Social Work; Essays on the Meeting Ground of Doctor and Social Worker

by Richard C. Cabot

History and catastrophe

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 all they are 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 with or 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 "just happened to 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 unforeseeable accident it 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 one night 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 is the natural 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 with the catastrophic point of view, 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 of the 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 down the thing for which the patient comes—headache, cough, emaciation, poverty, desertion, unemployment. This is the "presenting symptom"; it should always be the 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.