THE SOCIAL WORKERS' INVESTIGATION OF FATIGUE, REST, AND INDUSTRIAL
DISEASE
_Fatigue and rest_
Fatigue is more important for medical-social workers to understand than
any single matter in physiology or any aspect of the interworkings of
the human body and soul, because it comes into almost every case from
two sides: (_a_) from the workers' side because the quality of work that
she puts into trying to help somebody else depends on how thoroughly she
is rested, and how much she has to give; and (_b_) from the side of the
patient, his physical, economic, and moral troubles, because fatigue is
often at or near the root, of all these troubles. It is unfortunate that
in spite of its importance, we do not know much about fatigue from the
physiological point of view. Since the war of 1914-1918 we have
prospects of knowing more about it than ever before; for one of the
grains of good saved out of the war's enormous evils has been the
fruitful studies of fatigue made in England, studies more valuable than
any that I know of.
Let us take fatigue in some of its very simple phases, as it applies to
your life and mine. The first thing to recognize is that it can affect
any organ; our stomachs can get tired just as well as our legs. When a
patient complains of pain, vertigo, nausea, we first ask ourselves,
"What disease has he got?" That is correct. Disease must be found if it
is there. But the chances are he has no disease, but only a tired
stomach, since fatigue easily and frequently affects that organ. When
the whole person has been strained by physical, moral, and especially by
emotional work, he may give out anywhere. He may give out in his weakest
spot, as we say. That weak spot is different in different people.
Therefore the study must be individual. We cannot do anything important
with our own lives until we learn how and when we get tired. It is the
same with people whom we try to help in social work.
Fatigue, then, may be _referred_ to any particular spot in the body.
People often go to an oculist to see what is the matter with their eyes,
when there is nothing in the world the matter with their eyes: the
honest oculist tells them that they are tired, and that for some reason
unknown to him their fatigue expresses itself in the eyes.
This is a very common and very misleading fact. The patient finds it
hard to believe that medicine ought seldom to be put on the spot where
he feels his pain. If the pain is in his stomach he wants some medicine
to put in his stomach and not a harangue on his habits, which is usually
the only thing we can really do to help him. If he has a pain in his
back he wants a plaster or a liniment for his back. It is very hard to
get people out of that habit of mind, and we shall surely fail unless
we are clear about it ourselves. It must be perfectly clear in our
minds, or better, in our own experience, that fatigue may be referred to
one spot or to another, in such a way as seriously to mislead us. I
suppose that half of all the pains that we try to deal with in a
dispensary--and pain, of course, is the commonest of complaints--are not
due to any local or organic disease in the part. Doubtless there are
some wholly unexplored diseases or disturbances of nutrition in that
part, as there may be in the eyes when they ache because you have been
walking up a mountain. But medical science knows nothing about that.
What we do know is that the pain, if it is to be helped, will be helped
not by thinking about that spot or doctoring it, but by trying to get
that person rested.
Fatigue, then, ought to be one of our commonest medical-social
diagnoses, and to help people out of it, one of the attempts that we
most often make. In Dec., 1917, a dozen or more Y.M.C.A. boys consulted
me in France, all with coughs, all wanting medicine to stop the cough,
and most of them a good deal disappointed because they were told to go
home and go to bed, told that they were tired, and that this fact
depressed their resistance against bacteria, so that bronchitis or
broncho-pneumonia resulted.
The second point, then, that one wants to make about _fatigue is_, that
it is _the commonest cause of infectious disease_. Pasteur's great
discovery, which set modern medicine upon the right bases, sometimes
gets twisted out of perspective. Sometimes we fail to realize that the
seed may fall upon stony ground. The seed, of course, is bacteria, and
its discovery was Pasteur's immense service to humanity. But Pasteur was
so busy that he did not emphasize the truth that a seed can fall upon
good ground or upon bad ground. When bacteria fall upon bad ground, that
is, upon healthy tissue, they do not grow, they do not spring up and
multiply. Tired tissues, as has been abundantly proved by animal
experimentation, are prone to infection. They are good soil for the
growth of bacteria. It is true generally; it is true locally. A part
that has been injured, for instance, a part that has been bruised
without any break in the skin, without the entrance of any infection
from the outside, is damaged by something that hurts its resisting power
as fatigue does. Such a part will often become inflamed, will often
become subject to the action of bacteria which must have been in the
body already, but which had been kept on the frontier by our powers of
resistance.
Our "powers of resistance," then, which we cannot more definitely name,
which we do not as yet know to be identified with leucocytes or with
anything else, can get tired. When they get tired we "catch" a cold or a
diarrhea, or a hundred things which seem to have nothing to do with
fatigue, but _have_ nevertheless.
_Accumulated fatigue or physical debt._ If you go up a long flight of
steps at a moderate rate, you can get to the top without being tired;
if you go up at a rapid rate, as most of us do, you are tired at the
top. Physically you put out the same amount of energy, I suppose. I do
not see that there can be any considerable difference in the energy
consumed by the performance of that act whether we do it slowly or
quickly. The difference is that in the first case we _rest between each
two steps_ as we rest between each two days at night. When our
activities are so balanced as not to run in debt, we rest between each
two steps. You and I can walk at our individual peculiar gait on the
level for a long time without any accumulation of fatigue, often with
refreshment. But push us and we are soon exhausted. Suppose that our
normal walking rate is three and a half miles an hour; push us to four,
and it may not be a quarter of a mile before we are done up, because we
have not been able to avoid accumulated fatigue by resting between each
two steps. It has been said that in rowing the crew that wins is the
crew that rests between each two strokes. The person who does not get
tired is the person who rests between each two days. He does not
accumulate fatigue. It is the accumulation that finally breaks you,
makes you bankrupt. It is the little unnoticed bit added day by day,
week by week, month by month, that makes the break.
Fatigue we should think of as running in debt. One of the figures of
speech that has served me best in teaching patients how to live is that
figure of income and outgo. I have often said to people, "Physically
you are spending more than you earn, not to-day merely, but right along.
You must earn more than you spend. You must get a plus balance in the
bank. Then you can run along with fatigue or illness."
That figure of speech helps us also to express another fact about
fatigue, which is important to recognize in ourselves and in our
patients, because otherwise we get thrown off the track: _delayed
fatigue_. The first day that your income begins to be less than your
expenditures, nothing necessarily happens. The bank does not proclaim
that there is no deposit there. It is some days later, usually, that you
begin to reap your troubles. It is the same in physical fatigue.
Patients say to us, "I slept ten hours last night. I spent a virtuous
Sunday. Why should I be tired to-day?" We should answer, "Because of
something you did last Tuesday or thereabouts." We all are familiar with
this in relation to sleep. It is not the day after a bad night, but
several days later that its effects depress us.
Delayed fatigue, then, is an important thing to notice in ourselves and
to bring home to the people that we are trying to help. I suppose one
could say that _a great part of our business in social work is to call
people's attention to things_; if they have recognized them before, they
will perhaps get a lesson out of what we say. Such matters are _referred
fatigue_, _delayed fatigue_, _accumulated fatigue_,--familiar enough,
only the person does not act on them because he does not notice them.
The fatigue-rest rhythm, the alternation of fatigue and rest, I have
already phrased by the metaphor of earning and spending. You can phrase
it also by a metaphor very close to the physical facts as we know them,
the metaphor of building up and tearing down. During the daytime, from
the point of view of physiology and the workings of the body, we burn up
tissue. In us oxidation processes are going on which are really burning,
as really as if we saw the flame. Tissue is being destroyed, broken
down, going off in the form of heat, energy, and life. That is good in
case it is followed, as it should be, by a period of rest in which we
build up. Presumably, if we could see with adequate powers of the
microscope or powers of observation of some sort, what goes on during
rest, we should see a perfect fever of rebuilding all that we have torn
down during the day. People often say, "Shall I take exercise?" Yes, but
remember that half of the process of taking exercise is getting rested
afterwards. It will do you good provided you rest after it, provided
what has been torn down in exercise is replaced by sufficient tissue or
fresh power in rest.
The English studies of fatigue to which I have referred have been of
great importance because, so far as I know, they are the first attempt
we have had in the way of testing when men or women in industry are too
tired and how much too tired they are. I do not suppose that any
employer of labor would want for his own profit or for more than a short
time to overwork people in this sense, if he had the facts called to his
attention. If he realized what he was doing, he would not want to break
down his working force any more than he would to spoil his machinery.
But some employers are careful of their steel machinery and careless of
their human machinery. They will continue to be so, I fear, until we
know more about fatigue.
It is one of the most difficult things to measure that I know. Take it
in your own case: what tires you one day does not tire you another day.
The individuality of it, the disturbing factors when we try to measure
it, are perfectly extraordinary. Such a disturbing factor in our
calculations is "second wind"--mental or physical. A number of men
marching along will grow less tired as time goes on by the acquisition
of what we call "second wind." We do not know what it is. We have tried
to connect it with the condition of the heart, to say that the heart
finally gets to deal with the volume of blood that is running through it
so that there is no overplus of blood stored in any one chamber at any
moment. But we do not really know anything about that. We do not know
what second wind is; but it is important to know that it exists.
Moreover, as Professor William James pointed out in that essay called
"The Energies of Men," there are "mental second winds." Just when a man
is worn out he often finds new strength. He often cannot get his best
strength until he pushes himself even to despair. In the spiritual
experiences of the world's saints and heroes we find that it was just
when it seemed as if they were about to go under that this second wind,
or third wind, for it sometimes comes again and again, this mitigation
of fatigue without rest, comes to them. This is a most disturbing fact.
If we were like a pitcher which is emptied out and filled up, we should
know all about fatigue very soon. We are like a pitcher to a certain
extent, but the similarity is disturbed by such factors as second wind,
and disturbed, moreover, by mental and emotional intruders like music. A
military band coming upon a body of marching men will give them strength
when they had no strength. That is not a sentimental but a practical
fact which army men have to take advantage of. Then the fact that many
people can rest by change of work without stopping, is also
disconcerting. We say to a person, "You have been working hard all day;
you must stop, lie down, go to bed." That person disobeys, keeps going
on something different, is altogether fresh next morning, and we have to
confess that we were wrong.
It is a very familiar experience that one may be almost dead from one
point of view, but quite fresh from another, as one wants no more meat,
but has plenty of room for dessert. Some people can rest by change of
work and some cannot. It is very important for us to keep finding out in
a great number of ways which of the classes into which people's bodies
are divided we each belong to. Do we belong in the class of the people
who must get their rest by giving up, by the abolition of all function,
or in the class who rest by the change of function, by doing something
different from the day's work? It is a question of fact and must be
found out by each individual for himself.
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 England[3] 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.
FOOTNOTE:
[3] See Health of Munition Workers Committee. Final Report, _Industrial
Health and Efficiency_. (London, 1918.)