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

by Richard C. Cabot

I want to deal a little further with some examples of what nature does in the way of warding off disease. For a large part of what we call disease, and what we feel in ourselves as disease, is not the attack of the enemy, but is our defence against the enemy.

Take, for instance, inflammation. When germs are beneath the skin, one finds redness, swelling, heat, pain, as the symptoms of inflammation. What does that mean? It is all like the defences which were set up round Paris when the Germans were coming there, or that are set up anywhere when one is getting ready to repel attack. The inflamed finger gets red because a great deal of blood is going there. The blood cells, especially the white cells of the blood, are coming there to defend. The finger gets red for the same reason that the railroads get congested in time of battle, namely, because so many soldiers are being carried there for defence. The finger gets swollen because so many cells and fluids are coming to attack the enemy; it is their crowding outside the blood vessels that makes the swelling. There is heat in the finger because there is more blood in the part and therefore the part is hotter. There is pain because with the extra accumulation of defenders there is a squeezing of the little nerve terminations there. When a lot of soldiers are suddenly quartered, billeted in a town, it is a painful process. There is pain in having defence come to your city. There is pain in having defence come to your finger.

All of these symptoms, which we are apt to hate and to think of as misfortunes, we should realize are the thing which saves us from very serious illness. Suppose these things did not happen. Following out the metaphor, if it were not for these defences the enemy would penetrate into the whole body and we should have blood poisoning. It is because this local heat, redness, swelling, pain, appears at the point where bacteria are attacking us, that they do not penetrate the whole body with a septicemia, which is one of the most dangerous of all diseases. So while suffering what we must suffer, we ought to be glad of all that nature is doing, because if she neglected it the consequences would be very serious to us.

But we may ask, "If this is true, where do medicine and surgery come in? Why do they ever interfere if nature is so very wise?" Because nature overdoes the thing every now and then. Nature is first enormously wise and then a little blind. In another example I can bring this out a little better. You have sprained your knee and the knee gets very stiff. That in itself is good; it is a defencive reaction. The stiffness is like a splint. The knee ought to be kept quiet. So far so good. But nature overdoes the thing. The knee ought to be kept quiet, but for how long? We will say three days more or less, according to the severity of the injury. Then you have to fight nature which stiffens the knee too much. You have to fight it by the use of the knee, by walking or by massage, which is not, however, so good as walking. If we respect blindly what nature does in stiffening the knee even to the exclusion of nature's other functions, such as walking, then the knee will get worse. One of the greatest improvements in the modern treatment of sprains, is that we no longer keep the patient in bed and put plaster of Paris on, which makes the sprain last for months sometimes; but we let him walk at once on the sprained ankle, whereby the attempts of nature to cure by stiffening are not carried too far.

Another example of how nature overdoes things is in the formation of scar tissue. If a scar did not form to close the wound, the wound would remain open. Hence the scar is vastly better than nothing. But scar tissue is never as good as the original tissue. One of its known ill results is contraction, so that a scar on the hand or on the neck often draws the part out of place. Then we have to fight nature. We have to go against the workings of nature by surgery, in order to get the person right.

In suppurative disease, such as appendicitis, it is often difficult to decide when nature is doing better than we can do, and when we can do better than nature. The appendix is a hollow tube the size of one's little finger, and hangs off from one part of the large bowel. When it gets inflamed nature at once begins the defences which I have described in the lung, namely, the walling-off process, which tends to make the bacteria harmless. There is danger that they will spread from the neighborhood of the appendix and produce a very dangerous disease, general peritonitis. Hence nature begins to glue around the appendix the adjacent parts of the bowel and anything else at hand. This generally makes it harmless. Most of us physicians now believe that the great majority of cases of appendicitis cure themselves, and that still more would cure themselves if given a chance. On the other hand, there are cases in which nature does not do her work rightly. Then if the surgeon did not interfere the person would die. That is why medical and surgical judgment, the particular, minute, individual study of the person from hour to hour, makes the difference between right and wrong treatment. The surgeon who operates every time he makes a diagnosis of appendicitis, or who says he will never operate, is just as wrong as the person who gives money the first time he sees a case, or who never gives money. But most surgeons are wiser than that.

I hope through these illustrations to make it clear that nature generally cures disease. When she does not, it is generally incurable. There is a small residuum left for the doctor. We have a function as physicians or nurses. We have a function, and that function is intermediate between two extremes. In disease or in other misfortune, there are three types of fortune, two extremes and a mean: (1) The people who will get out of their troubles whatever you do, get out of their misfortunes, rally to meet their griefs, pull themselves out of financial difficulties, get over their disease. Then (2) there are people on the other side, who will die whatever you do. Some cases of pneumonia, for instance, seem to be doomed from the start. It is the same with many other cases of disease and with some people's misfortunes. We have to face the fact in social work that there are many people whose mental twists and agonies we cannot help in the least, and many people who will be in money difficulties as long as they live. But (3), intermediate between these two extremes—and our happiness and our success depend on our finding that group—are those cases where what we do makes the difference between success and failure. This triple division indicates a point of view which makes, not only for individual understanding of the situation, but for practical success.

Take the case of those maimed by war or accident. There are three classes of them: first, the people who will get back their jobs and get back into industry unaided; they are probably the majority. Then the people who cannot be put back by any process. Finally, there is the rather small intermediate class who, with our help, with a little extra education, with a hand in the back, will get back into work, but who never would succeed, humanly speaking, without our help.

So it is in disease. The vast majority of diseases get well without any help from anybody, and that is the thing we must teach most often and to most people, in season and out of season. In our day and generation few people get a chance of observing that fact, because somebody comes along and gives them a drug. And unless one has seen people get well without any drugs, one continues to believe that it was the last drug given that cured every case of illness one has known to get well. On the other hand, the majority of illnesses that do not get well without drugs will not get well at all. I have mentioned before the figures which seem approximately true in relation to the cure of disease by drugs. Drugs will cure about six or eight diseases out of about one hundred and fifty diseases known to science. Anybody who fails to give a drug for one of those six or eight diseases is criminally negligent. We should press that drug upon the patient. I do not want anybody to think that I do not believe in drugs. I believe in them tremendously, in the particular cases where they are of use. But I do not stand for the habit of bolstering up people's beliefs that we have drugs all ready to cure most diseases.