Cabot Richard Clarke
Social Work; Essays on the Meeting Ground of Doctor and Social Worker
CHAPTER VII
THE SOCIAL WORKER'S BEST ALLY – NATURE'S CURE OF DISEASE
Fatigue is a matter that seems to me of particular importance in social work for two reasons: first, because it concerns the visitor's own work and the way she does it; and second, because it concerns the troubles of a large proportion of all patients. The ultimate diagnosis, if we could make it, in probably half of all the people who come to a general clinic, is fatigue of some form, falling upon the weakest organ or function.
I want to connect this subject of fatigue with one of the policies which should govern medical-social work, namely, that we should be honest both in diagnosis and in treatment. That is a policy for which I have struggled and fought for a long time, but which we are still far from attaining. We have not yet an honest practice of medicine on any large scale, a frank declaration to patients of what ails them, how they may avoid its recurrence and so avoid coming to the doctor again. In the American Red Cross Dispensaries in France we tried to pursue the policy of honesty in diagnosis and treatment. We were told by wise people at the beginning that it would not work there, that with French patients it would not do to explain carefully and honestly what was the matter or to refuse to give them drugs when we knew that drugs were no use. But one of the pleasantest experiences of our war work was to find that this warning was not true. We used the truth exclusively and successfully. Our success seemed to me natural because on the whole the French are the most intelligent race that I have ever come in contact with. Hence they took to this particular part of our policy even better than people take to it in America.
That policy links itself up with the management of diseased states due to fatigue and with the explanation of how to prevent getting into poor condition again. In newspaper advertisements and advertisements in the street-cars, it is the fashion to state that a given remedy, a given panacea, "will cure you in spite of yourself." That is exactly what the patient wants. He wants to be put in perfect condition by the first of March, we will say. Inquiring into his present distress we almost always find that he has been violating in some obvious way some hygienic law. But he wants to be cured without reform, in spite of persisting in his bad habits of eating, drinking, sleeping, working, worrying – to be cured by means of miraculous interference which he thinks a drug will produce. He wants a tonic, and he often does not take it well when you tell him that there is no such thing as a tonic. There never was and presumably there never will be such a thing. A tonic is a thing which does nature's work, which gives us in a moment artificially what food and sleep and air and rest and recreation slowly and naturally give us. There is no such thing. The nearest thing we have to a tonic – a thing which we sometimes give when people ask for a tonic – is an appetizer. There are drugs which will help a little in giving an appetite. But only to that extent can we give a tonic. But this is not what people want to be told. They want something to take away "that tired feeling." There is one thing (as unfortunately people discover only too soon) which will take away the feeling of fatigue – alcohol. That is why people take it, because alcohol, a narcotic as it always is, dulls the sense of fatigue, and allows people to go ahead straining themselves, when they ought to have been compelled by nature's warnings to stop. Perhaps it is because so many "tonics" contain alcohol that people have not got over the idea that there is any such thing as a real tonic, which abolishes, not the awareness of fatigue, but the fatigue itself.
The promise to "cure you in spite of yourself," then, is the bait by which the quack attempts to tempt us, and his lie shows exactly the line in which we, as social workers or as physicians in a dispensary, ought to labor. We must try to show people that fatigue, strain, worry, and other natural causes have brought them where they are, and that there is no possible getting out of their troubles without following the line of common sense. No drug, no tonic, can take the place of obedience to common sense.
We see people who have varicose veins, for instance, and whose work forces them to stand a great deal on their feet. They often come to us hoping to get cured in spite of the fact that they are standing all the time, and inviting the force of gravity to produce stagnation of blood in their legs. In advising such people we have two courses open to us, quite characteristic of the courses which may be followed in all such matters:
1. We can say, "Well, I understand that you really cannot arrange to get off your feet. All right. The varicose veins will not get cured. But, on the other hand, they are not very dangerous; the consequences of neglecting them are not very serious. The number of cases when an over-distended vein breaks and causes a serious hemorrhage is not great. The chances of ulcer are not very great." Force the patient to face the danger and realize what will happen, in case he does not make any change in his habits; it is then perfectly proper in certain cases for a person to go on violating hygienic common sense provided he has counted the cost and faced it.
Each of us comes to some point in his life when he makes up his mind that for a good cause he will smash his health. I do not believe in the worship of health. There are many better things in the world than health. Many a man makes up his mind to do what he knows will probably cost him a number of weeks or a year of his life. That is all right; only we must face it, in peace as well as in war.
Or (2), when people come to us for the relief of skin abscesses, boils, and demand some drug which will cure these abscesses, we must ask the important questions, Whence did you get them? Why did they come? Presumably not because the patient has failed to take a drug. We must find the fault in hygiene, generally constipation or overwork, or lack of sleep, causing a lowering of the body's vital resistance, whereby the germs, the staphylococci, which are deep in our skin and never to be rubbed off by any washing or sterilization, begin to multiply. The soil has become such that they can multiply.
I have tried to suggest the importance that we ought to attribute to soil as well as to seed. Modern doctrine about the cause of disease has called our attention to the tremendous importance of seed, that is, germs, bacteria. But on the whole, if one had to say which is the most important single factor in disease, he would have to say, not the seed, but the soil. Take the tuberculosis bacillus, for instance. I do not think it is an exaggeration to say that nine tenths of all persons have had tuberculosis, usually in a harmless form, because the soil has been stony and so has killed off the bacteria. You know that the figures obtained by means of tests with the Von Pirquet reaction in almost any city or town, show that ninety per cent of the children of twelve years of age and on, have a positive reaction to this test for infection by tuberculosis. They have the tuberculosis bacillus somewhere in their bodies. That does not mean that they have the disease, but they have the bacteria in their bodies, and mostly in the process of being killed off by the tissues of the body which resist this infection.
One of the reasons why I go into detail here about the changes that take place in the body through disease, is to make social workers feel as strongly as I feel, and convey to patients as strongly as I try to convey it, what nature does in curing disease. We have read of people who were walled up in masonry by way of vengeance, and left to die in a casket of stone. That is what nature does to a bacillus, literally walls it off in stone. After death when the pathologist's knife cuts down into a lung, the knife is sometimes broken by coming upon what feels like a stone. A stone it really is, a deposit of lime salts in the tissue, around a nest of tubercle bacilli. If one cuts such a stone in two, one finds in the centre bacilli often still alive and perfectly capable of increase, but harmless to the body because nature has built this wall around them. I do not think one can get the full force of this fact until one has seen it. That is one of the long list of things that the body is constantly doing in this process of resisting disease, and doing more intelligently than we can.
Since, then, it is chiefly the soil, the vital condition of our tissues, which resists disease, we must do our part in making that soil good or bad for disease. That is why our hygiene, our obedience to the individual laws of our own experience, which show us how we can keep well and how we get sick, must be learned and taught by every one of us so far as we can in such a place as a dispensary or a patient's home.
For example: disease is often produced by lack of sleep; hence it is of central importance to teach people how to sleep. Excluding organic disease in the causation of most cases of sleeplessness – for most people suffering from insomnia do not have organic disease – one can say this: Insomnia usually depends on something wrong in the patient's day. The state of the night depends on the state of the day. If the day has been free not merely from gross sin, but free from hygienic blunder, then the night will go somewhere nearly right. If the day has been filled with concentrated work in which the mind has been wholly upon the thing it has in hand, if there have been no elements of strain through distraction or worry, causing double currents in the mind, then when night comes one can turn the mind off and go to sleep. On the other hand, the mind which has been intent half on its own job and half on its own worries, never wholly "turned on" during the day, cannot be "turned off" at night. Any physician or any patient succeeds in curing insomnia who succeeds in finding out what is wrong in the way the sleepless person lives, and how it can be corrected.
But most people want to go on living in just the same stupid way and yet to get rid of the sleeplessness "in spite of themselves." The obvious way is to take a drug that for a while will stop insomnia even when life goes on as before. There are many drugs that will give sleep, but there are no harmless drugs that give sleep – none. Physicians receive about once a year advertisements of a drug for sleep which is "wholly without ill effects," but I do not think it shows undue skepticism or dogmatism to say that those drugs never do what they say, and never will. Sleep being a natural process, anything that forces it upon us hardly can be free from ill effects. Hence the first thing in attacking a case of insomnia is to say, "Never take a drug again." Natural processes whereby fatigue accumulates and puts us to sleep do not go on rightly if we are being artificially driven into sleep by a drug.
One gives drugs for sleeplessness rightly when there is some rare and special reason for being awake, some catastrophic reason which will never occur again. This exemplifies the principle which I have tried to emphasize throughout this book. We may give money for some catastrophic cause which puts the person down and out, and will not occur again. So we give a drug for sleeplessness if there has been some special thing to interfere with sleep – if, for instance, you have been talking very hard with a friend and you know by your own feelings that your mind will not stop that night. Then you may perfectly properly take a drug to put you to sleep, knowing that there is no reason to suppose that such a talk will occur again in the near future. Knowing this, you do not need to waste that night. You take the drug. But it is only in rare catastrophic moments that one can be cured in spite of one's self, any more than one can give or take money safely.
It is the same in the matter of constipation. The first thing to make clear to a patient is that drugs must be abandoned before he can ever teach his bowels to behave as they should. But it is a great deal of trouble to do that, and because people shirk that trouble, and want to be "cured in spite of themselves," they come to a doctor to be cured by drugs. Alas, he is often weak enough to give them what they seek!
I have tried to make this drug-fearing practice one of the policies that honest medicine must always stand for, because it seems to me that when the doctor allows himself to be tempted into behaving as a considerable number of his profession do – that is, into giving people what they ask for – he very soon loses his ideals, gives things that he knows more and more clearly that he has no right to give, and goes downhill. Social assistants must help the doctor to avoid this disaster. They can do so by helping him to teach the truth.
I want to deal a little further with some examples of what nature does in the way of warding off disease. For a large part of what we call disease, and what we feel in ourselves as disease, is not the attack of the enemy, but is our defence against the enemy.
Take, for instance, inflammation. When germs are beneath the skin, one finds redness, swelling, heat, pain, as the symptoms of inflammation. What does that mean? It is all like the defences which were set up round Paris when the Germans were coming there, or that are set up anywhere when one is getting ready to repel attack. The inflamed finger gets red because a great deal of blood is going there. The blood cells, especially the white cells of the blood, are coming there to defend. The finger gets red for the same reason that the railroads get congested in time of battle, namely, because so many soldiers are being carried there for defence. The finger gets swollen because so many cells and fluids are coming to attack the enemy; it is their crowding outside the blood vessels that makes the swelling. There is heat in the finger because there is more blood in the part and therefore the part is hotter. There is pain because with the extra accumulation of defenders there is a squeezing of the little nerve terminations there. When a lot of soldiers are suddenly quartered, billeted in a town, it is a painful process. There is pain in having defence come to your city. There is pain in having defence come to your finger.
All of these symptoms, which we are apt to hate and to think of as misfortunes, we should realize are the thing which saves us from very serious illness. Suppose these things did not happen. Following out the metaphor, if it were not for these defences the enemy would penetrate into the whole body and we should have blood poisoning. It is because this local heat, redness, swelling, pain, appears at the point where bacteria are attacking us, that they do not penetrate the whole body with a septicemia, which is one of the most dangerous of all diseases. So while suffering what we must suffer, we ought to be glad of all that nature is doing, because if she neglected it the consequences would be very serious to us.
But we may ask, "If this is true, where do medicine and surgery come in? Why do they ever interfere if nature is so very wise?" Because nature overdoes the thing every now and then. Nature is first enormously wise and then a little blind. In another example I can bring this out a little better. You have sprained your knee and the knee gets very stiff. That in itself is good; it is a defencive reaction. The stiffness is like a splint. The knee ought to be kept quiet. So far so good. But nature overdoes the thing. The knee ought to be kept quiet, but for how long? We will say three days more or less, according to the severity of the injury. Then you have to fight nature which stiffens the knee too much. You have to fight it by the use of the knee, by walking or by massage, which is not, however, so good as walking. If we respect blindly what nature does in stiffening the knee even to the exclusion of nature's other functions, such as walking, then the knee will get worse. One of the greatest improvements in the modern treatment of sprains, is that we no longer keep the patient in bed and put plaster of Paris on, which makes the sprain last for months sometimes; but we let him walk at once on the sprained ankle, whereby the attempts of nature to cure by stiffening are not carried too far.
Another example of how nature overdoes things is in the formation of scar tissue. If a scar did not form to close the wound, the wound would remain open. Hence the scar is vastly better than nothing. But scar tissue is never as good as the original tissue. One of its known ill results is contraction, so that a scar on the hand or on the neck often draws the part out of place. Then we have to fight nature. We have to go against the workings of nature by surgery, in order to get the person right.
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.