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

by Richard C. Cabot

Or (2), when people come to us for the relief of skin abscesses, boils, and demand some drug which will cure these abscesses, we must ask the important questions, Whence did you get them? Why did they come? Presumably not because the patient has failed to take a drug. We must find the fault in hygiene, generally constipation or overwork, or lack of sleep, causing a lowering of the body's vital resistance, whereby the germs, the staphylococci, which are deep in our skin and never to be rubbed off by any washing or sterilization, begin to multiply. The soil has become such that they can multiply.

I have tried to suggest the importance that we ought to attribute to soil as well as to seed. Modern doctrine about the cause of disease has called our attention to the tremendous importance of seed, that is, germs, bacteria. But on the whole, if one had to say which is the most important single factor in disease, he would have to say, not the seed, but the soil. Take the tuberculosis bacillus, for instance. I do not think it is an exaggeration to say that nine tenths of all persons have had tuberculosis, usually in a harmless form, because the soil has been stony and so has killed off the bacteria. You know that the figures obtained by means of tests with the Von Pirquet reaction in almost any city or town, show that ninety per cent of the children of twelve years of age and on, have a positive reaction to this test for infection by tuberculosis. They have the tuberculosis bacillus somewhere in their bodies. That does not mean that they have the disease, but they have the bacteria in their bodies, and mostly in the process of being killed off by the tissues of the body which resist this infection.

One of the reasons why I go into detail here about the changes that take place in the body through disease, is to make social workers feel as strongly as I feel, and convey to patients as strongly as I try to convey it, what nature does in curing disease. We have read of people who were walled up in masonry by way of vengeance, and left to die in a casket of stone. That is what nature does to a bacillus, literally walls it off in stone. After death when the pathologist's knife cuts down into a lung, the knife is sometimes broken by coming upon what feels like a stone. A stone it really is, a deposit of lime salts in the tissue, around a nest of tubercle bacilli. If one cuts such a stone in two, one finds in the centre bacilli often still alive and perfectly capable of increase, but harmless to the body because nature has built this wall around them. I do not think one can get the full force of this fact until one has seen it. That is one of the long list of things that the body is constantly doing in this process of resisting disease, and doing more intelligently than we can.

Since, then, it is chiefly the soil, the vital condition of our tissues, which resists disease, we must do our part in making that soil good or bad for disease. That is why our hygiene, our obedience to the individual laws of our own experience, which show us how we can keep well and how we get sick, must be learned and taught by every one of us so far as we can in such a place as a dispensary or a patient's home.

For example: disease is often produced by lack of sleep; hence it is of central importance to teach people how to sleep. Excluding organic disease in the causation of most cases of sleeplessness—for most people suffering from insomnia do not have organic disease—one can say this: Insomnia usually depends on something wrong in the patient's day. The state of the night depends on the state of the day. If the day has been free not merely from gross sin, but free from hygienic blunder, then the night will go somewhere nearly right. If the day has been filled with concentrated work in which the mind has been wholly upon the thing it has in hand, if there have been no elements of strain through distraction or worry, causing double currents in the mind, then when night comes one can turn the mind off and go to sleep. On the other hand, the mind which has been intent half on its own job and half on its own worries, never wholly "turned on" during the day, cannot be "turned off" at night. Any physician or any patient succeeds in curing insomnia who succeeds in finding out what is wrong in the way the sleepless person lives, and how it can be corrected.

But most people want to go on living in just the same stupid way and yet to get rid of the sleeplessness "in spite of themselves." The obvious way is to take a drug that for a while will stop insomnia even when life goes on as before. There are many drugs that will give sleep, but there are no harmless drugs that give sleep—none. Physicians receive about once a year advertisements of a drug for sleep which is "wholly without ill effects," but I do not think it shows undue skepticism or dogmatism to say that those drugs never do what they say, and never will. Sleep being a natural process, anything that forces it upon us hardly can be free from ill effects. Hence the first thing in attacking a case of insomnia is to say, "Never take a drug again." Natural processes whereby fatigue accumulates and puts us to sleep do not go on rightly if we are being artificially driven into sleep by a drug.

One gives drugs for sleeplessness rightly when there is some rare and special reason for being awake, some catastrophic reason which will never occur again. This exemplifies the principle which I have tried to emphasize throughout this book. We may give money for some catastrophic cause which puts the person down and out, and will not occur again. So we give a drug for sleeplessness if there has been some special thing to interfere with sleep—if, for instance, you have been talking very hard with a friend and you know by your own feelings that your mind will not stop that night. Then you may perfectly properly take a drug to put you to sleep, knowing that there is no reason to suppose that such a talk will occur again in the near future. Knowing this, you do not need to waste that night. You take the drug. But it is only in rare catastrophic moments that one can be cured in spite of one's self, any more than one can give or take money safely.

It is the same in the matter of constipation. The first thing to make clear to a patient is that drugs must be abandoned before he can ever teach his bowels to behave as they should. But it is a great deal of trouble to do that, and because people shirk that trouble, and want to be "cured in spite of themselves," they come to a doctor to be cured by drugs. Alas, he is often weak enough to give them what they seek!

I have tried to make this drug-fearing practice one of the policies that honest medicine must always stand for, because it seems to me that when the doctor allows himself to be tempted into behaving as a considerable number of his profession do—that is, into giving people what they ask for—he very soon loses his ideals, gives things that he knows more and more clearly that he has no right to give, and goes downhill. Social assistants must help the doctor to avoid this disaster. They can do so by helping him to teach the truth.