nip disease in the bud or to check the
spread of epidemics, is due to our knowledge of the causes of disease.
The instructions of the doctor at the dispensary can accomplish but
little in this field when compared with the detailed teaching of the
social worker in the patient's house, in his workshop, in the schools
and factories where disease is spread so much more frequently than in
the dispensaries. If we hope to show people how they can avoid the
disasters of illness, our teaching should be given in the very place
where these disasters most often occur. There we can illustrate and
demonstrate with the objects in sight what is to be done and to be
avoided.
It is for this reason that the social worker is above all others the
person who can convey life-saving information to the public in an
effective way. A considerable amount of this precious knowledge is now
possessed by the medical profession; but it is shut away useless,
unavailable, in medical libraries and in doctors' minds. The social
worker can fight disease by spreading the contagion of medical truth.
She can multiply the foci from which truth can spread still more after
she is gone, just as disease is redistributed again and again from new
nests of infection.
The _prognosis of disease_, like its causation, is a subject on which
the social worker should know almost as much as the doctor. This is
possible because medical knowledge on this subject is still so very
limited. For the purposes of one who has to combat the poverty, sorrow,
idleness, and corroding fears which disease produces, knowledge of
prognosis is a most useful tool. For example: if one is to make plans
for the care of a group of children during their mother's illness, one
must have some idea how long that illness is going to last. If it
affects the bread-winner of the family, how long will he or she be
disabled, and how completely; what are the hopes of ultimate and
complete recovery; will chronic invalidism follow; is it worth while in
this particular disease to spend a great deal of money and time in
trying to achieve a complete cure, or is cure so improbable and at best
so incomplete that our resources can be expended more wisely in other
directions?
A knowledge of prognosis will help the home visitor greatly in the
solution of such problems. But it must be added that such knowledge as
she already possesses about the prognosis of a disease, such as
tuberculosis or heart trouble or kidney trouble, must always be
supplemented by all the information that she can gain from the doctor as
to the present prognosis in the case of the particular patient with whom
the social worker has to deal. For the general prognosis of a disease is
greatly modified by the particular circumstances in each individual
case.
Physicians are not at all eager to impart their knowledge about
prognosis, because this knowledge is so limited and so faulty. No
scientific man likes to make definite statements upon so indefinite and
hazy a matter as prognosis. Nevertheless, it is essential for the
patient's good that the doctor should be asked to give her as clear and
definite a statement as is possible for him to make with the facts that
he possesses. For it is only upon the basis of such a statement that an
intelligent plan of social treatment can be constructed.
Besides acquiring all that she can learn of the causes and prognosis of
disease, the social worker should be familiar with the symptoms of the
more important and _common types of disease_. There are now several
books written particularly with the object of conveying to social
workers and others such knowledge as I have referred to, yet without any
pretence of equipping the person either for nursing or for the practice
of medicine. I will mention here a book by Dr. Roger I. Lee, Professor
of Hygiene in Harvard University, "Health and Disease: Their Determining
Factors" (Little, Brown & Co., Boston, 1917), and my own book, "The
Layman's Handbook of Medicine" (Houghton Mifflin Co., Boston, 1916).
In order to understand such books, and to arrange her knowledge of
disease in such form that it may be easily handled, the social worker
must have a slight knowledge of anatomy and physiology, so that she can
arrange the symptoms of disease in connection with the different systems
of organs: circulatory, digestive, respiratory, urinary, nervous, and
locomotive.
Finally, the social worker must know the _principles of hygiene_, in
order that she may effectively combat medical quackery and the prevalent
medical superstitions of the people. That portion of hygiene which is
both securely founded upon scientific evidence and useful in the
preservation of health, makes up only a very small body of knowledge, so
that it can be easily mastered by any intelligent person. Our knowledge
upon such matters as diet, exercise, bathing, sleep, ventilation, when
such knowledge is both scientific and practically useful, could be
written upon a very few pages. It consists largely of negatives which
contradict the current superstitions.
In my own work in this field I have found it essential that there should
be no mystery and concealment, no obscurantism and mediæval Latin in the
methods of treatment which the social worker explains or carries out
under the doctor's directions. She must be able to deal with the
patients frankly, openly, without concealment or prevarication.
Otherwise she will not have moral force enough behind her statements to
bring them home to the patient so as to secure any reform in his
hygienic habits. Such reforms are difficult enough in any case. They are
usually impossible unless they can be initiated by one rendered eloquent
and convincing by the consciousness that she leans upon the truth and
has nothing to conceal. If she has mental reservations, if she is trying
to protect the authority of the physician in a statement which she does
not believe to be wholly true, the force of her appeal will be so
weakened that it will probably be ineffective.
_Technical methods_
There are some technical processes of diagnosis and treatment which are
usually carried out by the visiting nurse, but which may well be
performed after a brief training by the social worker who is not a
nurse. Among these are:
(1) The accurate reading of the patient's temperature, pulse, and
respiration, which she must often teach the patient to do for himself
and to record accurately and clearly. This is of especial importance in
tuberculosis, for in suspected cases of this disease one often needs
daily measurements of the temperature as an aid in determining the
diagnosis or in estimating the severity of the case and the fitness of
the patient for work.
(2) The arrangement of a window tent or some other device for insuring
the maximum of fresh air for the tuberculous patient both day and night.
This device is also useful in pneumonia, typhoid fever, and other
diseases, in case they are to be cared for at home and not in a
hospital.
(3) The application of simple dressings to wounds, abscesses, and common
skin diseases such as eczema, and impetigo.
(4) The care of the skin in bedridden patients. Our primary object here
is the prevention of bedsores, those ulcerations which occur in very
emaciated patients at the points where their weight presses a bone
against the bedclothes.
(5) The simpler procedures for the preparation of milk for sick children
and of other foods commonly advised for patients who are confined to
bed.
(6) The methods of emptying the lower bowel by means of an enema.
Into the details of these procedures this is not the place to enter, but
I wish specially to assert that all of them may be learned within a few
weeks by persons who have not studied medicine or had the full course
for the training of a nurse. Any one who possesses these simple bits of
skill can do all that is necessary for the physical care of the sick
poor in their homes, unless continuous attendance upon the patient is
necessary. Such attendance is not within the province of the social
worker. But in the technical procedures just described it is all the
more important that she be expert, because such skill makes her a
welcome visitor and a trusted adviser outside the field of medicine.
Because she has given relief by dressing a wound, curing a skin disease,
or applying a poultice, she will be listened to with liking and with
confidence when, later, she comes to give advice in economic,
educational, or moral difficulties.