Cabot Richard Clarke
Social Work; Essays on the Meeting Ground of Doctor and Social Worker
This is an example, then, of an ideally complete and compact, though a very sad, social diagnosis. It is almost the only good one we have worked out as yet. The only other is "tramp." The tramp in a technical sense is a person who has what the Germans call "Wanderlust." He is unable to stay in one place. Perpetually or periodically he desires to move and to keep moving. The tramp is a medical-social entity. He has certain physical limitations, certain economic limitations, certain moral deficiencies. But in America he is rather a rare being. One does not see many typical tramps here.
Since few social (or medical-social) diagnoses can be stated in a single word, one is usually forced to write down one's diagnosis in a great many different items. As a guide I made four years ago a schedule for our use at the Massachusetts General Hospital. Use – the only test for that sort of thing – has shown this schedule to be of some value.
To make a social diagnosis we should make a summary statement about the individual in his environment. That summary is to include his mental and physical state, and the physical and mental characteristics of his environment. (I here use the word "mental" to include everything that is not physical; that is, to include the moral, the spiritual, every influence that does not come under physics or chemistry.)
When the investigation of a patient is divided between doctor and social worker, the doctor studies his physique; the social worker studies the rest. I believe that there is nothing that we can want to know about any human being, rich or poor, that is not suggested in that schedule. Suppose, reader, that a friend of yours was engaged to be married. Suppose you wanted to know something about the fiancé. You would certainly want to know about his health and his heredity; then what sort of a person he was, his mentality, whether he had any money – what are the obvious physical facts about his environment. To what influences has he been subjected, and what mental supports, such as education and recreation, family, friends, and religion, can he count upon? You would not want to know any more and you ought not to want to know any less.
So in summing up a social diagnosis I think it is convenient to use the four main heads that I have put down here. I think these headings will remind us of everything that we want to put down, and of everything that we may have forgotten to look up. That is one function of such a schedule – to remind us of the things which we have forgotten.
Made up in such a way as this, of course the social diagnosis will have many items, and like medical diagnosis it will be subject to frequent revisions. The doctor who never changes his diagnosis is the doctor who never makes one, or who makes it so elastic that it means nothing. So social workers should never fear to add to, to subtract from or to modify their social diagnoses.
The best medical diagnoses – those made after death – often contain fifteen or twenty items. Before death in a recent case we found pneumonia. After death we found in addition: meningitis, heart-valve disease, kidney trouble, gall-stones, healed tuberculosis, and ten minor troubles in various parts of the body.
So a good social diagnosis will name many misfortunes of mind, body, and estate, healed wounds of the spirit that have left their scar, ossifications, degenerations, contagious crazes which the person has caught, deformities which he has acquired.
CHAPTER VI
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 England3 they took a body of people of approximately the same age and sex, living under the same conditions approximately, doing the same work. They changed the working hours of one set and left the other set unchanged as a "control." In any scientific test we have to have what we call a "control," something that enables us to compare the changes that we bring about experimentally with the unchanged state of things.
(a) In one room the hours of labor were left unmodified, in the other modified, first increased, then decreased. They made interesting experiments to see whether a man produced as much output, in eight hours as he could in ten; they showed that he could produce as much in the shorter time as he could in the longer time, presumably because he was less tired, less bored, less strained. They made a further cut and found that then he did not produce as much. There is a limit, therefore. He could not probably produce as much in four as in eight hours.
Then they experimented on continuity and discontinuity of work – whether a person could produce as much or more in five continuous hours as in two batches of two and a half hours with rest in between. They found that the shorter periods did distinctly better.
Output, then, was the first rough, but still serviceable, test that they used in relation to fatigue.
(b) Next they recorded the general look and feeling of the men as the foreman and other interested people could size it up – the look of listlessness, of boredness, of fatigue in the working-man when they varied the hours and continuity of work in the ways that I have spoken of.
(c) Next they took the amount of illness, of time off, away from work, as a measure of fatigue, and it was very definitely shown that with a diminished number of hours the number of sicknesses of all kinds, such as colds, were diminished, illustrating the point that I made a moment ago, – that accumulated fatigue diminishes our resistance to infection.
(d) Finally, they made some physiological tests of powers of sight, quickness of answer, etc., after fatigue, and showed that a man was less keen in his senses, less capable of accurate response, after a certain number of hours' work than before, and that fatigue could to a certain extent be measured in that way.
All these tests of fatigue can be applied in our lives and in the lives of people we are trying to help in social work. We have to take account of the number of hours, the possible breaks, intervals, that can be made in otherwise continuous labor. Many people can get on very well if they break the day into manageable fragments. We must also take account of the effect of fatigue in producing infectious disease, of the general look of the person, and of such little physiological lapses as I have spoken of, weakened attention, the capacity for forgetting names, and mental numbness or the sense that things are unreal.
In dispensary work, when we try to give up the use of particular medicines which are useless (as contrasted with the medicines that are useful), one of the chief things to put in their place is the study of fatigue and of the methods for resting our patients. We cannot make the social work of a medical-social clinic successful unless, whenever we take away something which we know to be a fraud and an untruth, we put something else in its place. It is for that reason that I have devoted so much space to the subject of fatigue and rest.