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.
In suppurative disease, such as appendicitis, it is often difficult to
decide when nature is doing better than we can do, and when we can do
better than nature. The appendix is a hollow tube the size of one's
little finger, and hangs off from one part of the large bowel. When it
gets inflamed nature at once begins the defences which I have described
in the lung, namely, the walling-off process, which tends to make the
bacteria harmless. There is danger that they will spread from the
neighborhood of the appendix and produce a very dangerous disease,
general peritonitis. Hence nature begins to glue around the appendix the
adjacent parts of the bowel and anything else at hand. This generally
makes it harmless. Most of us physicians now believe that the great
majority of cases of appendicitis cure themselves, and that still more
would cure themselves if given a chance. On the other hand, there are
cases in which nature does not do her work rightly. Then if the surgeon
did not interfere the person would die. That is why medical and surgical
judgment, the particular, minute, individual study of the person from
hour to hour, makes the difference between right and wrong treatment.
The surgeon who operates every time he makes a diagnosis of
appendicitis, or who says he will never operate, is just as wrong as the
person who gives money the first time he sees a case, or who never gives
money. But most surgeons are wiser than that.
I hope through these illustrations to make it clear that nature
generally cures disease. When she does not, it is generally incurable.
There is a small residuum left for the doctor. We have a function as
physicians or nurses. We have a function, and that function is
intermediate between two extremes. In disease or in other misfortune,
there are three types of fortune, two extremes and a mean: (1) The
people who will get out of their troubles whatever you do, get out of
their misfortunes, rally to meet their griefs, pull themselves out of
financial difficulties, get over their disease. Then (2) there are
people on the other side, who will die whatever you do. Some cases of
pneumonia, for instance, seem to be doomed from the start. It is the
same with many other cases of disease and with some people's
misfortunes. We have to face the fact in social work that there are
many people whose mental twists and agonies we cannot help in the least,
and many people who will be in money difficulties as long as they live.
But (3), intermediate between these two extremes--and our happiness and
our success depend on our finding that group--are those cases where what
we do makes the difference between success and failure. This triple
division indicates a point of view which makes, not only for individual
understanding of the situation, but for practical success.
Take the case of those maimed by war or accident. There are three
classes of them: first, the people who will get back their jobs and get
back into industry unaided; they are probably the majority. Then the
people who cannot be put back by any process. Finally, there is the
rather small intermediate class who, with our help, with a little extra
education, with a hand in the back, will get back into work, but who
never would succeed, humanly speaking, without our help.
So it is in disease. _The vast majority of diseases get well without any
help from anybody_, and that is the thing we must teach most often and
to most people, in season and out of season. In our day and generation
few people get a chance of observing that fact, because somebody comes
along and gives them a drug. And unless one has seen people get well
without any drugs, one continues to believe that it was the last drug
given that cured every case of illness one has known to get well. On the
other hand, the majority of illnesses that do not get well without
drugs will not get well at all. I have mentioned before the figures
which seem approximately true in relation to the cure of disease by
drugs. Drugs will cure about six or eight diseases out of about one
hundred and fifty diseases known to science. Anybody who fails to give a
drug for one of those six or eight diseases is criminally negligent. We
should press that drug upon the patient. I do not want anybody to think
that I do not believe in drugs. I believe in them tremendously, in the
particular cases where they are of use. But I do not stand for the habit
of bolstering up people's beliefs that we have drugs all ready to cure
most diseases.
I think the future of cure by drugs is very hopeful. I do not feel
hopeless of our discovering drugs for the one hundred and forty-two out
of one hundred and fifty diseases which we still cannot cure. But if we
falsely suppose that we have a cure already, we do not hustle around to
get it. It is not until we realize that we have not a cure already, that
we do hustle around to get it. _It is not until we realize that we are
now very helpless in medicine that we shall labor in a way to become
less so._ At present the best that we can do for most patients is to
explain what the trouble is, let them know what is going to happen, to
preach some hygiene, and above all to make them realize that we care and
suffer with them. That is the essence of medical work and of the social
assistant's work in the dispensary and in the home.
_Industrial disease_
Industrial disease is a phrase we have heard much in the last ten or
fifteen years, meaning that diseases are caused--some of them--by the
conditions to which people are exposed in industry. A great deal of
indignation, some of it fruitful, much of it harmful, has been aroused
against employers and against the whole system of industry--because we
have now recognized the fact of industrial disease. Employers in the
past have been more interested in their machinery than in their human
help. That is not only bad, but very stupid. Most of us believe that
because it is stupid it is not likely to continue indefinitely.
But aside from all these matters of controversy, there is one important
distinction to make at the start. (_a_) Industrial disease in the
narrow, strict sense, i.e., something produced by the industry,
something which would never have occurred in any form if the person had
not been in that industry. (_b_) Disease affected, modified, in some way
by industry, but due in part to other causes.
There are very few clear-cut and common industrial diseases. Lead
poisoning is almost the only one. Disease due to the inhalation or
swallowing of other poisons and the penetration through the skin or
irritation of the skin by definite poisons are real dangers, but not
common. More common, more difficult to deal with, and therefore more
within the province of the social worker, are the diseases in which
industry is only one factor in the complicated skein of causes. Take
such matters as exposure to unusual heat or cold, unusual humidity or
dryness in industry--very common conditions; or still more, exposure to
unusual strain and hurry from what we call "speeding-up" or from the
piece-work system. I do not think there is any good evidence that those
things produce any single disease. I think there is excellent evidence
that they often dip the scale whereby a person who has been in
equilibrium, able to get along with his outside troubles, and to keep
his balance, is finally knocked down into disease.
A person has tuberculosis. One of the favorite tricks of unscrupulous
political orators is to say, "Look at all that tuberculosis due to the
greed and the cruelty of employers!" Bad conditions of industry are
doubtless a factor in the production of tuberculosis, but we must
realize how many and important the other factors are. The eight or ten
hours a person spends in industry is often a small factor in producing
his ill health, compared to the fourteen or sixteen hours he spends
outside the industry. Hence if we are to understand the diseases of
workmen we must investigate _these_ hours just as carefully as those in
the factory. That is what we ordinarily omit. We find so many cases of
tuberculosis in a given industry, and we say, "Ah, then, these cases are
_due_ to the hardships of that industry."
In refutation of this idea there is one more dogma packed for
transportation, which I should like to offer in the form of a logical
fallacy which the mediæval logicians put down in Latin terms: "_Post
hoc, ergo propter hoc_": "After this, therefore because of this." One of
our duties as doctors and social workers is to combat fallacies, to
teach people to think straight instead of crooked about their ill health
and their other troubles. When thus occupied, a large part of our labors
will consist in trying to overcome the popular fallacy quoted above.
"You went into a particular industry and you had tuberculosis: therefore
you had tuberculosis _because_ you went into that industry." "You had a
given disease and you took a certain remedy: you got better, _therefore_
the remedy cured the disease." So the superstitions flourish. I do not
believe it is easy for any of us to extricate ourselves from that
particular fallacy, but we must try.
In industrial disease we have the causative factor of industrial
hardship intimately mixed up with other factors. One of my colleagues,
Dr. Roger I. Lee, of whose book I have already spoken, investigated, in
our clinic at the Massachusetts General Hospital, the cases of one
hundred young working-girls, factory employees, who either had
tuberculosis or were suspected of tuberculosis--were in what is wrongly
called the "pre-tubercular stage," when the doctor has not made up his
mind whether the patient has tuberculosis or not. He studied these
cases, as people ought to study them, always in proper coöperation with
a social worker. He made his own careful observations in the dispensary.
Then he employed a social worker to study the girls in the home and
outside the home, following up in their lives and personalities the
tangles of disease. His total result was that he could not say in any
given case that industry had produced a single one of the diseases which
he found, though he was not willing to swear that it had not done so. He
found that a certain number of these girls, in their perfectly natural
search for recreation, were running around the streets or elsewhere
until the small hours of the morning. That is an obvious factor in
producing a diseased state. It is not that we want to blame people for
seeking recreation; but the results cannot also serve as evidence of the
harm done by industry, except in a very wide sense in which we might say
that industry does harm because it does not provide for recreation,
which is, I think, an extreme view.
Dr. Lee's social assistants found that a good many of these girls had no
habits of eating. It was not that their habits were so bad, but that
they had none of any kind. Sometimes they ate very well and sometimes
they did not. Then he found, as of course one would know that he would,
the psychical factors in many of these cases--their love affairs and
other worries which were often much more deleterious to their health
than their habits of sleep or food or even their industrial conditions.
When, therefore, one tries to consider industrial disease, one must
realize how complex a thing it is, how essential it is to go beyond the
inspection of the factory and to study all the conditions of the lives
of the people that one is concerned with.
In a big Western American town that I visited recently, where the
automobile tire industry was employing some fifty thousand hands in
factories, the most obvious cause for ill health was the tremendous
congestion in that town, and as a result the fearful state of the
available lodgings. Again most of the factory hands were foreigners;
very few of them spoke English; they were wholly dislocated from normal
family life, from any connection with their own countries and from their
own previous interests. That is in itself a dangerous condition for
hygiene as well as for morals. Factors like that must be taken account
of when we want to help anybody to get free of the troubles, the fatigue
or strain or debility, which we are apt to attribute to industry.
We are keen, and rightly keen, to find and to abolish poisons, such as
lead, such as phosphorus, such as carbon monoxide. We ought to be keen
to study poisons of that kind, and more interest has lately been
concentrated upon them through war work and war industries than ever
before. But there are moral poisons which we do not notice or mention.
_Monotony, for instance._ Monotony is not altogether a horrible or
hateful fact. Most of us want _some_ monotony in our day. We want a
rhythm and a certain recurrence in it, whereby our work comes to seem
familiar to us and we do somewhere near the same thing each day. There
is rest in that. But _how much_ we need is individual; the dose of
monotony, the amount that is good for you and for me is limited. People
often get too much, and when they get too much, then it is a moral
poison. One of the most appalling things, I think, is its effect upon
the mind. I have often wondered whether I ever had or ever would have
any mind again, when I have come to the end of such a day. Any one of
us, of course, can duplicate that experience, and it certainly ought to
make us think hard about the lives of manual workers whose days are
quite likely to be like that right along. At the end of such a
monotonous day a person may be pretty reckless, may feel that he does
not care what happens to him. I have met that in a great many histories.
It is not so much that monotony makes machines of them as that it makes
wild animals of them.
Another moral poisoning is _the sense of injustice_, a sense that it is
not right that somebody else, whom the Lord did not make very different,
has so much more of money and opportunity and happiness than the person
himself has. It is altogether a secondary question to discuss whether
that is true or not. I do not myself believe that the rich are any
happier than the poor. On the whole, I think the evils of money are just
as great as the evils of poverty. But the sense of injustice is often
just as real even though the reasoning on which it is based is wrong;
and the sense of injustice is a moral poison which breaks down health
and spoils happiness.
Can we do anything about it? Sometimes. By going over the details of
people's lives, by telling them stories of other people's lives, by
confessing a great deal about our own life, we can help people to see
things differently. When I was speaking of pains in the region of the
heart I said that one of the most important things that one could learn
is _to distinguish between the pain and what we think of it_. The pain
often cannot be changed, but our interpretation of it often can. The
patient often suffers chiefly from what he thinks of the pain, and when
he knows that the pain is not due to heart disease and that he probably
will live to be a hundred, that particular form of suffering leaves him.
So in this matter of the sense of injustice, the causes for suffering
may be unchangeable, but if we can change the patient's point of view we
may help him a great deal.
A greater evil, I think, than any I have mentioned, and one that we are
almost powerless to attack, is lowered sex standards, which come from
the crowding of people of all ages and both sexes into industry. As in
the housing problem, it is the moral rather than the physical side of
crowding that is most serious.
That is why the visiting part of social work seems to me so much the
most important. The important part is what we hope goes on in home
visits, when the social assistant meets people where they will talk as
of course they cannot talk in the dispensary.
_PART_ II
SOCIAL TREATMENT