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

I have said in the Introduction that home visiting may easily and properly spring up in connection with various institutions; for example, in connection with the schools, courts, or factories of the city as well as with the dispensaries. But it is essential in home visiting, no matter what institution it is connected with, that the social assistant should be distinctly recognized as part of the machinery of that institution, or, in other words, as one of the means by which that institution does its work. If she is connected with the schools, she should be a part of the school system alone, not responsible to a Board of Health or to any other outside agency.

So in the type of home visiting which now particularly concerns us, it is essential to make it clear from the outset that the social worker is a part of the medical organization. She is one of the means for diagnosis and treatment. All that she does from the moment when she first scrapes acquaintance with the patient is to be connected with the condition of the patient's health. She is not to pursue independent sociological or statistical inquiries. She is not to be the agent of any other non-medical society. It is unfortunate even if her salary should be paid from any source other than the medical institution itself.

There are great advantages in this apparently formal and obvious point of connection. In the first place the medical method of approach to close relations, to friendly relations, with a group of people, is decidedly the easiest. Persons who may be suspicious or resentful of our approach if we appear primarily as investigators, or primarily as persons concerned with economic or moral control, will welcome the visitor if she appears as the arm, the cordially extended hand, of the medical institution where they have already found welcome and relief. I know well that charity organization workers, court workers and others may establish just as close a relation with their clients in the end as is possible for the medical social worker. But the start is harder and needs more experience. Because disease is the common enemy of mankind, all sorts and conditions of men are instinctively drawn together when it becomes necessary to resist the attacks of disease as the enemy of the human family. Members of a family may disagree about many matters, and may be far from congenial with one another in ordinary times and upon ordinary subjects, but will draw together into the closest kind of unity if any one attacks the family, accuses or criticises the family. So human beings of widely different environment, taste, economic status, heredity, may find it quite easy to begin and to maintain friendly relations when that which brings them together is their common interest in the struggle against disease. It is, indeed, almost too easy to get friendly with people when they are suffering physically and we are endeavoring, however lamely, to bring them relief.

The medical avenue of approach, then, the plan and hope of establishing intimate relations with a person or a family while we are trying to give them medical assistance, offers incomparable advantages. These advantages become clearer still if we compare them with the special difficulties which arise if one tries to begin an acquaintanceship with financial inquiries or with moral investigations. People who will agree on everything else will quarrel on money matters. There is nothing that so easily leads to friction, suspicion, and unfriendliness, as the interview in which one is trying to make out whether people are speaking the truth, the whole truth, and nothing but the truth, in relation to their income and expenditure. This matter very naturally seems to people their own business. They quite naturally resent inquiries on such matters by strangers. They feel attacked and in defence they are apt to conceal or color the truth. And yet, if a friendly relation has first been established through the patient's recognition of our genuine desire to help his physical difficulties, the financial inquiries which make a necessary part of the home visitor's work can much more easily follow. One has to understand what money is available in order to make the best plans for nutrition, for home hygiene, for rest and vacation – all of which naturally form part of our medical interest. I wish to make quite clear here my appreciation that good social workers never begin their relationships with a client by assuming a moral fault on his part and never push the economic questionnaire into the first interview. All I wish to point out is that it is perhaps easier for the medical social worker than for others to avoid these blunders.

At the outset of a relationship which aims to be friendly, investigations which start with the assumption that there has been some moral fault or weakness in those whom we wish to help are even worse than financial inquiries. The instant that the social worker finds herself in the position of a moral critic, it becomes next to impossible that a friendly relation not hitherto established, shall be built up from the beginning. Late in the course of a friendship established long before, moral help, even moral criticism, may be welcome. But it cannot often or easily be one of the topics of conversation, one of the points of investigation, in the early stages of what we hope to make a friendly relation.

Everything stands or falls with this. We cannot even teach hygiene, we cannot even make medical principles clear unless we have succeeded to some extent, perhaps without any merit on our part, perhaps through extraordinary good fortune, in acquiring a genuine liking for the person whom we want to help. Once that is attained, we can work miracles. But if it is wholly lacking, we cannot count upon accomplishing the simplest interchange of accurate information; we cannot achieve the most elemental hygienic instruction.

But there is another signal advantage in the medical point of approach to a relationship which, as I have said, must be friendly in fact, not merely in name, if it is to succeed in any of its ulterior objects. When the social worker begins the difficult task of acquiring her influence in a family, she starts with a great deal in her favor if she appears in the home as the agent of the physician. He has prestige. By reason of his profession, by reason of the institution which he represents, by reason of confidence already established by him in the patients' friends and neighbors, the new family is ready to have confidence in him. He is not thought to have any axe to grind. He is assumed to be genuine in his desire of helpfulness. Therefore any one who appears in his name, as his assistant, has a great deal in her favor, especially when compared with the visitors of societies which might be supposed to begin with economic or moral suspicions about the family. If the visitor appears in the home with the prestige of a medical institution enhancing the value of her own personality, she has a very definite advantage.

Light on the severity of illness

I have said that it is essential to the success of a medical visitor's work that she should be part of the medical machine, acknowledged as the doctor's agent, concerned wholly with helping to carry out his plans. But we must ask now, what part? And the answer is that the social worker is an assistant to the physician both in diagnosis and in treatment. I will begin with an account of what she is to do as his assistant in diagnosis.

She is to discover, so far as she can, what the disease is, how much the disease is, and why it is. I do not mean, of course, that she is to ape the doctor's scientific investigations, that she is to use instruments of precision, or to try to prescribe medicines. But she is to help the physician in some of the following ways:

He is often very much at a loss to be sure how bad the patient's symptoms really are, how much the patient suffers, how serious the case is. The social worker is often able to help in discovering why the patient really came to the dispensary, discovering, perhaps, that the reason is such as to show that the malady is really a trifling one. She may find, for instance, that the patient has come merely because her husband had to come, anyway, and she thought she would get the benefit of whatever there was to be had in the way of medical assistance at the dispensary, even though, unless her husband had been going, anyway, it would not have occurred to her to make the independent visit upon her own account. Or, again, the visit may be due chiefly to curiosity, especially if the dispensary has been newly established or has added some new features to its methods of diagnosis and treatment. These facts are passed along from person to person; the person hearing of them may appear as a patient chiefly to see just what it is that her neighbors are getting when they go to the dispensary. I have known a patient to come merely because he was alarmed as a result of a recent conversation with a friend. His friend had been hearing about heart trouble and had mentioned some symptoms such as pain about the heart or cold extremities or dizziness. Any one sick or well on hearing such symptoms may easily remember that he has had them himself not long ago, or may even begin to feel them as a result of suggestion. Straightway, perhaps, he will betake himself to the dispensary, complaining of symptoms which never would have been noticed but for his talk with the friend.

Or, again, the patient may have some definite organic disease or some obstinate train of discomforts and physical inconveniences. But he has adapted himself to them tolerably; he has settled down to bear or forget them as best he may. He may know that his troubles are really incurable and yet not serious. He may have become as accustomed to them as he is to an uncomfortable lodging or to a modest income. Yet, as a result of some temporary fatigue, some newspaper paragraph, some fragment of gossip overheard, there may arise in him a crisis of alarm and worry about his familiar discomforts or inconveniences. Thereupon he may betake himself to a dispensary, and give the physician an account which may be very difficult to interpret, because the physician does not understand the train of events which appear acute and new in that they have led the patient just now, rather than at any earlier time, to seek advice. After nearly twenty years' experience of dispensary work I should say that in no respect can a social worker give the doctor more welcome help than by discovering now and then reasons such as I have just suggested whereby the patient comes to the dispensary now rather than at any other time, and at a season not really connected in any special way with the nature of his disease.

Perhaps I can make this clearer by contrast with its opposite. A person who has just developed a scarlatinal rash, who has just coughed and raised a considerable quantity of blood, who has just lost the power to move half of his body, who has just begun to have swelling of the face, naturally consults a doctor at once. If he then comes to a dispensary for treatment, he has come at a time which is the right time, the reasonable time, considering the nature of his malady. Something new has happened. An attack has been made which should be foiled if possible at once. The clue for usefulness on the part of the doctor is thus fairly clear. If, on the other hand, a person has had more or less back-ache all his life, and has grown used to getting along and doing his work, even enjoying life in spite of it, he may suddenly come to a dispensary for that back-ache because he has seen in the newspaper the wholly false statement that pain in the back means kidney trouble. Yet when he comes to the dispensary he may say nothing whatever about his having seen this newspaper advertisement. Indeed, it is very unlikely that he will mention this at all. He will describe his back-ache as something which demands immediate treatment, and the doctor may set in motion extensive and probably useless activities of investigation or treatment which never would have been undertaken had he known just what it was that brought the patient to the dispensary that day rather than months earlier or later.

So far I have spoken only of cases in which the visitor's studies in the home make it clear that the case is not as bad or not as manageable as it might have seemed if one had known only what the patient himself could reveal in the dispensary. But occasionally on reaching the patient's home the visitor may find reason to believe that the symptoms are much more serious, the disease much more urgent, than could have been realized from the story told and the facts obtained at the dispensary. The visitor may find in the home conditions of disorganization, dirt, disorder, serious malnutrition, discouragement on the part of other members of the family, arguing a much more serious condition of the patient than one would have realized from talking with him at the dispensary. As a result of such findings the doctor, who must spend his energies for the patients who need him most, will see that he had better give more time and more effort to the patient than he would otherwise have thought right.

Still, again, the visitor may find that the symptoms are neither more serious nor less serious than he would have supposed from the dispensary interview; yet the clinical picture is different from the doctor's because the patient has thrust into the foreground of the clinical picture something which further knowledge shows to be really unimportant, while he has said almost nothing of some other feature of the trouble which is really much more serious. For example how much does the patient really eat, how does he do his work, are there complaints about him from his "boss," has he always had the cough which he has only just now begun to complain of? Such questions can be better answered after visits at the home and talks with the whole family.

Clearly the supplementary information thus secured by the social worker will count for nothing unless clearly explained to the doctor, and is taken up by him as part of the evidence on which he bases his diagnosis and his treatment. It is absolutely essential that the social worker should not merely make her visits and record them in her notebook, but should incorporate her findings in the medical record and deliver them not formally but effectively to the doctor's mind.

Such help is needed because she can often learn far more in the quiet of an interview at home than would be possible for the doctor despite all his medical skill. For at the dispensary he questions the patient when he is confused and forgetful, alarmed, perhaps, by the sights and sounds of the clinic, and so very unlikely to give a correct and well-balanced account.

Nests of contagious disease

So far I have been describing the work of the social worker as a process of finding out how much ails the patient and what his symptoms signify. But it is also a part of the social worker's duty to find how much disease is present not only in the individual who appears in the clinic, but in his immediate environment, to discover nests, foci or hotbeds of disease. In the case of a disease like smallpox, this is obvious. If a patient presented himself at a dispensary with the pustules of smallpox upon his body, it would be criminal negligence on the part of the physician not to set on foot a search of that patient's home, his industrial environment, or, in the case of a child, his school environment, for evidence that others have been exposed to the same contagion and possibly already infected. This sort of duty cannot be abandoned merely because there is no health officer at hand. It is a crying need and must be attended to at once.

Now in a minor degree this is true of many other diseases as well as smallpox. We are beginning to realize that it is true of tuberculosis, so that when one case of advanced and therefore contagious tuberculosis is seen at the dispensary, machinery should automatically and invariably be set in motion to search out possible paths of contagion from that patient to others, just as if he had smallpox.

This principle which is well established in the case of dangerous contagious diseases like smallpox and diphtheria, and is beginning to be established in relation to tuberculosis, is even more important in dealing with syphilis. Every case of syphilis means more cases of syphilis, and the danger of still more each day that the contagious patient is at large. No physician has done his duty unless, after seeing a case of syphilis, he attempts, through a social worker or otherwise, to get knowledge of others from whom this disease has been acquired, or to whom it may be freshly spread. At the Massachusetts General Hospital each patient with syphilis is asked to bring to the clinic for treatment the person who infected him. The method sounds impossible but in fact it works, and many cases are thus brought under treatment and prevented from infecting others.

With contagious skin diseases such as scabies or impetigo, the principle is obviously the same, though the dangers of disregarding it are not so great. With typhoid fever, which not very infrequently shows itself even at a dispensary, the duty of the social worker is not so much to search for other persons through whom it may have been contracted or to whom it may be spread, as to investigate the water-supply and the milk-supply of the patient and of others in his environment. One case of typhoid always means more cases, usually more cases acquired, not by contact with one another, but through their share in a contaminated water-supply or milk-supply. The social worker, therefore, should know how to search out contaminated water-supplies, or at least to put in motion such machinery of public health investigation in the city or town where the case arises as may lead to good detective work in the attempt to track down the source of the trouble. It has been well said that every case of typhoid is some one's fault. It has even been asserted that for every case of typhoid some one should be punished. Certainly there are some grounds for such an assertion.

Hotbeds of industrial disease

Commoner and not less important than the contagious diseases that I have just mentioned are industrial diseases, or diseases aggravated by the conditions of industry. A physician may serve for many months in a dispensary without seeing a case of smallpox, of trichiniasis, or of typhoid fever, or feeling it his duty to set in motion the forces that I have just mentioned for rooting out the sources of contagion and preventing their further spread. But he cannot serve a month in any well-attended dispensary without seeing cases of industrial disease in the narrow sense, such as lead poisoning, or of independent disease aggravated by the conditions of industry, such as the functional neuroses of cigar-makers or of telephone operators. With such diseases, as with the infectious and contagious diseases, the presence of one case in the clinic should lead straight to the inference that there are others elsewhere, out of sight but no less important from the point of view of public good. This conclusion should lead in turn to the search through a social worker for the cases of disease which do not present themselves to any physician, which may be totally unknown even to the patient himself, yet which are important to the health of the nation.

Difficult though this field of industrial disease has shown itself to be, difficult though it is to separate out that portion of the patients' complaints which can justly be referred to the conditions of his work, and to distinguish it from the portions which are due to the way he lives, to his inheritance, to his habits or to diseases like tuberculosis and syphilis which may have been acquired without any connection with his work, – nevertheless we must try to disentangle and to recognize the elements in this knotty problem. And we can hardly fail to see that the social worker is an essential and logical assistant in the processes of investigation which we must carry out. If we can ever unravel the tangled skein of causes and effects whereby the hours of work, the strain of work, the patients' heredity and his home conditions, all combine to produce the symptoms of disease, it will be through such intimate, prolonged, detailed studies as the social worker can carry out, especially if she becomes a friend of the family. The doctor in his hours of consultation at the dispensary certainly can never do it. The official agent of the Board of Health, perhaps feared, certainly not a natural confidant for the family, may easily miss the truth which the social worker unearths, provided always she succeeds in differentiating herself altogether from the impersonal and professional investigator, and gradually becomes in the mind of the family and in truth their friend.

I said above that the social worker should try to find out what disease, how much disease, and why this disease is present. The answers to these three questions cannot be kept separate. If one knows how much importance to attribute to a given symptom and whether it is as bad as it seems or worse than it seems in the dispensary interview, one may be steered straight to a correct diagnosis. To know how much disease may thus mean knowing what disease is present. Furthermore, the understanding of these questions, even though it be only partial and unsatisfactory, leads us a considerable distance towards understanding why the disease has arisen. The search for sources for contagion is an example of a search for a why in disease. The search for psychical factors – groundless fears, misleading newspaper advertisements, distracting rumors – all this is also a search for the cause as well as for the nature of disease.

The social worker's investigations into the cause of disease may perhaps be still further exemplified. I once sent a social worker to my patient's home with the request that she try to find out what I had failed to find out, namely, why a young girl could not sleep. Physical examination of the girl had revealed no cause; the exploration of such parts of her mind as she would reveal to me had thrown no light upon the trouble. I was at a loss and asked for help through the more intimate knowledge of the patient sometimes to be gained through a social worker's studies. Such a search might easily have been fruitless – it often has been fruitless in my own experience. But in this case it was almost comically swift in reaching its goal. The visitor found that this girl was sleeping with two other girls of about her own age, in a bed hardly more than a metre wide. It needed only that she should acquire a separate bed for herself, which she was able to do without any financial assistance. She then regained her power to sleep. How often have such cases been treated with drugs or perhaps with more complicated physio-therapeutic or psycho-therapeutic procedures, when some simple fact like the size of the bed, the temperature of the sleeping-room, or the mental activities of the evening immediately preceding bedtime, are really responsible for the whole trouble.

Medical outfit of the social worker

In order to carry out the particular procedures of diagnosis and treatment which belong within the province of the social worker, a certain amount of medical knowledge is needed. Because this is true, it has often been assumed that the social worker must be a trained nurse, prepared by months or years of experience in a hospital. But experience has shown that much of the knowledge possessed by nurses who have had this training cannot be used by the home visitor. On the other hand, the information which the social worker needs is often quite lacking even in well-trained nurses. Furthermore, it may be said with truth that the training of a nurse, as we know it in America at any rate, really unfits a woman in some respects for the work of a social worker, since it accustoms her to habitual obedience and subordination. These habits are very useful in their proper place, but they are antagonistic upon the whole to the temper and mental activity which is important in the social worker. I mean the temper of aggression in relation to disease, and the mental attitude of the teacher and leader in relation to the patient. But of this point it will be more in place to speak when I come to consider the functions of the social worker as a teacher.

Let us return, then, to the question, What knowledge should the social worker possess in order to do her part in the "team-work" of the medical-social dispensary? Her knowledge should approximate that of the public health officer. Like him she should be, above all, familiar with what is known to medical science about the causes of disease. This is of great importance because it is especially in this field of medical science and medical ignorance that the public, the patients among whom the social worker will work, is most in need both of new knowledge and of the uprooting of old error and superstition. Medical science knows very little of the causes of many diseases. But our patients, especially the more ignorant of them, are very glib and confident in their assertions as to what has caused the particular disease from which they just now suffer. They tell us about their "torpid livers," their "congestive chills," their "ptomaine poisonings" and the like. Their supposed but unreal knowledge is extensive and detailed. Indeed, so stubborn are their beliefs upon such matters that they often present a firm wall of resistance which must be broken down by the social worker before any truth upon these matters can be introduced into their minds.

The social worker, then, should share such knowledge as the medical profession possesses about the causation of infectious disease, about direct personal contagion, and also about the indirect methods by which disease is conveyed from person to person through insects or through instruments and utensils, such as the barber's razor, the family towel, or the public drinking-cup. She should be familiar with the small body of knowledge which we possess upon the transmission of disease by drinking-water, by milk, and other kinds of food. She should appreciate our still smaller body of knowledge about the relation of disease to climate, to weather, and to other physical agents such as the extreme heat and cold produced by some industrial processes, and the action of X-rays.

In addition to this definite and specific knowledge of causes, she should know the generally accepted views of the medical profession on the subject of bodily resistance, immunity, inheritance, the diseases and perversions of metabolism, and the other non-bacterial factors in the production of disease. 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. Obviously, this truth bears a close relation to what is to be said on the "historic and catastrophic points of view." Chapter III.

The importance of teaching the social worker all that is known about the transmission and causation of disease is due to the following fact: whatever we succeed in accomplishing in our efforts at preventive medicine, whatever we do to nip disease in the bud or to check the spread of epidemics, is due to our knowledge of the causes of disease. The instructions of the doctor at the dispensary can accomplish but little in this field when compared with the detailed teaching of the social worker in the patient's house, in his workshop, in the schools and factories where disease is spread so much more frequently than in the dispensaries. If we hope to show people how they can avoid the disasters of illness, our teaching should be given in the very place where these disasters most often occur. There we can illustrate and demonstrate with the objects in sight what is to be done and to be avoided.

It is for this reason that the social worker is above all others the person who can convey life-saving information to the public in an effective way. A considerable amount of this precious knowledge is now possessed by the medical profession; but it is shut away useless, unavailable, in medical libraries and in doctors' minds. The social worker can fight disease by spreading the contagion of medical truth. She can multiply the foci from which truth can spread still more after she is gone, just as disease is redistributed again and again from new nests of infection.

The prognosis of disease, like its causation, is a subject on which the social worker should know almost as much as the doctor. This is possible because medical knowledge on this subject is still so very limited. For the purposes of one who has to combat the poverty, sorrow, idleness, and corroding fears which disease produces, knowledge of prognosis is a most useful tool. For example: if one is to make plans for the care of a group of children during their mother's illness, one must have some idea how long that illness is going to last. If it affects the bread-winner of the family, how long will he or she be disabled, and how completely; what are the hopes of ultimate and complete recovery; will chronic invalidism follow; is it worth while in this particular disease to spend a great deal of money and time in trying to achieve a complete cure, or is cure so improbable and at best so incomplete that our resources can be expended more wisely in other directions?

A knowledge of prognosis will help the home visitor greatly in the solution of such problems. But it must be added that such knowledge as she already possesses about the prognosis of a disease, such as tuberculosis or heart trouble or kidney trouble, must always be supplemented by all the information that she can gain from the doctor as to the present prognosis in the case of the particular patient with whom the social worker has to deal. For the general prognosis of a disease is greatly modified by the particular circumstances in each individual case.

Physicians are not at all eager to impart their knowledge about prognosis, because this knowledge is so limited and so faulty. No scientific man likes to make definite statements upon so indefinite and hazy a matter as prognosis. Nevertheless, it is essential for the patient's good that the doctor should be asked to give her as clear and definite a statement as is possible for him to make with the facts that he possesses. For it is only upon the basis of such a statement that an intelligent plan of social treatment can be constructed.

Besides acquiring all that she can learn of the causes and prognosis of disease, the social worker should be familiar with the symptoms of the more important and common types of disease. There are now several books written particularly with the object of conveying to social workers and others such knowledge as I have referred to, yet without any pretence of equipping the person either for nursing or for the practice of medicine. I will mention here a book by Dr. Roger I. Lee, Professor of Hygiene in Harvard University, "Health and Disease: Their Determining Factors" (Little, Brown & Co., Boston, 1917), and my own book, "The Layman's Handbook of Medicine" (Houghton Mifflin Co., Boston, 1916).

In order to understand such books, and to arrange her knowledge of disease in such form that it may be easily handled, the social worker must have a slight knowledge of anatomy and physiology, so that she can arrange the symptoms of disease in connection with the different systems of organs: circulatory, digestive, respiratory, urinary, nervous, and locomotive.

Finally, the social worker must know the principles of hygiene, in order that she may effectively combat medical quackery and the prevalent medical superstitions of the people. That portion of hygiene which is both securely founded upon scientific evidence and useful in the preservation of health, makes up only a very small body of knowledge, so that it can be easily mastered by any intelligent person. Our knowledge upon such matters as diet, exercise, bathing, sleep, ventilation, when such knowledge is both scientific and practically useful, could be written upon a very few pages. It consists largely of negatives which contradict the current superstitions.

In my own work in this field I have found it essential that there should be no mystery and concealment, no obscurantism and mediæval Latin in the methods of treatment which the social worker explains or carries out under the doctor's directions. She must be able to deal with the patients frankly, openly, without concealment or prevarication. Otherwise she will not have moral force enough behind her statements to bring them home to the patient so as to secure any reform in his hygienic habits. Such reforms are difficult enough in any case. They are usually impossible unless they can be initiated by one rendered eloquent and convincing by the consciousness that she leans upon the truth and has nothing to conceal. If she has mental reservations, if she is trying to protect the authority of the physician in a statement which she does not believe to be wholly true, the force of her appeal will be so weakened that it will probably be ineffective.

Technical methods

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 emaciated patients 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.