wx 205, C365h 1918 >V.. >«>£- " ?U.>f;'V *-■-*-;-■. ■'..-.-. ■ :-.--■■ •u.. ,-a»E;rp-. "'^^fe^^iViVv^1-: WX 205 C365h 1918 53620910R NLM D5Efilfl7E b NATIONAL LIBRARY OF MEDICINE SURGEON GENERAL'S OFFICE ^LIBRARY. Section No. 113, W. D.S.G.O. no.4>.£.2.13Ji. NLM052818726 The Hospital as a Social Agent in the Community BY Lucv Cornelia Catlin, R. N. Director of Social Service Work and Executive Director of the Out-Patient Department Youngstown Hospital, Ohio Illustrated Philadelphia and London W. B. Saunders Company 1918 W X Z05 C3G5h lilt /*"<■/.. ffi-,p > Copyright, 1018, by W. B. Saunders Company PRINTED IN AMERICA PRE88 OF W. B. SAUNDERS COMPANY PHILADELPHIA To the Memory of my Aunt and Foster Mother, MARGARET ELIZA CATLIN This Book is Lovingly Dedicated, in Honor of Her Philanthropic Spirit and Unselfish Devotion to the Training and Care of Little Children, the Education of Young Women, the Uplift of the Fallen, the Aid of Families in Need, Besides the Countless Manifestations of Loving Thought for Neighbors and Friends, and the Living Inspiration of a Christ - like Life in Her Home PREFACE In offering this little book to the part of the world which is interested in social work, especially those engaged in hospital social service, the purpose of the author has been to present certain principles which she has found effective in establishing, developing, and maintaining the department in hospitals where she has been privileged to work. No special literary merit is claimed for it; no effort has been made in this direc- tion except to express the thoughts in a clear, concise, forceful way to prove the subject in hand. Case histories have been selected to illustrate different points in the text, and all of them are true records of actual cases handled. Even the mere reference to certain conditions and facts surrounding indi- viduals or pertaining to the point in question have their origin in the author's memory of a real case. She has thus endeav- ored to add weight to the statements and arguments through the avenue of true facts rather than theory. Probably any cases recited can be duplicated by social workers who read them; they have been chosen for illustration rather than for any especially remarkable features. The mission of the book is expressed in the following words by one who read the manuscript: "Your book will be a much needed, guide for social workers, especially in the new field of hospital work in smaller cities." Few hospitals in communities of any size exist in these days without a social service depart- ment, and as the years go by all hospitals will seek to broaden their usefulness by contributing in this way to public welfare work. Indeed, before many years pass the author hopes to see the hospital made the center for all the medico-social work in the community. 7 8 PREFACE It is the author's hope that this volume may find its way into the hands of those who are estabHshing hospitals and dispensaries in new fields, and that it may be a help to them as well as to those who realize the need of reorganizing and are at a loss to know just how to accomplish it. It was not expected to present suggestions adapted to the older, larger hospitals; their work differs in some measure. Social service originated there, and is now developing to meet the needs in smaller communities where co-ordination of all the forces in welfare work is both possible and desirable. The thought throughout the book has been to show how the hospital may be made an important social agent in the community, and to present a practical, working basis. For the benefit of workers in entirely new fields forms of blanks which have proved comprehensive and effective have been reproduced in the Appendix. Where it has been possible case histories have been written in regular record style, making notations under successive dates. Other cases are put in story form for the purpose of condensing, yet they illustrate how many of the histories may be written to good advantage, espe- cially those covering a long space of time with slowly develop- ing features. The author is indebted to Micheal M. Davis, Jr., Director of the Boston Dispensary, for his thoughtful review of the manuscript, and for valuable suggestions made by him. Many others also have lent kindly advice and encouragement which have helped to make the book what it is. May this small contribution to the cause of Hospital Social Service be a guide to workers, and through them a bless- ing to humanity which will redound to the glory of God. Lucy Cornelia Catlin, R. N. YOTJNGSTOWN, OHIO. May, igi8. CONTENTS CHAPTER I PAGE Reasons for the Existence of Social Service Departments in Hos- pitals................................................... 11 1. Completion of Service to the Patient.......................... 11 2. Help to Physicians and Surgeons in Diagnosis and Treatment..... 14 CHAPTER II Out-patient Departments, and the Advantage of Establishing Them on a Social Service Basis........................ 17 1. Organization of Early Dispensaries and the Development of the Need of Reorganization................................... 17 CHAPTER III Relation to and Correlation with Other Social Agencies ..___ 23 CHAPTER IV Sickness or Injury—Dire Adversity and the Time When Social Service is Most Needed................................ 32 CHAPTER V Service to the Individual, to the Community, and to Society. . 40 1. The Tuberculous Patient.................................... 41 2. The Epileptic, Insane, and Feeble-minded Patient.............. 45 3. The Problem of the Unmarried Mother........................ 47 CHAPTER VI The Problem of the Hospital Child............................ 58 9 IO CONTENTS CHAPTER VII PAGE Human Economy and Economy of Resources..................... 67 « CHAPTER VIII The Place of the Hospital in Public Health Work............ 79 Conclusion...................................................... 86 Appendix........................................................ 88 Facsimiles of Blanks Used in the Social Service and Out-patient Departments of the Youngstown Hospital.................... 90-108 Diagram Illustrating "Service and Co-operation".................. 109 Index........................................................... Ill "THE HOSPITAL AS A SOCIAL AGENT IN THE COMMUNITY" CHAPTER I REASONS FOR THE EXISTENCE OF SOCIAL SER- VICE DEPARTMENTS IN HOSPITALS 1. Completion of Service to the Patient. 2. Help to Physicians and Surgeons in Diagnosis and Treatment. The rapid development of social work in this country the past ten years is but an outcome of the growth in science and education, coupled with a broader philanthropic spirit which pervades the minds and hearts of our public-spirited citizens. Sociology and political economy are receiving an important place in the curriculi of universities and colleges; scientific research is enquiring into the causes of danger in the industrial and mining worlds; schools of philanthropy are training workers in the theory and practice of social work. These factors are educating the public to a realization of existing social conditions and setting the people to work to find the remedy for the unfavorable aspects of these conditions. Social work has become as scientific as medical work; the Russell Sage Foundation is the great social laboratory, as valuable to social workers as Rockefeller Institute or Phipps Laboratory is to medical science. ii 12 "THE HOSPITAL AS A SOCIAL AGENT " This is an age when philosophy and science are turning the microscope upon the causes of social sickness and maladjust- ment, as well as upon the microbes which are the cause of so many of the physical ills. The detection of the fundamental causes suggests the remedy, and treatment is much more effective than that which is directed to symptoms only. The analogy between social work and medical work is so close that we may find it profitable to call attention to it here. The social history of an applicant for aid includes personal and family history and present complaint; then symptoms are noted, including working ability of the wage earner, family harmony or discord, degree of industry, immorality or drunk- enness, poor management of money or family affairs, and many others. These symptoms are brought out by the social worker's investigation, just as the physical symptoms of a patient are shown in the doctor's examination by laboratory findings, z-ray, etc. After examination follows diagnosis and treatment. Many times the social worker, like the physician, is able to diagnose as soon as the first history is taken, and there is no question what the general treatment should be. Idio- syncrasies must be taken into consideration as the treatment continues, and so each case becomes individual. Sometimes the nature of the disease is so obscure that it requires much study and time for development of symptoms before a true diagnosis can be made. Nomenclature and classification of social diseases may be as clearly defined as in medicine. There is an acute and a chronic state, climax and convales- cence, recovery or death; the social worker sees her people in all these stages, and her responsibility for the treatment is as great as that of the doctor. Malpractice on her part may be the cause of the social death of an individual, or of the infec- tion of a whole community, for sin and want and poverty and dependence are as contagious as smallpox. Prophylaxis is as COMPLETION OF SERVICE TO THE PATIENT 13 much a part of the social worker's responsibility as that of the physician. This is the day of specialization in all lines of work; it is especially true in medicine, as we often find out, when it takes the combined efforts of the family physician, the surgeon, the eye specialist, the laboratory man, the radiographer, the neurologist, and perhaps a few others to determine the nature of our trouble and to treat it. In the field of social work there are just as many specialists, and they should be available for consultation and treatment along their special lines in solving the complex problems that arise. Relief agencies are best equipped to supply temporal needs and reconstruct the family; child placing associations, to deal with the homeless child; juvenile courts with the delinquent youth; and the hospital social service department with medical problems. There are accidents and emergencies where prompt action is necessary. The surgeon amputates a crushed limb to save a man's fife; the social worker is called upon to act just as promptly if she finds a baby left at home with a drunken father when the mother has been rushed to the hospital in a serious condition. So the analogy might go on, and to the nurse who is doing hospital social service work it is very significant, for she learns to think and reason along these same lines, so that it becomes a part of her mental habit. That hospital social service should have developed along with other philanthropic organizations is only a most natural result of the advance in science and medicine; an outcome of the broader vision of thinking men and women. The work grew out of its own needs, and now is recognized as one of the special departments, as necessary in the successful treatment of patients as almost any of the others in the hospital. The hospital social worker is a "specialist" in the field of social work, and is consulted as such by outside agencies. Even in 14 " THE HOSPITAL AS A SOCIAL AGENT" the hospital she is consultant, diagnostician, prescription writer in social problems, and her judgment is considered supreme in her sphere of activity. It is not necessary to review the history of hospital social service; it beginning in the mind and heart of a physician who came face to face with the needs of suffering humanity in his every-day hospital service. He recognized that these people were not getting all they needed, they were not receiving the benefit of the treatment that the doctors were trying to give them, yet what more could the physicians do? The gap was between the hospital, dispensary, doctor, and the home. The home, that integral part of society and of a nation upon which depends health, wealth, and happiness. The social service nurse has become the bridge over this gap, and she it is who co-ordinates the forces to bring about the completion of service to the patient. The case of Mrs. J. well illustrates this. Mrs. J. was a hard-working, respectable colored woman who was referred to the dispensary by a lady for whom she worked as laundress. The doctor's examination showed a pelvic condition which needed surgical treatment, and also cardiac symptoms re- quiring rest in bed. She was advised to enter the hospital for medical treatment. This seemed to her an impossibility, and the social worker, already familiar with the family history, came forward to help her to plan to carry out the doctor's order. The social history was as follows: Mr. J. was in the penitentiary for the murder of their oldest daughter. The support of the family, which consisted of two boys and one girl, devolved upon the mother, and she had worked very hard to have the children cared for and kept in school. The probate court had granted her a window's pension of $15.00 a month, but she did laundry work beyond her strength, which had been the cause of her heart's overstrain. Even before her husband's murderous deed she had been obliged to help in the family support, as he was too shiftless to hold steadily to work. How HELP TO PHYSICIANS AND SURGEONS 15 was she to leave her children and come to the hospital? That was her problem. Following a visit to the home by the social worker, Mrs. J. was able to arrange with two of her friends to take the two younger children, and the oldest, a boy of fifteen, could be left at home with the minister to keep a watchful eye over him. She then entered the hospital as a city-paid case for the rest and medical treatment she was so much in need of. Three weeks showed a marked improvement, the medical doctor called the surgeon in consultation, and the decision was that an operation was necessary to put her in shape to take care of her family as she should, and the doctors advised her to remain for it, as she was in better condition than she would be if she went home to her work again. But she said, "Doctors, I cannot stay, for I cannot leave my family so long." The facts were reported to the social worker, who talked over the matter with her, and set to work to arrange the home affairs so that it would be possible for her to remain in the hospital for the operation at this time. The pastor was called upon to look after the oldest boy and get him employment if possible, a friend to keep the girl, and the Fresh Air Camp to take the youngest boy. The minister advanced the money for the pay- ment of insurance dues, which she was anxious to keep up, as this provided in part for her children should she be taken. Her mind was then at rest, and she went through the operation well, made a good recovery, and returned to her family in condition to be of service to them. A year and a half has passed since then, and she has gone back to her former work, her son has secured a good position, and the family is not only self-sustaining, but they have saved enough to pay off some old debts which Mr. J. incurred before he went to the peniten- tiary. How incomplete would have been the doctor's and the hospital's service to this woman if the work had stopped at the dispensary after the examination had been made and advice given. This example illustrates the advantage of the social history in the physician's diagnosis and of the social service in his treatment. It also shows the importance of team work be- l6 "THE HOSPITAL AS A SOCIAL AGENT " tween social worker and doctor in order to secure the best social and economic results. The dispensary patient or the free hospital patient is entitled to the best medical treatment which can be offered. The staff doctor who is giving his time to them is entitled to every aid from the social worker to carry out adequate treatment. Without it his efforts may be futile, and his discouragement will lead to indifference or a desire to make the patient the victim of experimentation. If this re- sults, medical and hospital standards are lowered, public con- fidence is lost, and best service to the individual, to the com- munity, and to society is withheld. The time is coming, and may not be far distant, when hos- pital staff physicians will receive compensation for their pro- fessional services to so-called free patients, not because they have not given their best service in the past, but because the public demands a greater service than doctors are able to give freely and at the same time earn their livelihood. The patient who, by reason of circumstances, is obliged to seek free medical advice is entitled to the best treatment that can be provided, not alone for his own sake, but for the sake of the community, which is thus spared the danger from spread of disease, and from the necessity of caring for dependent individuals. By maintaining a high standard of medical efficiency hos- pitals are in a position to render the highest service to the com- munity in public health work, and such an equipment will com- mand the respect and confidence of the public, especially if it is coupled with an efficient social service department. CHAPTER II OUT-PATIENT DEPARTMENTS AND THE ADVAN- TAGE OF ESTABLISHING THEM ON A SOCIAL SERVICE BASIS Organization of Early Dispensaries and the Develop- ment of the Need of Reorganization The need of the unification of social service work in hospital wards and in the out-patient department cannot be too strongly emphasized. The social service department of a hospital should embrace all departments of the organization where social work is needed, the worker being at least consultant if she is not the logical person to follow out details. Between the dispensary and the hospital there should be the closest relation both as regards medical and social work. Whether or not the same medical staff serves in both places at the same time, there should be co-operation and co-ordination for the best interests of all, and the social service department links these forces and interests. The hospital organization today stands as one of the chief agents of public health, it cares for the injured and acutely ill in its surgical and medical wards, for those suffering from contagious diseases in its isolation ward, and for ambulatory patients in its out-patient depart- ment. Its medical, nursing, and social service equipment must be adequate to meet this responsibility. Social service needs were first recognized in the dispensary, and the department developed from this point to include 2 »7 i8 " the hospital as a social agent " hospital ward patients. Let us, therefore, look back into the history of dispensaries that we may better account for the development of the need for reorganization. As the root of the word implies, a dispensary is a place where certain things are dispensed to those who ask, and the term came to be applied more exclusively to the place where drugs or medicines were given out free of charge to needy patients. Probably there have been dispensaries in some form ever since there have been doctors, for sickness comes to rich and poor alike and seeks relief, but the wide-spread establish- ment of dispensaries came with the development of medical education. It was a demand of medical schools in search of clinical material, and the demand is justified now as well as it was then. The physician with the large experience in free hospital service is the one who gains and holds the greatest public confidence. It is an old saying that "physicians ride to eminence on the backs of the poor." Many of us owe our lives to physicians whose skill has been acquired and ex- perience gained in the free treatment of patients. Dispensaries have an important field in medical education not only for the student of medicine, but for the postgraduate, and recognition must be given to this phase of the work. But there is another side which now demands attention and which has led to the reorganization of dispensary work. Individual, community, and society interests occupy the part of the field now being cultivated, and which calls for the united efforts of physicians and social workers, the "team work," as Dr. Cabot calls it, which is so essential to success. This large part of the great field of human life and economy is now being occupied by experts who have driven their stakes, laid their claims, and proved their rights. It now remains for these experts to show what the field will yield for the betterment of the human race under their scientific cultivation. organization of early dispensaries 19 It is only within the last decade that newly organized dis- pensaries have been placed upon a social service basis. Here- tofore they were established on a medical basis because the medical side of the work was naturally the first thought, and dispensaries connected with old hospitals or with teaching hospitals will no doubt remain for some time to come under medical supervision. In these dispensaries there has been introduced the Social Service Department to which the doctors refer cases in need of any kind of social service. Many of these departments are covering all cases in certain clinics where there is always need for service. Few surgical clinics require general follow-up work, and those patients who do may be easily referred to a social worker. With medical cases the need is greater. All tuberculous patients, all orthopedic cases, practically all children, all mothers with babies, all gonorrheal and syphilitic patients should be social service cases for more or less intensive work. This plan is generally followed now in the larger, older dispensaries where the daily attendance is too large to make any other procedure possible. Whatever the organization, or whatever the plan of work, the department no longer needs an excuse for its existence. The importance of social work in connection with hospitals and dis- pensaries has been established, and is now recognized as a necessary factor in completing the hospital's service as a social agent in the community. The superintendent of one of our large city hospitals bit- terly opposed the introduction of social service into his institu- tion, and allowed it only under protest. A few years after, when the department was well established and demonstrated every day its value, this same superintendent was asked how he regarded it then. His prompt reply was, "I consider it of inestimable value; I would rather give up almost any depart- ment in the hospital than social service." 20 " THE HOSPITAL AS A SOCIAL AGENT " In the general public health program it is indispensable, and herein its latent possibiHties he. What social worker is better able to know the menace of physical defects and disease to the individual and society than the nurse doing social work in the hospital? And who is in a better position to remedy these defects, and to bring about the cure or isolation of these diseases than this nurse? The hospital has always been an important agent in the community for the benefit of society in caring for the sick and injured, and as medical science and surgical skill have devel- oped, the hospital has grown wonderfully in its usefulness. But with the introduction of the social worker the hospital has been placed in the forefront as a medicosocial agent, and its service as such depends upon the scientific, practical, sensible development of the social service department. Hospitals must realize their responsibility in this direction and turn their attention to the working out of the underlying principles. As new fines of work spring up which especially appeal to the public mind, they are bound to pass through a period of excrescent growth, they are like wounds which throw out excessive granular tissue in their overabundant effort to heal. Generally speaking, hospital social service has suffered as little in this direction as any of the lines of benevolent work of recent development. Fortunately for the work its pioneers have been men and women of conservative thought, broad vision, and practical experience, and they have laid foundations upon which a superstructure is being built that will stand. Let us urge, therefore, that hospitals in the smaller com- munities who are planning to establish social service work keep in mind their responsibility as a social agent in the com- munity; then, when the dispensary is opened, it should be es- tablished on a social service basis and come under the direction of the social service department. This will bring about the need of reorganization 21 unification spoken of in the first part of this chapter, the ad- vantages of which will be shown later. May we describe a model organization along the fines of the theories set forth, that we may best illustrate the reasons for such a plan. One of the first requisites is the selection of a well-qualified woman, preferably a graduate nurse, but one who has a broad conception of the hospital's opportunity and obligation, the patient's needs, the doctor's service, and the community's problems. She should be the admitting officer in the dis- pensary, taking the social history of all applicants, basing her judgment of the eligibility of the patient for free treatment upon this history, and upon the liability of his becoming a menace or a burden to the public if treatment is denied. With this initial touch the social worker is prepared to be of special service to the patient and to the doctor whenever there is need, and, by further investigation, to take up any deeper problems that are indicated. The head worker should be the executive director of the dispensary, responsible for the proper conduct of the operation of its service, and helping to lay out its pohcies and plans for development. She should see that every possible aid is given the doctors in the examination and treatment of patients, to conserve their time, and to complete their service. Through her assistants, follow-up work should be done wherever it is necessary to carry the doctor's directions to the home, to secure the patient's return to the dispensary, or to arrange for relief or transfer to other agencies or institutions. If, after examination, a patient is referred to the hospital wards for treatment or operation, arrangements may be made through the social service department for his admission either as a free or part-pay patient, suiting the time for his admission to the needs of the case, to the family convenience, or to the 22 "THE HOSPITAL AS A SOCIAL AGENT " number of available beds on the ward. Often the social worker may help to persuade or assist in overcoming prejudices or dif- ficulties, through her friendly interest and advice. This case may be followed into the hospital with any social service that is needed, and if necessary returned to the dispensary for treat- ment or observation. Thus the completion of service to the patient is accomplished, and the doctor is able to see the results of his work in diagnosis in the treatment which it is possible to have carried out. Team-work like this, bringing such satis- factory results which spread out into the community, effecting the home-life of its members, and proving to the medical profession the possibilities of scientific treatment, furnishes just encouragement to both social workers and doctors. Both are inspired to put forth best efforts for the amelioration of physical suffering and social distress, and with such co-opera- tion the success of the dispensary is assured. It must be the definite purpose of the social worker either in the hospital or dispensary, first, to procure adequate treat- ment for the alleviation of suffering, or for the removal of a handicap in the individual; second, to assist in combating disease in the community; and third, to take up the more dis- tinct social problems which effect the life and health of the community and the state of society. The province of the dispensary is extending far beyond the clinic walls, until it now reaches out into the community as a public agent. This is the need which has brought about a readjustment by the injection into the operation of dispen- saries social service principles and public welfare interests. CHAPTER III RELATION TO AND CORRELATION WITH OTHER SOCIAL AGENCIES The social worker in her travels about the city for the pur- pose of investigation and service makes many trips on the street car, and has many waits which are unavoidable, but she learns to use these hours of apparent waste in the study of human nature with which she comes in contact, or in thinking out some of the fife problems that are puzzling her. She comes in touch with many factors which constitute and influ- ence the life of individuals, and observes their setting in society and in the community. Indeed, the many hours of travel or waiting are precious ones if they are used for observation and thought. On the car this morning is a working man with his dinner- pail going to work to provide food, shelter, and clothing for the family at home. The mind at once pictures the home, with the influences there which make or break society, and we real- ize our responsibility in helping to maintain and upbuild that home. In the corner, sitting all in a heap, is a poor specimen of drunken humanity, sleeping his way along, scarcely aware of any desired destination, empty handed and empty headed, an undesirable individual, and seemingly hopeless. It is not hard to trace the train of influences which are responsible for this downfall, and as our eyes glance out of the car window while we pass through the main street, the saloon, which is much 23 24 "THE HOSPITAL AS A SOCIAL AGENT " in evidence, points out the cause of this effect with which we are riding. At Griffith Street, a man well along in years and rather under par physically, boards the car, carrying a few pieces of aluminum ware. We recognize him as a patient who has visited the dispensary, and we recall the history he gave. He is a widower, without children who are willing to make a home for him, past the age to be employed for heavy, responsible work, yet he maintains a worthy spirit of independence by endeavoring to earn a respectable living for himself. We know from the doctor's diagnosis that his earning capacity will not long be sufficient to meet even the bare cost of his living, and a feeling of pity passes over us as we contemplate what his future may be. Next, the visiting nurse on her rounds of ministration joins us, and she tells of a family which she has just left, where three of the children are fighting the battle with pneumonia. The father must keep at his work to meet the extra expense brought by this sickness, for the children must be spared if it takes his last penny to pay the doctor. The mother is left at home to watch and wait for the crisis which will decide the battle. We are reminded of the old song with its chorus, "For men must work and women must weep, For there's little to earn and many to keep." But we cannot muse longer, for the car has reached the street where we must get off. Up the hill we go, turn to the right and enter a house, following the lead of a lad of ten years to the room where his mother lies in bed. She is about to be confined and is already in labor, yet has no doctor to attend her, no one to take care of her and the baby, no fire in the house, very little food for the other four children, no money, and last, but by no means least, her husband has left her in such a plight. CORRELATION WITH OTHER SOCIAL AGENCIES 25 What can be done? It is no place for a baby to come, even if a doctor can be secured, and there is no time to be lost. She must go to the hospital, and a neighbor sought to care for the children until the next day, when some arrangement can be made for them until the mother can return. The bed upon which the woman lay was the only one they had, the children's mattresses lay on the floor, and the rooms were almost divested of furniture. They had bought on the instalment plan, and most of the furniture had been confiscated because of failure to make payments. The little woman, a Hungarian, was earnest and courageous, she had trained her children as best she could, her house was neat and clean, but her Jewish hus- band had a habit of disappearing at this critical hour and leaving her to the mercy of passersby, she being fortunate if the "Good Samaritan" chanced that way. As we go on our way to work out this problem we find our- selves wondering why this maladjustment exists, what it is in man that freezes his heart against his duty at such a moment when woman faces the anguish and suffering for him and his child? Our next visit is to the basement of a dirty, dingy building, where we find a drunken man, a blind woman, a feeble- minded boy of fifteen, and a six-year-old girl who has no cloth- ing on but a dress, and her hair is one mass of filth and vermin and scales. The tin cans from which the family ate their last meal are on the dirty table, the corners of the room are filled with refuse, dirt and tin cans, where it has been swept to make room in the middle of the floor to get about. The feeling of revolt which we have and the creeping, crawling sensations may easily be imagined. We retrace our steps to the car, realizing that there is little more than the animal nature in such human beings. On the return trip to the hospital the car is delayed some 26 " THE HOSPITAL AS A SOCIAL AGENT " time by a large traction engine belonging to a construction company which is relaying and reconstructing the street car track. The powerful engine is driving its shovel under the track, tearing it up and lifting ties, brick, dirt, and everything into the air. Then slowly the great arm swings about, the engineer manipulates the levers, and the shovel lets go of its load, dumps it into carts to be hauled away where materials are sorted, some thrown away, and others set aside for the work of reconstruction. A short distance up the track the other machinery is at work laying the rails and filling in with gravel and cement and we see the completed work. Efficient social work in the community is just as construc- tive as this material work, differing only in completeness of finish because of the human material with which we have to deal. It is like a great chain in the hands of the Almighty to lift people from the bed of want, degradation, poverty, sick- ness, dependence, and unwholesome surroundings, to swing them about and drop them on new ground where there are new opportunities for readjustment. Each social agent in the community is a link in this chain, and effective work depends upon the efficiency of each agent and the working together of all. The day of miracles is past. The Almighty chooses to work through human agents, but how can He lift the load if even one of the links of His chain is weak, or if all do not pull together? Efficiency and co-operation must be welded together to make each fink, if the work of social readjustment and reconstruc- tion is to be accomplished. This crude figure illustrates what is meant by the relation of hospital social service to, and its correlation with, other social agencies in the community. The social service depart- ment of the hospital should be equipped to take care of the medicosocial problems which come to the hospital or dispen- sary, and its work should be so efficient that public confidence CORRELATION WITH OTHER SOCIAL AGENCIES 27 is assured. On the other hand, it cannot be adequate to proper child placing, or family reconstruction, or relief work, and therefore it is dependent upon other organizations. Let us recall the cases cited in the first part of this chapter, and point out the correlation and interdependence that is abso- lutely necessary for the most successful accomplishments in social welfare. First, here is the man with the dinner-pail, all honor to him and his insignia, the pail. He represents an honest struggle for independence, the man with the steady job, equal to the support of himself and his family when work is plenty, and all goes well with the wife and children. But there is no surplus, and when sickness or adversity comes, his re- sources are soon exhausted and he must have help. His own injury or the illness of one of the family may be the means of their introduction to the hospital social worker, and her first duty is to help bring about adequate medical treatment by co- operating with the doctor in every possible way, acquainting him with the social history if it will aid in his decision. It is the responsibility of social workers to preserve the home unless the good of the individuals or of the community demands that it be broken up. All the forces that are necessary to be called into play, therefore, should be directed to the preservation of this home where sickness or injury has made its inroad. The agencies giving hospital care, relief, temporary loans, or tem- porary care for the children should work shoulder to shoulder to this end. This poor fellow in the corner of the car is most likely to fall a victim of accident and be sent to the hospital for repairs. Possibly a limb must be amputated, then as the days go by the social worker asks what of the future for this man, crippled, penniless, homeless, morally broken. The day is coming when the doctors will discharge him "cured," but where is he going? What is he going to do? He is a more useless member of society 28 "the hospital as a social agent" than he was before. Disregarding for the time being the man himself, with whom it is hard to sympathize, what is best to do with him for the community's sake to relieve its burden? The treatment is evident—reform the man, secure for him an artificial limb, then find proper surroundings and get him work. This is more easily said than done, but work must be directed toward this end, and it will take the combined efforts of a number of individuals and agencies to even make a beginning toward success. Incidentally, the social worker should use all the influence which she can bring to bear upon the abolish- ment of the source of evil which has been the means of bring- ing about this combination of disasters. The man with the aluminum ware, whom we are treating in the dispensary, calls forth our interest because the time is coming when he will be obliged to give up his independent life, as he will no longer be able to be self-supporting. We may prepare for this time by a personal, friendly interest shown in his welfare as we see him from time to time, or possibly by putting him in touch with some church or some organization which may be able to find a better home and other occupation with less risks and surer pay. It is not enough for that man to merely eke out an existence as he is doing, he needs the friend who will help him with the burden which is too heavy as he is trying to carry it. With his physical strength conserved, he may be able for a longer time to maintain his independence. So, if the social worker cannot enter into this problem to carry it out successfully, she should call upon the agent which is the best in this individual case to give the most adequate service. The district nurse reminds us of one of the most important co-operating organizations. It is she who will go to the home and treat the baby's discharging ear after the dispensary doctor has prescribed for it; she will watch for unfavorable symptoms, and send the mother back with the child for further examination correlation with other social agencies 29 and treatment. The district nurse is one of the first aids to the social service department in the hospital. The woman deserted by her husband, and left so desolate when in the throes of childbirth, asks nothing, but her need calls for prompt, concerted action. The agencies co-operating are the hospital, the neighbor who takes the four children in her home for temporary care, the ambulance service, the Jewish Charities, the husband's mother and sister, the juvenile court, and the Children's Home. Her baby'was born soon after she reached the hospital, the boys were committed temporarily to the Home, the little girls went to the grandparents' to stay, and the Jewish Charities took up the family problem when the mother returned from the hospital and the family was re- united except for the return of the father. The next home, where drunkenness, blindness, feeblemind- edness, and filth are combined, we see no way except to break it up, for the sake of the children, the mother, and the com- munity. The first touch with this iamily was when the woman came to the dispensary with her eyes in very bad condition and her sight much impaired. With treatment prescribed, the case was referred to the visiting nurses for supervisory care in the home. She did not improve, and the nurse tried for four weeks to get her to return to the dispensary, but in- stead she found her way to a general practitioner, who pre- scribed certain drops for her eyes. After a few applications of this drug her eyes were so much worse that she returned to the dispensary, and it was then discovered by the oculist that a drug had been used which was contraindicated in the disease from which she was suffering and her sight was almost gone. Although by this time her eyes were past repair she was ad- mitted to the hospital wards, that everything possible might be done in the effort to save her vision. It was unavailing, for the harm had been done, she was hopelessly blind. Followed 30 " THE HOSPITAL AS A SOCIAL AGENT " back to the home when she left the hospital, accompanied by the blind teacher, we found the hopeless condition described above, the filth being the most desperate factor. The little girl was sadly in need of attention, as the condition of her head .was due to filth and neglect, the boy of fifteen had a mind of a four-year-old child, and he had been excluded from school be- cause he was a moral pervert and a menace to other pupils. The man, a drunken, shiftless being, was abusive and did not provide for his family; they could not buy from neighboring stores without money, as their credit was gone, and the woman and children often went hungry. Here we have a most desperate situation that can only be re- lieved by disintegrating the home. This is accomplished by the Charity Organization Society's investigation, and the prosecu- tion of the parents for neglect of the children by the Humane Society in the juvenile court. Hospital social workers, visit- ing nurses, school teacher, resident of a neighborhood settle- ment house, and the truant officer are called as witnesses, and the judge sends the little girl to the Children's Home, the boy to the State Bureau of Juvenile Research, and the mother to a blind industrial home. There being no adequate means in the city to forcibly put the man to work as an act of punishment or for the purpose of keeping him out of trouble, he was left to his own destruction through the sure channel of the police court. The hospital social service department is not fitted to meet all these situations, neither should it expect to be; others are better fitted by position, equipment or authority to work out the more intensive, complex social problems, or, in other words, they are specialists along their different lines, and should be consulted as such. Duplication of work is avoided by such co-operative plans. A program well thought out to meet the requirements of a cer- tain family problem may be entirely upset by independent, in- CORRELATION WITH OTHER SOCIAL AGENCIES 31 dividual work, and the good that might be accomplished is com- pletely overthrown. Hospital social workers have no more right to interfere in general family reconstruction that is being handled by associated charities than the latter have to dictate the kind of treatment a patient should receive whom they are sending to the hospital. This sort of interference indicates low standards of social work, a narrow conception of the indi- vidual and community needs, and should not be tolerated. The interests at stake are too vital to be dealt with in any spirit of self-interest or dominance of opinion. Social work in the community should be as complete a unit in operation as the medical and social work in a hospital, which functionates as an individual, each department being available for consultation in any case where it is indicated. It is most gratifying to note the splendid organization that has been effected in some of our cities, and we believe it ap- proaches the ideal, at least it gives us a basis upon which to work out the best plan for co-ordination and correlation of forces for community welfare work. It is not a part of the subject of this book to go into the details of such an organiza- tion, but we hail the day when there shall be a unified central plan for the management of all welfare agencies in communities large enough to contain the complex social problems. CHAPTER IV SICKNESS OR INJURY—DIRE ADVERSITY AND THE TIME WHEN SOCIAL SERVICE IS MOST NEEDED It is often true that sickness or injury to one member of the family becomes the first occasion for any necessity for outside help, and, as the hospital social worker is dealing with the sick and injured, naturally her introduction to the patient may mean the beginning of some more or less intensive social work in that home. Surely sickness or injury may prove to be dire adversity in many cases, and affords the opportunity for "the study of character under adversity" which Dr. Cabot says is "the essence and center of social work." We have often seen strong men melt under the ravages of disease, and express a desire to see mother or wife or sister to whom they owe much, yet have become estranged through a wandering, dissolute life. This is the psychologic moment to do all that is possible to bring about a reconciliation and send the man away from the hospital with a new determination. Often it takes a severe shock to bring a man to his senses, and even if he does seem hardened to all good influences, or we feel is apt to retrace his steps afterward, we must make the most of our opportunity, realizing that our work at this time is like bread cast upon the water, and we may find it after many days. It is not sufficient to concentrate our efforts while he is in the hospital; our work is almost sure to be a failure unless we follow it by putting him in touch with an outside agency that will continue the good influences. We recall one man in whom we felt interested, and put in touch with the Y. M. C. A., a settlement house, and a minister, 32 SICKNESS OR INJURY 33 after he left the hospital, in our effort to bring about his reformation, obtain work, and secure some further education for him. He tried, and stumbled along, and fell and rose, passing through the jail several times, having delirium tremens, went to the county house, returned to town, and got into jail again for drunkenness. Finally, by the tactful handling and good influence of the minister who kept in touch with him through all these vicissitudes he straightened up, returned to his wife, and obtained work. In this case the hospital touch was the social worker's opportunity to inaugurate some work which proved effective. Often patients need a friend, only a friend, to take an interest at this moment in their lives and give them courage to go on after they get well, to show them that there is some good in this world which has seemed to use them so roughly. There is another class of cases, however, where sickness is a dire calamity, and which calls for the truest kind of service, when the breadwinner of the family or the mother is stricken and adversity first enters the home. They may struggle along by themselves in their endeavor to maintain their independ- ence, but when resources are exhausted they are obliged to seek advice and help. The social worker in the hospital, be- cause of her acquaintance with the medical side, foresees this result, and starts her work in time so that the extremity may not be reached. Or she is in a position to advise an outside agency, already handling the family problem, what the result of the illness or injury may be or the length of time the patient may be incapacitated. In case of tuberculosis or insanity or chronic disease co- operative action may be taken for the patient's transfer to an institution, and the care of the family arranged for. In the dispensary, disease is often discovered in its incipient stage, and with prompt, adequate treatment, medical and social, the 3 34 "THE HOSPITAL AS A SOCIAL AGENT" patient may be saved much time and suffering and the com- munity a danger and burden. Some people are utterly unable to meet adversity, especially that of sickness, and they need the most careful, tactful help to brace them up or to press home to them their part of the responsibility. Sometimes their helplessness is pitiful; this is especially so with a husband who is left with the baby at home when his wife must come to the hospital; he has no idea what to do. Also an aged person, separated from the companion of many years, often seems as helpless as a child. So a most valuable opportunity comes to the worker in the hospital to accomplish most effective social work as well as to assist in bringing about most urgent medical or surgical care. A mother who fears to leave her child in the hospital to have an abscess opened may have those fears overcome by the friendly visitation and urgent entreaties of the social worker, and once the mother's confidence in the hospital is gained by successful results, it remains steadfast. Here once more is demonstrated the doctor's aid in treatment through the co- operation of the social service department. Hospital social workers have opportunities for service that are not accorded to others: first, because sickness or injury in- capacitates the individual, rendering him helpless and de- pendent; second, because his helplessness makes him more sus- ceptible to good influences; third, because his stay in the hospital brings him under direct observation and care; fourth, because most complex social problems may develop from the patient's illness, calling for intensive work. Jake, John, and the Mission Man In Fig. 1 are seen three patients snapped while taking their outing on the hospital lawn, and they represent three different ^ I * Ja Fig. 1.—Jake, John, and the Mission man. JAKE, JOHN, AND THE MISSION MAN 35 types of cases to which principles set forth in the foregoing chapter may be applied. Jake, a Russian Jew, had been in the hospital a long time, suffering from a diseased ankle, which had not yielded to treat- ment, and the doctor finally told him his foot would have to be amputated. He had a wife and several small children at home, and he could see nothing but dependence for all of them if he were deprived of his foot. He brooded over this until he be- came desperate, and one day secured a razor from another patient in the ward, went into the toilet, and cut his throat. Fortunately he was found almost immediately, and hurried to the operating room, where doctors were sewing the wounds and inserting a tracheotomy tube within twenty minutes. Jake recovered, and soon realized what a foolish trick he had done. He was most grateful to all who had worked so hard to save his life that he might have it for his family. A spirit of encouragement and cheer was thrown about Jake during his convalescence, and he viewed life in a different light. The Jewish Charities were called upon to take up the family problem, and, through their interpreter, they were able to assure him that his wife and children should not want while he was in the hospital. One of the most remarkable parts of this story is that while Jake's neck was healing his ankle got entirely well, and the doctor was deprived of his amputation job. While Jake's own operation at the other end of the fine brought such favorable results, we would not advise other patients to try it. Jake looks quite content sitting on the bench with his wife and child, and he was indeed happy then. John, the boy standing on crutches, had a tuberculous knee. When he came to the hospital he was rescued from among the little "wharf rats" that hung around the boat landings, so he needed much taming down in conversation and in actions. The effect of hospital discipline and kind treatment of hospital attaches was soon manifest, and John became quite a respect- able and respectful boy. One time, after weeks of confine- ment, John borrowed without leave a pair of crutches from one of the other children and disappeared from the ward. He was 36 "THE HOSPITAL AS A SOCIAL AGENT " discovered at home and brought back by his mother. For a year he was in and out of the hospital, attended the dispen- sary, and was visited by the social worker to keep him in line, all for the purpose of saving a boy from being a lifelong cripple and making something better than a vagabond when he grew up; indeed, something approaching a worthy citizen. Both of these were saved for the home. The Mission Man was one of those single, unattached men, who had been rescued by a city mission, and who was trying to make amends for his past useless life. But health was gone, he was suffering from a kidney trouble which incapacitated him for work which would keep him independent, and was destined to become a burden to someone somewhere. This is a type of case representing very little service that can be rendered by the hospital social worker, yet needing the friend who will see that a clean, comfortable place is found for him when the hos- pital can do no more in the way of treatment. It is only a question of a permanent home, but that must be managed in a kind, friendly way, that the man may not feel his desperately dependent situation. So the Mission Man stands in the back- ground of our picture, alone in the world and dependent upon it; apart from the other two, whom we are endeavoring to put into their places in the world for service to themselves and to others. The "A" Family Italians; children—boy, age eight; twins, age four; baby, age four months. This case illustrates the complex problem which may de- velop when sickness brings dire adversity. A young Italian woman was referred to the out-patient department by the visiting nurses because she was in an ex- tremely nervous state, and unfit to care for her children and her home. Her husband had died in the hospital the previous week, entering as a private patient, yet she was so destitute that she did not have shoes to put on to come to the hospital when summoned at the time of his death. After the doctor examined her in the dispensary he thought it would be best to place her on the ward for observation and treatment. It Fig. 2. Fig. 3. Figs. 2 and 3.—The "A" children in the "Home." THE "a" FAMILY 37 was hoped that rest, good food, and a change of surroundings would restore her nervous and mental equilibrium. Her baby was admitted with her, as she was nursing it. It was then necessary to make some provision for the children, as they could not stay in the house alone, nor were the neighbors able to care for them longer. They had done much for the family the past few months. The boy was sent temporarily to the detention home, one of the twins to the children's home, and the other one to the hospital, as she was not well. Through some Italian neighbors it was learned that Mr. A. had been a hard drinker and very abusive to his wife, not providing the necessities of life for the family, and the house was destitute of furniture. He had threatened the life of his wife, and she lived in constant terror of him. She was a devoted mother and a good home-maker until the brutality of her husband divested their home of all the elements which make for happi- ness and comfort. Rest from care and responsibility did not bring about the improvement that was hoped for, she became more disturbed mentally, and the doctor thought it was best to have her transferred to the State Hospital for the Insane. The social worker filed a petition for her hearing in the probate court, and the judge came to the hospital to take the testimony and have commitment papers made out. The next day she was taken to the State Hospital. It then became necessary to make some more permanent disposition of the children. They were all declared dependent in the juvenile court and committed to the Children's Home. The social service depart- ment being the only agency handling the whole family problem, it was agreed by the judge that the children should be held by the home until it was determined whether or not the mother would recover so as to be able to return to care for them, and that the social worker should keep informed of her condition. The superintendent of the State Hospital was made acquainted with the social problem involved, and letters were received at intervals from him. No favorable report came from her, but she gradually grew worse, and died at the hospital a year and a half after being admitted. As will be seen by the accompany- ing pictures the children are beautiful, attractive children, and they have displayed good traits during their stay in the home, 38 "THE HOSPITAL AS A SOCIAL AGENT" so there has been no difficulty in finding suitable homes for them since the mother died. After the mother was removed to the State Hospital, an Italian man who had been a neighbor and friend, found in a trunk at the house two bank books, one belonging to Mr. A., showing a balance on deposit of $200 and over; the other one, Mrs. A.'s, with the last item a balance checked over to her husband. This is only one link in the sad story of this little woman whose life was wrecked by the brutality of the man she had bound herself to. Elizabeth The following case demonstrates the hospital social work- er's opportunity for service. March 28/14. Patient was brought to the hospital about midnight in an intoxicated condition, having cut her arm on a beer bottle, severing the flexor tendon and ulnar nerve, and bleeding profusely. She remained in a drunken stupor the following day. March 30th. Interviewed patient. Find that she is a domestic in the employ of Mrs. O.; has been there one year; earns $4.00 a week. Her parents live in a suburb of the city, and she thinks she can return to Mrs. O. 's when she leaves the hospital. Later: Interviewed Mrs. O. when she came to the hospital to see Elizabeth. She says that the patient cannot return to her house. She is a bad girl, immoral and dissipated. Mrs. O. has allowed her to remain, thinking she might be able to do her some good, but there are small children in the family and she cannot run the risk of her influence with them. Mrs. O. states that on the night of the accident Elizabeth was out with a married man in company with others of the same sort. They were all drinking, and when well under the influence of liquor, as they walked along the street, she stumbled and fell, breaking a beer bottle which she was carrying, and made the ugly wound she had. She was first taken to her home, and her people sent her with the man to Mrs. O's. The latter saw that Elizabeth ELIZABETH 39 needed medical attention at once, and she insisted upon the man's taking her to the hospital. Mrs. O. says the wife of the man is very angry with Elizabeth, and if she is allowed to come to the hospital to see her a disturbance will be created. The woman will be barred from visiting the patient. Mrs. O. asks if this case might not be taken up with the proper authorities, to place the girl where she will not be a menace to the community, as she feels that she is either de- fective or delinquent. The social worker promises to talk with the probate judge, and see if there is not some State institution where she may be committed. March 31st. Called upon the judge, and stated the case to him. He says there is no State institution that will take her, and he is unable to do anything unless she can be adjudged insane. He advised seeing the chief of police. Called upon the chief, and he stated that the girl had violated no laws and there was no cause for her arrest. April 1st. Through the C. O. S. found that Mr. B., who conducts a mission in the neighborhood where her parents live, knows Elizabeth very well, and also knows the lack of sympathy and help in the home. He was called and came to see her at the hospital. He found her quite penitent and ready to promise that she will lead a different life when she leaves the hospital. The outcome of the case is as follows: Mr. B. talked with the family, pointing out their duty toward the girl at this time, and told them she could turn over a new leaf if they would give her their support. He asked their co-opera- tion in his efforts to place her in surroundings that would help to uplift as soon as she was discharged from the hospital. A sister who lived just outside of town offered her a home until she was entirely recovered, and then Mr. B. found her a place to work in a family where she would be kindly treated and helped in the upward road. Although it is three years since the accident, she has not retraced her steps, but has gone steadily on in the better life. She is now a respected member of the community in which she lives, active in the little church, and is planning to marry a man who has passed through much the same change that she has. CHAPTER V SERVICE TO THE INDIVIDUAL, TO THE COMMUN- ITY, AND TO SOCIETY 1. The Tuberculous Patient. 2. The Epileptic, Insane, and Feebleminded Patient. 3. The Problem of the Unmarried Mother. Much stress is laid on the responsibility of social workers in their service to the individual, to the community, and to society; this is the tripod of efficient work. Each foot of the tripod is equally important, as each carries an equal share of the whole burden of humanity's welfare. Work accomplished in one direction is a benefit to the whole because of the close interrelation. The relation of the individual to the com- munity and to society, and the maladjustment of this rela- tionship through the reactionary influences, is the cause of the many and varied social problems. One cannot live wholly apart from society, as is well illus- trated by the life of a hermit, who, after years of separation, is suddenly thrust upon the community by means of sickness, accident, or death as a real social problem. The kind of life an individual lives has its influence upon society, and con- versely the good or bad in society affects the life of each indi- vidual member. Each person is a part of the community and of society, with his responsibilities and moral obligations, and the members of society, as a whole, are deeply responsible for the influences which surround the individual. We are "our brother's keeper," and we cannot escape this responsibility. It is not necessary for us to engage actively in service to fulfil 4o THE TUBERCULOUS PATIENT 41 our obligations; our habits and every-day actions speak to the world for good or evil. The solitary life of the recluse has its influence as truly as that of the man who figures prominently in the courts. So the life of the individual ramifies into the life of the community, making the warp and woof of society, and, like the finished cloth, the texture exhibits the quality of the threads which are woven into the fabric. As members of society, then, we are gravely responsible for each individual, both personally and in so far as we allow conditions to exist which are deleterious to the life of the community. Social workers should keep in mind this tripod of efficiency as their standard and base their case work upon it. Do not follow out the lines of least resistance or dispose of a case in the quickest way, as this habit tends to narrow one's ability to do effective work, or else it leads to a desire for numbers rather than efficiency, and social work can never be estimated in numbers. This threefold responsibility is demonstrated in the three classes of cases with which the hospital social worker comes in contact: the tuberculous patient, the epileptic, insane and feebleminded, and the unmarried mother. 1. The Tuberculous Patient From the standpoint of sickness, physical suffering, and death there is probably no other medicosocial problem that carries with it into the community more serious results, and consequently calls for more intensive work, than that of the tuberculous patient. Further, with the exception of the vene- real problem, no other presents such difficulties in the way of solution. Recognizing as we do that both tuberculosis and venereal diseases are preventable, we realize that medical treatment, prophylactic measures, education, and social re- 42 " THE HOSPITAL AS A SOCIAL AGENT " adjustment are the factors which make up the armed force to combat these diseases. The tuberculosis problem has made gratifying headway in spite of its enormity, yet it is far from being solved. The results of this disease are so apparent, so open; its spread, its suffering and death so appalling, that the whole mass of people have been made aware of its dangers and have readily enlisted in the fight against it. The diffi- culties in the way of an adequate solution of the venereal problem are more insurmountable because of a more or less marked secrecy which is maintained by persons afflicted with syphilis or gonorrhea, and because it is so acutely involved with the evil which is responsible for its existence in the com- munity. It is only in recent years that publicity has laid bare the real facts regarding the extent of venereal disease and its awful consequences. People are only beginning to be educated in this direction, and there can be no successful campaign inaugurated without first a universal plan of education. The enormity of the problem and the huge difficulties in the way have not yet ceased to stagger workers and inhibit their activities, for at every turn an insurmountable wall looms up before them. In setting aside this problem for that of the tuberculous patient we do not regard its dangers as less, but the present outlook for the great white plague as more nearly ripe for substantial results. Whatever the community's facilities are for caring for tuberculosis, the social worker should keep in mind the prin- ciples which govern the treatment of the disease and the ele- ments which make up the danger to others. Very few com- munities are prepared to meet in an adequate way the needs of this problem, cases are not discovered until they are too far advanced, patients are dying in the homes and infecting other members of the family; hospital and sanatorium facili- ties for the care of incipient cases are unequal to the demand, THE TUBERCULOUS PATIENT 43 and our hands are so far tied. However, we know that a be- ginning case has every chance to recover if he can have fresh air day and night in abundance, good, nourishing food, mod- erate exercise, and cheerful surroundings. He must use cer- tain precautions for his own sake and for the sake of others in the family. This routine intelligently carried out, and the patient kept under supervision of a physician, either private or dispensary, may bring about very satisfactory results in the home without removing him to a sanatorium. We recall the case of a young boy, fifteen years old, whose treatment was supervised from the dispensary. Someone interested in him provided a tent which was pitched in his own yard, where he slept even in the coldest weather. One night the wind blew the tent over, but he set it up again and continued sleeping there, for he knew it meant life to him. A little nephew in his home attended kindergarten, and he took him each day to and from the school, thus getting a proper amount of exercise outdoors. Then he secured a few pigeons and built a house for them, and this afforded occu- pation for him. Returning regularly to the dispensary he was weighed each time, gaining steadily, and improving in every way. The following summer he went to the country, where he was doing well at last accounts. After the fresh-air treatment was accepted as curative, and before special sanatoria were built, tents were pitched in yards, porches were enclosed with screens, beds were put on the roofs, windows were extended, any outdoor corner was arranged for the patient to sleep, and even in the crowded cities good results were obtained. Reference to some of the early reports of social service work in hospitals will show how extensively this was carried out and what the results were. In these later days, since special institutions have become more abundant, we have too easily fallen into the habit of 44 " THE HOSPITAL AS A SOCIAL AGENT " thought that all cases must be removed from the home to a sanatorium for effective treatment. The facts are, institu- tions are always full, and the number of beds available falls far short of meeting the demands, and it behooves social workers to save these places for patients who cannot be cared for successfully at home, or where they are a danger to young persons or children in the family. There may be other social reasons why the home cannot be utilized; all these should be taken into consideration before deciding where and how the patient should receive the treatment. One advantage to be gained from the sanatorium care is the training which patients receive in prophylaxis, and if there is a degree of intelligence to grasp this, much good is done in the way of education. If it is possible to establish in connection with the tuber- culosis clinic a broad, comprehensive program, such as has been followed out in Bellevue Hospital, New York, the re- sults will be found much more satisfactory. The dispensary should be made the examining agent at least, and the dis- ease may thus be detected in its beginning stage when proper treatment can be inaugurated. Or, if cases are advanced, they may be placed where they will not be a danger to others. Again, having access to all the special clinics and the laboratory, x-ray, and hospital wards, there is opportunity for careful diagnosis and treatment of complications. The educational phase of the work with tuberculous patients has not been developed in dispensaries as extensively as it should be. The chief reason is the lack of a sufficient force of social workers to carry out such a plan. But it is a most important measure in the fight, as it is possible to reach in groups those who are the carriers of infection, and so to dis- seminate the knowledge of prevention from a most impressive source. Classes for instruction upon the principles of the treatment, upon the technic of precautionary measures, THE EPILEPTIC, INSANE, AND FEEBLEMINDED PATIENT 45 upon the importance of cheer and hope, and the teaching by graphic posters the many sources of danger; these are features of the educational work. This important aid in pub- lic health work will be spoken of in another chapter. It is only necessary to visit the special tuberculosis clinics where intensive, well-organized work is carried on to be convinced of the opportunities for most effective service. Our plea is for its introduction into the smaller dispensaries where re- sults differ only in degree. 2. The Epileptic, Insane, and Feebleminded Patient One of the greatest responsibilities of social workers to the individual, the community, and society is the disposition into proper channels of mental defectives. It would seem as though this were so self-evident a fact that there need not be much said, and this is true where the condition of the patient is so dangerous that immediate steps must be taken to safe- guard all concerned, but with the milder types of defectives there is a tendency to leniency when the question of cus- todial care arises. It is a well-established truth that all mental defectives are a menace to society unless they can be guarded and controlled, if not in the home, then in an institution. The detection of the milder types of mental disorder is, there- fore, most important, and this may be more easily done in the hospital and dispensary, as patients are under more constant observation than otherwise. It is sometimes difficult to dif- ferentiate closely enough between insanity, feeblemindedness, and epilepsy to decide which is the proper institution for the patient. Where a psychopathic ward is available in the com- munity it serves as a clearing-house and should be used as such, entrance to a State institution being more easily secured through its specialists. In justice to society, the mental defective should have 46 " THE HOSPITAL AS A SOCIAL AGENT " proper attention; those who are in condition to be a menace, or whose home surroundings are unfit for adequate super- visory care, should be placed in an institution, and those who are amenable to medical treatment should be given every opportunity for readjustment and improvement. Clinics for nervous and borderline mental cases are of won- derful value in the community, especially when the doctor's work is supplemented by that of a social service nurse who investigates the home conditions and surroundings, and helps in the patient's readjustment in the home. The work which is being done by a number of the States through a well organized mental hygiene society or committee is keeping many a mental case out of the State Hospital, and helping many more to return to their homes and remain well because of the efficient social service rendered. These societies have been the means of establishing mental clinics attended by specialists, and of placing there a nurse with experience in mental diseases to visit the home and learn the contribut- ing causes of the breakdown. If there are readjustments either in the home or with the patient, the nurse may render very valuable assistance. These clinics sift out the cases that are amenable to treatment from those which are a positive menace to society and make possible adequate medical or social care. What a service to the individual and to the com- munity when people are thus returned to their place in the life and work of the world! On the general hospital wards there will be found the occasional case of insanity following a fractured skull, or a postoperative mental disturbance, or a case of paretic demen- tia, where the physical symptoms have been of such a nature that mental symptoms were obscured or unnoticed until the patient was under more close observation in the hospital. The epileptic insane drift into the hospital as emergency THE PROBLEM OF THE UNMARRIED MOTHER 47 cases, and the wandering types of insanity find their way there because they can so readily assume physical illness. Cases of hysteria prove to be a great deal of trouble and annoyance on the wards, and are sometimes hard to get rid of, as they develop some very convenient and seemingly serious symptoms when told they may be discharged. The social worker has a definite responsibility with these patients, and should not allow them to be sent out into the community without at least making an effort to place them in the right channels. It is often difficult or impossible to carry out adequate plans, owing to opposition by patient or friends which cannot be overcome, but the worker has not done her full duty until she has made every possible effort to serve the individual and the community in an adequate way. The responsibility goes back of the social worker to the hospital physician, upon whose medical opinion the social work must be based. It is a true but unfortunate fact that gen- eral practitioners, many of them, neither recognize the mild types of mental disorder nor the real import of the social problem involved; they are more or less indifferent to the danger of the presence of these patients in society. We can- not help feeling, however, that these same doctors may be educated to a realization of the importance of this question by the tactful efforts of the social worker. Her responsibility is, therefore, twofold, but we believe she is equal to it if she can be awakened to its importance. 3. The Problem of the Unmarried Mother The unmarried mother who finds herself in the hospital is introduced to the social worker at the crucial time when her problem becomes a vivid reality, and she must decide which course she will take, whether she will follow the path of duty or her own inclination to cover up one sin with another. 48 "the hospital as a social agent" It is a crucial time also, because the mother instincts are most delicate and keen, and may be nurtured into maturity to help the mother in her decision for the right. Unless the girl is wholly unfit physically, mentally, or morally to rear her child, the mother and baby should not be separated; this is the rule from which we should not deviate except under ex- tenuating circumstances. All the influences should be focused at this time upon this one course, nurses and doctors insisting upon her nursing the baby, and social worker encouraging her in her duty and securing assistance to help her carry it out. It almost always appears to the girl that it is impossible to follow out the plan suggested, and she has previously made up her mind that the only thing to do is to give the baby away, because she does not wish to face the disgrace before the world, and because she thinks she cannot care for her baby and at the same time support both. Then the family, if they are aware of the circumstances, prefer the "cover-up" method in their effort to save the girl's disgrace and that of the family. They do not realize that "murder will out," and when it does, it brings much more disgrace because the double sin is now trebled. The girl should be impressed with two things, namely, that she is not altogether blameless in this situation, so is responsible for her part in the care of the baby, and that it is possible for her to take care of her baby and support both. The mother's duty is to follow nature's own way of nourishing her offspring, nurturing and giving to it the best she has, in order to establish a physical foundation which will insure a strong child, able to meet life as he should. The first weeks and months of the life of a babe are critical ones; if he can be safely carried through these he has a better chance in life than if he is deprived of his mother's care. This in itself should be sufficient argument to make the girl decide to keep THE PROBLEM OF THE UNMARRIED MOTHER 49 her child no matter what it costs her. The charge of child abandonment is a serious one for a girl to face, much more serious than the lesser disgrace which she thinks she cannot face before the world, and rescue homes of all kinds and de- nominations are refusing to separate mother and babe because they realize the serious results to both from this procedure. The girl is responsible for the life of the child, and she should be deeply impressed with this fact from the first. At the same time, her mother instincts must be appealed to, and the joys and blessings which are sure to come from association with the child, as well as the satisfaction which results from duty fulfilled, should be earnestly set forth. Say to her, "How can you give up your baby, your own flesh and blood? How can you throw your innocent child upon the world to face the disgrace that you wish to avoid? How can you deprive him of both father and mother?" Show her that her friends and the world in general will respect her more for holding to her duty, and that she will be happier for doing it. The following letter, written by a girl seven months after her baby was born in the hospital, shows the result of this course pursued. "Dear Friend: Your welcome letter was received some time ago, and I wish I could tell you what a bracer it was. I have not worked for two weeks; have been very sick with grip. I still have a very bad cough. The doctor was here twice and I went to his office once, then I caught more cold. Baby Helen is quite well just now, with the exception of two sore fingers, Mamma says comes from her teeth, although I have seen no signs of a tooth yet. She is getting so noisy now. I do not know what I would do without her now, as my whole life seems to be wrapped up in her. I never realized I could love a little baby so much. Without her I do not know what I would do, for when I get tired or downhearted and stop to think of her, I take up my burden with renewed energy, and 4 50 "the hospital as a social agent" then it is a comfort to me to know that I am not the only one who is traveling this same road. I get a letter from a girl friend of mine in the city every now and then that always gives me the blues, she is always telling me what the other girls are saying, so I wrote her not to write any more. The girls who were true friends of mine I still have and the others I don't want. Her letters did me more harm than good. Well I will have to close now. Write again soon for I can hardly wait till I get your letters open to read them. Trusting you always, your friend." The morning after her baby came the social worker, talking with her, asked her what she planned to do. As was expected, she said she thought she would have to put the baby some- where and go to work, that she did not want her parents to know of her trouble, for they were not able to help her, and she knew her father would be very angry with her. Her duty to the baby and the possibility of getting work in a private home when she was strong enough was presented to her as a better plan, and she was left to think it over. When the worker visited the ward on the following morning she was greeted with a bright smile from this girl, and her first words were, "I have been thinking about what you said yes- terday, and I have decided to take your advice." Such good news was most gratifying, and immediately the social worker began to plan for the consummation of this purpose. Corres- pondence with her mother living in a nearby town was be- gun, the girl's pastor was called, and his interest and help solicited. He knew the relatives in town and got in touch with them. They came to the hospital to see her, and an uncle offered her shelter until she was strong enough to work. The visitor from the Associated Charities called to talk about a suitable place for her to work where she could have her baby. When she left the hospital she went to her uncle's for two weeks, then a good place was found in a home where THE PROBLEM OF THE UNMARRIED MOTHER 51 there was an invalid wife. The family became very fond of the baby, and they appreciated the good work done by the girl; the baby kept well and was devotedly loved by the mother. Upon the death of the wife in the home it became necessary to find another place, but the girl faithfully and contentedly stuck to her duty. In the fall it seemed best for her to go to her own home, where her mother and father re- ceived her with open arms, and soon the baby won her way into the hearts of all the family so they would not let her go. This girl is experiencing the joy and satisfaction of duty done, her compensation is the bond of love between herself and the child, which is strengthening every day, and she is happy when she looks at Baby Helen, to think she did not cast the innocent one upon the world to fight her battle alone. Regarding the father of the child, with him the hospital social worker has little to do, her problem is the immediate question of the care of the mother and babe, and making provision for them when they leave the hospital, and she has her hands full if she accomplishes this successfully. But he should not be disregarded altogether, as he is a guilty party in the situation, and has his share of the burden which he should be made to carry if it is possible to bring him to it. If marriage is a reasonable solution at all, this is the best advice to give; if not, some means should be sought to find him and secure support for the mother and child. This is a matter for personal consideration, as marriage might be the most disastrous thing to all concerned, and the publicity to which a girl is subjected by bringmg the man into court is sometimes more harmful than beneficial. This whole question of the man in the case is best turned over by the hospital worker to an outside agency, as it is usually involved, and calls for follow-up work for some time. The province of the hospital social worker is to start 52 " THE HOSPITAL AS A SOCIAL AGENT " things moving in the right direction, to put the case in the right channel to accomplish just service to the individual, to the community, and to society. Whether this is brought about by marriage, by return to the home by reconciliation with the family, by placing out in a private home, or by sending the mother and babe to a rescue home for the usual allotted time, must be determined by circumstances. In the case of an irresponsible girl or woman, especially if it is her second offence, it may be best to separate mother and babe, placing the mother in a proper custodial institution and the baby in the hands of a child-placing agency. Each case must be decided upon its own merits, as it rests on our tripod of efficient service. Two rather unusual cases of unmarried mothers may be cited here. FOURTEEN-YEAR-OLD JANE Jane was admitted to the maternity ward of the hospital a few days before she was to be confined, and the social worker became acquainted with her at this time. She was but four- teen years old, a mere child. Her attitude was that of in- difference to the situation which she was facing, she seemed to feel that it would be an easy matter to get rid of the baby and return home again as free as before. Her parents were re- spectable people, entirely out of the dependent class, but at this time needing the most tactful assistance in the social problem they were going to be obliged to meet and solve. When the mother came to see the girl the social worker talked with her, and found much the same feeling that the girl pos- sessed. She stated that her husband must not become ac- quainted with Jane's real condition, for he was a very high- tempered man, and she feared what his anger would lead him to do. She knew the truth would entirely upset him. The girl's duty in the matter was presented plainly to the mother, and she was urged to help follow out the right course, going to her husband, and telling him frankly of the trouble. Their effort to keep the real facts from their friends would be futile, and it was better to face the situation in an open, just way, FOURTEEN-YEAR OLD JANE S3 giving their daughter the support she needed now more than ever before. The mother claimed that she had tried to watch Jane in every way to prevent trouble of this kind, and she did not understand how it could have come about. The first day of her interview with the social worker she went away in tears, but the next day returned with smiles, for she had told her husband, and the storm that she expected did not come. They were willing to follow the advice given, and stood ready to help in any way they could. Jane's father called on the social worker to talk over the plans, and broke down with emotion during the conversation. It was suggested that Jane go out of the city with her baby when she was ready to leave the hospital and stay at a refuge home, where she would learn to care for her baby and to do many of the things which are necessary in the home. This was agreed to, and the transfer was successfully made. In the course of the investigation the boy who was responsible was found, though, much to our surprise, it was difficult to attach the right one. According to his statements he was not the only boy who might be impli- cated. He belonged to a good family, and his father had a prosperous business, in which his son, then seventeen years of age, was receiving training for his life-work. The boy at once expressed a willingness to do the right thing by Jane, and his parents also took a most sensible view of the situation and promised support. A most unique situation thus existed, where the parents on both sides stood ready to help, and by coming together and talking things over they agreed upon the best plan for both the boy and girl. On account of their youth they were neither of them mature enough to establish and maintain a home, so it seemed important that Jane should spend a year at the rescue home, where she would have the training and discipline she needed, and she courageously ac- cepted her duty. Before she left the hospital she had learned to love the dear baby, and nothing could have persuaded her to give her up. Bringing the mother and father of the baby together, as social investigation and work on the case had done, served to foster a growing attachment between them, and they pledged their troth before Jane left for the home. Only a short time passed before the boy-father realized how 54 " THE HOSPITAL AS A SOCIAL AGENT " much he loved the girl-mother and the baby as well, who ap- pealed to him as a fatherless child. He determined to have them both and make the home for them. His parents were willing to share their home and her father and mother to assist with the family expenses, so Jane returned to the city, and they were married in an Episcopal chapel in the presence of the immediate relatives. It was the privilege of the social worker on the following Sabbath to act as godmother when the baby was christened. When a visit was made a year later they were living happily, the father had finished his apprenticeship, and was receiving regular wages. It is granted these two were not mature enough to marry and undertake the responsibilities of parenthood and of establishing a home, but with the support and guidance of the parents of both was it not best under the circumstances to assist in bringing this about? Florence and Her Twins One day in January the hospital office called the social worker's attention to a woman in the maternity ward who was about to be discharged, but who seemed to have no place to go with her twin babies, and neither did she have money to pay the hospital bill, as she had promised when she was admitted. Because she was a paid case she had notbeen interviewed before by the social worker. So it came about that at this late day the worker was presented with Florence and her twins, and it was found that Florence was not married, did not know where she could go, nor what to do with the babies. Furthermore, she had no money to pay the hospital bill, as some friend she thought she could rely upon to furnish the money did not ap- pear, and Florence had no definite address with which to reach her. This poor woman was evidently under par mentally, this was her second offence, she having a girl seven years old staying with some people in the city. She had worked at a hotel until a short time before coming to the hospital, so had no home to go to. The people who were keeping the girl would have nothing to do with Florence if she kept the babies, and it was no place for her, as they were poor and dirty. As usual, the only thing that seemed could be done was to give the babies away and go back to work, but, of course, she was FLORENCE AND HER TWINS 55 dissuaded from this thought, and the better plan was presented to her, with assurance of help to follow it out. Commitment through the city charities to a nursery where she could take care of her own babies was secured, and the transfer was soon made. Here she found a friend in the superintendent, who was a good, motherly, wise woman, and probably for the first time in her life she received the uplifting encouragement that showed her there was another road to travel better than the one she had followed, one with greater rewards and more happiness, because it was the right road. Florence learned to love and tend her babies, and to be helpful about the nursery, so as we visited her from time to time we found her very happy and contented. She had no desire to go out nights, she stayed close to her duty, and as time went on she was given more general work to do and soon became indispensable to the house because she proved herself faithful and reliable and efficient. For a year and a half that we were able to keep in touch with her she was happy, contented, and useful. This story would not be complete without relating the close call that Florence had to being sent to the State Reformatory because of her seeming irresponsibility due to her feeble- minded condition. The public commissioner determined that there was no use in expending public funds to support a woman who had no moral sense, and was bringing babies into the world at the rate of two at a time for the community to take care of. A warrent was issued for Florence's arrest on a charge of dependence. The poor woman was brought to the city jail the night before the time set for trial, leaving her babies crying for food, and she herself suffering the discomforts of engorged breasts. When she appeared in the court room she was frightened and bewildered, and did not know how to answer the judge's questions. The court's decision was soon made that she should be sent to the State Reformatory. Just at this point the police matron appeared with a message from the superintendent of the nursery, asking that Florence be given six months' probation and left at the nursery, as she had already shown an improvement, and they were glad to do all in their power to help her in the upward road. The judge granted this request, and Florence was returned to the nursery 56 " THE HOSPITAL AS A SOCIAL AGENT " a happy woman and warmly greeted by her babies. The commissioner was the unhappy one after this because he had not accomplished his desire, and he consoled himself by with- drawing the city support for Florence at the nursery. She was retained, however, at their own expense, and in time earned not only her own board but was given wages. While it is granted this woman was mentally weak, and in so far irre- sponsible, the results justified the trial she was given to make good, and the good influences thrown about her were as ef- fectual as the evil ones had formerly been. She was just weak minded enough to be influenced either way, but why should she not be given the chance to find her place in the world when she displayed the ability for good work that she did? Both of these had their far-reaching influence in the com- munity, which will be readily recognized, and society was benefited, as it always is, when these girls are taught to pro- tect themselves and others against a repetition of the same offence. The baby is a tie which holds the mother. If she is relieved of her burden, it falls upon the community, and leaves her free to travel the same road again and add another burden. It is not an easy road for the girl, for she finds her- self alone in the midst of difficulties and perplexities which are naturally shared with the partner, and for this reason she should have the encouraging, uplifting, helpful influences and surroundings to hold her to the path of duty. One factor is important in these cases which we must not lose sight of. Remember that we are dealing with the result of one of the strongest of human passions. This thought should modify our first natural feeling of disgust, and the tendency to attach merciless blame to either party concerned. God has endowed man with this passion, and made it an overpowering, ruling one, that the race may be preserved to the end of time. This passion is the impelling force in all of man's activities, and nature demonstrates that the stronger this impelling force is, the greater are man's activities. It is the THE PROBLEM OF THE UNMARRIED MOTHER power that moves the world. Nature proves that all things that have life possess the power of reproduction, and the con- stant struggle is to preserve life through this power. In man only has the Creator placed a censor for the control of this power by the use of the will, and just so far as man recognizes his moral obligation and lives up to the rules and customs of society this censor will keep him within the bounds of what we term "right living." However, "right" is a relative term, who can define it absolutely? Our standards are high com- pared with those of some others who are constantly thrown into temptation, and it is easier for us to maintain our high standard than it is for those others to resist the promptings of this powerful impulse in the midst of temptations to uphold a standard that is lower. There are others who have no moral standard, and who recognize no moral obligation. They do not fall, they are only following nature's impulses and demands, scarcely know- ing that it is a sin to yield to these impulses indiscriminately. Another class know what their moral duty is in this respect, and, as a rule, fulfil it, but temptation comes, the impulse is stronger than the will, and the censor is removed. This group furnishes many of the cases with which the hospital social worker in the smaller communities comes in contact, and her sympathetic, tactful handling of them is sure to spare many a good, right-meaning girl from social ostracism or from drifting into a life of degradation. In dealing with the unmarried mother in the hospital ward we must accept her in her present situation, determine what her moral standards are, and what should be done for her best good and for the good of the community and society. A good religious influence is important with many of these girls, but if we try to make it a panacea, we lose sight of the different types of girls and of the causes, within and without, which bring about the unfortunate results. CHAPTER VI THE PROBLEM OF THE HOSPITAL CHILD The children's ward is one of the most interesting places in the hospital. Because of the child's helplessness and de- pendence he always finds a benefactor when in need, but the sick or injured child especially calls forth universal sympathy. The children's ward is interesting to the social worker because of the varied problems of vital importance which are offered for solution. The recognition of a lifelong handicap through disease, deformity, or injury calls forth far-reaching sympathy, which outweighs pity for present suffering and leads to intensive work for the welfare of the child. Our little Baltomero, whose story is recorded on page 62, suffered for weeks from the many operations he underwent to make for him better hands, but how little did that count compared with the deleterious effects of dependence resulting from such a handicap as his? This child was one of the bright spots in the experience of the worker. He was so lovable and showed signs of such a bright mind it was a joy to receive his greeting each day on the ward, and to know that there was opportunity for lasting service to him. The encouraging feature of the work with children is the advantage to be gained by early service, and the opportunity for prevention which is thus afforded. This fact, coupled with a natural interest in children, furnishes an incentive for real active work. Take the six children on the car who were snap- ped while on their way to the roof garden, they are all tuber- 58 Fig. 4.—A group from the children's ward. ■3fe: - Fig. 5.—On the way to the roof garden. THE PROBLEM OF THE HOSPITAL CHILD 59 culous or syphilitic. How important that their treatment should be started now and continued until they are well. Annie's open sinus and Angeline's may be healed if taken in time. Gisella's tubercular hip needs attention before the disease gains headway. Josie and Barbie with rachitic legs may be helped by treatment now while the bones are soft. All of these children were greatly benefited by their hos- pital care, and the social service rendered is beyond question. It required a great deal of encouragement and persuasion and friendly advice on the part of the worker to hold them until the medical and surgical work could be completed, and in the case of Angeline, whose story is coupled with that of Mary (page 63), she became a real social problem. It is sometimes necessary to institute court proceedings against the parents in order to obtain for the child the hos- pital care which is necessary to save him from being an un- fortunate cripple. This is not resorted to, of course, until all other methods of persuasion have failed. A two-year-old girl, with a corneal ulcer which was the result of the parents' neglect to give her proper care, was obliged to lose the eye because it had ruptured. The infec- tion would have extended to the other eye if the diseased one had not been removed, and total blindness would have resulted. No amount of persuasion or threatening moved the parents to consent to the removal of the child's eye, so it was necessary to bring them into juvenile court for neglect. The judge issued orders for Eva to be retained in the hospital as long as it was necessary, and the doctor was permitted to carry out the treatment which, in his judgment, would pre- vent blindness. The story of Charles on page 64 illustrates the necessity at times of asking for the help of the court to obtain treat- ment that preventive measures may be carried out. 60 " THE HOSPITAL AS A SOCIAL AGENT " It is the duty of society to protect the innocent, helpless members, and this duty is performed partly in self-defense. The strong are responsible for the weak, and if children are in danger of becoming the victims of the ignorance and stub- bornness of parents, the better members of society who are capable of recognizing the danger signals should serve as the children's defense. Parents have their rights, but individual rights and those of society must take precedence in a critical moment. Lest the overzealous worker in the small community should be led into error through a misuse of this idea of duty, it must be repeated that the court is a last resort. Sometimes the sacrifice of one child will strengthen the cause of all others to follow, and a misdirected plan to force parents may be the means of losing their confidence, and the social worker loses her opportunity for valuable service. The greatest wisdom and foresight is necessary in handling many of the acute problems. It is a terrible thing to see a child suffer, and to know that it is innocently bearing the pain inflicted by someone who is either ignorant or evil. But the wrongs may not all be righted in a day, and it is the ultimate good to the greatest number that must determine the best methods of procedure in individual cases. Many things must be taken into consideration. Parents are prejudiced by their love for the child, and although it may be more of an animal love than human it must be recognized, and often the best way to win them is to gain their confidence by taking their point of view. Then, parents have their rights, and those rights are just, as far as their responsibility goes. Ig- norance may be due to superstition which influences them, and superstition is very hard to overcome. Again, we must be able to answer the question, What method of action will gain our point or bring about the best results? THE PROBLEM OF THE HOSPITAL CHILD 61 Sometimes our hands are tied, and it is impossible to ob- tain the co-operation from other agencies to properly place a child for care when he leaves the hospital. This was the diffi- culty with little Mary who is pictured with Angeline. It may be, pressure enough cannot be brought to bear upon proper authorities to improve sanitary and living conditions which are responsible for the illness of the baby, and the work of hospital physicians is wholly undone when the child returns home. Indeed, there are many stone walls which we cannot climb over, but some day an opening will be made through which we may freely pass, if we continue our efforts persist- ently. If we would win in many of these difficult problems we must establish public confidence by the careful, practical handling of case work. Social workers should have definite knowledge of facts through complete investigation, a definite problem, and a definite plan of action. The hospital child presents such vital problems, and our love and sympathy play such a large part, the work receives an impetus which assures ultimate success with any undertak- ings in his behalf. The child will some day be the man, and service to the child is service to the man. In other words, disease overcome in childhood, or a strong constitution es- tablished through proper feeding and care of the infant, lay the foundation for the making of a man equal to his task in the world. All through his life he will be an asset in the community instead of a liability. This is the sum and sub- stance of all social work, and the work with children offers great opportunities in this direction. Just here may be mentioned an important service in the out-patient department, because it has to do with making better babies, who stand a better chance to become strong men. 62 " THE HOSPITAL AS A SOCIAL AGENT " In small communities an out-patient obstetric service may be maintained through the co-operation of the district nurses. The prospective mother is given a complete examination in the dispensary, including urinalysis, and is then placed on the waiting register for outside delivery. The case is re- ported at once to the district nurses, who take up the pre- natal care. The patient is delivered in her own home by a doctor and nurse from the hospital and the district nurse follows with postnatal care. This plan, with slight variations, is in operation in a number of places, and may be handled in any hospital with the dispensary under social service super- vision. There is no question as to the value of such a service to the mothers and babies. Many of the ills which follow child- birth attended by midwives and careless doctors are averted; the danger to the baby from infected eyes is lessened 100 per cent., and the close touch with its accompanying influences, which is thus obtained for two important social agencies, gains an effectual vantage point. Better mothers and better babies must result from this kind of service, and the cribs in the children's ward would go begging for the poor little starved creatures which never had a fair start in life. Baltomero Baltomero was eighteen months old when he was admitted to the hospital. His parents were Italians, living in a poor quarter of the city in crowded rooms. Since birth he had had webbed fingers, and he was brought to the hospital to see if something could not be done to improve his crippled hands. The surgeon operated several times, cutting down between the bones that were at all normal, and making separate fingers as far as possible. Since the child gains much knowledge through the manipulation of his hands, this boy was in danger, through his handicap and through ignorance of the parents, of losing Fig. 6.—Baltomero. ^ 0 Fig. 7.—Mary and Angeline. MARY AND ANGELINE 63 much natural brain development if he did not learn to use these new fingers. As soon as he was old enough for kinder- garten he should be started there, but in the meantime he should be taught to handle his food, playthings, books, etc., and so it was essential that no time be lost. Visiting at the home, the mother was shown how to give him playthings of different shapes and forms, and the social worker took blocks and other things to him to demonstrate to the mother what was necessary. It was most gratifying to notice how his little, bright mind and determined spirit taught him naturally because there were placed before him the things that were attractive to him. Nothing was too hard for him to attempt to do. He learned to hold a spoon and feed himself with it, and could pick up a dime which was offered him as a bribe, following the much used custom of foreign parents. Realizing that such supervision needed to be carried on for years to come, the social worker felt it would be best to place the child under the care of a permanent agency in the community, and so the case was placed before the Children's Aid Society for considera- tion. After investigation, they agreed to assume this super- vision, and a visitor began regular visits to the home. Mary and Angeline The two children seen in the picture are grouped together because they were in the hospital ward at the same time, and because they are poor, dear children whom no one wants, yet must be cared for somewhere by someone. Both are diseased, Mary, on the left, having a congenital syphilitic condition, pro- ducing an ever-recurrent eye trouble; Angeline, on the right, suffering from bone tuberculosis, appearing at different times in different places. It will be noticed the middle finger of her right hand is amputated, this being done when she was but eighteen months of age. Mary's mother died when she was one year old; her father was too feebleminded to support him- self or even to give Mary the daily care she needed, and he died in the County Infirmary from cancer. With such a family history and such a physical condition even the Chil- dren's Home did not want her, the hospital could not keep her 64 "the hospital as a social agent" all her life, and no one would adopt her. After two years of supervision and hospital care she was taken over by the State Board of Charities, who will see that she has all that can be provided for her welfare as long as she lives. Angeline has a mother, but she is more irresponsible than not, and has left Angeline to the tender mercies of others, so she might be free to go her way as she chose. Fully half of the time the past three years the child has been in the hospital, sometimes with three discharging sinuses. The mother finally married, and it has been our task to insist upon her keeping Angeline and caring for her, although many times she has come and begged to leave her in the hospital. The grandmother, who has kept the child much of the time, is now too old to have the responsi- bility, and the mother, who seems fond of her, is now in- fluenced by her husband to put her away because of her disease. So it has been a struggle to keep Angeline where she belongs, in her mother's home. One's heart naturally goes out to these little ones who are unwelcome guests, yet they present one of the most difficult problems. Charles Charles was three and a half years of age when referred from the dispensary to the hospital for treatment of a possible injury to his hip. His parents were Germans, and the mother was loath to leave him for fear he would cry, and as he under- stood nothing but German she thought he would not be able to make his wants known. Her fears were allayed and she consented to let him stay. How little did the social worker realize that this was the beginning of desperate struggles with these parents to give this child what he must have to prevent his being a lifelong cripple. Examination in the hospital showed the hip was tuberculous, and the only treatment was the application of an extension and weights. Before doing this the doctor asked the social worker if she would see the parents and explain the treatment, and find if they would con- sent to it and to the child's staying several months, as it would necessarily take a long time. The worker visited the home, and told the parents that the trouble was a disease of the hip Fig. 8.—Charles. CHARLES 65 and not an injury, and if the child was allowed to go without treatment the disease would progress and the limb grow shorter, resulting in a crippled boy. As the father had received an injury more than a year ago which had crippled him, the appeal was made that he surely would have everything done for his boy to prevent such suffering and dependence. They said they were willing to have the doctor go on with the treat- ment which he thought was necessary, and they would leave Charles in the hospital as long as it was best. This cleared the way for the doctors, and they applied the weights for the beginning of the treatment. Imagine the consternation of the intern when he was called to the ward the next day and found the mother there in a state of great excitement. She had loosened the stays and released the weights, completely un- doing the work which the intern had so carefully finished but a short time before. She was demanding Charles' clothes and preparing to take him home, for she said it was cruel treatment, and no amount of argument could persuade her that it was the kindest thing that could be done for him. After signing a release she took him home. The next day the case was re- ported to the Humane Society, asking if they could help in forcibly retaining the child in the hospital. The result was that the agent went with the social worker to the home, and found the parents indignant because Charles had been hurt; they, in their ignorance, could see no farther than the child's tears, and those were increased by the solicitude of the mother. They were told that they were neglecting the child, and if they did not bring him to the hospital and leave him for proper treatment a warrant would be issued for their arrest. They then consented, and brought him the following day. The child remained for some months under the order of the Humane Society, but a great deal of trouble was experienced with the parents; they were ugly and unreasonable at times. After a siege with scarlet fever, contracted on the ward, it was thought best to let Charles go home and return to the dispensary for observation. His father brought him back just once, and al- though visit after visit was made to the home, they flatly re- fused to bring him. It was evident the disease was progressing, for the child was looking pale and thin, and he could not stand s 66 "the hospital as a social agent" or walk. Finally, after repeated efforts of the social worker, the father brought Charles to the dispensary and the doctor found that both hips were now involved, and the only thing for the child was to place him in the hospital. As the father was ugly and demanding at this time, trying to dictate the kind of treatment the boy should have if he left him, the only course to pursue with success was to get control of the case through the intervention of the court. The matter was taken up with the Humane Society again to get a court order to hold Charles for treatment without any interference from the parents as long as the doctors deemed it best. This was accomplished, and Charles is receiving every attention that his case demands. The court told the father that he and his wife must not inter- fere in any way with the hospital, that if they did the work- house sentence which the court imposed would be carried out, otherwise it would be suspended. Even after this it was necessary to exclude them from the hospital as visitors, because they came one evening under the influence of liquor and threatened to make trouble. CHAPTER VII HUMAN ECONOMY AND ECONOMY OF RESOURCES Much that has been said in previous chapters bears more or less directly upon the conservation of human energy and the economy of resources in the community, so we will en- deavor now to gather together the important points and clinch them. After all, human economy is our object in social work. By eliminating the unfit, we strengthen the beings that remain; by repairing the injured or crippled member, we literally put individuals on their feet and give them to the world for useful service; by effecting a cure in the best possible way and the least time, we may not only spare a life, but make it yield more abundantly in energy for the world's work; by taking care of the mother's problem in the home so as to make it possible for her to take necessary treatment in the hospital, we economize her strength and vitality for use in her family; her children are better physically, mentally and morally for her best care, and they will be more to the world. The following stories of Josie and Frankie illustrate the economic value of social service in putting individuals on their feet. JOSEE Josie was three years old, but owing to a congenital condi- tion he had never been able to walk. The visiting nurse found him sitting on the floor or in a chair trying to amuse himself, and determined that something should be done to 67 68 " THE HOSPITAL AS A SOCIAL AGENT " better his condition if possible. She brought him to the dis- pensary for examination, and the doctor referred him to the hospital ward for treatment. Josie's father had died a few months before, leaving the mother with three children and pregnant. A widow's pension was secured for her and help from a relief agency, that she might take care of her children herself. But Josie was bound to grow up a helpless, dependent child unless something was done to straighten his legs and make them strong enough to hold him up and to be of use in walking. The mother had a great enough task to keep her family together without having a crippled child to support, to say nothing of the boy, whose whole life would be marred by this handicap. The problem in this case was to direct the medical social service toward making a normal child who would be capable of taking and holding a normal place in the home and in the community. These facts were given to the doctor, who at once became interested, and set to work to build up the physical condition of the child ready for the operation. Josie was especially bright and attractive, becoming a favorite with everyone in the hospital, and he was given every opportunity with medicine, food, and fresh air to prepare for what was before him. Finally the doctor operated on his legs, putting them in casts, as he is seen in the picture. In his usual happy disposition, Josie spent the weeks in this constrained position waiting for the day when he should be free from the fetters whose purpose was a mystery to him. The great day came at last when the casts were removed, and it was only surpassed by the day when he stood for the first time in his life on both feet. He soon learned to walk, and the social worker was instructed by the doctor to obtain proper shoes that would give the support he needed until he gained strength in his feet and ankles. Any- one witnessing the mother's joy and gratitude when she took Josie home would feel that time, money, and efforts had been well spent in putting this boy literally on his feet. Josie now has a new father, the family are living in the country, are self- sustaining, and in a position to continue so, and the case has been closed by the different organizations assisting. The derrick has lifted the load, swung it about, dumped it on new ground, and reconstruction has been accomplished. Fig. 9.—Josie in casts. Fig. 10.—Josie returned to his family. FRANKTE 69 Several important principles in social work are illustrated in this case. First and foremost, the individual was trans- ferred from the dependent class to the independent; second, the family was kept together, and through the close touch of different organizations the mother was taught many things of value about the care of her children, and the moral support she received helped to make her a better home-maker; third, the Home for Crippled Children was robbed of one poor victim, and the dismal, dark room where Josie spent his days lost the child who now runs about wherever he will, playing like other children; fourth, the case demonstrated the need for hospital social service, and shows its place in the commun- ity. There is no question of the economy of individual and public resources. Frankte Five-year-old Frankie was brought to the hospital with badly crushed legs, having been run over by an engine while " hopping trains," as he hrmself said. The surgeon found there was no hope of saving his limbs, and it was necessary to am- putate them at once. He made a good recovery, and in time was completely healed and ready to leave the hospital, but where was he going and what was he to do, with his whole life before him and no means of locomotion? He had been living with his uncle and aunt in a mere shack of a place, under the worst home conditions that could be imagined—drunkenness, dirt, and shiftlessness abounding. His parents were Slavish, but nothing is known of them or any other members of his family except an older brother, who came to see him later. His uncle and aunt soon stopped visiting him at the hospital, for they considered him no good to them, and as he was devel- oping into a very lovable, bright boy their home was not the place for him. The first thing to investigate was the arti- ficial limb proposition, and see if he could be fitted at so early an age. This was found entirely possible, and a subscription was started to raise the necessary funds. Among nurses, officers, and doctors at the hospital, friends, railroad officials, 7o " THE HOSPITAL AS A SOCIAL AGENT " and hospital board the sum of $200 was raised and the limbs were ordered. At Christmas time Frankie received the gift of a little wagon, with which he pushed himself all about the hospital. He was so agile he climbed about like a monkey, and no task was too hard to deter him from attempting. These qualities showed what there was in the boy to make him worth while. The day came when Frankie was to go to a nearby city, where his limbs were being made, to have them tried on, and the journey was a wonderful experience for him. As one night must be spent in the city, arrangements were made with a sister hospital to care for him. When he returned the days seemed long awaiting the arrival of the "new legs," as he called them, but at last they came, and there never was a prouder, happier boy than he when he stood on them and realized that he was to be like other boys again, or nearly so. As soon as he could get about without help he was transferred to the County Children's Home, and so became a county ward. Frankie has made a place for himself in this home, is much beloved, goes to school with other children, and is waiting for someone to love him hard enough to adopt him. So we might go on, showing specific examples of medico- social work directed toward human economy. Every indi- vidual member of society is needed for some part of the world's work, and just so far as he is unfit for his job the world in some degree suffers. Our task, then, is to eliminate the evil and dangerous influences, to effectively repair waste and damage, and to create wholesome surroundings for human beings. It is the whole man, physical, mental, and moral, that must have consideration, as the normal or abnormal condition of one part affects the others. Jack London says, "Men cannot be worked worse than a horse is worked, and be housed and fed as a pig is housed and fed, and at the same time have clean and wholesome ideals and aspirations." This is only too true, and the trend of the present age is to bring about the adjustment of affairs and conditions so that Fig. 11.—Frankie, after three years in the home. HUMAN ECONOMY 71 human energy will be conserved and used to the best advan- tage. There are many individuals who form a part of society who do not appreciate values in any way; their life is more or less of an existence without thought of economy or any day beyond today. Neither do they realize their relation to other members of society, so live independently and freely. Those who do understand values and relations have a deep responsi- bility for the education of the rest, and for the forcible ad- justment that is necessary for the protection of all classes. In this matter of human economy the hospital is deeply concerned, for it is dealing with the physical energy in man. As it was stated in a previous chapter, the patient who is forced by reason of circumstances to seek free or part free treatment is entitled to the best service that can be provided, and the hospital organization must be equal to this demand. The medical staff is a most important part of the organization, and the guards at the entrance should be so watchful that it is impossible for any unscrupulous or self-centered doctor to gain admission. Viewing the hospital from the side of its responsibility as a social agent in the community, nothing is more deleterious to its life and growth than to have on its medical staff physicians and surgeons who are careless and indifferent in the performance of their duties, or who make free patients the victims of exploitation. Some doctors of this type in their private practice obtain money from ignorant, unsuspecting people who receive no benefit, and when their money is gone they are obliged to seek free treatment either in the dispensary or hospital. Fortunate are they if the delay has not jeopardized their chance for recovery. Knowing these facts, then, are not social workers who admit patients for dispensary service justified in accepting a person for treatment who is ignorant enough to become a 72 " THE HOSPITAL AS A SOCIAL AGENT " prey to such doctors? And in sparing such a victim are we not relieving the public from a possible danger or burden? We would refer to Chapter II (p. 21), where the duties of the admitting officer are spoken of. There is another class of persons we believe to be eligible to dispensary service. It is those whose financial resources should be conserved either for the support of the family or for the waning human forces which will be soon exhausted. Again, there is a class of patients whose condition is such that if the complete facilities offered in the hospital and dispen- sary are made use of there is every chance for their full re- covery, whereas the inadequate office equipment of the pri- vate physician to whom they might afford to go lessens their chance. Do not principles of human economy and economy of resources apply here? We would not for one moment submit to any abuse of the dispensary or hospital if we were aware of it, nor would we rob the private physician of any practice that rightly belongs to him, but it does seem that human rights may claim as much as unscrupulous, selfish doctors. The economic resources of the communtity should be a matter of much concern. All that has been said about human economy applies to this part of the subject, for adequate treatment saves time, and time in the hospital costs money. Every man of good earning capacity helps to circulate money, and every one who is equal to his task is worth money to his employer. Compare the ablebodied, efficient workman with the shiftless, broken, incapable class that is shipped about the country for cheap labor purposes and employed by big corporations in construction work. They are a burden to every community they enter, either in the police courts, almshouses, hospitals, or relief agencies, and they contribute nothing to the business, as they have no money to spend. JOHN R. 73 The case of "John R." shows how one of these undesirable floaters was returned to his own people and the community was spared the burden of his support. John R. John R., age thirty-one, U. S., address European Rooming House, laborer, not working now.; physical defects, right arm amputated, apparently feebleminded. The patient applied at the Out-patient Department for treatment of an axillary abscess. This was taken care of, and he was discharged as cured in a week. Although the medical service rendered was very small because the need was slight, a complicated problem was opened up which called for intensive social work. The record reads as follows: Sept. 3/15. Patient was very dirty when he came to the dispensary for treatment, calling forth a protest from the doctor who attended him. As he was staying at a cheap lodging house, without proper facilities for a bath, he was given a card to a settlement house in the neighborhood for a bath. Clean clothing was provided also. Sept. 5/15. Patient returned to the Out-patient Depart- ment for surgical dressing. He looked much improved and expressed gratitude for the favor. Something in the man gave the impression that there must be some refinement back of his feebleminded, unkempt condition, and inquiry was made about his home. Handicapped as he is, it is going to be dif- ficult for him to support himself, and he will be likely to fall a prey to unscrupulous persons who will take advantage of his feeble mind. He gave a very accurate address of an aunt in the East, and a letter was written to her at once, stating his circumstances, and asking if there were some relatives that could come and take him where he might have the protection he needed. Sept. 12/15. Reply was received from the aunt, saying that John had two sisters and a brother whom she was writing to the same day, and she was sure they would send money for his return home. They had been trying to locate the boy for some time, but had failed, and were indeed glad to know of his 74 "THE HOSPITAL AS A SOCIAL AGENT " whereabouts. Call made on this date upon a Mr. V., who keeps a lodging-house across the street from the one where John is staying. As we knew that Mr. V. would co-operate with us in the case, we asked him to get John over to his place that he might help to keep track of John, and whatever ex- pense was incurred for his board would be met when the family were again heard from. Sept. 13/15. Mr. V. telephoned that John would not change his boarding place, as he preferred to stay where he was. He says certain lawyers have his case to try and get a settlement from the railroad for the loss of his arm. They are paying him $5.00 a week while he is waiting, and say they have sued for $50,000. John expects to get one-half when the claim is settled, so he is much elated at the prospect. Sept. 29/15. Letter received from the sister in the West, enclosing one for John and $30 to be used for his expenses home. John visited the hospital, and his letter was given to him, but the money was left with the social worker until he is ready to go. Oct. 5/15. John's uncle from the East came to see what was best to do with him, as the family did not wish to have him roaming about the country. The uncle seems to be a kind- hearted, good, intelligent man, and says that John has lived at his house much of the time since his mother died. He has a roving disposition and will not stay at home, although they have done everything they could to hold him. For months at a time they would not know anything of him, and he has not been home now for about three years. Oct. 7/15. The uncle returned to his home. In the two days of his stay he called on the claim agent of the railroad and also the lawyers. The claim agent said John was a trespasser, and so they were in no way responsible for his treatment, but they had paid the hospital bill, gotten him a new suit of clothes, and given him $10 for his ticket home. Nothing else could be expected of them. The lawyers said they were hopeful of getting a settlement, that they had many such cases on their list, and were very successful with them. They wanted John to stay in town until the case came up in court, and they were willing to pay his expenses in the mean- JOHN R. 75 time. While in the lawyers' office John came in, and the uncle was much shocked to see how changed he was. His mental state was much weaker than when he last saw him. John was a patient in the Texas State Hospital a few years ago, and he has been wandering about since he was released from there. The uncle talked with him in a confidential way, and found that he had delusions and hallucinations, and he felt that it would be difficult to care for him at home. If possible to accomplish it State Hospital care was best for him. Not wishing to take the responsibility himself, he telegraphed to his sister, asking if she would advise placing him in a hospital for the insane. She replied she wished the uncle to use his judgment in the matter. He called upon the Probate Judge, to ask if he would commit John to a hospital in this state, but he said John's legal residence was not here and he should go to his home to be committed. As the laws of the other state would not permit a relatiye to bring a patient back for the purpose of committing him, the judge advised leaving him until the lawyers had finished with his case. It might work against his chances for a settlement to declare him insane. With these facts in consideration, the uncle thought best to go back and leave John's case in the hands of the social worker to complete as matters developed. Nov. 12/15. John reported that the lawyers had not suc- ceeded in getting his case brought into court, and as it might be some time before they would accomplish anything they thought he had better go to his home, and they would send for him if it did come up. John is willing to go and wants to start at once. Nov. 13/15. Bought railroad ticket and wrote out direc- tions for changes of cars, etc., and arranged with Mr. V. to put John on the train, giving him a small amount of change for meals. Telegraphed the uncle when he would arrive home, and sent balance of sister's money by mail. Nov. 17/15. Received letter, saying that John had arrived home, and that they would keep him there until they could decide what was best to do with him. A year later learned that John had been at his uncle's or his brother's ever since he left here, and he was getting along 76 "THE HOSPITAL AS A SOCIAL AGENT " pretty well, but they could see he was failing mentally. Before leaving for home he started to drinking quite heavily and took no care of himself, seeming to desire nothing but a mere existence, so he was a pitiful specimen when he was put on the train. The uncle, having seen him, and knowing how unkempt he was, desired to save the family the shock of his appearance, so he met him at the train and had him cleaned up before taking him home. There are some undesirable persons that can never be made to take their place in the world, but there are others that may be helped to become self-sustaining and relieve the community of the burden of their support. If municipal and county authorities could appreciate these economic values, they would then become helpful social agents, and money spent for useless individuals might be saved for those who are beyond working ability or who are accidentally help- less. These officials would profit by securing the service of a competent, experienced social worker, who would help to give them a social vision which they are incapable of because of the blinding effects of politics or greed of gain. How use- less to support a young fellow indefinitely in the county home, who is unfortunately crippled by a double amputation, in- stead of spending $200 to secure artificial limbs and fit him for some place in the world. With a social worker to adjust him to his work and to his place, he may be transformed from a useless dependent to a self-respecting citizen, capable of his own support. From the standpoint of the saving of money it is a simple problem in arithmetic, counting the man's board in the home at $15 a month, in one year he would cost the county $180, almost as much as the artificial limbs. Multi- plying this amount by forty years, which would complete the average life, one can readily appreciate the fact that public funds are expended to no purpose except to keep the man alive. ECONOMY OF RESOURCES 77 The loss of service to the world, and the injustice to the young man by depriving him of his ambition and opportunity, is also a serious consideration. Social workers are well aware of the disadvantages arising from the lack of appreciation of the real social needs of the indigent poor by public officials in town and county. The proper solution of a social problem may require the assistance of one of these agencies, but there is often great difficulty in getting them to understand the value of real adequate treat- ment, and, as there are no other means at hand, workers are at a loss to know what to do. These officials are prone to employ incompetent persons for positions where experts alone should be placed. While larger salaries must be paid to secure such competent help, money would be saved by shortening the period in which the individual might be de- pendent. The most efficient service is the most economic all around. True, the indigent class of people are very unsatisfactory to deal with, but the community demands proper handling for its own protection, and do not these people with their social problems properly belong to public agencies? Then why should not the tax-payers insist upon the most economic, practical, efficient expenditure of the public funds for the care of its indigent, dependent members, both for the sake of the individuals themselves and for all who make up the community? This question of human economy and economy of re- sources then should enter into the solution of all our social problems. Any slipshod way, or the one which follows the lines of least resistance, is an injustice to all concerned; in- deed, it is almost a crime against humanity. No case should be taken care of without the ultimate good in mind, and in these days of experience and research there is no excuse for any social work which is not as scientific as medical work. 78 "THE HOSPITAL AS A SOCIAL AGENT " The wonderfully scientific work which has been done in France in the treatment of wounded soldiers illustrates in a remarkable degree the principles of economy. The work is medical, but it is also social service. The whole plan of organ- ization is based upon the economy of the lives of the soldiers, of their vitality, and the economy of time and money. There must needs be as many men saved and returned to their places in the army as possible, and medical experts have stud- ied to find a method of treatment which would conserve vitality by hastening repair. Prophylactic measures are used as soon as men are brought wounded from the battlefield without waiting for the hospital to be reached, and many lives have been saved through this one precaution. Again, those who are maimed beyond complete repair, receive the most skilful attention to produce the best possible results that utter helplessness may not be their lot the rest of their lives. Here is a social and a medical service to the whole world as well as to individuals, and it should be a lesson in economics to all social workers, but especially to those engaged in hospital work. CHAPTER VIII THE PLACE OF THE HOSPITAL IN PUBLIC HEALTH WORK The latent possibilities of hospital social service lie in the important aid which may be given to public health work. Both the immediate community and the state have or should have comprehensive programs for public health work, and the hospital should be included among the co-operating agencies. Public health must be promoted by the efforts and co- operation of every member of the community. If one man suffering from tuberculosis spits on the sidewalk he endangers every other person in the community, but if every person re- frains from spitting, no one is put in danger from this source. The question resolves itself then into a matter of educating the public to avoid the sources of danger. That part of the public which does not wilfully recognize danger, must be forced to observe certain laws for the protection of all. Thus it has become necessary to make laws prohibiting spitting. The people of the United States have sometimes misconstrued the idea of freedom to mean, that if I wish to throw my garbage over the fence I am permitted to do it, so long as it does not annoy me nor my family and if it saves me trouble and expense. I am the cine, as well as my neighbor who is ignorant of the danger there is in my open garbage and his uncovered manure pile, for whom public health laws are made and enforced. 79 80 " THE HOSPITAL AS A SOCIAL AGENT " Not only must we educate people, either willingly or for- cibly, but we must provide adequate means and facilities for the care of communicable diseases or those which are the result of unsanitary surroundings, and see that health offi- cials enforce the laws which eliminate and regulate all possible sources of danger to the health of the community. Adequate means and facilities for the care of disease include sufficient hospital beds, and proper equipment to take care of tuber- culous patients and those suffering from all contagious and specific diseases. Unless a community can properly take care of those who are sick from these ailments, it cannot expect to stop the progress of disease nor to effectively educate the public to its danger and to the necessity of medical care. Another feature is important, that of careful examination and diagnosis, and the detection of disease in its beginning stage. This is where the hospital and dispensary can aid so efficiently in Public Health Work, for its equipment is com- plete and its medical service equal to the demand. Differ- entiation in diagnosis can be more easily determined, and the social worker is able to direct her efforts in the right direction. This is especially true with venereal diseases and tubercu- losis. Those needing special hospital care are placed where they can be treated; those who may be taken care of in the homes and treated by dispensary physicians can be followed up with evident benefit; those who are beyond help may have medical and social treatment directed toward the com- fort of the patient or his removal to a place of safety for others of his household. David, a Tuberculous Patient David, age seventeen; single; born U. S. Feb. 7/14. Patient referred from the Out-patient Depart- ment to the hospital, quite sick with pleurisy. Investigation Fig. 12.—A breeding place for physical and moral disease. Fig. 13.—The little girl on the extreme left is already showing the truth of Jack London's saying. DAVH), A TUBERCULOUS PATIENT 8l shows that he and his sister, nineteen years old, live with and support their grandmother, who has raised them from child- hood. The sister is a typewriter, working in a company office, earning $35 a month. The patient has been making $10 a week for a short time, driving for a grocery store. The family pays $15 for three rooms in a flat, without heat or light. The boy has been sick three weeks, consulting a doctor but once before coming to the Out-patient Department. Examina- tion in the dispensary showed pleurisy with effusion and prob- ably pulmonary tuberculosis. Called David's sister by tele- phone to tell her that he was admitted to the hospital, so she might explain to the grandmother. She came to the hospital to see the social worker, who told her the nature of David's trouble, and what might be necessary for him when he was ready to leave the hospital. Feb. 9/14. Visited the home and saw the grandmother. She fears that they must move into cheaper rooms if David is ill and unable to contribute to the support of the family, but she will do the best that she can. The family being Catholic, the case was reported to the St. Vincent de Paul Society for as- sistance if it became necessary. Feb. 21/14. Visitor from the St. Vincent de Paul Society called to say that they had no funds to pay for David at a sanatorium, if it seemed best to send him there, but they would be glad to give the family relief if that was necessary. Feb. 25/14. The attending physician on the ward reports the condition of the patient so favorable that he thinks it will not be necessary for him to go to a sanatorium. As he has an uncle on a ranch in Montana, he thinks he may be able to arrange to go out there to recuperate. This plan is approved by the doctor, when the weather is favorable and the patient's strength will permit. Feb. 26/14. Saw sister and talked over the plan with her, and asked if David could be cared for properly at home until he was able to go away. She said she thought he could, and that she would write at once to the uncle, so as to start preparations for the trip. March 1/14. Visited the home and talked over necessary arrangements for the home care. Find that he can have the 6 82 " THE HOSPITAL AS A SOCIAL AGENT " exclusive use of the front room, where fresh air can be obtained day and night. Gave instructions as to the importance of fresh air and proper food and necessary precautions to take. March 14/14. Patient was discharged from the hospital and went home. Ordered 1 quart of milk and \ dozen eggs sent every day, and had same charged to the Antituberculosis Society, by their order. He is to report to the dispensary twice a week for observation. April 2/14. Visited patient in his home, and found him in splendid condition; he has gained 10 pounds since leaving the hospital. He has heard from his uncle in Montana, who sent him the money for railroad fare, and he will let him know as soon as the weather is warm enough out there for him. April 11/14. Patient returned to the Out-patient Depart- ment with a return of pleurisy, and the doctor referred him to the hospital wards again. His condition at this time seems to point more decidedly to a tubercular involvement, and the doctor advises a short stay at the sanatorium before starting to Montana. It was then necessary to find some means to pay the $5 a week fee at the sanatorium. This was obtained ($30) from the "Fellowship Fund" in one of the Protestant churches. May 16/14. Patient transferred to the sanatorium by his sister, she furnishing the money for the trip. July 11/14. Patient returned from the sanatorium, very much improved, having gained 20 pounds in weight, and looking rugged and well. He made good progress during his stay, and the doctor's judgment is that his is an arrested case, which will do well in right surroundings. July 18/14. Patient started for Montana, very happy and grateful for all that had been done for him. Before leaving a visit was made to the pastor's study at the church which had furnished the money for sanatorium fees, in order to thank the minister in person for the aid which had been given. Nov. 10/14. The following letter was received by the social worker which will speak for itself: "Dear Miss C: I'm sending you a few lines to tell you how I am. I feel fine out here, the air is fine, and I can eat like a horse. I hope you feel the same. Please excuse THE HOSPITAL IN PUBLIC HEALTH WORK 83 me for not writing, we've been branding calves and horses and making hay for winter. I got awfully strong out here, I have lots of fun riding horses and hunting wolves and wild ducks and chickens. I have 320 acres of land right near my uncle's place. Be sure and write and tell me how you are and everything at home. I lost the minister's card, so do not know his address, you can send it to me, I like to write him a letter. Well, goodby, from your friend, David." Recognition should be granted the hospital as a co-oper- ating agent in the program for public health work, and in order to command this service the hospital organization, medical and social, must prove its efficiency. With this es- tablished, why should not the dispensary be sought by city and county authorities for its examining agent, and a certain amount of money be appropriated regularly for this service? Would this not be better, from the standpoint of economy, than to trust this important work to incompetent means at their disposal? And would not more efficient work be accomplished for the welfare of public health? Another valuable aid is shown, by careful examination and accurate diagnosis that is possible in the dispensary, in the detection of such contagious diseases as diphtheria, scarlet fever, and small-pox. Take, for example, the young man who arrives in the city without money or friends, and, feeling sick, seeks the dispensary for the doctor's advice. General symptoms, throat condition, laboratory examination, present unmistakable evidence of diphtheria. He cannot be taken into the hospital that has no contagious ward, nor is it just to him or to others to send him out on the streets, knowing he has no home to go to, nor any means of obtain- ing suitable care. A message to the local board of health, whether or not they have a contagious hospital, should be 84 " THE HOSPITAL AS A SOCIAL AGENT " all that is necessary to obtain immediate attention in this case, and it is the only one that should satisfy the public mind for the protection of every member of the community. Aside from the accurate diagnosis of cases and actual care of patients, the dispensary is an important aid in the program of public health work through its value as an edu- cational center. There is no focal point more crucial than this for education in the laws and principles of hygiene and good health. Especially is this true with tuberculosis and ve- nereal diseases and the disorders of infants due to ignorance of parents. The social worker makes special effort to investi- gate the home surroundings, discovers the unsanitary condi- tions, and sees the unhygienic ideas manifested in the symp- toms of the patient and recognizes the danger to others. With this intimate touch in the home, and the vantage point in the dispensary, where numbers may be gathered together in classes, the benefits of teaching are enhanced many fold. Such splendid work may be done by grouping the mothers and babies, and, by means of demonstration and instruction, to show the mothers the proper methods in the care of their babies and the reasons why. A spirit of interest may thus be engendered to follow instructions and watch the results, not only each one in her own baby, but in every other child that is brought to the class. This is a part of the program for infant welfare which should form one of the co-operating forces in this line of public health work. The importance of education in the clinics for venereal diseases cannot be overestimated, as we are dealing with the direct results of the cause of the trouble. We are able to reach the very source of the spread of the disease, bringing special emphasis upon the dangers to present and future generations, besides the danger from direct contact. Illustrative of this is the case of a young girl seventeen v rS"^*.- Fig. 14. Fig. 15. Figs. 14 and 15.—What can be expected from children with playgrounds and "igs like these? THE HOSPITAL IN PUBLIC HEALTH WORK 85 years old who visited the dispensary for treatment of a throat trouble. The specialist recognized an active case of syphilitic infection, which called for prompt treatment to prevent further progress of the disease and imminent danger to others. The girl was a nurse maid in a family where there were several small children, one a baby which was her special care, and whom she was in the habit of kissing and fondling. Here was a desperately critical situation, where not a moment should be lost in starting immediate medical and social work, and it is needless to say the girl had hardly left the dispensary before the note of warning to the mother of the children in the home was sounded over the telephone. In the prevention of the spread of eye diseases and the conservation of sight there is an important co-operative work. Wonderful results may be obtained through home investigation and instruction in prophylaxis and hygiene, and in bringing about the persistent return of the patient for treatment until he has been cured. Also in co-operation with school nurses and teachers, securing necessary glasses for pupils that the sight may be saved, a public service is rendered. So we might go on elaborating along different lines, but enough has been said to expose the underlying principles which the social worker in any small hospital community may put into practice in the development of her department. We feel sure that all will agree that the development of hos- pital social service must be along the lines of public health work, which is broadening out to meet the demands of the community for protection against all sources of danger to the health of its individuals. CONCLUSION In the foregoing chapters an endeavor has been made to demonstrate the established work of the hospital social service department and to show its future possibilities. The hospital has always held a most important place in the com- munity, indispensable in its service to suffering humanity, and winning its way into the hearts of the people through increasing confidence in its work. Social service has devel- oped the hospital's value and increased its usefulness as a social agent. It has placed the hospital in the forefront as an important asset in the welfare of the community and of the state. Much stress has been laid upon the service to the indi- vidual, to the community, and to society, and the reiteration may seem superfluous and tiresome to some degree, but its great importance links it so closely to effective, adequate service that it will bear frequent repetition. Individuals make up the community, communities form society, so what- ever good or evil is in one affects the others, and whatever influences are brought to bear upon one helps to make the others. An individual burden becomes a community burden and individual economy is a community benefit. These are things that science teaches us. Social work has become scien- tific in as great a degree as medical work, for it deals with the whole man—his physical condition, his aspirations, his pas- sions, his work, his place in the world. Sickness is often the adversity which changes the life and purpose of the man; it sometimes forces him into entirely different channels, 86 conclusion 87 where new adjustments are necessary. "The study of char- acter under adversity is the essence and center of social work." Opportunities for great service, therefore, come to hospital workers and make the obligations to the community most profound. Social service is not new in its conception or operation. It is but the scientific development of what was formerly called "charity work." Yet there existed in the minds of the charity workers years ago the essential principles of most effective social service. Because of the voluntary element organization was incomplete, and facilities which are at hand today were not available for the proper conduct of case work then. Illustrious examples of volunteer workers remain in the memory of beneficiaries never to be erased, and these workers are the ones who have laid the foundations for the present scientific system. While hospital social service is one of the new developments, it is really only the application of old, tried principles to the needs of hospital work. The inspiration for this book came from long association with one who was a leader in many benevolent enterprises thirty or forty years ago. She worked out social problems with a wonderful insight into the causes of social maladjust- ment, and broad ideas of reconstruction. Yet her days of active duty were over before the hospital child was scarcely out of its swaddling clothes. It was her love of humanity and her sympathy for people to whom adversity came, and her service which was actuated by a Christ-like spirit, that produced the far-reaching results whose influence is still felt in the community where she lived and worked. We can scarcely conceive of a successful social worker in the hospital whose life is not dominated by the love and spirit of Christ. The hospital has always been a sacred in- stitution. The first one was established by the Good Samar- 88 " THE HOSPITAL AS A SOCIAL AGENT " itan when he found the wounded man, placed him on his own beast, and took him to an inn. We are told he took care of him, and in the morning when he departed he endowed the first hospital ward for this patient. Thus, what we now call social service was made complete in this case, and Jesus said to the lawyer whose question called forth the parable, "Go, and do thou likewise." APPENDIX Facsimiles of the different forms of blanks used in the Social Service and Out-patient Departments of the Youngs- town Hospital are here appended for the purpose of suggest- ing to those who are seeking help a plan of record keeping which has been worked out and found to be complete and yet simple. The matter of records is most important. Social histories which exist in the memories of workers are utterly valueless, yet it is many times a question with busy workers whether to sacrifice the social work or the records. History taking and record keeping then resolves itself into a matter of pro- viding blanks that are simple but comprehensive, and of developing an indexing and filing system so easily understood that the records are available to any hospital official seeking information. Reference blanks are of the greatest value, as they work automatically in carrying out the system for the proper care of the patient, and help to complete the records. This is shown in the set of cards and blanks which take the patient, Annie Yorchek, from her admission to the out-patient depart- ment, through the hospital, back to the out-patient depart- ment again. Record keeping should be so planned that a complete history of a case may be made with the greatest conserva- tion of time and energy on the part of the worker. The plan should also be perfect enough to furnish accurate information of the medical and social status of the patient, and the full 89 go "the hospital as A social agent" record should be filed in one envelope or holder with all cor- respondence or papers which pertain to the case. Some of the blanks in the facsimiles have been filled out to demonstrate their use, while others are self-explanatory. Q^h**£*/*-*-,^-.<9j , 7 * *i-^*qt,'L,/i Ho«pltalNo//f-/ ff f Wart 'Of-________SerHc. Q/fr^ f^S ^g____tfattonam, qt4pS3CTn.v.±tll,$---at, Xt»-^U *«*»»*__c£&A<0^> . g^i^y^^L/* ■&- -&^S Fig. 16.—Hospital Social Service case, short history form. This card combines the case history and index card, and shortens the process of history taking and filing. The name, address, hospital number, ward, service, and date of admission is obtained from the hospital admission blank, and the card is taken to the bedside of the patient for the record of the social history. If no special work is necessary for the patient, all that is required to complete the record when he is discharged is the diagnosis, discharge date, and a statement of the disposition of the case. This card is then filed with the other index cards, and its face shows it to be a short history case. appendix 91 yif*.* *\ <%*. 0^ Fig. 17.—Reverse side of history case card. 92 "the hospital as a social agent The Youngstown Hospital Association Social Service Department Hospital No. Name S. S. Dept. No. XAA4.fi--------------RAT,0ft, BOBTTi!---------------------------------------558------ Address Service W:ui "*,""■♦■" «♦-■------------------------------------Q*1*^-------------11---------- Admined Discharged Age Nationality Years in U. S. City 1/S1/1B a/13/tR-----84-------Huns.----------2-----------2--------- Religion Pastor Hime»i-<»" WafnT-mnrl------ReV.Panlffl--------------------------M. ft W. ^.--------- Diagnosis ---Pregnancy ■------——-------------------------------------------------— History, etc. . , Jnn.31.1915. Patient presented herself at the front door asking ad-— mission for her confinement. The case was referred to the S.S.Sept. to obtain social history before admitting her. Her story was that her husband was not good to her, that ha swore and abused her, and she wished to escape these troubles when she was sick. There was no one to care for her at her home, and she felt she would soon be slcir. Her husband works at the Steel Hills, and they liye In a part of her husband's father's house. As she was a member of Rev.Panto's Church called him by 'phone to ask If he .knew of the woman and her troubles. He came to the Hospital and saw her, listened to her story, and said It was no doubt true What she said about his abuse, and that her sad face told the story. These fasts were corroborated by a patient in the ward and her husband, as they knew her. The doctor's examina- tion' showed a probable wait of two weeks longer, but as the weather waa most severe outside, and her husband had driven her from home the night before, she was admitted, after consulting the superintendent. Feb.!.1915. Patient was confined early this morning. Feb.13.1915. Patient's husband took her home. The minister had talk- ed with him and prepared the way for the home-coming. Fig. 18.—Hospital Social Service case history form. This record is used in cases where more intensive work is done, or the nature of the case needs a fuller record of the facts. BALOG, ROSIE #538 114. flanfftt. «♦ __________________________________ Fig. 19.—Index card for Hospital Social Service case. ^ JThe Youngstown Hospital Association PTt CHARITIES Out-patient Department mi ik/t AN£ £OC. Social History and Record V.N. A. Q/dt^CA/CC*^ My COS. Fig. 20.—Out-patient Department Social History case form. The so- cial history of each applicant for medical treatment is taken on this blank, and the eligibility of the patient for admission is based upon this history. Any necessary investigation of the case is subsequently made, and if inten- sive social work is done, a record is written on the reverse side of the blank. THE YOUNGSTOWN HOSPITAL ASSOCIATION O. P. D. »«V*U/^,/ V07? 5*iyD nn^K Ssb pa ,j$o jyiy> map yry>n Tf d>b wan* .ty^vya .d5 "vtk »tid lyaana w n bdwwb -un* nap yryn Fig. 23.—Reverse side of admission card. APPENDIX 95 39-37718 The Youngstown Hospital Association Out Patient Department, Oak Hill Avenue Hours 10:00 to 11:00 a. m. daily except Sundays and Holidays Name Referred b\- 5%\ &J^L Clinic List Other Side Fig. 24.—Reference card for outside agencies. CLINICS General Medical, Every Week Day. General Surgical, Every Week Day. Genito-urinarv, Every Week Day. Eye and Ear, Monday, Wednesday and Friday. Nose and Throat, Monday, Wednesday and Friday. Obstetrical, Friday Only Orthopedic, Tuesday and Saturday Dental, Every Week Day. Fig. 25.—Reverse side of reference card. 96 THE HOSPITAL AS A SOCIAL AGENT PATIENT'S CHECK Take this to Druggist to be stamped be-fore leaving. Youngstown Hospital Association Out-Patient Department Treatment Free to the Poor Medicines and Supplies at Nominal Prices Amount Supplies Furnished Price Prescriptions,__ Silver Irrigat No. Supplies Fur. Total........ ..............................................................M. D. Supplies furnished must be indicated above and signed by physician before patient will be passed out Date PASS CHECK Amount Paid Fig. 27.—These round tickets, kept on a spindle at the desk, are given the patient to indicate his turn for treatment, and to avoid confusion in getting him into the blg. lb— Fatient s check which is given right room. Different colors indicate dif- to him when he is admitted each day. ferent rooms. APPENDIX 97 Form M-WUO The youngstown hospital association O. P. D. NOTATION ON THIS mcORD) MAY.28 J?16_.....,.._.............................................lOfyf.: S'- &......................................................."'""......"~......... . /^%*4j^ a£u 1916 J^/. ??%'- r/2./f?. /£ Fig. 28.—Medical history card. The date is stamped at the desk on the day of each visit before the card is placed in the clinic room, thus insur- ing correct dating. 7 THE YOUNGSTOWN HOSPITAL ASSOCIATION O. P. D. Date P^/f/* Executive Director:— In my opinion this patient should be admitted to the hospital for treatment—tot operation. Diagnosis..........^^<^T^^..................................._.......... Fig. 29.—Reference slip used when a patient is referred for admission to the hospital wards. This is pink in color. Q^V-^-^WtL I would recommend that this patient be admitted to the Hospital. Investigation would show that charge should be made to ial Service Director Patient admitted under No. .^...^„i^1^k^dk^^..i......-."........... Af Supt Fig. 30.—Reverse side of reference slip. This accompanies the patient to the hospital office, and is returned with his admission number, and is filed with his record in the Out-patient Department. 98 APPENDIX 99 YOUNGSTOWN HOSPITAL ASSOCIATION OUT-PATIENT DEPARTMENT REFERENCE CARD £st*st*-^ Q^t-A^f/"* Length of Tir State / »wy Support .of Family ffife>< \Ay> O/Ctf* tf 7^' Employer Up- Weekly Wag« $JM Physical Defects or Other Extenuating C Name* of Children CaicNo. -5C«*w*-* 4^ J?jr-*g At. J14- ReleWTby 94-„>^/ /p.? 7 X RcfeW3by @>A./«dt /?7S ■£ P P y—^-^t-J Silt 7^»vv edition Dr. Galbraith's book tells you how to train the physical pow- ers to their highest degree of efficiency by means of fresh air, tonic baths, proper food and clothing, gymnastic and outdoor exercise. There are chapters on the skin, hair, development of the form, carriage, dancing, walking, running, swimming, rowing, and other outdoor sports. Personal Hygiene and Physical Training for Women. By ANNA M. Galbraith, M.D., Fellow New York Academy of Medicine. i2tno of 393 pages, illustrated. Cloth, $2.25 net. Published January, 1917 Galbraith's Four Epochs of Woman's Life This book covers each epoch fully, in a clean, instructive way, taking up puberty, menstruation, marriage, sexual instinct, sterility, pregnancy, confinement, nursing, the menopause. The Four Epochs of Women's Life. By Anna M. Galbraith, M.D., with an Introductory Note by John H. Musser, M. D. 12mo of 296 pages. Cloth, $1.50 net. Third Edition published March, 1917 Griffith's Care of the Baby NEw (6th) edition Here is a book that tells in simple, straightforward language exactly how to care for the baby in health and disease; how to keep it well and strong; and should it fall sick, how to carry out the physician's instructions and nurse it back to health again. Published June, 1915 The Care of the Baby. By J. P. Crozer Griffith, M.D., Univers- ity of Pennsylvania. 12D10 of 458 pages, illustrated. Cloth, $1.50 net Aikens' Ethics for Nurses ™,™otn?S This book emphasizes the importance of ethical training. It is a most excellent text-book, particularly well adapted for classroom work. The illustrations and practical problems used in the book are drawn from life. Studies in Ethics for Nurses. By Charlotte A. Aikens, formerly Superintendent of Columbia Hospital, Pittsburg, nnio of 318 pages. Cloth, $1.75 net. Published April. 1916 Goodnow's History of Nursing Miss Goodnow's work gives the main facts of nursing history from the beginning to the present time. It is suited for class- room work or postgraduate reading. Sufficient details and personalities have been added to give color and interest, and to present a picture of the times described. History of Nursing. By Minnie Goodnow, R.N., formerly Super- intendent of the Women's Hospital, Denver. i2mo of 370 pages, illustrated. Cloth, $2.00 net. Published December. 1916 Berry's Orthopedics for Nurses The object of Dr. Berry's book is to supply the nurse with a work that discusses clearly and simply the diagnosis, prog- nosis and treatment of the more common and important ortho- pedic deformities. Many illustrations are included. The work is very practical. Or:hopedic Surgery for Nurses. By John McWilliams Berry, M.D., Clinical Professor of Orthopedics and Rontgenology, Albany Medical College. Cloth, $1.00 net. Published July. 1916 Whiting's Bandaging This new work takes up each bandage in detail, telling you— and showing you by original illustrations—just how each bandage should be applied, each turn made. Dr. Whiting's teaching experience has enabled him to devise means for over- coming common errors in applying bandages. Bandaging. By A. D. Whiting, M.D., Instructor in Surgery at the University of Pennsylvania. 12110 of 151 pages, with 117 illustra- tions. Cloth, $1.25 net. Published November, 1915 10 Smith's Operating-Room The object is to show you how to assist the surgeon according to the newest operative technic. You get the result of active experience systematized, and in concise form. You get a thor- ough digest of every essential; detailed lists of instruments; glossary of medical terms. Every phase of the subject is covered by ample, practical instruction. The Operating-Room. A Primer for Nurses. By Amy Armour Smith, R.N., formerly Superintendent of Nurses at the Woman's Hospital of the State of New York. 12mo of 295 pages, illustrated. Cloth, $1.50 net. Published October, 1916 Bandler's The Expectant Mother This is an anatomy, physiology and hygiene covering those points and functions concerned in child-bearing and designed for the use of the nurse and the mother. Every question of interest to the expectant mother is treated. The Expectant Mother. By S. Wyllis Bandler, M. D., Professor of Diseases of Women, New York Post-Graduate Medical School and Hospital. Cloth, $1.25 net. Published October, 1916 Winslow's Prevention of Disease Here you get a practical guide, giving you briefly the means to avoid the various diseases described. The chapters on diet, exercise, tea, coffee, alcohol, prevention of cancer, etc., are of special interest. There are, besides, chapters on the preven- tion of malaria, colds, constipation, obesity, nervous disorders and tuberculosis. It is a record of twenty-five years' active practice. By Kenelm Winslow, M.D., formerly Assistant Professor of Com- perative Therapeutics, Harvard University. 12mo of 348 pages, illustrated. Cloth, $1.75 net. Published November, 1916 Brady's Personal Health This is different from other health books. It is written by a physician with some fifteen years' experience in writing for the laity. It covers the entire range of health questions—care of mouth and teeth, catching cold, adenoids and tonsils, eye and ear, ventilation, skin, hair and nails, nutrition, nervous ail- ments, etc. Personal Health. A Doctor Book for Discriminating People. By William Brady, M.D., Elmira, N.Y. 12mo of 400 pages. Cloth, $1.50 net. Published September, 1916 11 Hoxie & Laptad's Medicine for Nurses Medicine for Nurses and Housemothers. By George Howard Hoxie, M. D., University of Kansas; and Pearl h. LapTad. 12mo of 351 pages, illustrated. Cloth, $1.50 net. Second Edition—April, 1913 Bohm & Painter's Massage Massage. By Max Bohm, M.D., Berlin, Germany. Ed- ited by CnAS. F. Painter, M.D., Tufts College. Octavo of 91 pages, 97illustrations. Cloth, $1.75 net. June,1913 Boyd's State Registration for Nurses State Registration for Nurses. By Louie Croft Boyd, R. N., Graduate Colorado Training School for Nurses. Cloth, $1.25 net. Second Edition—February, 1915 Morrow's Immediate Care of Injured Immediate Care of the Injured. By Alberts. Mor- row, M.D., New York Polyclinic. Octavo of 354 pages, with 242 illustrations. Cloth, $2.75 net. Third Edition—November, 1917 deNancrede's Anatomy EIGhth edition Essentials of Anatomy. By Charles B. G. deNan- crede, M. D., University of Michigan. 12mo of 400 pages, 180 illustrations. Cloth, $1.25 net. Sept., 1911 Morris' Materia Medica seventh edition Essentials of Materia Medica, Therapeutics, and Pre- scription Writing. By Henry Morris, M. D. Re- vised by W. A. Bastedo, M. D., Columbia University, New York. 12mo of 300 pages, illustrated. Cloth, $1.25 net. Published March, 1905 Register's Fever Nursing A Text-Book on Practical Fever Nursing. By Edward C. Register, M.D., North Carolina Medical College. Oc- tavo of 350 pages, illustrated. Cloth, $2.50 net. June 1907 I WX 205 C365h 1918 53620910R NLM 055A1A72 b NATIONAL LIBRARY OF MEDICINE sit rvWw W gP« !%«>:*« }'•»?•?*.'■'-»; ^^j&vfe lAraSKy^K if»iv.a.;i»;jji ^wi ,t,^^^ NiiPi Ji>S*3»W'-R>5 ftSt w« :#P$ ■ ; >•;■ *>,*,»*,•'...•■! V;.*Uk..,\^W»TJK»>-.>§JJ '■v-i* NLM052818726