Richard C. Cabot

“ Do we belong in the class of the people who must get their rest by giving up, by the abolition of all function, or in the class who rest by the change of function, by doing something different from the day's work? It is a question of fact and must be found out by each individual for himself.
Just here the individuality of fatigue, which I have been trying to make clear all along, becomes obvious. We are rested by making a success of something. If we have been making what seems to us a failure of something, it is amazing how it rests us to make a success of something. ”

“ We must not get our perspective distorted. It is the doctor's commonest fault, that he sees only the disease that is just now before him, and nothing of its "background," economic, mental, or moral. Hence he does not make a fundamental diagnosis or prescribe fundamental treatment.
We need in our dispensary work to find truth. Yes; but we need to find joy also in our work; we need to see the foreground. We do not want to have attached to us the stigma and the weakness which we think of in professional work. ”

“ 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. ”

“ Much as I hate the fault of never going beyond the fact that we see before us, I hate just as much the opposite error of not getting the full vision of the foreground. We ought always to be able to feel, at the end of any single home visit, that we have done something, accomplished something. Well: one of the things that we must make every effort to accomplish, and to feel ourselves a failure if we have not accomplished, is to find and to give pleasure, to enjoy ourselves, and if possible to give a little courage. ”

“ I have no doubt that there is waiting for each of us to-day a job much more individual than we have ever yet done.
Although, then, we can rightly give in social work merely as people who pass on to others in gratitude and wonder the energies which create our bodies and our souls, yet we can be perfectly sure that if we do what it is up to us to do, we shall in time be giving as people never gave before and never will again. ”

“ 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. ”

“ 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 [Pg 147] 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. ”

“ Above all, she should realize the multiplicity of causes which science more and more clearly recognizes in their single result. She should learn both by precept and by experience that for a single fact such as disease or health there are always many causes, so that any one who points confidently to a single cause, such as cold, fatigue, bacteria, or worry as a sufficient explanation of a person's disease, is almost certain to be wrong. ”

“ 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. ”

“ Two and two always will make four. But by a peculiar accident we have hitched on to one tense the whole body of eternal truth. Why did we hitch the eternal to the present rather than to the past or to the future? Because anything that we really grasp now, as truth or as joy or as beauty, anything that we really comprehend, can be eternally ours. ”

“ No human being, linked up in a world-order as we all are, is ever independent. What we mean by that not altogether satisfactory phrase is that we want to be dependent only upon something that we can rely upon, only upon permanent, central, orderly powers of the universe. Physical independence does not mean independence of food or of rest; one soon comes to the end of his tether if one attempts such independence. ”

“ 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. ”

“ One well-known difference between a feeble-minded person and a person competent to manage the affairs of life, is that the former forgets so extraordinarily, and therefore cannot build up through remembrance of his past how to steer better through the future. Of course we all of us have this disease in varying degrees. We all forget, in the moral field as well as the physical, things that we ought to remember. ”

“ It may make him clever and so able (like German science in war) to do more harm than if he knew less.
But when we give education—for example, hygienic or economic education—we give something else than information. Education is that which, by reason of practice, by doing something again and again, and doing it if possible in the presence of a good model (living or dead, book or person) , changes our character and our habits, as the use of a muscle changes the muscle. A person learns to write. That is not merely information—he has learned to do something. Learning to swim is not information. ”

“ Any present fact, then, so far as we realize its truth or its wonder, is eternally ours. Hence presence of mind is the quality needed in social work to balance the scientific habit which looks for past and future, for what is not present. Investigation and history-taking must always be completed by appreciation, the other half of our mental life, which is acutely conscious of the present and therefore can be conscious of eternity.
I hope I have not put the contrast of science and art in social work so sharply that it seems as if one must take one extreme or the other. ”

“ Social medicine was what I wanted. So many a man shifts within his profession. That is why the wrong choice made at the start does not always get people into serious trouble. But the chronically shiftless man remains immobile. He does not know where else he might be besides the place where he is. So he stays where he happens first to fall, gets bitter, hard, poor, drunken, all because he is in the wrong niche.
One sees racial shiftlessness when people cross the ocean and try to take root in a new country. ”

“ 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. ”

“ 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. ”

“ But this cannot be done without some care to shape it, without some labor to put it in a form in which somebody else will understand this sense of our admiration or gratitude. Without form and study to give it form, our enthusiasm is mere noise and good spirits. As I have described the fund of energy which comes into us, is felt as gratitude and then pours out of us in social work, one may have wondered, where does man's individual will and choice come in? ”

“ Insanity is feared, I think, even more often than heart disease. Every doctor is consulted by people who are sure on most trifling evidence that they are going insane. We hear people say, "Why my mind must be failing, for I read down a page and when I get to the bottom I cannot remember what I have read." Or, "I am losing all memory. I met a man recently suddenly and I could not remember his name." These two normal fatigue-products—failure of attention or failure of memory—often make people think that they are going insane. ”

“ 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. ”

“ In the old days, when shops were small and the employer could know his employees personally, no intermediary such as a home visitor was necessary. The employer could keep human touch with his men. He could know not merely the amount of work done by each man, but something of the circumstances of his life, something of his personality, his adventures and misfortunes, so that help could be extended to him from time to time when special need occurred. ”

“ Then they will feel no shame in taking since they know that they do not take from us. There will be no sense that a higher being is distributing what a lower being has to take, if we make it clear that we are sharing that which it is uncomfortable not to share. We are sharing that which we share because in view of all the bounty which we have received, in view of the beauty which has struck us dumb, in view of the flood of affection that we never have answered, we know what to do next. ”

“ It has freed us from the limitations contained in the old idea that a dispensary is an institution concerned solely with the poor. Tuberculosis, of course, like every other infectious disease pays but little respect to distinctions of property. From the point of view of the State a tuberculous individual is as dangerous to others and a cured tuberculous patient is as valuable as a possible asset to the State, whether his income is above or below a certain figure, whether, in other words, he is inside or outside the imaginary group sometimes called the poor. ”

“ One of the dreary things in human beings' work is that sometimes, after a month or a year, they cannot see that they have accomplished anything. It is all a mass of details. I remember a very marvellous social worker saying to me, "I do not want to die thinking that I have never done anything but case work." Case work seems to me as great a thing as any one can do. ”

“ Calmette's measures have the tone and the point of view of preventive medicine, and of that sound science which we have learned to associate with the Pasteur Institute and all that development of medicine which took its rise from Pasteur.
The focussing of interest upon a single disease which began, so far as I know, with Calmette's anti-tuberculosis dispensaries, has been fruitful in many ways. In the first place, it has enabled science once more to conquer by dividing the field, to help humanity by devoting itself to a single manageable task. ”

“ One gets doubtful whether there is any special reason that the individual called by one's name should persist on top of the earth. Then it is well to go back to simple, elemental facts like finger-prints, with the pretty nearly irresistible conclusion that the rest of our body and soul must be as unique as that, and so possesses something as original to contribute to the world. ”

“ 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. ”

“ It was at this very unfortunate and undignified stage in the development of our dispensary work in America that we received priceless help from France, help which I am all the more anxious to acknowledge to-day because it has not, I think, been fully appreciated in the past. We in America have not given to France the full expression of the gratitude which, for her services in the field of medicine, as in even more important phases of our national life, it is to-day particularly fitting that we should utter. ”

“ It may just run through us, as much of our information runs through us, uncaught, unused, sacrificed for us, and nothing come of it. But it may be used right.
When we come to think of our mental energies, are we any less incurably borrowers, incurably indebted to the universe, incurably wasters except in so far as we make use of what we borrow? Anybody who has not studied how the child learns to talk, does not realize what a borrowing the simplest acts of language are, what imitators we are from the earliest moments of our lives. ”

“ But if we admire anybody, that fact gives us a duty to get our admiration over to somebody, to share our enthusiasm. The whole of a Christian's duty might be phrased as the duty to share his sense of the beauty and the wonder that is in Jesus Christ. Almost the only act that we can be sure will be of use in the world is the act of sharing what enthusiasm we have. ”

“ The bones of a human being come out of the bones of the earth through his food, animal and vegetable. The breath of the trees, the oxygen which the trees give out every day and every night, we breathe in. They take up in turn the carbon that we give out, so that there is constantly an exchange between the animal and vegetable kingdom and ours. We are warmed by inheritance from thousands of years in the coal that plants have laid down their lives in layers and strata to form; we are warmed also by the constant literal burning up of food energy in ourselves. ”

“ 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. ”

“ I will now sum up the last four chapters in a diagram which we have used in Boston at the Massachusetts General Hospital to assist us in making our social diagnoses. A social diagnosis can very seldom be made in one word, such as idiocy or tramp. It must include the patient's physical state. It must summarize a person's physical, moral, and economic needs. Our best social diagnoses, such as idiocy or feeble-mindedness, do not refer to the mind only. They refer to the body just as much. ”

“ 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. ”

“ On the whole, the safest form of giving that I know, that which is surest to perpetuate itself, to be [Pg 166] planted like a seed and go on without our having to stand by it, is giving information—a cold-sounding thing, but sometimes very useful. One difference between the social worker and the person for whom she works ought to be that the social worker has had more education, more freedom, more friends, more opportunity to look around the world and see resources. ”

“ 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. ”

“ 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 is the natural first impression of any untrained person that his troubles "simply happen" without any explanation that he knows. ”

“ If the social assistant has not the medical knowledge or the authority necessary to reassure the patient, she can bring him to somebody who has. At the present time there is no piece of medical service more clean-cut and satisfactory than the power to reassure a person about an illness that he thinks he has, half-consciously fears he has, and therefore tries to banish from his mind. ”