There are some technical processes of diagnosis and treatment which are usually carried out by the visiting nurse, but which may well be performed after a brief training by the social worker who is not a nurse. Among these are:
(1) The accurate reading of the patient's temperature, pulse, and respiration, which she must often teach the patient to do for himself and to record accurately and clearly. This is of especial importance in tuberculosis, for in suspected cases of this disease one often needs daily measurements of the temperature as an aid in determining the diagnosis or in estimating the severity of the case and the fitness of the patient for work.
(2) The arrangement of a window tent or some other device for insuring the maximum of fresh air for the tuberculous patient both day and night. This device is also useful in pneumonia, typhoid fever, and other diseases, in case they are to be cared for at home and not in a hospital.
(3) The application of simple dressings to wounds, abscesses, and common skin diseases such as eczema, and impetigo.
(4) The care of the skin in bedridden patients. Our primary object here is the prevention of bedsores, those ulcerations which occur in very emaciatedpatients at the points where their weight presses a bone against the bedclothes.
(5) The simpler procedures for the preparation of milk for sick children and of other foods commonly advised for patients who are confined to bed.
(6) The methods of emptying the lower bowel by means of an enema.
Into the details of these procedures this is not the place to enter, but I wish specially to assert that all of them may be learned within a few weeks by persons who have not studied medicine or had the full course for the training of a nurse. Any one who possesses these simple bits of skill can do all that is necessary for the physical care of the sick poor in their homes, unless continuous attendance upon the patient is necessary. Such attendance is not within the province of the social worker. But in the technical procedures just described it is all the more important that she be expert, because such skill makes her a welcome visitor and a trusted adviser outside the field of medicine. Because she has given relief by dressing a wound, curing a skin disease, or applying a poultice, she will be listened to with liking and with confidence when, later, she comes to give advice in economic, educational, or moral difficulties.
History-taking concerns the social assistant especially because history-taking is one of the things one does, if one is wise, in any matter in which one is trying to help a human being. Even if you were concerned to help not a stranger, but a member of your own family, still you would need a story or history of the person's life whether you wrote it down or not.
In our attempts to be of use to people in their misfortunes, there are two very common and quite opposite points of view (roughly the right and the wrong), which I call (a) the "historic" and (b) the "catastrophic," the accidental, or the emergency point of view.
Confronted with people's troubles, whether physical or mental or spiritual, we are tempted, and above alltheyare tempted to regard the sickness, the poverty, or the sorrow in the light of an emergency, an accident, and therefore as something to be treated at once and by means which have little to do with the past and the future. On the other hand, the standpoint of science and philosophy, and of any one who has labored long in the field of social work withor without science or philosophy, is the point of view of history. This is the habit of mind which makes us believe that a supposed "accident" belongs in a long sequence, a long chain of events, so that it is impossible to understand or to help it without knowledge, as extensive as our time and our wisdom will allow, of that whole chain.
Consider a few examples which contrast these two points of view. When a boy is brought into court for stealing, it is almost always his attempt, and the attempt of those who defend him, to show that such a thing has never happened in his life before; he "justhappenedto steal." But as we inquire more closely into the facts, we almost always find that this is a fundamentally untrue statement of the case. For the offence which brought him into court is almost never the first offence. He has always stolen before. On the present occasion he was a member of a boy's gang; it was not in the least accidental that he got into that group of boys. As we search back in his history, and perhaps into his father's history, we find reasons why he is what he is now. Again, we are trying to help some wayward girl who has taken an immoral step. We are told what a wholly unforeseeableaccidentit was that got her into her trouble. But if we can get a good picture of her past, we find that we could have traced the tendency to weakness of this kind from the time she was born.
So it is in medical matters.Emergencies are rare.I remember being called out of a sound sleep onenight to go "as quickly as possible" to see a man who had discovered a lump upon his breast bone. He was quite sure that the swelling had appeared since the time when he went to bed. It was then one o'clock in the morning, and he had gone to bed at eleven. Well, I found a slight bony irregularity in his breast bone which doubtless had been there about forty-five years, as he was forty-six years old. He did not pretend that it hurt him, and did not undertake to show that he was ill in any other way. But this lump had come and naturally he wanted help at once.
The great importance of the contrast between the historic and the catastrophic points of view is, in the first place, that one way is on the whole right and the other on the whole wrong; but still more, that the patients whom we are going to deal with, and all the unfortunate or needy people whom the social assistant tries to help, are very fond of the wrong point of view and hang to it extraordinarily. It isthenatural first impression of any untrained person that his troubles "simply happen" without any explanation that he knows. So that we have to start at once to tear down a structure of innocent and lifelong belief on the part of the patient, that troubles come suddenly and by accident. We have to disillusion him, a process which naturally he does not take to particularly pleasantly.
Our task in a dispensary is the same. The patient almost always starts withthe catastrophic point ofview, and can only be very gradually engineered into the other. And yet our work in relation to public health is largely to be summed up as finding out how,—that is by what history, through what chain of events, people come to be sick. Repetition and extension of disease can be checked only in case we succeed in finding such clues. Hence our labors to change people's point of view in this particular respect are as worth while as anything we can do, and we must not be discouraged by the fact that, week after week and year after year, we come up against the same difficulties, the same conviction, that troubles "just come" and have no cause.
I have said that the historic prejudice is essentially right and the catastrophic prejudice essentially wrong. Of course, there are exceptions. A man may be run over in the street for reasons that we cannot discover to be connected in any possible way with his previous history; a man gets a burn, gets a broken leg, is hit by a missile in an air raid over London or Paris, in ways that are essentially catastrophic. And yet even in the field of accidents, industrial accidents for instance, the more we study, the more we find that injuries are not wholly accidental. The whole of science is the attempt to prove that nothing is an accident, that everything comes out of previous causes. The percentage of accident in the so-called "accidental" injuries decreases as we study industrial accidents. (a) They happen at certain hours of the day more than at other hours ofthe day: if they were really accidental this would not be so. (b) They happen on certain days of the week, especially Mondays, for obvious reasons. (c) They happen especially to greenhorns, to the newcomers, who have not learned how to avoid them. One of the expenses incidental to hiring new help is the expense of accidents. Thus these events turn out to have a good deal of law and reason, a good deal in the history of the individual (alcoholism?), and the nature of the industrial process (speeding up?) which helps to explain them. By eliminating such causative factors, we may prevent some accidents.
The remedies that we apply fit the type of trouble;in so far as the trouble is accidental or catastrophic, the remedy is mechanical; in so far as the thing is historical and continuous, the remedy cannot be mechanical. When a man breaks his leg we put on a splint; that is mechanical. But if he is in a low state of health and the fracture won't unite, we have to do something non-mechanical, physiological, psychological. We may have to get him into a different state of nutrition or even into a better state of mind before his tissues will heal.
Our job, then, in taking histories—that is, in finding out how things happen that lead up to disease or misfortune—should begin by writing downthe thing for which the patient comes—headache, cough, emaciation, poverty, desertion, unemployment. This is the "presenting symptom"; it should always bethe first thing written down in our history, not in terms of medical diagnosis such as asthma or anemia, but in the form of a complaint. Our attempt is first to put that down, to get a starting-point, and then to weave that into a chain of evidence which we call a history. That history makes it possible to make a diagnosis and to plan treatment.
But the particular event, the particular complaint for which the patient comes to us, is woven not merely into one chain of evidence, but into several. Let us carry out the metaphor of the chain. We must imagine many chains woven into one another like the chain-armor of the mediæval knight. Each link is a fact. But many chains of facts are interwoven in the history of one single patient. First there is the chain of medical evidence, the links (or symptoms) leading up to a diagnosis; second, the chain of social evidence, which we try to classify on our social history card. Third, we must trace the links in the chain of relationship with other people, other members of the family, with friends and fellow workers or schoolmates. Finally, the chain of heredity, of which we cannot make much at present except in relation to tuberculosis and mental disease or mental deficiency. But these studies of heredity in its bearing on character are going to be more important as the science of social work develops.
Our first attempt, then, after determining the"presenting symptom," is to find out by a series of questionshow this symptom is linked up into a tissue composed of many chains of facts. Our next task which is usually difficult, and frequently impossible, is to find out why this great tissue of evidence issues just now in one particular "presenting symptom." Why did the patient come to us to-day? This question is often impossible to answer because the patient does not know, though he may think he knows. Nevertheless, the social worker must try to find out. Often it is not until we have known and liked a person for days or weeks that we find out why he came to us at this particular time. Yet the answer to this question may be the most important thing that we can find out. For two reasons it is important; first, because it furnishes the clue to all our later investigation and assistance in this case; secondly, because it may show that the individual's complaints are not of any significance at all.
I can illustrate this by a case studied at the Massachusetts General Hospital in Boston. We looked up a series of patients at their homes in order to find out if we had really been of any service. The cases were not selected, but were taken from our files in numerical order. Among others we visited a lady whose malady had been diagnosed as "sacro-iliac strain." She had been given a prescription for a belt. We wanted to find out whether she had ever bought the belt and whether it had helped her. After some difficulty the visitor finally got the following details:The lady had come from a city twenty miles distant from Boston. She had taken an early morning train, and could not get back to her home the same night. Hence she could not soon make another trip like that. She came to have her eyes examined. Now it happened that we had no eye clinic at the hospital at that time. But the lady had heard a great deal about the hospital and its efficiency. She was determined not to go home without having got something out of the hospital. So when she was told at the Admission Desk that she could get no treatment for diseases of the eye, she wandered into the medical clinic, trying to remember or imagine some symptoms for the relief of which she could be admitted to the clinic. Finally she managed to get out some sort of a story about a pain in her back; she was referred to the orthopedic division; there a diagnosis of sacro-iliac disease was made and a belt was advised. When she got home, of course, she laughed at the idea of buying a costly belt.
Now, if we could have found out in the beginning why she came to the hospital, we might have saved a good deal of bother for a good many people. It is astonishing how many patients turn out to have as little reason for coming now as this lady did. One of the things that shows the arbitrariness of choice in selecting a time for visiting the hospital, is the striking diminution in the number of patients in the week before Christmas. That suggests that there are many postponable visits. Or again, patients maycome merely because somebody else from the same neighborhood is coming.
As the history-taker traces out the symptoms of the patient's illness after finding an answer to this first question,Why to-day?two opposite habits of mind must be employed, one passive, the other active. We must be sure that the patient shall feel that he has had a good listener, that his troubles have really been appreciated. But if we are constantly putting in questions, as we certainly must later, the patient does not feel that he has been listened to. We desire first of all to get his own story in his own words, passively. We may not necessarily write down a single word of it. But I have found that the patient's own way of expressing the nature of his troubles is often important and characteristic. It helps to prevent our histories from looking too much alike, which is their commonest fault. Hence we should get into them somewhere a phrase or several phrases reported passively in the patient's own words; if possible a phrase in which he describes his "presenting symptom," the thing of which he chiefly complains.
But the second stage in the process of taking a patient's history is the most important. In this part we should be active, not passive. We must attack our task with a tool in our hand,a mental tool fitted to rake out of the mass of confused ideas in his mindcertain significant facts. That rake is a logical schedule of questions which you use upon him actively, not passively, and by using which you get answers either negative or positive. Whenever you think well, youthink with a scheduleof that kind in your mind. If you pack a trunk well, you pack it using a list, a schedule of the things that ought to go into that trunk. Our printed social face-card helps us to think and question with a schedule before us, to think in an orderly way, without forgetting our items, and thus to select what we need out of the mass of disorderly facts in the patient's memory.
In the second phase of history-taking, then, which begins after we have listened appreciatively but quietly to the patient's own version—usually catastrophic and full of fanciful theories—we lead him by questions (but not by "leading questions") along the paths which will open up a full view of the trouble, medical or social, which has been suggested to us by the patient's first statements. Suppose, for instance, one happened to know of an extraordinarily rare but curable disease, one symptom of which the patient had mentioned, "My hair comes out by handfuls." One would go on to ask, "Do you feel warmer or colder than usual this winter?" Then, "The expression of your face is not notably changed, is it, so that your friends comment on it?" "Is your skin drier or moister than usual?" "Does your tongue bother you in any way?" "Is your mind more or less active than usual?" Thus one would confirmor refute the suggestion of the disease called myxœdema, a suggestion which was given to us by the patient's first complaint—rapid loss of hair. Given one symptom in a known group, one can trace out the others as the anatomist who finds a single fishbone may be able to reconstruct imaginatively the whole fish.
I said just now that we must not ask "leading questions." If we do, we can make a patient of a very suggestible type of mind say anything. If you ask him whether he has any symptom whatsoever he may obligingly say "yes." The way to avoid this is to put our questions in the negative: "You have no headache at all, have you?" "You do not cough?" "You never spit blood?" By these negatives we can get at the positive symptoms if they are present.
Schedules of questions to be used in history-taking may be medical or social. Some of the social question-lists are suggested in later chapters of this book. A masterly account of social questioning is contained in Miss Mary E. Richmond's "Social Diagnosis" (published by the Survey Associates, New York, 1917).
I wish now to illustrate the methods to be used by social workers in questioning patients about their symptoms so as to assist the doctor in his diagnosis.
Pain: How long?For a day, a month, a year, six years? Very chronic pains are seldom serious but seldom curable. Headache that has lasted years either has no cause known to medical science, or elseit means neurasthenia. In either event it is apt to be stubborn. A headache that has lasted only a day, and did not occur before, cannot possibly be due to migraine. This suggests how the length of time that a pain has lasted is very important in diagnosis. The patient will often say, "I have always had it"; but to this we should oppose a pretty strong cross-examination. The patient usually means that he has had it off and on throughout an indefinite period. We ask him then, "When did you first have it?" and then, "How much of the time—half the time, a quarter of the time, for one day a week or one day a month?"
Pain: Where?Patients rarely come to a doctor for a singlepoint. But pain in several points is never as significant as pain in one point. One cannot learn much from scattered pains in relation to what ails the patient and what to do for him.
Pain: How bad?That is a very difficult question to get the answer to. There is no thermometer or measure for pain. I suppose every doctor has wished many times that he had one. But there are certain rough measures which are of some use in judging how bad a pain is. (1.) We ask, "Does it compel you to lose sleep?" Some headaches may be pretty severe and yet a person sleep despite the pain. It may link itself up with a dulling of consciousness leading to sleep. But most pains and even most headaches that do not keep a person awake are not as bad as those that do. (2.) We ask, "Does it prevent work?" Anyone can see all sorts of limitations to the use of that criterion. A man with a rugged type of mind will work with a pain that another weaker man will give up to. Yet the question does bring out evidence of some value.
(3.) Another criterion, more subtle and not quite so useful, is this, "Do you feel the pain more when you are quiet or when you are moving about?" The pains due to organic diseases are generally worse when one moves; while the functional type of pains are apt to be better when one moves about. One forgets it. Quite often patients are very lucid and candid about this.
Pain: How aggravated? How relieved?(a) A pain may be aggravated by position—for example, when the patient is on his feet—or worse when he is lying down—a headache, for instance. Most abdominal pains are worse when the patient is on his feet. (b) A pain may be aggravated by motion. Most of the surgical injuries, sprains, strains, tears of muscle or ligament, and fractures of bones are naturally made worse by motion. Pain may be aggravated by certain particular motions, as is the case with some of the innumerable pains in the back. Lumbago is a pain characteristically described as one that comes when the patient tries to lace his boots. Especially when he tries to get up from that position, the pain is intolerable. Pains in the chest are often worse on deep breathing—pleuritic pains, for example. But other thoracic pains may also be made worse by deepbreathing. (c) Pain may be aggravated by the taking of food, or by movements of the bowels.
Pain may also be relieved in any of these ways. The most important thing that one can know about a stomach pain is that it is relieved by food. The majority of all stomach pains are aggravated by food. Pains are also relieved by heat or cold or by drugs or by rest. But those are not very important points. They may be important in relation to what we do to help the patient, but not in relation to diagnosis. Some pains, whatever their cause, are relieved by cold, more by heat, and most are also relieved by rest.
Next to pain,Coughis the symptom, especially in the colder months of the year, that we have most to deal with. The questionHow long?is vastly the most important one about cough. One can also measure itsseverityby the question, "Does it keep you awake?" and to some extent by the question, "Does it prevent work?" More important is the question, "Is it dry or productive of sputum?" The patient's description of his sputa in gross, without any microscopic examination, is also of a good deal of use. There are usually three things a patient can tell us about it: either it is yellow, or it is white, or it is bloody. There are two other important questions about bloody sputa. Unless one gets these answered, the mere fact of spitting blood is not important. We must know whether there are merely streaks of bloodwhich one often sees in the sputa of anybody who coughs hard, are of no importance, and have nothing to do with tuberculosis. But if, in contrast with this, we can really establish evidence of the spitting of blood in quantity, we have almost proved a diagnosis of tuberculosis. In ninety-nine cases out of one hundred the spitting of blood in quantity means tuberculosis. "In quantity" means a cupful or thereabouts of pure blood. If the doctor does not find tuberculosis after that he should nevertheless assume it, for it is almost always there. I should pay no attention to negative physical finding in such a case.
The next point to ask about is whether the patient'sbreathingiswheezy. When a horse has become broken-winded we can hear his breathing in the street as he comes along. He has become emphysematous. We find this wheezing respiration in emphysema, asthma, and bronchitis, which are diseases important for us to distinguish from tuberculosis; we almost never get it in tuberculosis.
If the patient complains ofdyspnea—difficult, rapid breathing, "short breath" as we say—we shall ask aboutœdemaor swelling of any part, especially of the legs.
In every patient who has a cough we are concerned primarily with the diagnosis of one disease, that is, tuberculosis, its presence or absence. Hence every patient who coughs should be questioned about the other symptoms of tuberculosis and especially aboutemaciation. A man with a chronic bronchitis oremphysema does not lose much flesh; he does not become emaciated. A person does not become thin from throat trouble. Hence emaciation, especially recent, is a helpful guide to the doctor in making up his mind.Feverwe investigate for the same reason. The only disease that often causes cough and fever during a long period is tuberculosis. Unfortunately the patient's statement about fever is usually unreliable. We can believe most of what he says on the rest of these points. But he does not know whether he has fever or not.
In women we must ask also about themonthly sickness, because it is suppressed in cases of moderately advanced tuberculosis. Nephritis, anemia, heart trouble and emotional disturbances may have that same effect. It is a measure of the degree of disease, not its type.
For the purpose of dispensary consultations I do not think we should take any family histories except when we suspect tuberculosis. But when the history leads us to think that the person may have tuberculosis, the social worker can help the doctor by asking the patient questions about the possibility of the same disease in mother, father, or others who are in contact with the patient—grandfather, grandmother, or other relatives or friends living in the same house. We believe less and less in the heredity of tuberculosis, more and more in infection by contact. If separated from a tuberculous father or mother in early infancy we believe that the childdoes not acquire tuberculosis. But the main mode of infection is by association in the same house, over a prolonged period, with people who have tuberculosis. Often the patients do not know or will not confess that anybody in the family now has tuberculosis or has died of it. But if we can establish the fact that one of the patient's family has died after having a cough for many years, that he grew very weak, and spit blood, we have established the diagnosis without the name. Not the degree of relationship to a tuberculous patient, butthe amount of time spent in the same house with a tuberculous individual—what we call the degree of "exposure" to tuberculosis—is the important thing.
After getting the patient's present symptoms, one should ask, "Were you ever sickprevious to this illness? If so, what troubles have you had?" That is of use in clearing up the limits or boundaries of the present illness. The sicknesses which the patient says he has had are not of very much use to us in diagnosis because we cannot get true answers. The patient's diagnoses or his doctor's are apt to be vague or meaningless. But the questions about the patient's past history tend to make him more clear as to the date when his present illness began. Hence his answers on these points should be written down very briefly, a word or two only about each, and usually in the words used by the patient.
In our written histories in hospitals we usually take a considerable body of notes about the patient's habits. I do not advise this for social workers. But there are certain routine questions which should be asked of all patients concerning theirappetite,bowels,sleep,weight, andwork. The answers should be recorded in a separate paragraph, at the end of the history.
What is printed here is meant to give a sample, not a full account, of medical-history-taking. Competence in this field takes long practice. Nevertheless the intelligent social worker can learn in a few weeks to be of great assistance to the doctor by taking either in the dispensary or in the home such histories as I have sketched.
In social-history-taking there is no single order or schedule of questions agreed upon by all social workers. But there should besomeorder and system determined partly by the personality of the worker and partly by the nature of the trouble. If poverty or destitution is the presenting symptom, one must find out the items in the family budget, the figures of income and outgo, paying especial attention as in medical histories to the question, "How long?" How long have you paid that rent, earned that wage, been without a job, taken boarders, been in debt?
Is sickness, childbirth, alcoholism, injury a factor?
Is there any family history of tuberculosis, pleurisy, insanity, epilepsy, feeble-mindedness? Ofmiscarriages or of "scrofulous" children and "blood diseases"?
What previous hard times? What economic and moral high-water marks and low-water marks can we trace in the past history?
What relatives, friends, employers, doctors, teachers, neighbors, landlords, social agencies, public officials or records can be consulted for additional light on the person and his troubles?
From all these sources one arrives finally at an opinion on "what sort of personare we trying to help—what sort physically, mentally, and morally?" That is the central fact.
It should be clear from what I have said already that the work of the social assistantmayhave nothing to do with poverty. Her only business in visiting a family may be to assist the doctor in his diagnosis and treatment by bringing him additional facts about the nature, seriousness, or cause of the disease and about the means by which it may be combated.
But in many, perhaps most, of the families whom the social assistant attempts to befriend, there is a call for relief, for financial assistance, for money, food, coal, and clothes. This appeal like most medical appeals is apt to take theform of an emergency. Help (we are told over the telephone) is needed at once, or disaster will follow. The family is eager for immediate relief, not for a slow and painstaking investigation of the causes which have led up to the present state of things, or of the exact nature of their present troubles. They are like the sick in this respect. Prompt relief from pain is what the sick demand, not the tedious processes of questioning and examination. They want a remedy, a pain-killer, morphine or its equivalent.
But we all know the dangers of giving morphine for the relief of pain. It never cures a disease; it only stifles a symptom. It gives delicious ease; but theneed for its use soon recurs. Hence there is always danger that before long the patient will have to fight, not only the disease which originally caused him pain and made him call for morphine, but the morphine habit in addition. This is all familiar. But not every one realizes that the giving of money in case of poverty is as dangerous as the giving of morphine in sickness. Money like morphine satisfies an immediate need and hence is eagerly welcomed by the sufferer. But of money as of morphine it is true that a single dose soon makes the patient call for another, and often a larger dose; that it soon makes the patient dependent on this sort of relief, and so forms a dangerous habit. With the rarest exceptions, to give money or to give morphine does not cure. The state of things which produced the pain or the poverty is sure to recur. For (as I have said above) the patient's belief that his present troubles are an unforeseeable accident, a sudden catastrophe, is almost never true. The truth is that his pain or his poverty are but the last chapters in a long story produced by causes which can usually be traced out, and whose future action can often be foreseen. By giving money we are covering up a smouldering fire, not quenching it.
For economic bankruptcy or breakdown, like physical bankruptcy or breakdown, is generally the result offaulty organizationin the system of income and expenditure. Physically a person breaks down because he has been spending more energy than hecan recoup by rest, food, and recreation. Economically he breaks down because his scale of expenses exceeds his regular income. Hence it gives but temporary relief to pay the bankrupt's debts, to cancel the sufferer's pain. The operation will soon have to be done over again unless some constructive plan for increasing his income or decreasing his expenditure can be worked out.Giving creates dependencebecause it atrophies industrial and moral initiative, just as a crutch or a splint causes muscles to waste. Powers unused atrophy. If we support a person, except temporarily, he will soon lose the power of self-support.
But the point of view impressed upon us by the sufferer himself is apt to be quite the opposite. What he wants is something immediate and temporary for the relief of something accidental. The beggar who meets us in the street has "accidentally" lost his purse and asks of us a small sum of money to reach his home. Often I have said to such an applicant, "Meet me at the railroad station half an hour before the train leaves for your home. I will buy you a ticket and see you on board."He never comes.This is an extreme instance and involves almost always a deliberate attempt to deceive us. In home visiting it is not like this. The sufferer does not usually intend to deceive. Nevertheless his misfortunes are pictured by him as accidental and temporary catastrophes, maiming a life which needs no general reconstruction. He is so sure of this that he is apt to force the idea upon us unless we are alert, bracing ourselvesto question it and to make sure that it is true. But actual experience has shown me and hundreds of others that this point of view is almost never true.
It is not chance that the family is just now poor. It is no emergency which we are summoned to meet. It could have been foreseen long before and it will certainly recur unless we can trace out its causes and prevent their acting as they have hitherto. Hence the detailed, prolonged, individual study of the family's economic state is necessary. One must find out, first of all, all the details of income and outgo. The family is likely to forget some of these, so that one must be ready to assist their memory.
Further, one must inquire carefully into possible sources of help from relations, friends, fellow members in some club or association, and so forth. For next to self-help the help from those naturally bound up with one is best. Compared with impersonal charity, it is less artificial. It is less destructive to the natural family relationships which it is always our ultimate ideal and our immediate job to maintain or to restore so far as possible. Whatever disturbs or threatens them is hostile to the social interests for which we labor.
Naturally one does not invoke the help even of family, friends, or fellow club members, unless it seems impossible for the individual, under the best plan that he and you can think out together, to get along without outside help. But if we are convinced that, for the present at any rate, this financialself-maintenance is impossible, it is to securing help from those nearest to the sufferer that one should look with least regret. Gifts or loans from members of his family or from friends are more likely to be taken seriously by the recipient. He is less likely to feel (as he does with an impersonal agency or charity fund) that he can draw from a bottomless pit of money without making any one else the poorer. Moreover, when he takes money from his brother or the fellow member of some club, the pressure for regaining his economic balance is likely to be exerted from without him as well as from within. He feels the pressure of his debt and thereby is stimulated towards regaining his independence.
The sufferer's "catastrophic" point of view, which tends to isolate the present trouble from all its causes, to represent it as temporary and accidental, is related to his tendency to state that he has no friends, relations, or social connections through whom help could come to him. Without any deliberate attempt to deceive us, he quite naturally forgets some of his relations. He does not want to appeal to them. Hence they fall into the background of his mind, and are not easily recovered. When one finds them for him he is apt to say, "I did not think of him because I am not on speaking terms with him"; or, "I would not on any account take money from her, or allow you to ask her to help me." But such a sufferer may very properly be asked, "Why is it that you are willing to take money from me, astranger, or from this impersonal charitable agency, when you are not willing to call upon your own relations nor even to let them know that you are in trouble? You are concealing it from them, are you not? Is there really any good reason for this? Will it not be easier for you, as well as for them, that they should know at once? Are you not really storing up trouble for yourself, postponing the evil day which, when it comes, will be worse than anything which you would have to bear at present?"
Of course, in all such advice we intend to say nothing that we should not wish to have said to ourselves. The social worker tries to treat people always as she would wish to be treated. But one cannot always avoid giving pain or even estrangement. Because such interviews are necessarily difficult and may result in disaster to the relationship that we are trying to establish, they should be postponed if possible until we have already established in other ways a friendly understanding, a structure of friendship which will bear the strain of penetrating inquiries such as these economic matters necessarily entail.
I have said that the first guide to helpful economic relief is a realization of its danger. The next is awareness of the advantages of self-help and the truth that next to self-help, assistance from those naturally and nearly related to one is best.
The third principle, by following which we may hope to do the greatest good and run the least risk ofharm in our giving, is this: never give hastily except in extraordinarily rare emergencies such as acute hunger or exposure to the elements. In all other cases give in accordance with a plan worked out as carefully as may be, whereby we are confident that our giving can be temporary. Sometimes we can arrange that it shall come to an end automatically. That usually means that we arrange for a loan rather than a gift, with repayment either by instalments or in lump sum upon a definite date.
(a)Loans.It is in the hope of rendering service by these means that there have been organized philanthropic loan associations which lend money at low rates of interest and sometimes without interest or upon security which the commercial loan companies would not accept. The sufferer with whom we are dealing may know nothing of the existence of such agencies. If so, to connect him with one of them, to help in furnishing the security necessary to negotiate a loan, may perhaps be the best way in which we can help. Or one may buy some rather expensive article such as a piece of medical apparatus, with the clear understanding that we are to be repaid in instalments or at weekly intervals.
(b)Tools of a trade.Another example of the kind of giving which comes to an end and does not tend to form a habit like the morphine habit, is exemplified when we buy a man the necessary tools of his trade, or the stock and furniture necessary to start a store. The belief on which we rest in such cases is that afterthe initial act of acceptance, after an initial period of dependence, the individual will become self-supporting and independent.
(c)Furniture.Or, again, one may give or loan a cooking-stove, so that the sufferer may no longer have to eat at restaurants, or some furniture in order that he may get the benefit of the lower rent to be had when one hires an unfurnished room. In all these cases the ideal thing is to arrange for repayment in small instalments. Failing this we try to think out a plan such that after the original expenditure the sufferer will be able to go on independently.
(d)Aid in illness.A fourth example of temporary interference in the form of financial aid, is a gift or loan of money to tide a person over an illness, to make his convalescence complete or to rest him when he is dangerously tired. Usually such aid can be rendered through services or institutions (nurses, hospitals, convalescent homes) which do not involve giving money outright.
(e)Aid during unemployment.A fifth good reason for giving money or other forms of relief temporarily is to tide the sufferer over a period of unemployment, during which he is actively looking for work or for better work than he now has. Sometimes we can assist him in this search. But there is danger in this. A man is less likely to keep a job that some one else finds for him than one which he finds for himself. Still, we may help him without harming him in case we can give him facts, names, positions,employment agencies by means of which he may secure employment, he himself taking the active part in securing the job.Information, which is what we here furnish, is one of the least dangerous of gifts.
In all these cases the principle is like that whereby we do surgery. Surgery is a temporary injury to the body done with the expectation of ultimate good, a temporary interference of outside powers with the natural self-maintenance of the organism, in order that those functions may ultimately go on not only independently, but more satisfactorily than before. The surgery may kill the patient, or leave him worse than he was before. But our reasonable expectation is (in case our surgery is good) that his health—that is, the capacity of his body to maintain itself, or develop itself—will be improved. So in economic surgery we foresee a speedy end to the need for aid. The person is to be put upon his feet by our aid; our services can soon be dispensed with. The need will not recur. It is not chronic. It was not his fault and therefore is not likely to return upon him soon because of continuance of the same defect.
Obviously one must try to make clear—or, still better, try to have it clear without explanation, understood because of our previously established relation of trust, confidence, and affection—that it is not because of parsimony or close-fistedness that we are refusing to give quickly, constantly, and without inquiry. Medical analogies must constantly guide us and be in the minds of those whom we try to help.We refuse money, as we refuse morphine, for the patient's good. We try to make our giving of money temporary and self-checking, for the same reason that we try never to begin giving morphine unless we can foresee a speedy termination of it, a speedy cessation of the need for it, as we do when we give it in gall-stone colic or acute diarrhea, or just before a surgical operation. If morphine were a possession of the doctor's, as money is a possession of the visitor or those whom she represents, then the doctor might often seem stingy, cruel, selfish in his refusal to give it. We must make it clear if we can that our hesitations, limitations, or refusals in relation to money have no more connection with our own control over that money, our own enjoyment of it, our own sense that we have any right to it, than the doctor's refusal to give morphine rests upon his desiring to take the morphine himself instead of giving it.
All this is difficult to make clear, and it is chiefly for this reason that I have repeatedly insisted that the financial approach, the financial ground for anentente cordiale, should not be used early in our dealings with the sufferer, but should if possible be postponed until, through medical service and personal intimacy, something approaching true friendship has been established.
It should be clear from what I have said that our judgments about giving financial aid can be sound, can result in doing good without harm or (as insurgery) good with a small element of harm, only in case they are the fruit of detailed, prolonged, individual study. It cannot be a wholesale matter. It cannot be done in exactly the same way in the case of any two individuals.
Let us stop to realize for a moment how arduous, how bold a task we have undertaken. We hope to construct a person's economic future better than he can construct it himself. We hope to see what the individual himself, despite the vividness and pressure of his immediate need, has not been able to see for himself—namely, how he can get himself out of his financial difficulties. We who do not wear the shoe are venturing to say where it pinches and how the pressure may be relieved, and to know about this better than the sufferer who feels the pressure in his own person and longs for its relief as it is hardly possible for any one else to desire it. It is almost as if we were trying to use his mind for him. It must not be that. But if it is not to be that, we must be sure that our aid is given through stimulating the individual to think for himself. "What do you think," we must constantly be asking him, "is the best way out of this our difficulty?" He must feel that we know it to beourdifficulty as well as his, that we are not looking on with the cold gaze of an outsider, that we suffer in his suffering, and still that it is at last his, and that with all our best efforts we can only contribute a little to what must be for the most part his own reconstruction, a reconstruction like that which thebody performs when it heals a wound which the surgeon or the physician can only encourage a little towards its natural healing.
Without being impudent enough to attempt to use the sufferer's mind for him, to force our wills upon him, to take his burdens off his shoulders, to fill his place or to assume his responsibilities, we must try to help him in all these respects, largely by the kind of sympathy which stimulates, the kind of affection which encourages, the affection which changes useless brooding, ineffectual worrying, destructive grieving, into their opposites. We can help him to think by suggesting resources, possibilities that he does not know or that he has forgotten, by furnishing new material on which his mind may work, by helping to generate the power, the hope, the concentration, the prolongation of thought out of which new solutions may be born. He must really think of something new. He must really invent something, if he is to get upon his feet and become independent once more. Ordinarily necessity is the mother of invention. We pull ourselves out of our difficulties when we finally realize that we must because disaster is otherwise imminent. But such pressure of necessity as would generate inventiveness in one person, may generate only despair in another. It is to avoid this tragedy, it is to make fruitful what were otherwise fruitless, that we hope to warm the sufferer into better life. We hope to rouse in him, by affection or by the stimulus of new facts (perhaps),the courage necessary to see his situation afresh and to reshape it.
Because we are comfortable where he is suffering, because we have free power of thought whereas his mind is numb and cramped, we may be able to think of some possibilities, some changes, some sources of hopefulness which he could not even imagine. He cannot take them from us ready-made. If he does they will be useless to him. But if we have reached the central fire of his life, if we have stimulated not this faculty or that, but the centre of his personality, then by the grace of God we may be able to do with him what he alone could not do.
A part of the economic life of our patients, aside from the food and clothes for which they may most urgently ask our aid, is their housing.
(a) Is it hygienic?(b) Is it as inexpensive as can be obtained with due consideration of health, decency, distance from work, from friends, from amusements?(c) Is it large enough to safeguard the decencies of family life?
(a) Is it hygienic?
(b) Is it as inexpensive as can be obtained with due consideration of health, decency, distance from work, from friends, from amusements?
(c) Is it large enough to safeguard the decencies of family life?
The last of these questions is the most important of all.
It should be among the medical duties of the visitor to investigate the hygienic aspects of the home in order to explain them to the doctor, who can theninclude them among the facts on which his diagnosis, prognosis, and treatment are based. The social worker may then try to carry out such improvements in housing as the combined judgment of the doctor and the social worker suggests. More important than medicines, often, is the provision for proper warmth and proper ventilation of the patient's rooms during the day and especially at night. Darkness, dirt, poor ventilation, favor the growth of germs, vermin, parasites of all sorts. They also depress the vigor and power of the human organism to resist disease. Doctors and social workers cannot hold Utopian views in matters of housing, but must content themselves with trying to secure something a little better than they find in the worst of the patient's lodgings, especially when these lodgings represent conditions below the family's own standard of living at some previous time. People adapt themselves wonderfully to bad hygienic conditions, and once so adapted, they may be able to preserve their health for a long period. But if then a family is suddenly forced to crowd itself into smaller, darker, dirtier, noisier quarters than it has been used to, or if a family group increases its numbers within the same quarters, the adaptive powers of the human organism may be overstrained and break down.
It is against these conditions especially that the social worker and the doctor should labor. Housing problems are among the most difficult of all that confront society. Yet we should pledge ourselves toattempt some improvement, not disdaining slight gains because we are enamored of distant Utopias.
Sometimes people are living beyond their means, are accepting bad quarters at high prices when they could get as good or better quarters for less money in some less crowded and popular district. Human beings have a strong tendency to stay wherever they find themselves, to settle down by chance and resent any suggestion of change even for their own greater comfort. After a few months any place soon comes to have the attractions of home merely because we have been there. Hence we stick in the same place, though we may know that it is chance and not choice or necessity that has put us there. Under these conditions a social worker may do real service by her greater knowledge of other lodgings at lower prices, or (what is essentially the same thing) better lodgings for the same price now paid. If the social worker is familiar, as she should be, with the lodging conditions in the neighborhood in which she works, she may be able to give a patient facts about lodgings which were either unknown to him, or more probably unrealized, because he has never seen them. Our mental horizon becomes restricted. Any one who enlarges it by presenting new and helpful possibilities serves us well.
So far I have spoken of the housing question mostly from the standpoint of health or cheapness, but, as I have already suggested, the moral aspects of the problem are still more important. It isdifficult, for many impossible, to preserve personal decency and to keep family morality at a proper level, when adults and grown-up children are forced to sleep in the same room. Lifelong injuries to body and soul may be forced upon innocent children in this way. Nothing can be more important than this. We must remember, however, that custom and previous habits play a vast part here. One race or one set of people may have so adjusted themselves as to preserve decency under conditions impossible for another. We cannot generalize. We must know the particular people with whom we are dealing, and we must know their previous habits and standards in case they have shifted their lodging or increased the number of persons in a room within a short time, as is so frequently the case.
Work and the conditions of work are among the most important and the most difficult of the economic problems in which a social assistant may find herself inevitably involved. These concern the patient's trade, the physical and moral conditions under which he practises it, his fitness or unfitness for it, the wages he receives, the future possibilities of advancement in pay and type of work which it offers. In all of these problems the social worker can sometimes help a little because of her greater freedom of mobility, mental and physical. She is not tied to her task as blindingly, as deafeningly, as themanual worker is. She may know more or be able to find out more as to labor markets, as to other, possibly better, positions, shops, employers. She may be able to see, better than the worker himself, his fitness or unfitness for the work he is doing. She may be able to realize better than he that his trade presents animpasse, has in it no possibilities of development, personal or financial. She may realize better than he the bad effects of his work upon health or morality. In all these respects she may be able to give the safest, and in some ways the most satisfactory, of all help,—namely information.
I do not underestimate the difficulties of such help. It is not easy to know more about a man's business than he does. Yet if the social worker's education, her health, her circle of acquaintances, is greater than that of the wage-worker, she may really be of some assistance to him even in the field that is more specially his own and that she can understand but superficially. It is for this reason among others that the social worker cannot be too broadly educated, too fresh physically, too vigorous in her powers of thought and observation, too widely acquainted in her community.
Among the problems growing out of the basal economic needs of which I have just spoken, are others with which I cannot here deal adequately. Such are:
(a) The problem of industrial hygiene and industrial disease.
(b) The problems of school hygiene and school medicine, since school life is the industrial life of the child, who even receives wages for going to school in some communities.
(c) The industrial and psychological problems of those who are maimed by accident, war, or disease.
(d) The problem of industrial insurance and health insurance.
All of these questions involve matters of State action, legislative control, and economic reform with which I do not wish to deal. But I wish to make it clear, in closing this chapter, that the social worker as a citizen is as much interested in these hopes for radical economic reforms as any one else can be, though she does not regard them as her special business.
Preventive medicine and the daily fight against individual cases of disease which we hope some day to prevent—these two activities go on side by side, each helping the other. The social worker corresponds to the private practitioner of medicine; the economic reformer and discoverer corresponds to the laboratory student of preventive medicine or to the public health official. In social work as in medicine the case worker should bring to the inventor and reformer new facts and illustrations suggestive of the evils to be reformed or possibly of the ways of combating them. And in the difficult, often disappointing, task of trying to help individuals, the case worker will also take part of his inspiration from thehopes and ideals of a better economic order sketched for him by the legislative reformer. The method and technique of economic investigation is complex and difficult. For a masterly treatment of this and all other aspects of social diagnosis Miss Mary E. Richmond's epoch-making book on "Social Diagnosis" should be consulted. (Published by the Survey Associates in New York City.)
Ever since the days of Charcot, France has been the land of medical psychology. France has never failed, as other countries have failed, to take full account of the mental factors, the mental causes and results in disease.
In America, on the other hand, the conspicuous disregard of medical psychology by physicians has led to widespread and serious revolt on the part of the public. Our physicians have too often treated the patient as if he were a walking disease, a body without a mind. Medical psychology has been neglected in our medical schools and in the practice of our most successful clinicians. The result has been a revolt upon the part of the laity, expressed in the popularity of the heretical healing cults such as Christian Science and New Thought. These unscientific and unchristian organizations illustrate an error opposite to that of the physicians, but no greater in degree. Indeed, I think that our physicians are more to be blamed than the leaders of these irrational cults, because our physicians having received a scientific training ought to be more thorough, more unprejudiced, more devoted to the truth, and therefore less inclined to shut their eyes to a huge body of facts. The physician often shutshis eyes to the existence of the mind as a cause of disease. The Christian Scientist shuts his eyes to the existence of the body as a cause of disease. Both are equally and disastrously wrong. But the medical profession is on the whole more to blame, because they ought to know better, whereas the heretical healing cults have grown up among uneducated men who could not be expected to avoid the sort of narrowness and prejudice from which liberal education ought to free us.
The situation in America, then, is very different and on the whole worse than in France. There, scientific men, educated physicians have taken the leadership in the field of medical psychology. In America it has been left for ignorant enthusiasts, devoid of any scientific training or breadth of culture, to press upon our attention the neglected elements of medical practice, and to lead a revolt against the medical profession, an anti-scientific revolution which numbers its adherents by millions. But in neither country has our established knowledge of the mental elements of disease been properly incorporated into medical practice, especially into the practice of dispensary physicians, and it is here that the social worker forms an essential link in the chain of effective action. Let me describe more completely what I mean by the mental element in disease.
I refer not merely to the so-called nervous diseases, the neuroses and psychoses, the myriad forms of nervousness without recognizable basis in organicdisease, but also to the mental complications and results of serious organic diseases such as tuberculosis, arteriosclerosis, and surgical injuries. The classical studies of Charcot, Pierre Janet, and others have made clear to the whole world the existence of a body of diseases in which the mental functions are obviously deranged while still the patient is not insane in any legal sense, and does not show on physical examination any evidence of gross organic disease. Neurasthenia, psychasthenia, hysteria, are among the more common types marked out by the studies of great psychologists and clinicians. Little or nothing has been added by the studies of German, American, and English physicians to our knowledge of these diseases. But throughout the history and development of France's leadership in the study of these diseases, one cannot help noticing that interest is concentrated largely upon diagnosis; comparatively little attention is paid to treatment. The great leaders have not been extensively followed. Their suggestions have not been carried out on a large scale nor followed sufficiently into the field of practical therapeutics.
Especially is this true in the field ofvisceral neurosesor nervous symptoms referred by the patient to one or another organ—the stomach, the pelvic organs, the bowels—in which nevertheless no evidence of disease can be found. In these diseases English, French, and American physicians alike persist for the most part in humoring and soothing thepatient by the administration of remedies known to have no real influence upon disease and designed chiefly to make the patient feel that something is being done for him. This is superficial treatment. It makes no attempt to attack the determining causes of the disease. Whether or not there are any psychogenic diseases, whether or not purely psychical events can be proved to produce the group of symptoms known as neurasthenia, psychasthenia, or hysteria, or whether there are physical causes contributing to produce the symptoms, this at any rate may be said with confidence: that if we are to root out the patient's trouble, if we are to bring about anything approaching a radical cure, we must attack the mental symptoms directly and upon their own grounds, that is, by mental means, chiefly by reëducation.The mental element in these diseases is at any rate the most vulnerable point of attack.It is here that we can most profitably exert therapeutic pressure.
Even in organic disease, such as tuberculosis or arteriosclerosis, it may still be true that we can help the patient chiefly through psychotherapy. There may be little that we can do for his arteries or his lungs, and indeed the incurable destruction which has gone on in these organs may not at the time that we are treating the patient be producing any symptoms. All his symptoms just now may depend upon mental states which we can quite easily influence and thereby cure him of all that at present tormentshim, though we recognize that the organic malady remains untouched, unimproved. Many a case of tuberculosis suffers chiefly from his fears of the disease or from his discouragement. If we can rid him of his constant dread that the disease will advance or will injure others, if we can give him courage, the natural healing power of his tissues may be all that is needed to bring about the arrest of the disease. On the other hand, even an incipient case of pulmonary tuberculosis may go steadily on from bad to worse, because the patient is constantly fretting and worrying about his own condition, or about the present sufferings of his family.
I remember a case of very early tuberculosis, but recently established at the summit of one lung, but unfortunately occurring in a patient of very active temperament, prone to fume and worry the instant that he was taken away from his work. He was devoted to his family, but as soon as he was aware of his trouble, he could think of them only as doomed to be dragged down by the contagion of his own disease or by the poverty resulting from his own inactivity. Unfortunately, no proper study was made of this patient's malady. No account was taken of his character and temperament. The condition of his lung occupied the whole field of the physician's vision. The condition of that lung demanded for the patient isolation and complete rest in a sanatorium. This was prescribed and carried out. The patient remained in the sanatorium about two months,fuming and worrying constantly. He then refused to stay any longer, left the institution against the advice of his physician, returned to his family, and died about two months later.
Now I think it is at least probable that had we studied the patient's mind as carefully as we studied his lung in this case, his life might have been saved. But the physician who made the diagnosis and prescribed the treatment could spend but a few minutes upon the case, which formed but one of many trooping past him in his consultation hour at the dispensary. He had no time for the prolonged, detailed, wearisome studies necessary to win this patient's confidence, to make him feel that he was wholly understood, and bring him to the point when he would let himself be reëducated upon the mental side and receive docilely the advice given him. This work should have been carried out by the right type of social worker. Such a visitor would no doubt have realized that one must compromise to a certain extent with the difficulties of the patient's temperament. One must adapt and modify the treatment suitable for the average case because this particular patient differs from many others in important respects.
In the first place, he must be made to understand the importance of a correct mental attitude for the cure of his disease, must be taught that his recovery depends to a considerable extent upon his own efforts at self-control and self-education. Next he must beconvinced that his family will be adequately cared for during his absence from work. Furthermore, the complete rest in bed which would probably be advisable for him if one had only the condition of his lung to consider, should probably in his case be modified owing to the fact that his mental state makes it impossible for him to rest when he is confined to bed. In such cases one has the outward appearances of repose but not the reality, one clings to the form but misses the substance. What one has prescribed is in realityenforced impatience,enforced restlessness, because one has put the patient under a régime where no result can be expected except impatient struggling against restraint. Such a patient should be allowed a certain amount of work, carefully chosen and supervised, so as not to exercise the larger muscles of the body and thus produce fever, but sufficient to occupy an active mind and to make the patient forget himself. To find such occupation is difficult, no doubt, but it is not impossible. I have seen it done. In the case which I am now considering, no such effort was made. The patient was excessively lonely and isolated in the sanatorium to which he was sent. The doctor's visits were occupied with physical examination and the reiteration of commands that he should stop worrying and remain completely at rest.
Such treatment violated grossly one of the basal laws of medical psychology, which recognizes that no one ever stops worrying because he is told to doso. To give such a command is as irrational as to tell an epileptic not to have convulsions or a choreic patient not to wriggle his hands. Yet this sort of error is constantly committed by physicians who have been well trained to understand the physical changes of disease, but have never concerned themselves to recognize the simplest and most obvious facts about the mental condition of the sick. As I have already said, it is impossible for the dispensary doctor to become acquainted with the details of the patient's malady, or to find out by investigation and experiment how the patient's mind may be made to aid his recovery rather than to impede it. This is the proper task for a social worker, partly because she has more time, partly because she is a woman, and is for that reason more fitted to get into close touch with the patient's mind and to use skill and tact in managing him.
Such studies of the social worker are equally important in the case of the functional neuroses; for example, in the cases where the patient's troubles can be most effectively attacked by ridding him of his fears. Fear plays a dominant role in the sufferings of many cases both of organic and of functional disease. In a recent examination of six hundred and sixty-two young men about to enter Harvard University, it was found that "there were more boys who thought they had a serious organic defect, usually of the heart, and were found entirely sound than boys who thought they were well and had disease." Theyhad been threatened with heart disease by gymnasium instructors or ill-trained physicians. They had in consequence restricted their physical activities and been haunted by the fear that they might by some unusual exercise of mind or body make themselves seriously ill or perhaps suddenly die. Such fears were all the more disastrous in these young men for being only half realized by themselves. It is exactly these shadowy apprehensions, these dreads which dwell in the half light, never quite faced in full consciousness, which torment and incapacitate us the most. Careful physical examination showed that the young men just referred to were free from all disease, and the clear and emphatic statement of this fact rendered a prompt and important service.
But if such fears haunt the students about to enter Harvard College, who are young men drawn from the better educated and more well-to-do classes, we may be sure that fear plays even a larger part in producing the sufferings of patients such as we examine and treat in a public dispensary. For such patients are very apt to be influenced by groundless rumors, panics, neighborhood gossip. They are prone to believe medical lies which they read in newspapers and in the leaflets and circulars sent to them by charlatans. Almost all their medical education comes to them from such sources, and is made up of a mass of systematic falsehoods designed to excite fear and to produce symptoms by suggestion.
Now if it is true that even among educated and relatively self-conscious classes the most troublesome and incapacitating fears are those which are but dimly known to the patient himself, this is sure to be still more frequently the case among dispensary patients. It is especially difficult and especially important, therefore, that their fears should be understood and brought to light through the investigations of some one who has time, patience, and tact to devote to the task. This cannot be the task of the physician who sees neurological cases in the dispensary, any more than the psychological twists and tangles of the tuberculous patient can be followed out by the specialist in tuberculosis who examines the patient's lungs. It is the proper task of the social worker. When she has brought the patient's fears to light, when she understands the details of his malady, she can communicate these facts to the physician. He then can exorcise the unclean spirits with the full authority of his medical position.