On the Social Frontier of Medicine: Pioneering in Medical Social Service [Reprint 2014 ed.] 9780674493568, 9780674186088

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o η t h e S o c i a l F r o n t i e r of _M.eoicine

O n

the

Social Frontier of M e J í c i n e PIONEERING

IN MEDICAL

Ida M .

HARVARD

UNIVERSITY

SOCIAL

SERVICE

Ca n n o n

PRESS

· CAMBRIDGE

· 1952

Copyright, 1952, by the President and Fellows of Harvard College

Distributed in Great Britain by Geoffrey Cumberlege Oxford University Press London

Library of Congress Catalog Card Number Printed in the United States of America

52-8215

TO T H E M E M O R Y O F M Y

BROTHER

" W a l t er B r a d f o r d C a n n o n W H O I N H I S S E A R C H FOR S C I E N T I F I C T R U T H N E V E R FORGOT

HUMANITY

Preface T H E original purpose of writing the story of the pioneering years in the Social Service Department of the Massachusetts General Hospital was to offer to the younger members of our profession a background of the special phase of social work with which they were identifying themselves. I wished to give them some understanding of what we owe to Dr. Richard Clarke Cabot as leader of the movement and to encourage them to become familiar with his writings. As the years have passed, many of us have come to realize that while we were pursuing our primary purpose of bringing needed service to hospitalized patients, there was evolving a relation between medicine and social work that might well have far-reaching significance. Social workers had long known that disease was a major complication of poverty and one of the chief causes for broken family ties, and so a serious blight to childhood. As medicine moved out into public health activities, the relation between disease and environmental conditions of living and work became glaringly apparent. When social workers in hospitals had established themselves in the confidence of doctors and hospital administrators, the common interests of medicine and social work became obvious, at least to those who had experienced the demonstration. This book, then, has not been written for its historical uses alone, but is offered as a tribute to those young men and women in both the professions of medicine and of social work who face the responsibilities of furthering the common interests of the two professions in promoting the health and social welfare of our communities. And I hope that I have made clear my conviction that only as the general public can understand and work along with these professions can we move forward on our new frontiers.

vili

PREFACE

I am deeply indebted to Elizabeth Richards Day for her help in recalling the past and for her encouragement. I am especially in debt to Helen Boyer for her editorial assistance and her eager interest in my task. IDA M . C A N N O N

Cambridge June 1952

Contents FOREWORD

by James Howard Means PART

xi

ONE

Τ lie B a c k « r o u n d 3

1

A DOCTOR'S MESSAGE

2

THE ENGLISH

3

FORERUNNERS

4

A PERIOD OF SOCIAL AWAKENING

34

5

A PHYSICIAN

46

6

WE BUILD ON FIRM FOUNDATIONS

HOSPITAL

ALMONER

IN THE UNITED STATES

TAKES ACTION

PART

8 22

5¡

TWO

Pioneering 7

WE ARE "PERMITTED"

63

8

OPPORTUNITIES

72

9

WE CHOOSE OUR ADVISORS

81

10

PARTIAL

RECOGNITION

88

11

SEEKING

OUR SPECIAL ROLE

INCREASE

9j

CONTENTS 12

INTERESTING

THE DOCTORS

ιοί

13

A BROADER SCOPE

no

14

ACCEPTED

120

15

A PROFESSION

16

WE ANALYZE

17

THE IDEA BECOMES WIDESPREAD

OFFICIALLY RECOGNIZED OUR FUNCTION

PART

Fruits

126

Experience

18

A SPECIAL PRIVILEGE

19

A SOCIALLY

20

HAZARDS

CONSTRUCTIVE

FOR

157 DISEASE

164

THE WORKER

ιΊ9

21

ATTITUDES

CHANGE

22

"ITS

23

THE PATIENT

24

MEDICINE AND SOME SOCIAL TRENDS

25

FACING

WHAT'S

140

THREE

of

INDUSTRIAL

131

LEFT THAT

188 COUNTS"

TEACHES

20$ 219 23;

NEW FRONTIERS

247

NOTES AND REFERENCES

261

INDEX

267

orewor Χ Τ is given to but few men or women to participate, vitally, in the birth and growth of a new profession. It is also rare to have the opportunity and the skill, in the rich autumn of life, after nearly five decades of selfless service, to write powerfully the saga of an adventure that has resulted in bringing comfort to millions of suffering people. Such has been the privilege of Ida M. Cannon, and now it is our privilege to read her stirring account of her pioneering career in the field of medical social work. This book that she has given us is inevitably to a considerable extent autobiographical. This indeed is what imbues it with both strength and challenge. But also the book is the history, narrative and critical, of a great contribution to medicine in which she herself has played a leading role. Miss Cannon has successfully blended the foreground of her personal experience with the background of her intimate knowledge of all that was occurring as the years passed by in the development of a new profession. The forerunner of medical social service, as it was developed in the United States, Miss Cannon traces to the preexisting hospital-almoner system of England which had its origin in a "stirring of conscience concerning the overwhelming problems of London's poor." Miss Cannon herself, through her work as visiting nurse in the river slums of St. Paul, Minnesota, had become acutely conscious as early as 1905 of the evil effect of illness when added to poverty. V e r y early she came under the spell of Jane Addams, whose inspiration started her on her way toward social work as a life interest. Coming to Boston in 1906 to pursue her studies in the old Boston School for Social Work, she encountered Dr. Richard Clarke Cabot, who, a year before, had had the genius to introduce social workers to the Massachusetts General Hos-

xii

FOREWORD

pital, for the purpose of improving the over-all medical care of patients. Social work already existed at that time, but not in hospitals. It was in its extension to medical care that Dr. Cabot's great contribution lay. Miss Cannon has made him, and quite rightly, the central figure of her story. He enlisted her in his beginning social service department at the Massachusetts General Hospital, the first time they met, and she stayed there for thirty-nine years; for thirty-one of them she was the department's Chief. This department was the pioneer of all medical social service departments. It was a prototype from which a new professional activity spread throughout the world. Miss Cannon served in it longer, and carried more of its responsibilities, than any other person. Even now, in her retirement, she works in it as a volunteer. Dr. Cabot unquestionably invented it, and his faith nurtured it; Miss Cannon took a major responsibility in its brilliant development. The early days of the department were tough going. It was a problem of "selling" social service to the doctorsmembers of the most socially conservative of professions— and great was the sales resistance. But Miss Cannon has no resentment on that score. Quite the contrary! Sportingly she intimates that it was probably good for medical social service to have to make its way against obstacles. It has emerged all the more vigorous on that account. Today it would be impossible in any large urban hospital to give fully adequate medical care without a social service department, and all the doctors in such a place well know this. On the periphery, however, history repeats itself, and there is still some "selling" to be done. I learned very recently of a situation in a general hospital of one of our smaller cities, in which a few of the younger doctors wished to have a social service department established, but the majority, together with dominant members of the lay board of trustees, opposed it. They thought that it would be too much against rugged individualism, and the word "social" sounded too much like "socialized."

FOREWORD

xiii

The evolution of attitude on the part of the medical staff toward the Social Service Department at the Massachusetts General Hospital, as Miss Cannon traces it, went through these phases—resistance, tolerance, partial recognition, and finally full acceptance and establishment as an official and necessary department of the Hospital, a responsibility of the Hospital Trustees to support. This last event occurred in 1919. In some localities this sequence may be only beginning, but I predict that it will evolve in similar style in all of them, because, as Miss Cannon's work has shown, medical social service is not for the poor alone, but for any patient in whose care a social problem exists. Medical social service is just what its name implies. It is a service, not a charity. The wealthy may have need of it at times, no less than the poor. It is a service and a skill which enables the effective carrying out, in our complex society, of the medical treatment that the doctor of medicine prescribes. Through the years, as experience accumulated, the young profession gained maturity. Progressive thinking on function, objectives, relation to other activities, yielded everclearer understanding of purpose, and constant improvement in technique. Miss Cannon portrays all these things in vivid lines. In addition to its general role, which may be important in any case, and in an infinite variety of ways, medical social work has contributed greatly in dealing with such specific problems as those of tuberculosis, occupational diseases, venereal disease, infantile paralysis, and other crippling diseases which impose terrific social problems. And finally, with full maturity of the profession comes its need to reproduce its personnel. In other words, there enters the educational function. N e w medical social workers must be produced in ever-increasing numbers. It is very fitting that Miss Cannon's book should appear soon after the

publication of Social Work Education in the United States, by Hollis and Taylor, which reviews and analyzes critically the whole situation implied by the title.

XIV

FOREWORD

Education in the field of medical social work concerns not merely the education of medical social workers. There is a big job for medical social service to do in educating physicians, surgeons, and other professional medical people in the social aspects of medicine. Medical students, interns, residents, nurses, and even attending physicians and surgeons, nowadays need instruction in what social service can accomplish in the care of the patient, of what the "social laboratory," as Miss Cannon has well called it, can contribute to the study of the care problem. Miss Cannon has not gone at great length in the present work into the educational functions, but in her life she has contributed greatly to them. This book, I predict, will come to occupy a central and enduring position in the literature of medical social service. It will be found necessary for students both of medical social service and of the practice of medicine as well. It is the word of one having experience and deep understanding of human problems. J. H .

MEANS

PART

The

ONE

Background

1 A D o c t o r s M essage I T has been my privilege to spend nearly four decades as a medical social worker at the Massachusetts General Hospital in Boston, and to be, during those years, in close association with patients of many nationalities and varied economic conditions, to serve under several hospital administrators, and to work with doctors representing many specialties, with nurses and students, with the many professional men and women who make up the modern hospital— and with my colleagues in the Social Service Department. Throughout these years I have counted among my friends members of the Board of Trustees and of the Ladies' Visiting Committee—those devoted men and women who represent the public that sponsors the service the hospital renders and interpret the institution to the wide community it serves. Looking back over these four decades I realize that I have witnessed profound changes both in the practice of medicine and in the role of the hospital in community life. The clinician trained quite definitely to prepare himself for care of the individual patient must now meet broad social obligations in the field of public health, and must report to health authorities the diseases dangerous to others and industrial accidents sustained by his patients. In her field the bedside nurse is still in great demand for care of the sick in hospitals and homes, and scientific techniques have added much responsibility to her work. But nurses who wish to apply their professional training in other fields may now obtain education in public health, and the public health nurse has become the greatest asset in modern public health programs.

4

THE

BACKGROUND

Within these decades social work also has become a profession that requires special education and experience in dealing with community problems, and calls for skills and insight into the personal difficulties that press upon individuals in the complex life of today. It is my purpose in these pages to share my own experiences as I witnessed these changes through the years, to tell how and to some extent why social work has found its place in hospitals, and to sketch the general movement of social service in relation to medicine. I shall therefore call largely on my own work at the Massachusetts General Hospital and the activities that grew out of my experience there and kept me in touch with the development of the medical social movement in this country and in other lands. Many of my friends and colleagues have taken a vital part in the promotion of medical-social service in many centers here and abroad. But the central figure in this story· must be Dr. Richard Clarke Cabot, who, when he created the Social Service Department of the Massachusetts General Hospital in October 1905, gave impetus, through his initiation of an organized plan, to a general movement to deal with the social aspects of medical care of patients. So vital a part is he of this history that I see him moving energetically and purposefully through the years, influencing the practice of medicine and of social work and the administration of dispensaries. He made practical application of his religious convictions concerning the unique value of individual personality, always pressing forward, leaving old paths and pointing out more effective ways of accomplishing the purpose of better care of the sick—a fearless, self-confident spirit, an outspoken and constructive critic, a gay, delightful, and stimulating antagonist, a warm, trusting, and trusted friend. I well remember my first sight of Richard Cabot. It was in 1906, on an evening in early autumn when I had gone with my brother to Professor Royce's home in Cambridge, where a small group of young people met occasionally for

A DOCTOR'S MESSAGE

5

discussion of philosophical subjects. Our friends, Ed Holt, Ralph Barton Perry, Ernest Southard, and Robert M. Yerkes were there, I remember. The subject under discussion has gone from my memory—probably it was not very clear to me at the time! Directly in front of Professor Royce was a fair-haired young man, sitting on the edge of his chair and taking a vigorous part in the discussion, head tilted to one side and very positive and alert. A few days later I saw him again, at the opening of the then new buildings of the Harvard Medical School; he was leading the chorus of young medical men, with great energy and enthusiasm. Not long after, while attending the Massachusetts State Conference of Social Work in Worcester, I was a bit surprised to see this same young man on the platform, and to heir him tell of his first year's demonstration of social work at the Massachusetts General Hospital. The program told me that he was Dr. Richard C. Cabot. Coming so recently from the Middle West, I was too unsophisticated to appreciate the name of Cabot! But I did recognize that here within my experience was a new kind of doctor and that he was expounding an idea that seemed to be the answer to my own vague misgivings and desires. He was presenting the idea of social service within the hospital, where sick patients, although separated from their homes and families, nevertheless cannot separate themselves from their personal problems. At that time I was a student in the School for Social Workers. The School, under the sponsorship of Harvard University and Simmons College, was in its second year of pioneering in the training of men and women for the developing profession of social work.1 I had come from Minnesota for a year at this school, hoping to gain insight into the problems presented to me by my patients when I had worked as a visiting nurse in the St. Paul Associated Charities. I had vividly in mind my visits in homes down on the flats by the river; in "Swede Hollow" where Neis, a twelve-yearold with heart disease, was being tenderly cared for by his widowed mother. (Mrs. Olson always had hot coffee on

6

THE BACKGROUND

the back of the stove ready for my call.) At "Connemarra Patch" Mrs. Riley, reduced to bed-and-chair living, was still trying to manage her home with the help of her adolescent daughter and her hard-working and hard-drinking husband, who was alternately devoted when sober and abusive when drunk. In my work there I had seen again many patients first met in the wards of the City and County Hospital, where I had had my nursing training. In the Hospital, I had already come to realize how little we knew about our patients, and that ready as we were to recognize their ignorance, we had no conception of our own ignorance about them. As a visiting nurse, I had had other enlightening experiences. I had come to understand, in retrospect, the emotional distress of patients on the wards who, after the visiting hour, were found in tears over the outpouring of relatives about problems at home. One of my experiences was still a mystery to me. Why, in the Bohemian district down on the flats, in springtime floods, did families refuse to leave their homes? Water reached into the lower floor, and I had to walk along a plank resting on beer kegs to visit a sick patient upstairs. In those days public-health officials were less aggressive than now, and the poor immigrant in a strange land clung desperately to his wretched home. In those days we still had a "typhoid season" in our hospital wards. With such memories clearly in mind, I heard Dr. Cabot tell of his effort to have the doctors, nurses, and social workers together purposefully serve the patients, and to bring existing social agencies into closer relation to the hospital. I was deeply stirred by the simple and illuminating logic of his ideas. Dr. Cabot was the most approachable of men, and after the meeting I told him how much I had appreciated his talk about his new work. His swift response was: "Why don't you come and work with us?" I murmured something about being a full-time student at the School of Social Work. This he did not seem to hear, for I saw him turn to Miss Farmer, his assistant in the new social work at the Hospital, and to her he said: "Miss Cannon is coming down to see us

A DOCTOR'S

MESSAGE

7

on Saturday." And on that Saturday I did just that! And I stayed for thirty-nine years. M y plans to return to Minnesota soon dissolved; I knew I had found an answer to my gropings, and had discovered the work I wanted to do. When I asked to have my practice work in the School course shifted to the Hospital, I was told that the work there was not sufficiently established to be suitable for student training. But nothing could interfere with my volunteering at the Hospital on Saturdays and in my free time. So, for the winter 1906-07, I joined the group of eager volunteers, and after graduation from the School and a summer spent visiting hospitals in Paris and London, I joined the staff. Thus began my career as a medical social worker. Before beginning my story of the development of the organized application of social work at the Massachusetts General Hospital, it is fitting to confess that at that time I was ignorant of many earlier efforts to make more effective the isolated medical care of patients in hospitals and dispensaries. The traditional humanitarian activities of the church, especially among Catholic Sisters whose hospitals were also a refuge for those in dire need, were known to me. But of the earlier efforts of medical men and women specifically to relate the medical and social care of patients, I was not then aware. Although these efforts did not take deep root, they gave evidence that wherever doctors with imagination and humanitarian impulses are called upon to treat patients obviously in need, they will recognize and seek to meet such distress. In England, as I was also to learn, there had been for some time social workers who were assigned to the hospital field to bring help to patients borne down by such social conditions as pressed hard on the poor of London. Although these medical social activities were unknown to me at the time, they are the rightful background to any account of the growth of the medical social service movement of today.

2 T k e E n g l i s h H o s p i t a 1 A l moner I T was in 1895, ten years before Dr. Cabot initiated a social service for his clinic patients at the Massachusetts General Hospital, that an experienced social worker from the London Charity Organization Society was stationed at the entrance desk of the Royal Free Hospital—this, after long effort by the Society and its secretary, Charles Loch. Social work and social workers had been accepted for many years in application to community problems in Britain, and this new worker was accepted by the Hospital with the understanding that her function was to review applicants for admission to the dispensary and to exclude those unsuitable for free care. But in serving this restricted purpose the worker was soon aware that many patients accepted for medical treatment were in sore social difficulties as well. The original purpose and the primary function of the "hospital almoner," as this English social worker was called, were very different from those of the first medical social workers in the United States, yet the years have brought about a strong bond of fellowship and established warm friendships between the medical social workers of our two countries. W e have shared the common purpose of relating specific social services to organized medical care and thus making that care effective. From this insecure beginning in 1895, the hospital almoner became well established in England and in many hospitals in the British Commonwealth. Today she is recognized as an essential member of the required personnel. H o w did this come about in England? H o w did the movement for integra-

THE ENGLISH

HOSPITAL

ALMONER

9

tion of social work into organized medicine differ in our two countries? What are now our common interests, purposes, and differences? To understand a specialized application of social services, some knowledge of the general field of social work is necessary. Yet it is not within the scope of this story to relate in detail the evolution of "indiscriminate charity" in nineteenth-century England into the constructive profession of social work. It was a painful process, and many authoritative reports have traced the development.1 Basically, social work, wherever and whenever practiced at its best, is a constantly changing activity, gradually building up guiding principles from accumulated knowledge yet changing in techniques. Attitudes change, too, in response to shifting social philosophies. Unless such changes are taking place, unless social workers reflect on the problems they deal with, social work cannot remain vital. It is necessarily a profession highly sensitive to current social situations and problems in our community life, and it must be receptive to all suggestions for improving human welfare. Social work is concerned with standards of living and with deprivations as they affect the individual and the community. But many of the things human beings hold most dear are not material. They concern personal relations, family ties, friends, freedom to use our abilities in work and play, opportunities to develop our capacities, the satisfactions that come with participation in community life. For the freest and fullest use of our capacities we need health of body and mind. Sickness strikes at all these normal satisfactions and brings a severe strain on our spiritual resources. But in human affairs it seems that dire need can stimulate measures for its own relief, if courageous individuals lead the way to reform. So it was in England in the 70's and 8o's, when there was stirring of conscience concerning the overwhelming problems of London's poor. In the world's greatest city the time was ripe for renewed attack on its gross social pathology.

THE

BACKGROUND

The wretched conditions of great masses of people in the London slums were being revealed by those who went to live and work in close contact with the poor. Among these workers was Edward Denison. In 1867, in association with John Richard Green, the historian, Denison took up residence in Stepney. Before his untimely death in 1870, he had enlisted many university students to combat the evils and ignorance of that day. It was Denison's special conviction that there should be education of the public against indiscriminate giving of alms to relieve the immediate distress of individuals, and that vigorous action in constructive ways toward improving the condition of the masses was called for. In 1869, not directly through the efforts of Denison but probably influenced by him, the London Charity Organization Society was founded. Its declared purposes were: " ( 1 ) The organization of charitable relief; (2) The repression of mendicity; (3) T o improve the conditions of the poor." One of its first activities was to study the Statistical Society's Report on Beneficent Institutions. As this report dealt in part with the many medical charities in London, the Charity Organization Society thus became interested in its early years in the medical services provided for the poor. London's great voluntary hospitals had a record of many centuries of service to the "sick poor," a record treasured by the privileged classes that gave their financial support to these institutions. The best of these hospitals not only cared for the sick, but were increasingly important in medical education. Leading members of the medical profession served in their wards and clinics, and the medical care was of a high order for that day. As public confidence grew, the hospitals and dispensaries were increasingly sought out by those needing care. But the wards had limited bed capacity, whereas dispensary clinics could receive increasing numbers. This situation led doctors to protest that patients who should be treated in their private offices for a fee were coming to the hospital clinics for free treatment. In 1870, to take action on this problem, "a large and im-

THE ENGLISH HOSPITAL ALMONER

11

portant meeting of the profession was held at the Medical and Chirurgical Society in Berner's Street. It was called at the request of leading physicians and surgeons of London to discuss the outpatient system, which was assuming great and increasing abuse." Protest by the doctors became organized, and the records of that meeting, and of subsequent hearings before the House of Lords, give a clear idea of their reactions to the conduct of the medical institutions. It was stated that the overcrowding of the clinics was in part due to "the pernicious habit of advertising," since the hospital managers "quoted numbers of applicants as a means of touching the hearts of the public and drawing money from their pockets." One physician stated that the doctor, after giving two or three hours in the morning at the clinic, "returns home with freshness and elasticity gone for the day. Surely this is asking a great deal too much and pressing terms of the contract beyond what is reasonable." One doctor spoke differently of "another evil under which outpatient departments of hospitals suffer and it is this; that the applicants for assistance often need food and clothing as much as or even more than medicine." H e told of a poor woman who had been taking a tonic ordered by the surgeon. W h e n asked if she needed to have the bottle refilled, she had replied, " N o , thank you, sir. I have got plenty. It is ordered to be taken three times a day, but I takes it twice. It does give me such a appetite, and I can't get the grub." Another conviction expressed regarding such patients was that "having close at hand charitable institutions at which they may resort whenever sickness touches them is not likely to conduce to habits of foresight and self-reliance." This, it was added, "is detrimental to national life." Further, "the first thing that makes a man a pauper, so to speak . . . is the ease with which he gets medical relief." T h e suggestion that the patients pay a small fee at the dispensary brought the rejoinder that this was "unsound," since the patient might thus be led to consider the medical care a "right," and

THE

BACKGROUND

that, since the patient gets more than he pays for, it would "lower standards of medical remuneration in the district." These comments are illuminating in the light of changing public policy in Britain in recent decades! Such public criticism of the management of the medical charities was of special interest to the London Charity Organization Society and in keeping with its purpose to oppose "mendicity." A special Medical Committee was formed, with leading medical men as consultants. W . Fairlee Clarke, F.R.C.S., of Charing Cross Hospital, was chairman. Into this situation came an ardent spirit who was to give leadership to one phase of social reform and to bridge the gap between the protesting doctors and the purposes of the newly formed society. He was Charles Stewart Loch (later Sir Charles Loch). Loch graduated from Balliol in 1872, and in his Oxford days had breathed the atmosphere of that time, which was stirring the social conscience. Those were the days of rapidly developing labor unions and workingmen's clubs. University students were giving time to work in the slums of London; Huxley was giving his lectures to industrial workers; Sidney and Beatrice Webb and their associates in the Fabian Society were expressing their passion for social reform; Canon Barnett was ardently at work in the Whitechapel district. Some who were identified with this movement for reform turned to the political arena. Charles Loch, a deeply religious man, was especially concerned with the effect of social evils on character. Following his graduation from Oxford, he served in the Secretarial Department of the Royal College of Surgeons for three years, an experience that roused in him an interest in medical subjects and the care of the sick. This interest persisted throughout his long years of leadership in social work. In 1875, he was chosen Secretary of the London Charity Organization Society. Loch was but twenty-six years old at the time, and there was some hesitation about giving this responsibility to a man of so little experience. But those who knew his record thus far pointed out that this was a difficulty he was likely

THE ENGLISH

HOSPITAL

ALMONER

to overcome, and the Council of the Society made the appointment. From the beginning Loch identified himself closely with the Medical Committee, thus indicating his belief that the social aspects of medical aid to the sick poor would be of special concern in his new task. In the Committee's first report of 1872 on "The Use and Abuse of Medical Charities," Dr. Clarke had pointed out that "there was need for discrimination between those who are and are not, proper subjects for gratuitous medical charity." He declared: "Such an important duty should not be entrusted to hall porters. . . T o deal with patients there should be appointed a competent person of education and refinement who could consider the position and circumstances of the patients, one possessed of firmness, discernment of character, and tact. . . thoroughly acquainted with the neighborhood of the hospital and with all the charitable agencies." Following this report, the Royal Free Hospital in 1874 asked the London Charity Organization Society to make an "enquiry into the social position of their outpatients." Of the 641 patients reviewed, it was reported that only 36 percent were "proper applicants." Exclusion of ineligible patients seems to have been the sole purpose of this review. During the 1870's medical men, desiring to end the socalled "abuse" of hospital clinics, joined as a group with the London Charity Organization Society in attacking what the Society had accepted as its second purpose, the control of "mendicity." Out of their deliberations developed what were known as "Provident Dispensaries," available to persons of low incomes on payment of "a small fee." For example, a family with an income of 30 shillings a week could, it was assumed, afford to join the dispensary in its district. In 1874 there were seventeen such dispensaries in London. This was the situation into which Charles Loch was initiated in 1875. He worked closely with these medical interests, and fostered the referral of patients from hospitals and clinics to district offices of the Society for investigation. The reports of the Society for that period show that certain

*4

THE

BACKGROUND

doctors and nurses recognized the need that the patients be given a more discriminating consideration than mere classification as "worthy" or "unworthy." For example, a family whose breadwinner was ill, or a patient needing a period of convalescence in the country or at the seaside, were often referred by the hospital staff to the Society to provide such after care. Out of such requests, Loch came to see the need, which was to be twenty years in fulfillment, for a social worker within the hospital, who should function as a part of its medical service. In an address before the Metropolitan Provident Medical Association, on May 15, 1885, he expressed his ideas about hospital abuse and how to harmonize the many interests involved: "There is clearly a want of someone at the hospital to direct the patient who has done his service (to medical education) and received his benefit from it, where to go next. M y suggestion is that there should be in the outpatient department a charitable assessor, or coordinator, to represent those interests other than medical, and harmonize them with the purely medical interests. He should be well instructed as to all existing means of making provision against sickness. . . He should thus help those who could be made self-reliant to become so; and for those who, for the time at least, could not, he would be the means of obtaining what future help was required. His office would be to supplement the work of the medical officer by obtaining the general assistance without which medical relief will often faü of its purpose. As good nursing is useful in aiding the physician within the hospital, so would this be useful in aiding him without. . . Merely restrictive measures will never be satisfactory, nor will inspection. Organization in which each divergent interest is recognized and coordinated will alone meet the difficulty continuously and effectively." Loch recognized other principles of importance: "The cross purposes involved can only be harmonized, I believe, by ( 1 ) accepting the medical interest in hospitals as that of primary importance; (2) after providing for it, adjusting

THE ENGLISH HOSPITAL ALMONER

ι5

the other interests concerned by means of organization; and (3) for this purpose, appointing in free hospitals and dispensaries, an honorary or other competent Charity Assessor and Coordinator, who would utilize to the full all charitable means forthcoming for the cure and social betterment of the patients. Provident institutions would thus be promoted without injury to the general practitioner, and, when the patient was being helped, the family would not be forgotM

ten. But a constructive program did not quickly develop. The doctors still protested. Loch continued to foster social services by the Society to such patients as were referred by the doctors and sisters, but he also worked persistently toward a more practical and effective system that should function within the hospitals themselves. In 1891, he was called to testify before the Select Committee appointed by the House of Lords at the request of a thousand physicians. The reports of this hearing record that the system of outpatient service "tends to lower the fees and injure the position of the poorer medical practitioner, as many patients who applied to the hospital for advice could pay medical fees . . . [but] that the outpatient [departments] could not be abolished because they were requisite for medical teaching." It was at this hearing that Loch again urged "a practical plan, a plan of limitation, with what I should call an almoner." When asked to state the wage limit to be designated for a suitable patient, he characteristically replied that it was very difficult to be definite. "There must be a large section of the population who cannot afford to pay a doctor in case of a long and serious illness or in case of a large family." Loch also suggested that hospitals were placed at the convenience of doctors and not as needed in the community. When asked if he expected that the London Charity Organization Society could affiliate with many hospitals, he replied that almoners in hospitals should have training in "charitable work," and that patients found in need should be referred to the Society's agents for the further help required. He stated:

16

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" I hope that the use of general charities in connection with medical work will grow, and that with that will grow a combination." In the course of the hearing, Lord Monksville commented on the difficulties of caring for a sick person at home and asked Loch whether he thought that the time would come when the rich would go to a hospital and pay. T o this Loch replied that in the future possibly part of St. Thomas's Hospital might be so used, "a hospital hotel, so to speak, quite as a business." H o w swift are the changes in the hospital world! Following publication of the Select Committee's report, Loch persistently worked for the appointment of almoners to the London hospitals. The term "almoner" had been in use for several centuries to designate a functionary attached to institutions for the destitute, whose duty it was to give attention to those inmates leaving the institution who needed material relief. Loch wished to have the function of this agent redefined in line with more constructive helpfulness. For some time he pursued the subject by way of correspondence with G . F. Sheppard, a member of the Board of Management of the Royal Free Hospital, where in 1874 the earlier review of applicants had taken place. According to Β. E. Astbury, General Secretary of the London Family Welfare Society, 2 the correspondence between Loch and Sheppard resulted in a memorandum, which was submitted to the Administrative Committee of the Charity Organization Society in June 1894. According to the minutes of that meeting Mr. Sheppard suggested, "as an experiment, that the Charity Organization Society should provide a trained officer to take note of and refer to the Weekly Board such cases as might appear to be ( 1 ) suitable for Poor Law Infirmaries or Provident Dispensaries, (2) in need of additional relief to supplement that given in the Out-Patient Department." T o this the Society agreed on a three-months basis, and, in January 1895, Mary Stewart, secretary of the St. Paneras Committee of the Society, was loaned for the demonstration. Her duties were outlined as follows:

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( 1 ) T o prevent abuse of the Hospital by persons able to pay for medical treatment; (2) T o refer patients already in receipt of parish relief and such as are destitute to the Poor L a w authorities; and (3) T o recommend suitable persons to join Provident Dispensaries. Miss Stewart in her first report stated that not more than three or four out of 150 patients reviewed could pay for private practitioners. As a typical instance, she told of one patient, a child of fifteen months with rachitis, for whom the doctor had ordered milk. The family included the parents and six children. The father had lost his work through the death of his employer. A visit by the district agent of the Charity Organization Society found the family living in one room and the children undernourished. Relief was supplied while an effort was made to help the man, who had a good reputation, find work. T w o of the children were found to be ill and were sent to a nursing home. Although the three-months demonstration seemed thoroughly to justify continuing the service, the Hospital did not provide for its expense, and Miss Stewart returned to her district work with the Society. Loch's deep conviction concerning the dangers of encouraging dependence led him, I suspect, to decide not to continue to supply Miss Stewart's services unless the Hospital would share the cost. After a brief period a neat plan was evolved by which two doctors on the Hospital staff gave twenty-five pounds each, to match a like amount from the Charity Organization Society, on condition that the experiment be continued for another year. So Miss Stewart returned to the Royal Free Hospital as Almoner. From that beginning the movement grew steadily. The position of the Hospital Almoner was established and built into the British hospital organization through the changing years. In less than a decade seven other hospitals had appointed almoners. T o name but one, after several months as

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assistant almoner at St. George's Hospital, Anne E. Cummins was appointed the first Lady Almoner at St. Thomas's Hospital, and her long and distinguished career as a leader in social work began. Charles Loch's special concern at this time was to see that women suitable for this special type of work should be selected and adequately trained. Through the Society's Medical Committee a plan of training, theoretical and practical, was developed. In 1903 the Hospital Almoners' Association was formed for mutual helpfulness through discussion of their problems. In 1906, under the leadership of Loch and Miss Cummins, the Hospital Almoners' Council, later to become the Institute of Hospital Almoners, was developed to deal with the selection and training of almoners, to promote their appointment to hospitals, and in general to guide professional policy. Anne Cummins fulfilled Charles Loch's concept of what the hospital almoner should be. Her function as almoner went far beyond the negative task of checking "hospital abuse." She saw the opportunity of "utilizing to the utmost all charitable means forthcoming for the cure and social betterment of the patients," and extended the hospital's responsibility into many phases of preventive medicine. According to a memorial tribute to Miss Cummins written by Cherry Morris, her successor at St. Thomas's Hospital, "It was largely due to Miss Cummins's originality of outlook, to her enthusiasm, and to her power of inspiring others that St. Thomas's was in the forefront of the movements for maternity and child welfare as well as in those for the treatment of tuberculosis and venereal diseases." She pioneered in special classes for prospective fathers at the Baby Center near the Hospital and established a hostel for girls with venereal disease. Early in Miss Cummins's career her activity and vision attracted the attention and interest of the trustees of the Cicely Northcote Trust, which made possible the extension of the Almoners Department into the wards of the Hospital. For thirty years after the first almoner was appointed at

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the Royal Free Hospital in 1895, almoners were to be found only in voluntary hospitals, that is, in free hospitals supported by voluntary contributions. The Poor L a w made no provision for care of the sick except in the almshouses. Even in the revision of 1871, there was still no proper care for those having public relief. Since the legal "pauper" lost his vote, and was subject to the stigma associated with that status, it is easily understood why the sick poor sought treatment in voluntary hospitals (widely advertised for the "sick poor") where no stigma was attached. Charles Loch was especially interested in the changing social policy in Britain and its effect on the almoners' work. His frequent presence at hearings, when proposed legislation was under discussion, gave him opportunity to speak from vivid experience of work in the slums, and was cause for close attention from those unfamiliar with the real conditions among London's poor. Out of his personal experience he had evolved his own social philosophy, a philosophy influenced by his deeply religious beliefs. In his later years he expressed his convictions in an address prepared for social workers: "It is the interest of the State to prevent the existence of a class so poor as to be on the verge of dependence or actually in receipt of Poor Law relief. Pauperism is the social enemy of the modern State. The State wants citizens. It cannot afford to have any outcast or excluded classes—citizens that are not citizens. . . It must do its utmost to change the dependent section of the community into the independent. It cannot be content with the chronic indigence and social feebleness of any great mass of citizens; with paupers who are paupers indeed, whether they be classified as such in public returns or are the habitual recipients of the casual bounty of the rich and charitable institutions." Loch's sturdy convictions concerning the importance of maintaining the integrity of the individual had a strong influence on the almoner movement in Britain. The original interpretation by hospitals and doctors had been that the function of the almoner was to exclude from free outpatient depart-

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ments those patients who should pay for medical treatment; demonstration developed that concern must be equally given to the admission of suitable patients and to their further help through social service in support of the doctor's plan for medical care. This constructive turn to the almoner's function won the support of the doctors, and through the years that support has been sustained. The passage of the National Health Insurance A c t in 1 9 1 1 opened up new responsibilities for the almoners, as voluntary hospitals adjusted to this new provision for medical care for a portion of the people. During the war years voluntary hospitals lost much of the support they had had. It was inevitable that the troublous times through which England has passed in recent decades should affect such institutions. Significant changes have influenced the work of the hospital almoners with the establishment of the National Health Services in 1948. Whatever our differences in problem and resource, there has been for many decades a special bond of fellowship between the English "almoners" and the "medical social workers" of our country. There has been considerable interchange of literature and many visits back and forth. In the summer of 1907, while visiting St. Thomas's Hospital, before taking up my work with Dr. Cabot at the Massachusetts General Hospital, I had the pleasure of meeting Miss Cummins, who was in her first year of service there. W e discovered common interests, professional and otherwise, and a long friendship developed, reinforced by interchange of visits and correspondence through the years. Her sudden death in 1936, just before the meeting of the International Conference of Social Work in London, was seriously felt by the many medical social workers from several countries who had assembled for discussion of our common problems. One bond that Miss Cummins and I had enjoyed through the years was the experience of strong support through our pioneering years, she that of Sir Charles Loch, a leader and a

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pioneer himself in the profession of social work, a social statesman of his period; I, the comradeship of Dr. Richard C. Cabot, whose humanitarian interest merged with purposeful activity to assure to sick people better medical care.

3 F o r e r u n n e r s in t h e U n i t e d S t a t e s I N recording the background of medical social service in this country the dilemma of any recorder of medical progress must be faced. The history of medicine is usually presented as a succession of notable men. T o them are attributed original discoveries and new concepts; with specific contributions to the progress of medical science their names are permanently associated. From Hippocrates and Galen to Harvey, Jenner, Pasteur, Koch, and the great names of recent times, all the illustrious ones associated with additions to medical knowledge are accounted creative geniuses who have made medicine what it is today. But credit for advance in medicine cannot rightly be given to isolated individuals. New contributions grow out of the accumulated efforts of innumerable patient searchers for truth. The flowering of each new discovery and concept is deeply rooted in the fertile labor of a host of predecessors, whose names may be lost in passing time. Members of the medical profession, especially those devoted to research, are well aware of the interdependence of past, present, and future. Progress in medicine is increasingly dependent also upon growth in other sciences; the stage for dramatic medical advance is often set by developments in biology, chemistry, physics, and mechanics. Pasteur, the chemist, made one of the greatest contributions to medicine by his discovery of the nature of bacteria. The creative genius, recognizing an indebtedness to established medical knowledge and to what other sciences have revealed, brings to bear his intelligence,

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imagination, and industry, and in his turn pushes forward the frontiers. The history of science gives us many instances of almost identical discoveries announced in widely separated and unrelated places. Therefore, it is often difficult to determine the specific date of a particular discovery or to give credit to original discovery, although the period in which new facts are incorporated into general knowledge and applied can be recognized definitely, ßut it is significant that we often hear reference to "trends" in medicine, as a tacit acknowledgment that medical discovery ever moves forward, building on the past, alive and vigorous in the present, and open and receptive to change in the future. The eager pioneering spirit of our young country has expressed itself in many contributions to medical science. But vital forces other than the curiosity and imagination of the scientific mind account for the direction, the pace, and the scope of medicine as it advances. The establishment of institutions was the first expression of a recognized obligation to care for the sick, the insane, and the destitute. It was a crude remedy; out of sight too often meant out of mind, and our early public almshouses remain blots on our history. In time, through the efforts of determined and courageous men and women of insight and good will, the sick were separated for special attention and the story of our hospitals began. It was inevitable that the hospital, as it evolved, should become a self-centered institution, absorbed in the heavy burden of housing and caring for the sick, who came in great numbers, and of providing new facilities as methods of treatment improved. Beyond the accepted obligation of the open door, ready to receive all who sought admission, there is little evidence that attention was given to the personal problems of the individual or to the community relations of the hospital. What we call the Medical Social Service Movement had as its purpose to bridge the gap between hospital and community, to recognize their interdependence, and to determine the relation of cause and effect in the patient's disease and his

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environment. A t first this purpose was necessarily expressed in rather simple, practical action directed toward the immediate need of the individual patient. The modern hospital has now become so familiarly identified with the organizations of public health, preventive medicine, and community social service that the isolation of the early hospital is almost forgotten. But how did this new relation come about? There is little point in tracing the steps in great detail within these pages, but it is pertinent to mention that during the second half of the last century there were men and women who registered dissatisfaction with hospital care of the sick and made efforts to improve it. And in 1905 the readiness with which the organized plan for establishing social work at the Massachusetts General Hospital was received throughout the country gave evidence that many were aware of serious limitations in the medical care offered by our hospitals and dispensaries. Many patients were "lost" through failure to return for treatment; tuberculous patients were discovered in the clinics but returned to their homes untreated. Physicians and others were deeply troubled by such unsatisfactory care of the sick, and by the resulting spread of disease dangerous to public health. Notable among the forerunners in social service to the sick were the women doctors who pioneered in opening the profession to women. It was in 1853 that Dr. Elizabeth Blackwell, having secured a medical education after incredible difficulties, and being then denied any opportunity to serve in N e w York hospitals, had established in the crowded East Side a dispensary for women and children. Out of this beginning developed rather rapidly the N e w York Infirmary for Women and Children, an institution that through the past century has admirably served both medical education for women and the medical needs of a congested district. Intent on service, and familiar through personal experience with patients in their homes, these women physicians were well aware that personal problems complicated sickness among the poor. Home visiting by these doctors had been from the first

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a part of their medical care of patients. In 1857, a hospital beds were secured. In the report of the Infirmary for 1865, Dr. Blackwell states that 334 patients were visited in their homes: "White, black, Northerners, Southerners . . . worthy immigrants whose husbands died on shipboard or in the ranks of our army have sought refuge in their helpless condition in the Outpatient Department. These persons after recovering their strength have been helped with their infants by other kindly charities or by private benevolence. Then there were several unfortunate girls, mere children of fourteen or fifteen turned adrift by angry relatives." In Dr. BlackwelT's report for the following year (1866), we find record of the appointment of a "Sanitary Visitor" for special home visiting of dispensary patients and those discharged from the wards. This visitor was a Negro physician, Dr. Rebecca Cole. The report describes her methods in home visiting: "Entering into conversation with the mother or father, she ascertains the various facts relative to the physical condition of the family. When there are children in the family, this is entered on the record for continued oversight and instruction in hygienic matters. In succeeding calls, the visitor brings up subjects of ventilation, cleanliness, warmth, food, and clothing, making practical suggestions as they seem to be needed in each case. She sometimes taught them to cook their food or to choose it with economy and to vary it sufficiently. Nuisances found on the premises have been reported to the proper authorities and speedily removed. . . Employment has often been found for those who need it, for, though the work is educational rather than benevolent, pressing physical wants must be supplied before any improvement can be attempted." The title "Sanitary Visitor," and possibly some of her functions, may have been an outgrowth of experience with the United States Sanitary Commission of Civil War days, in which Dr. Blackwell and many public-spirited New York women had been active. The Commission had served as a channel for women's work in aiding the soldiers, promoting

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nursing, and furnishing supplies for the Army. In later reports this appointment seems to have been dropped, but home visiting continued as a regular feature of Infirmary activities for doctors and medical students. One of its purposes was to give the women medical students "an opportunity to study disease under tenement-house conditions." Although its official reports do not record the fact, it is stated by those familiar with the Infirmary's history that in 1890 Mrs. Robert Hoe anonymously provided funds for employment of a home visitor who worked for a number of years under the direction of Dr. Annie S. Daniels, the "Professor of Diseases of Children in Charge of Out-Practice." Dr. Daniels seems to have been an extraordinary person, with plenty of initiative, enthusiasm, and vitality. Her reports contained data on the size of families under care, their income, and the rent they paid. Dr. Daniels states that conditions in the homes were sometimes found to be such as to justify "reporting to the 'State Tenement House Investigating Commission' or the 'National Sweating Association.' " As an illustration, she reported on a home where "five people make cigars, including the mother. T w o children with diphtheria, both parents attending the children, would syringe noses of each child without washing hands and return to the cigars." She adds: "The same conditions are found in clothing shops and handmade shoes." These situations would be reported "to the Board of Health, but closing of [sweat] shop work means no food and no roof over heads. The fact that disease may be carried by their work cannot be expected to impress people." What an opportunity for service to a distressed family and for effective action in the interest of public health! But Preventive Medicine had not yet been conceived and Medical Social Service was not yet effectively organized. However, the spirit of service exemplified by Dr. Blackwell and Dr. Daniels may well be credited with influencing many of the medical missionaries who have gone out to many lands from training and experience at the N e w York Infirmary for Women and Children.

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Another illustration of a pioneer woman physician whose medical interest in patients' care reached into their homes is closely tied with the N e w Y o r k Infirmary. In i860 Dr. Marie Zakrzewska, who had been the first resident physician with Dr. Elizabeth Blackwell, was called to Boston by a group of "public-spirited and courageous women," who had started "a female medical college." She accepted the position of Professor of Obstetrics, with the understanding that opportunity f o r practical experience for the students must be provided. In 1862 she secured a house on Pleasant Street in a poor district of the South End in Boston, where she started a dispensary and had ten beds for patients. Here began the long record of care of women and children by the N e w England Hospital for W o m e n and Children, which in the seventies moved to its present location in Roxbury. A s in the N e w Y o r k Infirmary, home visiting was a part of the medical care and the students' experience. " T h e students learned how the poorer classes actually live and how poor food, bad drainage, ignorance of physical laws produce diseases whose ravages are by no means confined to the places where they originate. . . In the increasing interest in social sciences and sanitary conditions of cities, the value of such experience will be fully felt." This in the report f o r 1864! Such awareness of the unhappy conditions of sick persons living in the wretched quarters of our growing cities was probably not uncommon, and, although it seemed that the time was not yet ripe f o r rallying forces into effective action, w e shall see that the social consciences of several of our larger cities were beginning to stir. It may be assumed that the kind of personal service to patients reported in 1874 at the N e w England Hospital was to be found in other medical institutions. W e find evidence of such practical help in Dr. Susan Dimock's annual report: " E v e r since m y connection with the Hospital, a great need has been constantly under m y eyes . . . maternity cases in the last months of pregnancy before entering the hospital and also when the time comes f o r discharge." She tells of the vol-

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unteer work of "two ladies" (one of them the daughter of Rev. James Freeman Clarke) "who befriended those deserted wives and young unmarried mothers. . . B y untiring efforts they . . . obtained subscriptions, paid the board of these women before labor and after discharged, still convalescent, from the hospital, and when they became able to work found them situations where the child could be received with the mother in consideration of a decrease in wages." She adds: " N o w that a beginning has been made in this much-needed work, we trust that others will go on with it, feeling that they are not only relieving and preventing terrible misery, but also lending a helping hand to those who have fallen and who, without help, must fall deeper and deeper." Although there was no formal organization of medical social service at the N e w England Hospital until a much later date, home visiting by doctors and nurses in training was a regular part of its dispensary service for many years. Dr. Alice Hamilton, our leading authority on industrial diseases, served her internship there in 1898, and has written of her experience: "What interested me most was the life down in Pleasant St. Dispensary, where I worked with people of fifteen different nationalities and where each new call was an adventure." This vivid medical-social experience was built into the education of a great woman, whose unique contribution to both medicine and social welfare has a permanent place in our country's history. Throughout the nineteenth century "the poor" of Boston were being served, also, through the oldest medical institution of the country, the Boston Dispensary, established in 1798. Its purposes were stated in three historic principles: "The sick, without being pained by separation from their families, may be attended and relieved in their own houses. "The sick can, in this way, be assisted at a less expense to the public than in any hospital. "Those who have seen better days may be comforted with-

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out being humiliated; and all the poor receive the benefits of a charity, the more refined as it is the more secret." The history of the Boston Dispensary throughout its one hundred fifty years might be written in terms of the changing concepts of public responsibility for the sick and the steadily broadening scope of its service. A social conscience manifested itself early in its history, and its development of organized social services in recent decades has been in close and mutually helpful relation with the Social Service Department of the Massachusetts General Hospital. A pioneering activity of unique significance was that initiated by Dr. Henry Dwight Chapen in his program of convalescence for infants and children who came under his care at the N e w York Postgraduate Hospital. Early in his career there he came to the conviction that "a hospital was not a good place for convalescence at any age, and children are particularly susceptible to the influences that accompany collection of the sick." He considered that there were "in the wards children who were unsuitable for hospitalization." Again: "Babies come into the world singly, and individual care and love are fundamental for right development. . . Nature never intended that babies be cared for in droves." In 1890 Dr. Chapen secured volunteers to visit children in their homes, to report on conditions and interpret his instructions to the mother. In 1894, he appointed a woman physician for that purpose but soon found that "a trained nurse with instincts for social service did better than a physician." This experiment, which he supervised carefully, led to foster-home care of children whose homes were inadequate, and in 1902 resulted in the organization of what has become The Speedwell Society. This agency has for its purposes: " ( 1 ) to place convalescent and frail children in foster homes for temporary care under medical and nursing supervision; (2) to systematize and standardize the boarding out of convalescent and frail children with other organizations; (3) to promote the establishment of Units for the above purposes in

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the State of New York and other states under the general supervision of the Society." The plan included a committee in each community to sponsor the local group of homes, personal care safeguarded by placing not more than two children in each foster home, and provision of medical and nursing supervision. Although the need for this service arose out of the determination of a thoughtful pediatrician working in a hospital, the organization of the Society was independent. The Speedwell Society flourished as a valuable community agency, and was especially a resource when social service departments were later established in New York hospitals. A development of special significance to the history of the medical social service movement took place in Baltimore at the turn of the century, in the close identification of Johns Hopkins Hospital with the local Charity Organization Society. That public-spirited citizen, Dr. Daniel C. Gilman, president of the University, throughout his long administration encouraged the identification of the University with the City of Baltimore and its civic life. Helen B. Pendleton, formerly district secretary of the Baltimore Charity Organization Society, has stated: "Dr. Gilman made the University and the Hospital a powerful influence in the community. He was largely responsible for the new City Charter. The Charity Organization Society came into being in Dr. Gilman's office, and soon became a vital agency for social reform." It is of special significance to medical social workers that, close to the heart of social service activities in Baltimore, during those stirring and productive years, were four people who were later to become ardent promoters of medical social service as an organized movement in hospitals and dispensaries. They were Dr. John Glenn, later director of the Russell Sage Foundation, Mary Wilcox Glenn, Mary E. Richmond, and Jeffrey R. Brackett, all leaders in the development of the profession of social work and especially interested in its application to medicine. Miss Pendleton says further: "Johns Hopkins Hospital and the Charity Organization Society were the powerhouse where ideas were generated—a veritable nursery

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of social service ideas." Faculty members of the University and especially those of the Medical School served on the board of managers of the Charity Organization Society: notably, Dr. Gilman, Dr. Henry Hurd, the superintendent of the Hospital, and Dr. Charles P. Emerson. During this period Dr. William Osier was in the midst of his brilliant career at Johns Hopkins Hospital. In 1898-99, convinced of the close relation between tuberculosis and the home conditions of his patients, he assigned two third-year women medical students "to follow the tuberculosis patients of the clinic to their homes to investigate the conditions under which they lived, and to see that proper hygienic directions given at the hospital were actually carried out." A t the 1900 meeting of the Laennec Society, Adelaide Dutcher, one of the students, reported on her two years' work in visiting 190 patients. She told of Dr. Osier's instructions to her: he was of the opinion that much could be done to prevent the spread of tuberculosis in Baltimore, if the consumptive and his family knew more of the nature of the disease. " M y duty should be to learn all I could about the patient, his family, and his environment; to advise him of the nature of the disease, its mode of contagion, and method of prevention; to teach him first of all to destroy his sputum because it contained the seed which caused the disease and was the only way of transmitting the disease to others; to give him moral reasons for cleanliness to help him out when natural instincts were lacking; to give the reason why sunlight and fresh air were of preventive and curative value; and to make any suggestions that would be of help in each home I went to." Unfortunately this home visiting and instruction of tuberculous patients was not continued, but Dr. Osier was prominent in promoting the antituberculosis campaign that later developed in Baltimore. He insisted that there should be some program for the home care of tuberculosis patients, since only a small percentage could be admitted to sanatoria.1 It was inevitable that so inspiring a personality as that of Dr. Osier should have a deep and lasting influence upon his

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students. Associated with him during his Baltimore period was Dr. Joseph H. Pratt, who later came to Boston and in 1905, with the support of the Emmanuel Church, initiated the "class" (home) treatment of tuberculosis patients. Another student was Dr. Charles P. Emerson, later dean of Indiana University Medical School. In 1901, Dr. Emerson organized a group of medical students, volunteers through the Young Men's Christian Association, to give time to the Charity Organization Society and visit families under the supervision of the district secretary of the Society. Although, as Dr. Emerson later stated (in a personal letter to me, December 13, 1909), "the work started in order to bring the students in touch with the poor as a class and without regard to the medical subjects involved in the cases under discussion," under Dr. Emerson's leadership it became an expression of close cooperation between the Medical School and the Society. Dr. Emerson's ideas in teaching medical students what he called "Environmental Medicine" further developed during his years at the Indiana Medical School. In 1908 Miss Pendleton, the district secretary most closely identified with the volunteer groups of medical students, became the first social worker in Johns Hopkins Hospital. She was succeeded in 1909 by Margaret Brogden, who served as the director of the Hospital's social service department for twenty-two years and was active in organizing the American Association of Hospital Social Workers. These illustrations of growing interest in the relation between sickness and social conditions, and also in the limitations of institutional care of the sick, show significant trends in the latter half of the nineteenth century. With all their political confusion and unrest, these decades had also offered ground to seeds of social reform, destined slowly to grow into effectively organized forces that were to bring about constructive changes in our thinking, and to inaugurate several movements for social betterment, among them medical social service. As demand for reform became insistent, there was recognition that knowledge and skill were necessary if this so-called social

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service was to be intelligent and effective. Out of the awareness of need for trained workers came the establishment of special schools of social work, and men and women sought preparation for service in this pioneering field. T h e time was ripe for organized effort in many fields of social interest. T h e medical social service movement was especially fortunate in having the leadership of a physician, and one with imagination, vision, and dauntless courage. Dr. Richard Clarke Cabot brought to it not only these qualities but a consistency of interest that was both vital and progressive, from the establishment of the Social Service Department at the Massachusetts General Hospital in 1905 until his death in 1939. That Dr. Cabot jvas fulfilling the hopes of those who had earlier seen the need is expressed in a letter sent him by Sir William Osier from Oxford in 1909: " I have just spent fifteen minutes reading your Third A n nual Report and I must send a line of congratulation, not only to you but to all members of your staff. T h a t is what I call real work—getting at the problem at the right handle. H o w splendid it would be if every out-patient department in the country could have attached to it a similar organization! Practical sympathy is what is needed so I send you $25. I wish I could add two or three figures to that sum. . . Yours, WM.

OSLER"

4 A P e r i o d of S o c i a l A w a k e n i n g A L T H O U G H the program of medical social work to be initiated at the Massachusetts General Hospital by Dr. Cabot was, as it had been in England, a culmination of previous recognition and effort, in application it was to be the expression of his special insight and interest and of the American scene. As we have seen, the dire social conditions of the masses in England in the nineteenth century stirred ardent reformers there to constructive activity. The evils in the great cities of the United States were not so deep-rooted, but they were possibly the more shocking in a new country where equality of opportunity was the purpose and the boast. With the turn of the century, social efforts here were stirring into activity in our big cities, especially in the eastern areas. The previous half-century had seen tremendous, unrestrained expansion of diversified industries and phenomenal growth of congested urban communities. Following social disturbances in Europe and after the Spanish-American War, millions of aliens had come to the "Land of Promise." Industrial cities were especially affected by this influx of men, women, and children from the oppressed and impoverished countries overseas. For a time our thriving industries and growing cities readily absorbed the flow of human energy. By glowing tales of opportunities for a better life in America, the agents of our expanding steamship transportation system kept up the stream of newcomers. Immigrants sought out their compatriots here, and congested nationality districts became characteristic of our big cities. Their children swarmed into our public schools, and the melting pot began to simmer.

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Hospitals were among the first of our social institutions to feel the pressures of the rising tide. Bellevue Hospital in New York—that great public institution which is so vital a part and an expression of our biggest city—reflects in its history the impact of congested population and some of the consequences of unrestrained immigration. A vivid picture of Bellevue, in the terms of its tragedy and its merciful service, has recently been given in a history of its training school for nurses, A Candle in Her Hand..1 We see the teeming city that yields its sick for care, and the generous and public-spirited women and men who fought valiantly for reform in care of the sick and for the establishment and maintenance of the nurses' training school that transformed the institution into a house of mercy. The public service of Louisa Lee Schuyler, founder of the training school at Bellevue in 1873, is an example of a social conscience aware of responsibility for standards in public institutions. Her leadership in establishing the State Charities Aid Association, with its early committees of influential men and women for visiting public institutions, almshouses, prisons, and hospitals for the sick and insane, placed her in the forefront of reforms of the latter part of the century. Her influence spread beyond city and state to spur citizens in other places to look to conditions in their own communities. Closely associated with Miss Schuyler in New York was another valiant soul, Mrs. Josephine Shaw Lowell,2 who became active not only in the State Charities Aid Association and its manifold services but was initiative in forming, in 1882, the New York Charity Organization Society. Three other cities—Buffalo, Boston, and Philadelphia—had already organized such societies. The Charity Organization movement, which came into prominence in the seventies and eighties, claimed the interest of socially minded men and women who found in our cities symptoms of the great evils they had seen and read of in London. In visits to England many of those who were to become leaders in reform here

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met and discussed social problems with Charles Loch, whose influence grew through the years. As we see it now, the social movement in this country and the Charity Organization Societies may have followed too closely the pattern of the English movement in the trend toward a moralistic attitude in the investigation of cases. T h e classification of people as "worthy" and "unworthy" sounds crude to us now. But the pioneer social workers were thoughtful people, and change of attitude came with experience. In their search to relate cause and effect they became aware that the responsibility for dependency, poverty, and its attendant degradation had a broad base in the general conditions under which many people were forced to live and work, and that the individual had little control over these conditions. Edward T . Devine, secretary of the N e w York Charity Organization Society, in his biographical testimony, 3 writes that he came to believe "that behind every form of degradation, dependency, and injustice there was apt to be entrenched pecuniary interests which it is desirable to discover and expose and with which it is the duty of society to deal." This statement gave constructive expression to the principle back of investigation, namely, to know the facts of the particular situation before acting on it. In these years when communities began to stir under a spirit of reform, hospitals were being played upon b y other potent forces. Scientific medicine, gaining momentum in the latter half of the nineteenth century, was profoundly enriching medical education, affecting methods and offering possibilities of better care for the sick. Many branches of science were interwoven with medicine and adapted to clinical procedures, thus making the study of disease and diagnosis more searching, more exact, and, therefore, more complex. Advances in chemistry and physics, especially, opened up possibilities of discovery of the nature of bodily functions and pathology hitherto unknown or only suggested. More elaborate facilities in operating rooms, and the increase in specialization in medicine and specialized procedures, became char-

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acteristic of the "teaching hospital": adequate equipment for laboratories and skillful technicians were called for in an upto-date hospital. This elaboration, as already noted, institutionalized much of medical care. The "modern" hospital was establishing itself. In the first decades of the twentieth century our hospitals, although offering most vital service to those unfortunates who sought care in sickness, were rather remote from community life. Fear of hospitals was prevalent then, especially among recent immigrants. A vivid picture of the attitude of reluctant patients among the "sick poor" was given in an address by Jane Addams before the American Hospital Association in Chicago in 1907. Under the title "The Layman's View of Hospital Work Among the Poor," Miss Addams spoke out of eighteen years' residence at Hull House in Chicago. She gave direct testimony of the fears and experiences of people she knew, of the seeming evidences of neglect of the patient for the sake of teaching, or the folding of sheets and the neatness of the ward for the doctor's visit. She told of the effect on the neighborhood of the six-hour delay in operating on a patient sent to the hospital by a local doctor for an emergency operation for appendicitis on a Sunday afternoon. Miss Addams spoke of what this death on the operating table meant to the patient's family and neighborhood, and how difficult it was to try to explain. Miss Addams's talk of 1907 was not graciously received by the Association. She asked, however, that Julia Lathrop (later the first chief "of the Federal Children's Bureau) be allowed to take part in the discussion, and this was permitted after the presentation of other papers on the prepared program.4 Miss Lathrop in her discussion pleaded for better understanding of foreign-born patients. She spoke of patients "sent out too soon. Whether it is the hospital's provision that breaks down or whether it is something that fails to come up and meet the hospital, there is a gap which is inhuman and which human flesh and blood cannot be expected to meet many times with dignity." She referred to what she had heard of

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the beginnings of social service in hospitals: "I am sure this human side of the hospital is one of the things that is going to advance, until we shall realize that there is a great deal that is part of cure which is not strictly the purely medical side." Miss Lathrop also urged that convalescence should be safeguarded so that the patient could go back to work sooner. Dr. S. S. Goldwater of Mount Sinai Hospital in N e w York spoke during these meetings of 1907, and his spirit was expressed in his testimony concerning convalescence for the patient. He said that patients may be encouraged to go to a convalescent home by a friendly visitor but that "there are certain instances where it is necessary to remove obstacles in order to enable them to go." A different note was struck in the discussion when a hospital administrator advised: "Treat your patients the best you know how, treat your employees as well as you can, and let the public take care of itself." W e must remember that this was a meeting of administrators, not of clinicians—although, without exceptions at that time, administrators were all doctors—and that the purpose of the American Hospital Association at that time was "for promotion and efficiency in hospital management." Hospital administrators had many problems. The proceedings of the American Hospital Association reflect the seriousness with which they met their responsibilities, but the interpretation of efficiency—and also of the purposes of the American Hospital Association—was to change with the years. The hospital of that time was striving, among other things, for improved standards in handling the many housekeeping affairs of the institution as it grew in size and complexity. The disposal of garbage, the problems of disinfection, handling of laundry, artificial refrigeration, floor covering, construction and equipment, food purchasing and handling—all these responsibilities involved development of standards not yet attained; all these rested with hospital administrators. And each and every item was of importance for the good of the patient as well as for efficient administration. They were,

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most of them, new problems and had to be thought through and worked out in detail before they could be standardized and delegated to selected hospital personnel. Here, as in England, when dispensaries and outpatient clinics were established for free treatment, protests were expressed by physicians that the clinics were being exploited by patients able to pay for the services of a private physician. There was no such effectively organized protest as in England, but the protest was, nevertheless, vocal. In N e w York, as early as 1898, an effort was made to secure legislation to make it a misdemeanor for a person able to pay for medical care to receive it at a free clinic. This was before the extraordinary growth of preventive medicine and the establishment of free public-health clinics in the interest of early care for patients with tuberculosis, cancer, and venereal diseases. Persons who, like myself, clearly recall the first decade of this century realize that our memories of active social forces stirring the public mind at that time are vivid largely because of the great personalities who were loudly calling for social justice and for more attention to the conditions of living in our cities and of work in our factories. Jane Addams was surely one of the greatest of those who challenged the social conscience of that time. I well remember my first impression of her when, as a student of sociology at the University of Minnesota, I heard her address a crowded audience in Minneapolis. I was deeply moved by the quiet force of her passion for reform in the conditions of tenement-house life, in sweatshops, and in factories, with their prevalent hazards to life and health. These appeals for public attention, and the pictures she drew of the lot of little children in slums and crowded, dirty streets, suddenly enlivening my classroom studies in "Social Pathology," made me see the gap between social theory and reality in the lives of men. T h e y started me on my way toward social work as a life interest. Jane Addams awakened in me, as she did in many, a realization of the gross inconsistencies in our so-called democracy. It was obvious that there existed side by side, desperate pov-

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erty and vast wealth, illiteracy and our acclaimed system of free public education, abundant production for our use from industries that maintained hazards for those who worked in them: all these existed in our land while we in self-satisfaction assumed that "all's right with the world." Jane Addams aroused many young people of that day and became the most inspiring speaker and the most effective voice calling for social reform. Dr. Cabot once described her as "that wonderful spirit of sympathy with every sort of human need and of readiness to incur in a good cause the reproach and disapproval of the public." 5 Other courageous spirits of those days were Lincoln Steffens, Ida M. Tarbell, and Ray Stannard Baker, all fired with the conviction that all was not well with these United States. Writing in popular vein in McClure's Magazine, they presented, skillfully and with sharp outline and evidence, pictures of municipal corruption, unrestrained railroad combines by selfish interests, the plight of the Negro, the growing oppression by "big business." Their startling revelations and clearly presented evidence made news in those days, and the country was deeply stirred. Much of all this was resented, and from that character in Pilgrim's Progress who "could look no way but downward with a muck rake in his hands," these writers were termed "muckrakers." But few could question the righteousness of their purpose to work for a better day for the people who make up our country. Again at the turn of the century, evils grew out of the problem of storing and transporting food for the expanding population of the newly opened lands of the West and South. Preservatives and the adulteration of food became a center of conflict, and Dr. Harvey W . Wiley, a super chemist, came into prominence to lead the fight for pure-food legislation. As our country grew, so did the distance between producer and consumer, and out of this problem the great canning industry and preserved-food business developed. The commercial chemist became necessary to the big business of handling food on a large scale. Dr. Wiley, as chemist for the Federal

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Department of Agriculture, became one of the giants of reform of those days. He attacked with vigor and unswerving courage the practice of adulteration, use of harmful preservatives, false labeling, and, most important, the unhygienic handling of meats in slaughterhouses. Scandalous revelations of the way in which inspection had been carried out were blazoned in our press and magazines. A campaign for reform in medical and health matters that was led by Samuel Hopkins Adams, a layman, undertook to expose the evils of the patent-medicine business and other medical frauds. His book, The Great American Fraud, became a source book for us hospital workers. In the early days of our medical social service, we had frequently to check on nostrums with which patients had treated themselves—and spent much money—before coming to the clinic. "Consumption cures," "cancer cures," "cures" for diabetes, a terrifying disease in those days before the discovery of insulin, remedies for asthma, were constantly being brought to our attention by patients who had been advised by "a friend" or a druggist to try the medicine. They usually came to the hospital having lost faith in such nostrums, or because they couldn't afford to pay for more. Infants' "soothing syrups" commonly used by mothers then contained opium, and were naturally so effective that they were popular. It was only when legislation was passed to require the printing of the contents on the labels that a proper fear reduced their use. Mr. Adams did much to expose these evils, and the Journal of the American Medical Association, in its section "Propaganda for Reform," took up the fight through exposure and deterrent legislation. Another valiant person was Florence Kelly. I recall her clarion voice raised in behalf of the industrial worker, whose life she knew intimately through her work as a factory inspector. She had witnessed the hazards to which the factory worker was subjected in those days when machinery was unguarded and new processes in the handling of raw materials brought exposure to chemical poisons. She spoke with authority in condemning these conditions because she had

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firsthand information. Later she headed the National Consumers League in her zeal to arouse the public to insist on protective legislation in manufacture. I well remember her frequent participation in the programs of the National Conference of Social Work. An episode at one meeting, where we were discussing with considerable interest the proposal of legislation for "widows' pensions," was characteristic of her. How could such a law be administered so that the widow "could keep her self-respect"? What should be the rate of aid per child? and up to what age? etc., etc. Up strode Mrs. Kelly to the platform, her heels emphasizing her impatience and firmness of purpose. She turned on us that strong, rather stern, highly intelligent face of hers, and in clear vibrant voice she spoke: "What I want to ask is, why are there so many widows?" Then she poured forth her story of deaths among industrial workers, exposures to hazards, long hours (12 hours a day was common), association with tubercular fellow workers. She spoke also of child labor and the sweatshop—all sending a stream of patients to our hospitals. She challenged us as being interested in the human wreckage without giving fundamental attention to the causes of the social problems we were dealing with. All these calls for reform were in line with efforts to raise standards of living especially among industrial workers and those in the poorer districts of the cities. Pioneering demands for better housing and slum clearance were made the more impelling by published pictures of conditions in crowded tenement-house areas. Jacob Riis was stirring the public conscience by his tales of How the Other Half Lives. Lawrence Veiller joined the fight for better housing and became the recognized leader in such reform in New York. Many other cities were stimulated to study their own slums. We in Boston had been inclined to think of New York as the city especially cursed with slums. We had a rude awakening when it was discovered that the most congested area of tenement-house population in the couñtry was in Boston's North End, a section fortunately now cleared away.

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The Charity Organization Societies in several cities were in the forefront of these reforms, gathering specific evidence of conditions and forming special committees to plan and promote action. The New York Society was especially alive to its opportunities. In 1900, the Committee on Tenement House Reform, with Lawrence Veiller as secretary, declared its purpose "to get light and air into living and sleeping rooms; to lessen danger from fires, from contagious diseases, and from conditions directly subversive of decency and morality." Here we see that social work and medicine were recognizing their interdependence. At the annual meeting of the New York Society in 1901, Dr. Herman M. Biggs made a special report on "Tuberculosis and Tenement House Problems." It was at about this time that Dr. S. A. Knopf's little book, Tuberculosis as a Disease of the Masses and How to Combat It, was published. This was reprinted by the New York Department of Health, and had wide circulation. Dr. Knopf suggested the forming of a society to fight tuberculosis. As it was difficult to secure a medical man as chairman, the cooperation of the Charity Organization Society was sought and a special committee of doctors, social workers, and laymen was formed. The plan as stated was that executive and clerical service would be supplied by the Society, while "scientific and professional guidance required will be supplied by those who are competent to give it." This pattern of medical-social cooperation soon proved its validity and its strength. It also encouraged similar committees in other cities and was a step toward the independent formation of the antituberculosis societies that within a few years were to spread across the country. The history of the New York Committee on Tuberculosis presents a notable example of the interdependence of medicine and social work. Its purposes, as stated in 1902, were to be accomplished "by research into the social aspects of tuberculosis; by the application of information concerning the curability and the communicable character of the disease, through lectures, leaflets, and otherwise; by the promotion of

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the movement for erection of sanatoria; by obtaining special relief for those whose chance of recovery will thus be increased and in other ways to aid in the movement for prevention of this disease." T h e members of this committee attested its strength; among them were Dr. Herman M. Biggs, then Medical Officer of Health, Lillian Wald, Ernest Poole, Homer Folkes, and Robert W . de Forest, the president of the Charity Organization Society. T h e activity of this committee through several years is a notable illustration of the value of community backing in measures designed for public health. What was the effect of these new ideas on our medical institutions and on the medical profession? If one can judge from the discussions in the meetings of the American Hospital Association, there was little evidence that hospitals were clearly aware of the trends that before long would bring them into intimate relation with the community. In the proceedings of the National Conference of Charities and Correction (as it was then called) there were rumblings as to the "abuse" of dispensaries, much like the protests in England. Some ardent spirits, among them Dr. Chapen, as we have noted, sought to improve the care of patients by supplementing institutional treatment. Undoubtedly there was considerable dissatisfaction among the doctors, who worked under pressure of great numbers in the growing outpatient departments and clinics. Reform in management of care of patients in our dispensaries was surely needed. At the turn of the century, outpatient departments and dispensaries were growing rapidly. T h e y were crowded. Doctors were overworked. Those who were treating tuberculosis were clearly aware of the futility of giving their patients only cough medicine and advice. Yes, there was need for reform. But it came not in protest against the "abuse" of the dispensary by the patients but rather in recognition of the inadequacy of treatment of patients by the doctors. T h e protest was to be voiced by that free-spirited physician who proposed to do something to correct the situation—Richard Clarke Cabot.

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Meantime, behind all these stirrings of the social conscience among influential citizens and the special awareness of those active in the Charity Organization Societies, social work as a profession was beginning to emerge—a special calling for men and women who would give service purposefully and intelligently to the correction of adverse social conditions in their communities and personal service to individuals overwhelmed by social difficulties. Again the New York Charity Organization Society took the lead. It is true that, hitherto, apprenticeship in social settlements in Chicago, New York, and Boston had been possible for workers who sought to broaden their understanding of social problems by living close to the conditions of people in the congested areas. Also many Charity Organization Societies (called Associated Charities in some places) offered the supervision of experienced workers to those eager to enter into this newly recognized public service. For those who could give volunteer service special supervision was available. "Friendly Visitors" they were called in some cities. But more special training obviously was needed for those who would deal constructively as well as sympathetically with individuals in distress. In the summer of 1898, the New York Society had offered a six-week session for students of "philanthropy." This summer school continued yearly until χ 904, when, through an endowment, the New York School of Philanthropy (later called School of Social Work) was established. It is worthy of note that in the 1901 session three days were given to discussion of "medical charities." A new profession was in the making.

5 .A P k y s i c i a n T a k e s A c t i o n I Ν 1898, Dr. Richard C. Cabot was appointed "Physician to Outpatients" at the Massachusetts General Hospital. In writing later of those days, he recalls his futile efforts to give the clinic patient the kind of attention he was giving private patients in his office. "I needed information about his home, about his lodgings, his work, his family, his worries, his nutrition . . . my diagnosis, therefore, remained slipshod and superficial in many cases. . . Treatment in more than half of the cases that I studied involved an understanding of the patient's economic situation and economic means, but still more his mentality, his character, his previous industrial history, all that had brought him to his present condition, in which sickness, fear, worry, and poverty were found inextricably mingled. . . Facing my own failures day after day, seeing my diagnoses useless, not worth the time I had spent in making them because I could not get the necessary treatment carried out, my work came to seem almost intolerable." 1 During these early years when Dr. Cabot was serving in the outpatient clinic of the Hospital he was having an enlightening experience as a director of the Boston Children's Aid Society. Characteristically, that he might better understand the children the Society was caring for, he oifered to volunteer in direct work with boys under supervision. Here he was to learn something of social workers and their methods. He saw the care with which the workers studied the situation surrounding each child. In their discussions of each case they reported on "the character, disposition, antecedents, and record of the child, his physical condition, his inheritance, his

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school standing." Dr. Cabot occasionally saw these children in his clinic and had a demonstration of what it meant to him to know the child's background and his immediate problem. He felt satisfaction in knowing that his examination had contributed to an understanding of the child's total needs and to a well-thought-out plan for his future care. Thus it was that he became convinced that the introduction into his clinic of a social worker to supplement his own efforts would, as he often said, "make treatment effective." Another experience that gave Dr. Cabot a deepening understanding of the social difficulties that bear down upon people was his service as Consultant Physician for the State Industrial School for Girls. He learned not only from the girls who presented problems, and from Mrs. Glendower Evans and Miss Elizabeth Putnam, of the Board of Trustees, but also from that very able social worker, Mary Dewson. These women were revolutionizing the social treatment of delinquent girls in Massachusetts. In June 1905, Dr. Cabot wrote a letter circularizing a few of his friends who were as interested as he was in "the charities" of Boston. In expressing his ideas of some possible action for reform of clinic service, he said, " I have long felt the need at the Outpatient Department of another division or subdepartment for the numerous borderline cases between medicine and charity. . . Out of 500 patients a day who attend our clinics, I believe there are at least 50 a day who are sick, not because of germs or poisons or accidents but because of one or another lack in their lives or in their environment, of which they are often unaware and which they do not mention." He continues with a description of "all sorts of people, who wander into the clinic, who need advice and a chance to talk over their difficulties. The unmarried pregnant girls are among these. All the doctor can do for them is to confirm a dread diagnosis. . . The most acute want turns up there uncomplaining, half unaware of itself, the kind we all want to help—but often in the midst of our stethoscopy and microscopy and the rush and bustle of the clinic, these patients

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can't or don't get our attention . . . they slip by unaided. Our training and daily habits of mind are not sharpening our wits in the right direction for the early and prompt recognition of these cases." He further suggested the importance of the doctor's knowing the social situation of the patient for its possible bearing on the physical findings. The patient's personal difficulties, he wrote, may prove to be "the cause and not the result" in a case of digestive upset. Dr. Cabot then asked his friends to help him find the suitable person to undertake this work with him. He offered to help support the service for a time, but he knew these friends (Boston "cousins" they were mostly) and he was well justified in counting on their interest and practical help. Dr. Cabot found the "suitable person" in Garnet Isabel Pelton, who, as a resident of Denison House Settlement, frequently brought Syrian patients from the South End of Boston to the clinic. Miss Pelton was well aware of the limitations of the outpatient clinics, for she had become familiar with patients in the neighborhood who did not benefit by the doctors' orders, both because of language barriers and because the patients had not the means for carrying them out. Miss Pelton had previously had nursing training at the Hospital, and knew the institution and many of the doctors. She wrote later of Dr. Cabot's offer of the position and her discussion with him. He wanted her "to investigate and report to the doctors, domestic and social conditions, bearing on diagnosis and treatment—to fill the gap between his orders and their fulfillment and to form the link between the hospital and the many societies, institutions, and persons whose aid could be enlisted." Miss Pelton accepted the appointment and on October 2, 1905, her pioneer service at the Massachusetts General Hospital began. As the report of the first three months shows, she had readily grasped the possible scope of this new venture. Unfortunately, sickness cut short her work after six months of demonstration. Dr. Cabot later described her as "a gay,

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imaginative, vivid, hopeful, uncalculating, impulsive person, like a flame of fire . . . to whom the hospital and the word hospitable are essentially the same. . . She tried to make the hospital hospitable, a place of welcome and not of loneliness and fear." Dr. Cabot's infectious enthusiasm for his new practical ideas in promoting social service for dispensaries reached out beyond his demonstration in Boston. On every possible occasion he began to write and speak on the subject, not only to secure support for his venture but to promote the movement by extension of similar work elsewhere. Lay groups responded to his appeal on humanitarian grounds. Doctors accepted the idea as important to effective care of patients. One of the first and most significant responses came from old Bellevue Hospital in New York. Dr. T . S. Armstrong, the General Medical Superintendent of Bellevue and Allied Hospitals, a man of wide humanitarian interests, learned of Dr. Cabot's newly established service in Boston. He was also aware of what Dr. Chapen was doing in the care of babies at the Post Graduate Hospital in New York. Convinced that Bellevue Hospital needed such supplementary service, Dr. Armstrong enlisted the interest of Mrs. John L. Wilkie, a member of the Board of Managers of the Training School for Nurses. Quickly securing the enthusiastic support of the Board of Managers of the Training School, that remarkable group of women who had done so much to raise the standards of care of patients at old Bellevue, Mrs. Wilkie consulted Lillian Wald, who promptly suggested Mary E. Wadley, a former Bellevue nurse and for some time a school nurse on the East Side. Miss Wadley caught a vision of what might be done for patients in the wards of the hospital she knew well. Her comment: "Why hasn't someone thought of this before?" was a response frequently heard in the years ahead. The establishment of social service at Bellevue was authorized in July 1906, and Miss Wadley was appointed director. During her twenty years of devoted service she saw

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the extension of the service to hospitals throughout the great city of N e w York. Meanwhile in Boston, Dr. Cabot's pioneering adventure was going forward, although there were difficulties in the way.

6 W e Β U1 U on Firm Foundations T H E Massachusetts General Hospital, where in 1905 Dr. Cabot was to undertake to demonstrate Social Service as an essential component of adequate medical care, is an institution with deep-rooted traditions. Some statement of these is necessary in explanation of the difficulties encountered in introducing there an untried element in the care of patients. The convictions that have so long sustained these traditions must be understood if one is to appreciate why the Hospital seemed slow in giving unquestioned support to a Social Service Department. The Massachusetts General Hospital was established through the generosity of "the wealthy inhabitants of the town of Boston, who had always evinced that they were the 'treasurers of God's bounty.' " Its first unit, the McLean Asylum, in Somerville across the Charles River, had already been in operation several years when the General Hospital was opened in 1821, just back of Beacon Hill and the golden dome of the State House. Its beautiful Bulfinch Building stood between the wretched North End of Boston and the muddy banks of what was then tidewater on the Charles River. The growth of these two associated institutions has been recorded in four successive volumes. 1 These volumes tell how during a century and a quarter the Hospital has been consistently identified with the great changes wrought by the forward march of scientific medicine. They also suggest no less startling changes in social aspects of the Hospital. However, throughout years of development and change, the purposes under which it was established have

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remained consistent; namely, care of the patient, study of disease, and teaching. Its recognition of scientific medicine and social influences has steadily elaborated these purposes, to give the Hospital its continuing position of authority among modern hospitals. For comprehension of its character and of the traditions handed down there through the decades we may well look back at the persons responsible for establishing it and consider the purposes we shared with them. The Massachusetts Général Hospital was the outgrowth of the Almshouse on Leverett Street, an institution opened in 1800 to replace the original Boston Almshouse, which for more than a century stood at the corner of Beacon and Park Streets. Evidently, the new Almshouse was generally understood to fulfill its purpose, for in 1810 Dr. Josiah Bartlett, Physician to the State Prison in Charlestown, said of it: "From the nature of its establishment and the conditions of its inhabitants, it may be justly considered as combining with the kind offices of humanity to meritorious objects, the exemplary reproof to idleness and vice, an improvement of the healing art. The appointment of a physician of approved acquirements affords an extensive acquaintance with complaints of venerable age, respected indigence, intemperance, and unguarded seduction; whilst gratuitous consultations in important cases are an honorable source of instruction to candidates for practice." 2 He describes the building as "a spacious, well-constructed edifice . . . governed by the Overseers of the Poor . . . the average inhabitants 350, of which 130 were State paupers." He describes "the subjects of admission" as "meritorious poor, unfortunate females, vagrants, and maniacs. The usual number of sick and infirm is about 50." The earliest history of the Massachusetts General Hospital gives a quite different picture and tells how the young Chaplain of the Almshouse first stirred the citizens of Boston by his revelation of the needs of the sick inmates there. Although the Reverend John Bartlett was Chaplain only from 1807 to

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1810—and was then in his twenties—he rendered a lasting service. In later years, he wrote to his son about his experience at the Almshouse:· "Much of my time was devoted to the sick, but the portion of the diseased which most interested me was the insane. There were generally from ten to twenty in the house, and although care was taken of them which the circumstances of the House would afford, yet there was no proper place for their confinement and rest; a 2o-foot building with several cells opening into a long entry. . . The violent were confined in strait jackets, and the filth and wretchedness of the place was dreadful. . . The physicians at the Almshouse were humane, good men, but the subject of insanity they did not appear to understand. . . No facilities were afforded them for the employment of those moral remedies which Pinel and others have so successfully applied in France. The wretchedness of this class of patient and their miserable condition in the Almshouse moved my feelings exceedingly. . . I went to Philadelphia and New York, examined the hospitals there. . . I became deeply convinced of the importance of a similar Asylum in Massachusetts. What prompted me to action was several persons of respectability seized suddenly deranged, and who, brought to the Almshouse, were put in these cells. Among others, a Capt. Jones seized suddenly on Change violently deranged. He was a stranger, commander of a vessel, and instantly put in a strait jacket, and locked up in one of these cells. "I sat down to my desk and wrote from 15 to 25 billets addressed to some of the wealthiest and most respectable gentlemen of Boston, requesting them to meet at Conant H a l l . . . to take into consideration the importance of adopting some measures for the establishment of a Hospital for the Insane."3 Among those present at that meeting were Dr. John Collins Warren' and Dr. James Jackson. Bartlett's plea for the establishment of a hospital for the insane was reinforced by them, and by Dr. John Gorham, who suggested "the expediency of

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uniting with this object, the establishment of a Hospital for the sick," although "some fears were expressed that by proposing too much, neither object could be obtained." Bowditch's history of the Hospital takes up the story, treasuring for us the famous letter of appeal that resulted from the meeting brought about by John Bart I e tt. Written under date of August 20, 1810, and signed by Dr. Jackson and Dr. Warren, Boston's foremost physician and surgeon of that day, this letter not only pictured the needs of a special hospital for the physically sick and the insane but recognized the plight of those whose conditions of living at home were sadly unsuitable for care of the sick. This letter has been rightly called the "cornerstone" of the Hospital. The prophetic strength of that cornerstone may be noted in the inclusiveness of its appeal: it asked for "a hospital for the reception of lunatics and other sick persons." Years were to make ever clearer that the two branches of the Massachusetts General Hospital, the hospital for mental disease and the general hospital, were to find the scope of their common interests and interdependence in understanding the close relation of mind and body, both in disease and in health. The Jackson-Warren letter is a significant social document in its concern for the plight of the neglected sick, in "a lodging . . . deficient in all those advantages requisite to the sick. It may be a garret or a cellar, without light or due ventilation, open to the storms of an inclement winter. In this miserable habitation, he may obtain liberty to remain during an illness; but if honest, he is harassed with the idea of his accumulating rent, which must be paid out of his future labor. In this wretched situation, the sick man is destitute of all those common conveniences, without which most of us would consider it impossible to live, even in health. Wholesome food and sufficient fuel are wanting; and his sufferings are aggravated by the cries of hungry children." There were also the "Journeymen mechanics," who when sick are "placed in small, confined apartments, or in rooms crowded with their fellowworkmen."

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Although emphasis was on the destitute poor, since a hospital in those days was held secondary to a decent home, yet "in cases of long protracted diseases," instances of need for hospital care do "occur amongst the most industrious classes . . . and those who become sick just as they are entering active life, who have not had time to provide for this calamity. . . Disease is often produced by anxiety and exertion which belong to this period of life." The proposed hospital was to supplement home care "of the sick poor" by doctors of the Boston Dispensary, which had been established in 1796 "that the sick, without being pained by separation from their families, may be attended and relieved in their own houses." This now famous letter was addressed to several of the "wealthiest and most influential citizens . . . for the purpose of awakening in their minds an interest in the subject." The response was such that a group secured a charter in February 1811. The Bowditch history tells us also that a pamphlet, "a beautiful specimen of Typography," was published in 1816, in which the Trustees "laid their case before the public. They maintained that an establishment for the alleviation and cure of the sick and the insane was needed; they appealed to the intelligence and humanity of a Christian people to supply the want. By able statements and addresses, which were extensively published, and by letters and circulars to clergymen of all denominations and to private individuals of wealth and character throughout the Commonwealth, they informed and awakened the general mind, and created a strong and widely extended sympathy for their cause. All things having been thus prepared, they divided themselves into four Committees; and, abandoning their private affairs for a season, they went through our streets, day after day, soliciting subscriptions from all; for they deemed it important that every individual in the community should have an opportunity to contribute to a charity in which each was interested."4 With the contributions received, the Trustees were able to lay the foundation of the General Hospital on North Allen Street and the Asylum in Somerville. The Asylum, later to be known as

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McLean Asylum, in honor of a benefactor, Mr. John McLean, "a truly noble specimen of a Boston merchant," admitted its first patient in 1818. The General Hospital was opened in 1821. A chapter given over to comment on the patients contains a tale of the first recorded social service at the Hospital performed through the kindliness of Mr. Bowditch himself. "A sweet little girl of seven years, picking up chips in a basket in the Maine Railroad enclosure, was run over by a train of cars and had her foot cut off. . . After her limb was healed, I ascertained the time of the directors' meeting of the Maine Railroad and took the child there to argue her own case. In this instance, at least, the maxim proved false, that 'corporations have no souls.' They gave her case kind and merciful consideration, granting three hundred dollars to be held in trust for her sole use, at the discretion of the Superintendent and myself. Through the kindness of the Matron (Mrs. Girdler), it was even arranged that she should live at the Hospital, attend school in its vicinity, and finally become a seamstress in the establishment." Then Bowditch added, rather sadly it seems to me: " A future of usefulness and happiness seemed secure for her. Her parents, however, were Irish. They overpersuaded her to return to them." Social service methods have changed with the years, but kindly impulses, I believe, are no less genuine. The McLean Asylum, situated across the Charles River, seems to have observed a like kindly concern for its patients. In the New England Gazeteer of 1837 appeared a description of the beautiful grounds and gardens, and this statement: "The system of moral treatment adopted and pursued, is founded upon the principles of elevated benevolence and philanthropy and an acquaintance with human nature and the capabilities of the insane. The previous tastes, habits, and pursuits and the present wants, inclinations, and feelings of each individual are habitually consulted. A library for the use of the patients has been purchased and those of them who are permitted to read are permitted at stated intervals to send

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their names and the number of books desired. The list is examined and approved by the physician and distributed by the librarian." The recreation, games, walks, and so forth are listed and tasks assigned to some patients. " A regulated intercourse with the family and society is regarded as an important auxiliary in the means of cure and on suitable occasions they are invited into the House where parties are made for their special amusement and benefit." In 1892, a changing attitude toward mental disease is reflected in a change of name to the McLean Hospital. Removal to the suburb of Waverley has meant that the public has come to think of the McLean Hospital as having no official relation with the Massachusetts General Hospital. This is unfortunate, since the original founders of the Hospital recognized the fundamental soundness of the concern of medical care with disease of the mind as well as of the body. As the McLean Hospital has not developed a department of social service, our story will be that of the General Hospital, where psychiatry has become well established and is making its contribution to medicine. The nineteenth century saw great advances and expansion at the Massachusetts General Hospital as at other leading hospitals of our growing country. After the early years, when they had served the poor only, hospitals became generally acceptable because of their provision of essential facilities for better care of the sick. Anesthesia, following its public demonstration at the Massachusetts General Hospital in 1846, was accepted as essential to surgery, and antisepsis and asepsis had limited the hazards of surgery. Similar technical procedures had established hospital service as essential for all. In 1905, therefore, when our story of its Social Service Department begins, the Massachusetts General Hospital was in many ways quite another institution from that of a half century earlier, when the Trustees knew the patients individually and every fortnight "viewed" them. It had grown to a capacity of 500 beds, served a wide area of N e w England, and accepted for admission to its wards patients who could pay

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part or full rates of board; as provided in its charter, no doctor was paid for his services. The Hospital had an assured place in the confidence of the public—of both patients and those who gave their generous support. Its staff had made major contributions to scientific medicine which revolutionized treatment of patients and furthered clinical research. In teaching, it was strong in its active affiliation with the Harvard Medical School. Specialization was developing rapidly. Improved technical methods and equipment for diagnosis were provided. The old Outpatient Building, opened in 1883, had been replaced by a modern, much enlarged building, and attendance at the clinics was ever increasing. Despite these professional advantages, it was in this setting that Dr. Cabot found himself "constantly baffled and discouraged" as he sought to give care to the patients in his medical clinic. The Hospital's efficient facilities for finding out what was physically wrong with patients made clearer the ineffectiveness of carrying out treatment. Undoubtedly many dispensary physicians had similar feelings of futility in the rush of busy clinics. It was characteristic of Richard Cabot to spring to action and to expression of his convictions. In a letter of appeal for support of his idea he wrote: " W e need a new department housed first in a little room near where I work so that I can get it started right. Later as it proves its need and function, expanding to fill several rooms. Sooner or later, I think the Hospital, every hospital will plan such a department." Only a man with uninhibited self-confidence in the Tightness of his cause could have gone ahead so sure that into that bulwark of tradition, the Massachusetts General Hospital, he could introduce the foreign element he proposed and an altogether new way of doing things. And how characteristic of him to proceed oblivious of obstacles. W e were to undertake to inject a new concept of service into an old institution that was very conscious of its own high purpose, its long tradition of fine service, and its standing in the community. The task was to require the talents and energy, not of one or two

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leaders, but of a group with diverse abilities. Fortunately there were in that pioneering venture some who were bold, fearless, impatient, self-confident, resolute, and others who were prudent, sensitive, cautious (possibly a bit timid), who could temporize. But all were loyal to the old Hospital in its primary purpose of good service to the patient. To many long established there we social workers seemed at first to be intruders—as indeed, we were! But from the first we believed we had something to contribute to the established order, and that we belonged there. And so under the skeptical eye of the Hospital administration, but with the inspiring leadership of a great physician, Richard Clarke Cabot, we steered our course.

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O F all our humanitarian institutions, the hospital is undoubtedly the most rigidly organized. Its lines of authority and delegation of responsibility must be clear, since it is an institution concerned with life and death. The confidence of the public is built on such assumptions. Therefore, those who carry responsibility within the hospital are inclined to look askance at any new element to be incorporated into its smoothly functioning organization. Such rigidity was more marked fifty years ago than it is today, although the serious sense of responsibility is no less. In 1905 at the Massachusetts General Hospital, the Outpatient Department was less well organized than the main Hospital where the seriously ill were under care; this was characteristic of dispensaries throughout the country. Clinics were then used largely to provide resources for medical teaching and.for the aftercare of surgical patients discharged from the wards. The organization of dispensaries and outpatient clinics as facilities for consistent treatment of long-term diseases, and as assets in preventive medicine, was a much later development. With these facts in mind we can accept as generous the reference to the new venture of clinic social service in the annual report of the Hospital for 1906, a year after Dr. Cabot and Miss Pelton initiated the service. In this report Dr. Herbert B. Howard, the retiring superintendent, called attention to the group of social workers as an "unofficial department" of the Hospital. "It has tried to be of use to those outpatients who, by reason of circumstances, were unable to avail them-

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selves fully of the advice of outpatient physicians and surgeons. . . This was not started as a criticism upon the Hospital and its methods, but to do a work the Hospital was not doing and has not seen its way clear to do." It had been wise to start the demonstration in the Outpatient Department, where it was least conspicuous. Dr. Howard's comments may be further accepted as evidence of his confidence in Dr. Cabot and Dr. Putnam. It was revealed later that Dr. Cabot had secured the supporting interest of Mrs. Nathaniel Thayer, wife of one of the trustees, later a trustee herself, and a prominent member of the Ladies' Visiting Committee. A three- and a six-months' report, on mimeographed sheets, were issued by the "unofficial department." These give evidence of its usefulness to doctors and patients alike. There were noted the bewildered, ignorant mothers who had not understood the doctor's directions about their babies' care and "the impoverished patients with tuberculosis," needing special relief, instruction, and supervision, but for whom the clinic could do little. These latter comprised the largest group of patients referred. In the first six months, "Social Service" had given some help to 304 patients, about one-third of whom lived outside of Boston. Thirty-two different "charitable agencies" were enlisted to give special help to patients. Dr. Cabot noted significantly that "the majority of the cases came from the clinics in which the most careful histories are taken— the medical, children's, and nerve departments."At the end of six months, social service to patients was provided by two paid workers and "a group of competent and devoted volunteers." I well remember my first impression of the outpatient department when I went there in the autumn of 1906, a year after Social Service had been introduced in the Hospital. I found myself in a great crowd of people, all coming and going in many directions; in the confusion there seemed to be no one whom I could ask to direct me. I noted the great contrast between the brisk, assured, purposeful steps of the erect, uni-

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formed personnel and the slow, hesitant, more deliberate walk or shuffle of the patients, as though groping for assurance that they were in the right place. There were many patients on the long wooden benches, some of them obviously tuberculous, coughing, emaciated, hectic, apparently anxious. I remember, too, the impression of various nationalities and of men and women of a low economic level. On the south side of a big sunny corridor I found the social workers busy with patients. A few small tables, chairs, a bench for waiting applicants, and two white screens to give some privacy, were the furnishings. Here I was welcomed and set to work. This "Corner," as it was called for want of a more significant name, was the second location given the social workers. A small quiet room had first been assigned to them, but Gertrude Farmer, Head Worker at the time, soon realized that quiet and obscurity were not desirable for a service that had yet to demonstrate its value. So she had been allowed to transfer to an unused corner of a busy, noisy corridor where there was constant passing of both patients and doctors. It is not difficult to understand why, at first, we social workers aroused some antagonism among doctors and administrators. It was inevitable that an enthusiastic group of young women—a few trained social workers and some fifty volunteers—not officially responsible to anyone in the institution but having access to clinics and wards, should have been looked at askance, especially by those who had no idea what it was all about. For the eager initiate this situation was not a happy one. Sometimes, in response to a social worker's question about the need of aftercare plans for a patient, a doctor would state brusquely that the Hospital's responsibility ended when the patient went out the door. Some doctors were too busy with teaching and "running o f f " their clinic to bother with us when we intruded to ask for more specific orders for a bewildered patient. The hardest for us to deal with was the indifferent doctor—but there were few of them. Dr. Cabot's first annual report (1905-06), which bore the

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title of "Social Service Permitted at the Massachusetts General Hospital," was widely circulated not merely among the medical staff of the Hospital and the friends who had been aiding in support of the work but also to other hospitals and physicians who had expressed interest. T h e report opens with a challenge to dispensaries of that time; "In the Out-patient Department of the Massachusetts General Hospital (and I suppose in most other hospitals) there occurs many times each year a scene not unlike that described in 'Alice in Wonderland': 'Have some wine,' said the Hatter. Ί don't see any,' said Alice. 'There isn't any,' said the Hatter. Without any sense of the humor of the situation we say (in substance) to many patients; 'take a vacation,' or 'get a job,' 'get a set of teeth,' or 'get a truss.' There is none in sight and no means of getting any. W h a t do we do? W e pass cheerfully to the next patient." Dr. Cabot made his point vividly, even if he did misquote "Alice" and credit with impertinence the Hatter rather than the March Hare. T h e report of the first year was received with enthusiasm by friends outside the Hospital, and the list of contributors to the support of the Social Service grew longer. There was no precedent for organization in a medical institution of such a service as we were offering to patients. Our purpose, although not clearly defined, was to help any patient who faced difficulties in carrying out medical treatment. In part to serve this purpose we chose to be stationed in a convenient place where our availability to doctors and patients was obvious. Dr. Cabot soon gave us a slogan that became familiar—"Make treatment effective." W i t h our focus on the patients and their needs, it soon became clear that we must establish more satisfactory relations with the doctors in the clinics, with the administrative officers, and with the existing social and health agencies in the community. As our patients came from a wide area, the community was much of N e w England.

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A few doctors understood our purposes from the beginning and welcomed our assistance with their patients, but the Hospital administration kept a watchful eye upon us. One day the cleaning man shifted our white screen a few feet down the corridor to include a second window. I overheard one of the administrators say to the nurse "making inspection" with him: " Y o u will have to watch those social workers. Soon there will be no room for those who belong here." When, years later, I recalled to him this remark, he, having since become one of our stanch friends, insisted it could not be true. In those years my ears were keen. They did not deceive me! Since we, as social workers, recognized common interests with those associated with charitable agencies already existing in the city, and knew that they were sending many patients to the Hospital, we expected them to welcome our acceptance within the Hospital. Some of them did. But there was a question seriously asked by some of Dr. Cabot's friends who were active in the Associated Charities: " W h y another charity?" They expressed a conviction that our work should come under a branch or district of their society, related in organization with the "charities" of the community rather than with a medical institution. However, Dr. Cabot had his own convictions. He believed that medical service needed social case work within its own sphere of responsibility. There was another consideration. Although we both were appreciative of the high purposes of the organized charity movement of that time, we were critical of some of its methods which seemed to us more suitable to the detective than to social service as we conceived it. The Associated Charities was dealing with such problems as "vice, hereditary degeneracy, drunkenness, and desertion." Dr. Cabot declared that in cases in which individuals had declared war on society, police methods of investigation were justified but should never be used by social workers. W e recognized the ease of approach to people in trouble that the hospital offered. While seeking to relieve their physical dis-

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tress a relation can be established with patients that more readily leads to discussion of other personal difficulties. So we thought and, therefore, chose to keep free from any other organization. We discussed these ideas frankly with our friends in the Associated Charities, at the same time seeking their advice on many questions. In answer to the suggestion that we should be a part of the Associated Charities, Dr. Cabot's response was to ask his cousin, Miss Marian Jackson, a director of that organization, and its capable general secretary, Alice Higgins, to come to the Hospital for weekly conferences to discuss individual patients' problems. One of the basic principles of medical social work was soon demonstrated—that in dealing with the sick, effective social service must be based on a knowledge of the patient's physical condition, and further that the medical and social services should be consciously related. At these weekly conferences back in 1907 we began each discussion with a lucid presentation by Dr. Cabot of the physical condition of the patient; this was followed by a report of the personal situation as we knew it. Often the patient was already known to the Associated Charities, and Miss Higgins then presented the agency's record of the family. After several conferences in which their records had indicated that the man or woman was "indolent" or "shiftless" or "lazy," but the medical examination had revealed some organic disease, such as tuberculosis or anemia, Miss Higgins stood up: "This is something different." From then on we had hearty support from her and much wise counsel in our new adventure into medical social work. Miss Higgins wrote later ( 1 9 1 1 ) in her annual report: "Hitherto unsuspected physical causes of moral weakness are coming to be understood by social workers, and the connection between social and family conditions and bodily ills to be more generally appreciated by physicians." The time was opportune for an effective demonstration of the value of social service to physicians in the medical clinics. Adequate treatment of tuberculosis required more than cough

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medicine. During the first decade of the century the great antituberculosis campaign had been launched, led by the doctors and social workers of the Tuberculosis Committee of the N e w York Charity Organization Society, as we have already noted. The Boston and Cambridge Tuberculosis Societies were already established, with vigorous programs sponsored by leading physicians, social workers, and publicspirited citizens. The Boston Associated Charities had a special Tuberculosis Committee to study problems brought to the fore by the fact that many families under their care had members, sometimes several, with the dread disease. In his first report on the social work being introduced at the Massachusetts General Hospital, Dr. Cabot wrote: "Tuberculosis is everywhere the entering wedge for social work in hospitals. Confronted with the haggard and destitute consumptive, the physician easily sees the uselessness of his unaided efforts." The gospel of "fresh air, good food, rest, freedom from worry," proclaimed as treatment for tuberculosis, was not readily secured by advice only. So these patients, many of them emaciated and weak, gave us our greatest opportunity for demonstrating the interrelation of social conditions and ill health and of social service and effective medical care. The first five annual reports of the social service department at the Massachusetts General Hospital give in considerable detail the methods we used in this demonstration and the problems we met. Community resources for care of tuberculous patients were still very meager. Dr. Joseph H. Pratt, who had started his Tuberculosis Class at the Hospital in July 1905, was demonstrating one method for caring for a small group of patients who were physically able to make weekly trips to the class. His cheerful optimism and enthusiasm gave encouragement to his patients and many more applied for admission to his class than could be accepted. He aroused the interest of some of the young doctors on the outpatient staff and prompted two of them, John B. Hawes, 2nd, and Cleaveland Floyd, to join with "Social Service" to organize another class to care for patients in serious need of super-

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vision at home, since sanatorium care was not available. Then it was that these two young doctors began their long, devoted, and eminent careers, not only in the treatment of patients but also in the broad public-health fight against tuberculosis. It was in our work with tuberculosis patients that the great usefulness of volunteers was also proved. Under the stimulating leadership and close supervision of Ellen T . Emerson, 2nd, a large group of young women was trained in the simple hygienic procedures required to carry out the doctors' orders to the patients for rest, maximum fresh air, essential food, and care of sputum. The procedures in themselves were simple, but it was not easy for the patients consistently to carry them out. But frequent home visits, with reiterated instructions by the volunteers, the encouragement of the doctors, and the practical help of the social workers in securing extra food and necessary equipment all helped to keep them at it. W e went to extremes in those days in encouraging patients to get fresh air by outdoor living and to maintain an excessive consumption of eggs and milk. From the top of the outpatient building one might then look down on the tenement roofs of the West End and see many tents and shelters where our patients were living out of doors—unhappily not in as fresh air as one might wish. Our familiarity with the conditions under which tuberculosis patients were obliged to live proved useful when the time came to promote the Massachusetts State program against tuberculosis. Dr. Arthur T . Cabot, on his retirement from the Surgical Service at the Hospital, was appointed in 1907 chairman of the State Commission to develop a program for care of tuberculous patients. Dr. John B. Hawes was appointed secretary of the Commission. A n admirable plan for construction of several regional sanatoria was reported, and when the time came for urging appropriation of public funds for the buildings, we medical social workers, along with those in the Tuberculosis Societies, were called upon to give testimony before the Legislative Committee reporting

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conditions under which tuberculous patients were living and inevitably exposing members of their families to infection. This was only the first of such calls to come to us through the years when public health measures, concerning the need for which we had firsthand evidence, were proposed for legislation.

8

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Increase

I N these first years much of our work in the clinics and wards was to seek to give simple, practical help to bewildered patients. Through unfamiliarity or ignorance many were confused by the doctor's advice. No one in a busy clinic had time to explain; only two of the ten clinics had nurses in attendance. Many patients were without means of carrying out the treatment prescribed. Our work with patients from the Orthopedic Clinic began on this simple level of service. One of my earliest memories of the outpatient corridor near our desks is of a large walnut glass-covered showcase in which were displayed a variety of braces, skillfully made of metal and fine leather, all shiny and looking like new. I assumed these articles to be an exhibit from the Orthopedic Workshop, where skilled men were employed. I did wonder why passing patients should be expected to admire these restricting habiliments! On inquiry I learned that these braces and shoe plates had been designed and especially made for patients who had never returned to get and pay for them. So one of our first tasks was to secure return visits by patients to the Orthopedic Clinic and to arrange that payments for special apparatus be made, either in installments from the patients or through other resources. With men such as Dr. Elliott G. Brackett and Dr. Robert B. Osgood in charge it was to be expected that the request should come from the Orthopedic Clinic for our early entry into plans for their chronically sick patients. They often needed much more than the mechanical brace. There were adolescent patients with tuberculosis of the spine—a condition

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common in those days—who were deprived not only of schooling but of the normal pleasures of youth and prospects of independence. Other patients needed encouragement to keep up consistent treatment by attendance at the clinic over long periods. Transportation had to be arranged for some. Before the days of occupational therapy as a professional resource in the Hospital, Dr. Brackett's sister, Miss Minnie Brackett, served as a volunteer in the orthopedic ward, helping patients to develop diversional handicrafts. As more doctors came to understand that we might be helpful to them, our feeling of security was reinforced by the increasing number of patients referred to us. But we knew that there were still skeptics in the medical staff and in the administration, watchful of our expansion of this "unofficial department." I have always maintained that some skepticism was good for us, since this was overbalanced by support from those who believed in us. Out of acute awareness of our critics we evolved some of our soundest principles. Early we learned that in all our activity we must recognize that we were social workers in a medical institution, and that the doctor had the primary responsibility in all plans for the patient. This sounds so obvious now that it is difficult to make clear what a temptation it was to talk independently with any patient about a plan to meet an obvious social problem and to advise him as to outside resources for special help— this, before we were fully aware of the diagnosis or the doctor's advice. But we learned our lesson and adopted firmly the policy that we would undertake service only for those patients referred by the doctors and that our assistance should be linked with the medical plan for the patient. This policy did not prove so restrictive as it seems as I state it, nor as we at first feared. In fact, as the doctors came to have confidence in us, our recognition of their primary responsibility led to a procedure that fostered a dependence on us and a closer cooperation. Increasingly the medical plan was held in abeyance until the social data were reported. When patients were brought to our attention by outside

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social agencies, or if patients came to us voluntarily, we attached to their medical records a brief statement of their personal situation. This was a procedure not unlike that of the Pathological Laboratory in its reports to the doctors. Our evidence sometimes led the doctor to change his advice in the light of the social implications we indicated. Usually there then followed direct consultation between doctor and social worker. T o make it easier for the doctor to refer patients to us for help in carrying out his directions we placed on each clinic desk a small pad of pink paper, the shape but not the color of the familiar prescription blank, on which was printed: Referred to the Social Service Departmènt By Doctor Reason Referred: These served as reminders to busy doctors and proved a convenience to them and an authority to us. Some of these slips I have before me now as they came to us attached to the medical record, usually brought by a medical student. These slips read: "Well advanced tuberculosis, but not entirely hopeless. Was told for the first time today that he had T B . " "This patient has angina pectoris. Danger of sudden death. Should have lighter work. Has a wife and five children to support." "This patient's home conditions are bad owing to drunken abusive husband. Not physically sick but needs help for home conditions." "Patient lives in Lawrence and needs to come to hospital for probably a rather prolonged course of O. P. D. treatment. Cannot afford railway expenses and wants to get work in Boston." "This patient has very bad varicose veins, one of which burst 8 weeks ago. She was in the Accident Room and was given a note to enter hospital. She couldn't go because of a family to support. She needs to be put to bed till her phlebitis quiets down either at home or in the hospital. What arrangements can be made so that she can leave her family or go to bed?" And from the Neurological Clinic: "This patient tells me of abuse at home. Is depressed and moody. What is the situation?" This last

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patient was indeed depressed and, as we soon found out, had been for several months a great source of anxiety to his devoted family. On the basis of our report and after an interview arranged for the doctor with his wife and son in the clinic, the patient was admitted to a mental hospital for observation. He was later committed for needed care. This situation was typical of medical problems that could hardly be solved by busy doctors in busy clinics. But the special techniques we were developing and the associated social assistance for which we could arrange could make suitable medical treatment possible. Our work with the Orthopedic Clinic led to several developments. One was a consistent plan for follow-up of patients needing prolonged treatment. Another was a realization of need for more adequate attention to those patients advised to change their jobs or to secure training for work suitable to their handicaps. There were at that time no community resources especially designed for work with the handicapped that we could make use of for our patients. Friends of Dr. Cabot's who were members of King's Chapel proposed in 1 9 1 1 that a joint committee be formed for a cooperative adventure to meet our need. W e had many patients who, although handicapped, could work if employment suitable to their disability could be found, but no one in our group of social workers was especially equipped in vocational guidance and industrial placement. So we welcomed this proposal from King's Chapel and offered to provide a desk and space for the new worker. She was Grace S. Harper, a social caseworker of long experience who had prepared for work with the handicapped through special study and by familiarizing herself with many and varied industrial processes that could be performed by persons who, for example, had lost an arm or a leg, or must sit at work or were deaf. She also knew the opportunities for apprenticeship training of various kinds. Dr. Cabot said of Miss Harper: "She never asked an employer to mix up business and philanthropy but merely to give her a chance to prove that, despite crippling injury, a given applicant might

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have brains, perseverance, and ingenuity enough to be a 'bargain.' " Under this constructive purpose special training for many of our patients was secured, training approved by the doctor and adapted to the patient's physical condition. In comparison with postwar years, the concept of rehabilitation was somewhat limited at that time but then as now we recognized that one essential of success lies in the character of the patient and his being helped to help himself. After the Children's Medical Service was established as a separate unit in 19x0, with Dr. Fritz B. Talbot as Chief, it soon became evident that pediatricians in this clinic were especially interested in our work. In our annual report for 1 9 1 1 , Dr. Talbot wrote: " A few months' work (in the clinic) showed us that much of our work was without productive results because the successful treatment of infancy and childhood depends upon the regulation of habits, diet, and hygiene and not drugs. W e spend many hours explaining in detail exactly what should be done at home, yet in a surprisingly large number of cases the patient (and the mother) did not know how to carry out these orders. . . W e needed a trained social worker to visit the home to see that our suggestions were carried out." He reported especially on the need for supervision at home for the child with heart disease whose activities had to be restricted. This was a period when there was growing a general recognition of wastefulness in management of dispensaries. The Boston Dispensary had made studies of attendance at their special clinics. Following the publication of these studies and with the cooperation of Dr. Talbot and Dr. Richard M. Smith of the Children's Medical Clinic, we undertook a review of attendance there from October 1 9 1 1 to April 1912. Analysis of the data secured revealed that, of the 779 children who had come to the clinic, a large proportion had never returned after the first visit. Among these were many babies with digestive disturbances—a common condition in those prepasteurization days—and young children with anemia and rachitis. After joint consideration of this evidence by the doc-

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tors and the Supervisory Committee on Social Service, a public-health nurse, Laura Beaton, was employed on half time to help supervise the babies in their homes and to work in cooperation with the local visiting nurses. A pediatrician was assigned to give particular attention to these infants as they returned to the clinic. The special interest of the doctors in heart disease and the development of social service for that unit will be discussed later. It was natural, and to our advantage, that the doctors should use our services according to their special clinical interests. That this was so gave us both opportunity and a basis for sound growth. When clinical interest was combined with such humanitarian concern as we found in Dr. James J. Putnam, our experience was doubly enriched. Dr. Putnam, Chief of the Neurological Service, was especially interested in psychoneurotic patients, an interest in which Dr. Cabot shared. In the second annual report of Social Service (190607), Dr. Cabot wrote about "the cases of 'nervousness,' hysteria, morbid fears, of fixed ideas, hypochondriacal concentration on movements or sensations of the heart, stomach, or other organs, 'nervous prostration,' with torturing worries and discouragement, or with insomnia, nervous dyspepsia, and the constant sense of exhaustion," and stated that such patients formed a group that needed the attention not only of doctors but of social workers. "Nervousness, in all its protean forms, is often a family problem, arising from financial and other worries, domestic friction and incompatability between temperaments of members of the family." That we were able to contribute to the care of such patients was due to Dr. Putnam who, from the first, was deeply interested in the department, readily accessible when advice was needed, and wise in counsel. He himself wrote in our report for the following year (1907-08): "The physician in the clinic is apt to touch the real life of his patients as at the circumference of a large wheel; the social workers can often penetrate more deeply and may open avenues which the physician can then follow and may go still further. T h e y and we have acted constantly

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together and with complete understanding of each other's aims." W e had been fortunate in drawing into our group in the spring of 1907 Edith N . Burleigh, a former psychiatric patient who had worked through to a fine philosophy of living. She had been a resident of Denison House Settlement after receiving training in social work and was temporarily acting head worker when Dr. Putnam recognized her special qualities and asked her to work directly with him. He described her task as no less than "explanation, encouragement, rééducation of thought, of emotions, of the senses and the muscles, and the suggestion of that better point of view which the patient needs." This sounds a very presumptuous assignment, in the light of our deeper understanding of psychiatry as it has developed through the years. But Dr. Putnam was a wise guide and kept close supervision. Antoinette Cannon, who following graduation from Bryn Mawr was headed for a career in biological research, was persuaded by Dr. Cabot in 1908 to join our social service staff as Miss Burleigh's assistant. Dr. Putnam took upon himself the tutoring of these two workers in such knowledge of psychiatry as he considered necessary for their intelligent cooperation with him in serving psychoneurotic patients in the clinic. The Neurological Clinic had a wide range of illnesses to deal with—paralyses, epilepsy, feeblemindedness, borderline psychoses—with which other members of the clinical staff were dealing and for whom social service was called upon to help, but Dr. Putnam's special interest was in those "neurasthenics" with whom most of the doctors had little patience. A significant innovation in their treatment was our employment of Katharine Burrage, an artist and teacher of clay modeling. Dr. Putnam had been familiar with this form of occupation as a therapeutic aid to treatment used in private sanatoria for "nervous invalids," but so far as he was aware it had not been available to dispensary patients. " W h y not?" Dr. Putnam and Miss Burleigh selected a group of patients that began with a dozen and grew to thirty-two, and repre-

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sented a wide range of nationalities, education, and social conditions. T h e y met with Miss Burrage twice a week for two hours in one of the corridors of the outpatient department. B y working together, modeling with clay, these women "were given a new interest and a chance to develop their skill in a new direction, and, more than all that, a sense of mutual helpfulness and forbearance." Miss Burrage was helpful to Miss Burleigh and Dr. Putnam through her careful and discerning observation of character as expressed in their work, and skillfully guided these patients as she taught them how to improve the modeling of the crude clay into articles of beauty. As their feeling of being a group became established, they were given an opportunity to attend for two winters a series of talks by Miss Alicia Keyes at the Art Museum, arranged exclusively for them. This sharing of the beauty found there further increased their interest in one another. I remember that on one rainy day the group stopped on the way to the Museum to have pointed out to them the iridescent beauty of a mud puddle at Copley Square! Dr. Putnam, the kindest of men, often said that kindness alone was not sufficient for patients with emotional disturbances. He urged us to make personality the first object of our interest. He pointed the way although he probably realized that our reach must exceed our grasp. He was always seeking to understand better the emotional difficulties of his patients. W e had the benefit of exposure to this eager openness of mind to any means of securing deeper insight into emotional life. It was doubtless this that led him to seek to understand Freud's new concepts, which at that time were arousing attention, skepticism, and considerable severe criticism, if not scorn. When Freud came to this country in 1909, on the occasion of the twentieth anniversary of Clark University, Dr. Putnam shared in sponsoring his visit. I well remember Freud's coming with Dr. Putnam to the Massachusetts General Hospital after the meetings in Worcester. But especially I recall vividly the storm of abusive criticism heaped upon Dr. Putnam for

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urging a receptive attitude toward psychoanalysis, which he considered might be a possible new method of helping those psychoneurotic patients for whom so little was done and whom he cared most to relieve. H e became a spearhead in championing a tolerant point of view about Freud's theories of that time, although he openly disagreed with some of Freud's later ideas. Antoinette Cannon, who had attended Freud's lectures at Worcester while she was a member of our staff and who, for many years, taught in the New York School of Social W o r k , recalls those early years. She comments: "Psychiatry was emerging as a contribution of disturbing new ideas, relevant to theory and practice of medicine in all its branches, to psychology, anthropology, and sociology—all young sciences then; and to the theory and practice of social work, which was entering its more professional phase, establishing schools, formulating purposes, and discussing communicable techniques. .-. It is hard now for us to realize how revolutionary it was, but those of us who were young adults in the early twentieth century can follow in memory our own changing habits of thought as the Freudian ideas of personality and behavior slowly made a place for themselves in our culture."

9 W e

C l i oose o ur A dv i s o r s

A L T H O U G H our department was steadily increasing its service, we were still, in 1908, unofficially related to the Hospital organization, and were sponsored and financially supported by Dr. Cabot and Dr. Putnam and their friends. For us who had daily evidence of the patients' needs of social service, there was a growing conviction that our department would in time be understood and then accepted by the Hospital. Dr. Cabot's faith in our future was absolute. For myself, as I looked at the statements of contributions and increasing expenses at the end of each month, I was often aware of our precarious financial situation. Somehow we always came out even—thanks to our good friends. So great was Dr. Cabot's personal interest in our work that he would have been ready to carry the responsibility alone, counting on his friends to furnish the funds. But I felt no such security in the practical aspects of our situation. After some persuasion on my part, he agreed that it might be well to have a group of interested persons concerned for our activities to act as sponsors. So, in January 1909, the first Supervisory Committee for Social Service at the Massachusetts General Hospital was appointed. In our fourth annual report appear the names of the devoted group who became stanch supporters of the new "department." Sometimes I have wondered if ever another social worker had the opportunity to choose her governing board, for that is what our Supervisory Committee came to be. With Dr. Cabot's help it was my privilege to choose our first committee members. As it proved we chose wisely. The members repre-

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sented the various interests involved—even a skeptic was included. They were Dr. James J . Putnam, Dr. Robert B. Osgood, Dr. Daniel Fiske Jones, Dr. Frederic A . Washburn, director of the Hospital; Mrs. Nathaniel Thayer, wife of a trustee of the Hospital and a member of its Ladies' Visiting Committee; Mrs. Annie L . Chesley, a social worker; Mr. J e f frey R . Brackett, director of the School of Social Work; Mr. J . A. Lowell Blake, as treasurer; and, of course, Dr. Cabot as chairman. Many and diverse points of view were freely expressed at our monthly meetings with this committee as they guided us in policy and the extension of our work, and gave substantial help in securing financial support. Although a later chapter will discuss the growing responsibilities of this committee through the years, I wish here to express my deep appreciation for the stabilizing effect of that devoted group, every member of which had a genuine concern for our work at the Massachusetts General Hospital. I acted as secretary of the Supervisory Committee from its organization in 1909 through the change in its status to an Advisory Committee in 1919, and until my retirement in 1945. The minutes of our monthly meetings are at my disposal as I write this story. Several times, the Administration of the Hospital made suggestions that it should take over the management of the service while the Supervisory Committee continued to give their financial support. Such division of responsibility was not acceptable to Dr. Cabot, who reminded the Committee and the Administration that Boston had sound reasons for questioning "taxation without representation." So for some ten years social service in the outpatient department continued on the basis of a voluntary unit within the Hospital. Dr. Cabot had a rather special genius for selecting people who had special abilities for some particular piece of work. Nowhere was this better shown than in his choice of Jessie Donaldson Hodder to work with girls in difficulty, pregnant and unmarried, and those with so-called venereal diseases. In his first report of social service, he wrote: " N o one who has

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not worked in the Women's Department of a hospital and seen the miserable plight of an unmarried girl when first she learns that she is pregnant can realize how much she needs, and needs at once, the advice and help of the right sort of woman." Mrs. Hodder came to us in 1907. Her depth of understanding and her creative help to many girls referred to her in her four years of service are reflected in our published annual reports, and are further reported in a later chapter. Mrs. Hodder had a vitalizing influence not only within the department but in the community, in uprooting smug moralistic attitudes toward the girls to whose problems she devoted herself. She left the Hospital in 1911 to begin her long service as superintendent of the Reformatory for Women at Framingham, where her enlightened leadership revolutionized the Commonwealth's methods of dealing with women "offenders." It was quite to be expected that, as the medical staff increasingly made use of us in the outpatient department, they should presently ask our help as well with patients they referred into the wards. We welcomed such extension of our service. In Dr. Cabot's first report of "Social Work Permitted" at the Hospital, he illustrated the need for such help with ward patients: "Some months ago a baby whose digestion had been upset as a result of improper food given it by an ignorant mother was taken into our wards, fed and nursed into convalescence at a cost to the hospital of twenty to thirty dollars, and then discharged to the same untutored mother, who gave it the same fare and soon reduced it to the same plight as before. Later the hospital admitted the child again and went through the same trouble and expense, to say nothing of the suffering and danger to the child. . . T o make sure that the good done in the wards shall not be undone in the first few weeks at home is one of the tasks which our social workers have tried to do whenever they have been able to get in touch with cases about to be discharged." This assumption that we had a service to render to the ward patients had a sharp rebuff in June 1908, when I re-

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ceived an order from the Director, Dr. Washburn, that no social worker should thereafter go into the wards! We were told to refer all ward patients in whom we were interested to Alice O. Tippet, newly appointed Executive's Assistant. Our two ward workers found it hard to accept the order at first. But "Social Service" consoled itself with the thought that, although the Administration was not apparently cordial to our free functioning, it had some idea that our work was worthwhile, since Miss Tippet was to be employed by the Hospital to perform for ward patients what they conceived to be similar service to ours. It was soon evident that Miss Tippet wished to work helpfully with us and, for five years, she served ward patients devotedly and proved of great assistance to the Ladies Visiting Committee and the nurses. In 1 9 1 1 , John M. Glenn, director of the Russell Sage Foundation, asked me to prepare a textbook on hospital social service. Dr. Cabot had already widely distributed his yearly reports of our activities; his Social Service and the Art of Healing1 had recently been published; articles on hospital social work had appeared in periodicals and in proceedings of the National Conference of Charities and Correction and the American Hospital Association. But there had been published no general account of the scope, organization, and guiding principles and methods of hospital social work as developed in several centers up to that time. Schools of social work that were offering training for this new type of social service in hospitals were asking for reading material on the subject. Our department of social work at the Massachusetts General Hospital was only six years old and not yet officially recognized. We were still pioneering, as were several similar departments in a few other large cities. With considerable hesitation and many misgivings, I undertook the task, leaning heavily on the expressed confidence of Dr. Cabot and Mary E. Richmond of the Russell Sage Foundation, who had been assigned by Mr. Glenn to foster the preparation of my book. Always I had felt indebted especially to my associates at

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the Hospital as we actually "worked our way into our thinking" on method and principles. I had also had the eager interest of several of my colleagues who were in charge of social service departments elsewhere. I think gratefully of Elizabeth V . H. Richards of the Boston Dispensary, with whom I conferred frequently during the pioneering period. She and Michael M. Davis contributed much to more efficient clinic management and the relation of social service to consistent follow-up of patients. During those years I had been in close touch with Helen Glenn (now Mrs. Tyson) director of the department at the University of Pennsylvania Hospital. She had spent the summer of 1908 with us at the request of Dr. John Musser, who, through Dr. Cabot's influence, had become eager for the introduction of similar work in Philadelphia. Helen Glenn shared with me not only her experience in establishing this new service in an old and conservative institution but especially our common problems in community relations with health and social agencies. Edna G . Henry and Dr. Charles P. Emerson of the University of Indiana stimulated me in the teaching function of social service since I, too, had been drawn into teaching responsibilities. In the preparation of material for my book, I visited socialservice departments in other hospitals, from the east coast as far west as Chicago and St. Louis, about twenty in all. I became aware of the diversity of interpretation of the function of a social service department, especially in its confusion with nursing and administrative activities. I discovered a considerable variation in forms of organization; the majority of the "departments" were, as with us, unofficial and supported by groups outside the hospital or by lay groups such as auxiliary committees that were encouraging voluntary service in the hospital. Among the latter was the department at Bellevue Hospital in N e w York, where, under Dr. Cabot's influence, Dr. S. T . Armstrong had become interested in the idea and the Board of the Training School for Nurses had secured Mary E. Wadley to develop the service. It was obvious that clarification of many issues was desirable, and that that

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was a task not only for the workers themselves but also for those intent on furthering the purposes of social service in relation to care of the sick. With my own experience clearly in mind and with the stimulus of fresh contact with other pioneers, my book was written. The first edition, I believe, gives a fair picture of the situation of social work in hospitals at the time of its publication by the Russell Sage Foundation in 1913. 2 When Miss Tippet resigned from the Hospital in 1913, Dr. Washburn asked me to look into the situation in the wards and to make recommendations to him as to what I thought should be done about Miss Tippet's successor. Here was surely a great opportunity to be taken seriously. Might the wards be open again to social workers? Happily, I had come to believe that Dr. Washburn now accepted the idea that social service had a justifiable place in the care of hospital patients. Also, by this time, we were firmly established in the confidence of a majority of the clinical staff with only enough skeptics to keep us watchful of our course. What should be our next step forward? I studied what was going on in the wards and the needs as I found them, reviewing Miss Tippet's reports, talking with nurses and members of the Ladies' Visiting Committee and with members of the administrative group. T h e y were all deeply appreciative of what had been done in personal help to the patients. From the doctors I could not get a clear idea of the service that had been given beyond their genuine appreciation of the way Miss Tippet had "cleared" the wards, the familiar phrase for keeping the patient population moving and ridding the wards of an accumulation of the chronic sick. Miss Tippet, a gentle and most considerate person, had told me she had tried not to "bother" the doctors. I speak of this to point up the difference in our outpatient work, where we did "bother" the doctors but on the assumption that we were helping them to serve their patients the better. In my report to Dr. Washburn, which had the hearty support of Dr. Cabot and Dr. David L. Edsall, then chief of the

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Medical Service, and both members of the newly formed Executive Committee of the Hospital, I took the bold step of recommending that the Trustees consider creating the official staff position of Chief of Social Service and that the work in wards and outpatient department should be more closely correlated. Anxious weeks followed, at least for me, until, according to the Hospital's annual report, the Trustees "at length recognized the Hospital Social Service as a part of the Hospital system by creating the office of Chief of Social Service. They have long realized the importance of this service and its admirable and efficient management." Dr. Cabot was thus rewarded for his constant support and personal guidance of the work built upon his determination that adequate medical care for many patients must be medical-social care. One phase of our pioneering work had ended. Administratively we were still in two groups; in our work in the wards, we were officially a part of the Hospital, but in the outpatient department we were still privately supported and under the guidance of the Supervisory Committee for Social Service. Meanwhile we had established ever more satisfying relations with our colleagues in the social and health agencies in the community. And we had seen the beginnings of several vitally important activities, such as a trend toward specialization in social service and participation in educational projects. In the second phase of our growth, these were to develop into major interests.

10 Partial

Recognition

T o those who remember that time, the year 1914 inevitably recalls the beginning of general world unrest and the ominous tragedy of world war. But Sarajevo seemed very remote, and the wide world was full of a number of things that did not seem especially to concern or interest us. As opportunities in the Hospital were opened to us through our new status, we in the Social Service Department of the Massachusetts General Hospital were happily absorbed in extending our activities. M y new title, "Chief of Social Service," although official as of October of that year, applied only to my responsibility for our work in the wards. The title of "Executive's Assistant" seemed to have been dropped in 1910, when Miss Tippet began to sign her reports "Social Worker." M y responsibility for supervision of the social work in the wards was directly to Dr. Washburn, Director of the Hospital. M y first step toward meeting this responsibility was to find a well-prepared medical social worker who could develop our social service to patients in the wards, help establish better correlation of the two units of ward and outpatient department, and maintain the cordial relation of our department with the Ladies' Visiting Committee and the nursing staff. W e needed a group of three or four adequately to carry the work in all the wards. But here we became aware of the tight rein with which the administration held official departments in check. This was in sharp contrast to the freedom of expansion and experimentation we had enjoyed in the outpatient department under support of the Social Service Advisory Committee.

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W e were most fortunate to receive sanction for the appointment of a well-prepared medical social worker, Ruth V . Emerson. I knew that under her skillful guidance our new opportunities would develop along sound lines. She soon gained the confidence and support of the Ladies' Visiting Committee and demonstrated to them her need for additional workers; for many years they contributed to the support of the reorganized department. Miss Emerson also demonstrated that volunteers under supervision could perform many helpful services to patients. This help from volunteers and the kindly services to patients by the members of the Ladies' Visiting Committee, and the activities of the professional workers were increasingly of mutual satisfaction. In the outpatient department, our staff of twenty workers was still directed and supported by our Supervisory Committee, under Dr. Cabot's leadership. A separate yearly report of this branch of our work was published independently; of the work in the wards a brief report was included in the Hospital's annual report. In 1914 our staff in the outpatient department included twenty-four volunteers, twelve students of social work under supervision of our staff, and, during the year, eight pupil nurses who spent three months each with us, at the request of the Director of the Nurses' Training School. This last was a development in our teaching responsibilities to be commented on in a later chapter. Our sense of security grew firmer as the opposition of doctors and administrators decreased. In fact, the value of social service in organized medical care of patients in hospitals and dispensaries was becoming more generally accepted, not only in Boston but in many other large cities. N e w York City had several very active departments and, with the enthusiastic backing of their lay board members, had organized for mutual benefit the N e w York Hospital Social Service. Our department at the Massachusetts General Hospital received increasing numbers of visitors from other cities and from overseas, and we had widespread correspondence on many phases of the subject. During the summer of 1914, at

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the request of the Commissioner of Charities of N e w York City, I had spent two months studying the social services in the several large hospitals maintained by that city for the thousands of acutely and chronically sick, and had prepared recommendations for more adequate organization of social services for these hospitals. This experience made me appreciate the stupendous problems in providing adequate medical care for "the sick poor" of a huge metropolis and the serious difficulties of applying the principle of individualized social service. The situation posed a necessity for effective and understanding cooperation between the medical and social services of that great city. The administration of the University of Minnesota Hospital also asked me to confer with them concerning both the development of its social service and its relation with the Municipal Hospital. I returned from these experiences with deep appreciation of our protected position at the Massachusetts General Hospital, where we were privileged to work with no political pressures to combat. Our problems seemed very simple and our responsibility to make the most of our opportunities all the greater. I carry to this day vivid visual memories of the swarms of patients, in rows and rows of beds, on benches and in corridors of hospitals on Welfare Island— and of the devoted nurses who were doing so much to ease the plight of the patients. I had a deeper understanding of what people like Mary Wadley could mean to patients at Bellevue Hospital, where human kindness could readily be overwhelmed by the routine of managing the masses of people shifting to and fro. A bond of recognition and fellowship was growing between social workers in hospitals over the country. A t the National Conference of Charities and Correction (later called the Conference of Social Work) in Cleveland in 1912, there were special sessions to discuss medical-social relations in the care of persons in difficulties. Many medical social workers attended these meetings and took occasion to get together informally for discussion of common problems and experiences.

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W e were becoming conscious that we were a part of a movement within the medical field and that this movement recognized the interdependence of disease and social conditions and felt the necessity for integrating medical and social services and for enlisting the general public in public-health programs. Broader recognition of the social aspects of medicine was emerging. Concurrently several public-health movements were forging ahead in the large cities, under liberal-minded medical leadership and with strong citizen support. The antituberculosis campaign was widespread and already reaping good results. Social workers became active in this movement, as will be reported later. Better housing was a cause claiming the ardent interest of citizens of many cities; social legislation was being promoted to improve the lot of the industrial workers; sweatshop conditions were being exposed publicly with the backing of those combatting tuberculosis; "social hygiene," as it was later called, was attacking problems of venereal diseases in the name of "moral prophylaxis." Medical social workers, in their close relation to patients and their homes, were well aware of the need for aggressive action. Reformers were pushing protective legislation as fast as the public responded to education on these subjects and could accept their urgent call to action. During the years now under consideration, 1 9 1 4 - 1 9 1 9 , there had opened for us at the Massachusetts General Hospital significant opportunities for application of social service in medical care. These were to be expanded and developed. Probably the most important for improvement of the service was the opportunity to participate in the training of students in the Simmons School of Social Work. Several of our hospital workers had had a year in this school. Meantime a considerable number of women, some with no training, others with nursing or teacher training or with some experience in social ("charity") work, were coming to visit and observe in our department. Some asked for a period of work with us as volunteers, to prepare for assuming positions

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in social-service departments elsewhere. In 1909, we had twelve such applicants from five different cities. It was soon obvious that in our zeal for extension of the general movement we were assuming responsibilities for teaching for which we were not qualified. Also, we were being diverted from the immediate task at hand. The appointment to our Supervisory Committee in 1909 of Jeffrey R . Brackett, Director of the School of Social Work, had been prompted by our awareness that we needed guidance on this subject. In 1912, a special subcommittee on training of hospital social workers was appointed by Dr. Cabot, consisting of Mr. Brackett, chairman, Miss Frances R. Morse, and Dr. James J . Putnam. This committee recommended that applications for experience in our department should be accepted only in conjunction with the School of Social Work where students would receive theoretical work and related lectures. While this policy was accepted as wise, our record shows that it was not immediately and consistently applied. W e soon succumbed to the request made by a local hospital superintendent to Dr. Washburn, our Hospital director, that we accept a senior nurse to work with us for a year in preparation for establishing social service at her hospital. Our desire to please "the authorities" may have influenced us! Our sense of security was evidently not yet strong enough to give us independence. At that time there was considerable confusion between nursing and social work in medical institutions. Social work was in its earliest professional stage; nor was nursing, as yet, wholly accepted as a profession, although it had high standing as a vocation for women. As I had had nursing training and a year at the Boston School of Social Work, I found myself trying to discriminate in my own mind between the special contributions of each group and to define the common interests of nurse and medical social worker. As each group was changing, and finding its special function, and especially as public-health movements were calling for nurses to promote

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health education, a controversy developed that, for a time, was to cause some bitterness. Early in 1912, the School of Social Work first offered a second year for specialized training for hospital social workers. Dr. Cabot and I were appointed advisers for the course. This course was in the nature of an experiment, the funds having been granted by the Russell Sage Foundation. During the first year six of the special second-year students had their practical work with us. As we also had eight first-year students, the staff was heavily burdened. In the light of presentday standards of field-work supervision, our teaching was certainly inadequate, but we did give the vital experience of direct association with doctors and patients and participation in helping to meet the patients' needs. Meantime the Hospital's own Training School for Nursing negotiated with us to give selected pupil nurses some practical experience with us. This was to include visits to homes, so that the pupil nurse might get a clearer idea of the conditions from which the patients came and the kind of homes to which they would return on discharge from the wards. In 1912, to this end, we began to accept two nurses at a time for three-month periods, a plan that continued for several years until arrangements were made for their training with the District Nursing Association, an experience more closely related to nursing. W e developed a program with lectures by social workers presenting the social and personal complications of illness. Similar plans were carried out in many other hospitals. Participation in teaching medical students the social aspects of medicine, which was to become a significant chapter in the history of medical social work, began with us in September 1913, after Dr. David L . Edsall was appointed Professor of Medicine at the Harvard Medical School and Chief of the East Medical Service at the Hospital. The program he instituted was planned as joint teaching: a clinical lecture given by the doctor was supplemented by social history of the case

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by a medical social worker. Students were then encouraged to join in discussion. In a record of the subjects presented at that time, I find: "Social causes of debility; Occupational diseases; Social bearing of tuberculosis; The buying and preparation of food (with special reference to racial dietaries); The physically handicapped; Alcoholism and its social bearing." From this beginning participation in teaching medical students the social aspects of medical care, with many variations in method, has continued through the years. One consistent principle has been maintained, namely, that there should be clinical leadership in the teaching. Discussion by the students was encouraged, and the actual problems of patients known to them and illustrating the relation of sickness and social situation were the basis for the teaching. This aspect of our work had significant development through the years and a later chapter will relate the story.

11 S eeking O ur Special R o l e A L T H O U G H a readier acceptance of our department and the ever-greater demand for our services substantiated our real sense of "belonging" at the Hospital, it is obvious, in recalling those years, 1907 to 1914, that the special function of social service was not then clearly defined in our own minds, and was certainly not clearly understood by the doctors and the administrators. We had found many opportunities to be useful and had helped to improve clinic organization, but our own organization was still not sound and our financial support was indeed precarious, especially in the outpatient unit. I believe that what kept us going was our keen awareness that the patients needed us and that we could help them, together with the increasing interest of the doctors and the extraordinary loyalty of the members of our Supervisory Committee under Dr. Cabot's leadership. It may be that my own natural, and not especially reasonable, optimism was a considerable factor, for I have only vague memories of obstacles I now find writ large in the records of those years. Through all the pioneering years our primary concern was to combat the routine procedures that are characteristic of an institution dealing with large numbers of people. We realized that, from the point of view of the administration, the red tape was designed to treat all patients fairly, to insure equal attention to all. From our point of view such routine resulted in treating all patients alike, while we were striving to act on our conviction that each patient was unique, that to individualize the patient as a person socially and psychologically was as essential as for the doctors to seek to discover

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a physical diagnosis. We began to analyze our function under this conviction, as the first step toward organizing our special contribution. Dr. Cabot, as usual, helped us become articulate, and so to clarify our thinking. In his report for 1914 he indicated our gropings, which he characteristically formulated in an orderly way: "Nine years ago we asserted that the hospital patient's illness was often merely an incident in his real trouble—bis ignorance, recklessness, poverty, discouragement, feeblemindedness, loneliness. We organized social service in order to serve the patient in his real trouble, whatever that might be. Now, his real trouble is understandable and helpable only when you know: ( 1 ) his bodily state (medical diagnosis and especially prognosis); (2) his mental state; (3) his bodily environment (work, wages, food, clothing, housing, etc.); (4) his mental environment—the influences (good or bad) of his family, friends, enemies, neutral companions. T o get Nos. 2, 3, and 4 and contribute them to the doctor's pile so that he can use the information in his treatment and can ask for help when they go beyond his province, is the essence of medical social work, a sympathetic study of the individual in his home." 1 This statement sounds very presumptuous now that we have come to see the more significant meaning these words have taken on through the years of growth in professional social work. We are, I trust, somewhat humbler in assuming our capacity for so comprehensive an understanding of all the implications of these words. At least, as Euripides recommends, we did not "slight what's near through aiming at what's far." Our eager desire that the patient get his full value from the medical care afforded by the Hospital led us into a variety of activities toward patching up the inadequate organization of clinics at that time. Doctors working under great pressure appreciated this help. The patients most surely did. Every day we saw their confusion over the busy complexity of a great outpatient department. T o understand the plight of the

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individual patient, one must picture him as one among the 500 to 600 patients in attendance at the clinics. As we tried to clear the way for patients referred to us we became aware that we were apparently showing favoritism toward them. W e "steered" our patients to other clinics when consultations were ordered, we saw to it that laboratory and x-ray reports were at hand when the doctor saw the patient. W e made a note of future appointments, gave the patient a slip of paper naming the day and date of his return visit, and on that return visit made sure that patient, record, and doctor really got together. But was that our real function? We began to realize that we were helping comparatively few patients and that hundreds of others needed to have the way cleared for them. W e became aware that we spent a great deal of time in facilitating the medical care itself instead of giving primary attention to our special contribution of social work—to make medical treatment effective by helping the patient remove personal obstacles to carrying out the doctor's plan for his care. The fullest, fairest, and most economical use was not being made either of clinic resources or of our own resources. Here was a problem in dispensary organization that needed attention. Dr. Cabot further pointed up for us our special role when he wrote in our ninth annual report: "In course of time, the social worker must get around to handing back the task of nursing to nurses and the task of organization to organizers, in order that there may be some social work done in her department. What does 'social' mean? Social work means service based on a personal or intimate study of an individual and his environment. . . The essential distinction . . . is that between quick impersonal work (such as bandaging a leg, administering a dose of digitalis, giving a pair of shoes . . . sending out postals to 'old patients') and slow personal work (or social work) such as helping a discouraged boy with one leg to hold his job in competition with two-legged boys, winning a mother's confidence so that she is willing to entrust her child to the hospital's care, even for operation, training a

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neurasthenic to side-track his 'habit pains'. . . T o accomplish any of these tasks we must know (or 'investigate') the person and all that concerns him."2 Adequate clinic management had been a subject for discussion for some time at the Boston Dispensary where, in 1909, Elizabeth V . H. Richards (Mrs. Hilbert F. Day), then in charge of the social service there, had made, with the backing of Michael M. Davis, then director of the Dispensary, several clinic surveys to answer the questions: "What happens to patients who come to the clinic? Have the examination and advice been worth while for the patient and for the doctor? Are patients having consistent care?" Following the publication of these surveys in 1912, we at the Massachusetts General Hospital undertook several such studies, always with the cooperation of the medical staff. As has been noted earlier, from evidence revealed by the survey of the Children's Medical Clinic in 1912, the first step taken was to appoint a volunteer to keep track of the details of attendance and to see that patients understood when they were to return. This volunteer worker acted in the capacity of hostess in the clinic, making sure that the patients were seen in order and that the parent or escort understood when the child was to return. She was the forerunner of the Clinic Secretary, who, in a few years, was to be established as an organic part of clinic organization. Others in the Hospital organization were active in promoting greater efficiency in care of patients in the outpatient clinics. Dr. E. A . Codman had for several years challenged surgeons to look carefully to "end results" as a means of improving surgical techniques. Finally, in 1914, upon the urging of Dr. Algernon Coolidge, volunteers were introduced into most of the outpatient clinics, under the supervision of Ella L. Lyman (Mrs. Roger I. Lee) to act as clinic managers or secretaries. In our annual report for 1914, Dr. Cabot, who had eagerly promoted the plan, describes the duties of these volunteer secretaries as follows: "Their work is to see that the clinic runs smoothly, that the doctors find their patients and the patients find their doctors,

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that the records are ready when they are wanted, and that consultations and transfers from one clinic to another are promptly and satisfactorily arranged. . . In most of the clinics the secretary is also in charge of the follow-up system. . . All this work is distinctly valuable and fits in well with the medical and nursing service on the one hand and the social service on the other . . . connecting or relating what otherwise tends to fall apart."3 Although this new and officially recognized service for improvement of clinic administration drained our supply of volunteers, the better management of clinics relieved our workers from many details that were not clearly social service and permitted us to cope with increased demands for our special help to patients. As time went on, the clinic secretary became so essential to proper clinic management that in most of the clinics young women were regularly employed for this purpose, and a paid supervisor was added to the administration of the rapidly growing outpatient department. During the decade 1910-1920 great changes took place in clinics and dispensaries throughout the country, not only in their number but especially in new concepts of usefulness and standards. In 1900, there were approximately 100 dispensaries and outpatient departments in the United States; in 1916, the American Hospital Association's Committee on Dispensary Work reported 680 general dispensaries. In 1912, through the influence of Dr. S. S. Goldwater, New York City had organized the "Associated Out-Patient Clinics." While the purpose was, in part, better to coordinate the clinic service in that city, this pioneering organization and the American Hospital Association did much to create and establish better standards for dispensaries in general through more systematic organization, with definite procedures and efficient management. In 1918, the first volume on the subject, Dispensaries, by M. M. Davis and A. R. Warner, was published.4 By that time social service had become recognized as an important part in adequate medical care of patients, and in that publication the authors declared the principle that the head worker

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in social service should be responsible to the superintendent of the institution—a principle that sounds obvious now but was not generally followed in pioneering days. As I reread that statement, I recall how complex my situation was at the Massachusetts General Hospital during that decade, for I had multiple administrative obligations. For the ward service, I was directly responsible to Dr. Washburn, director of the Hospital. In the outpatient department, this direct responsibility to him held so far as Hospital policies were concerned, but there was also a direct obligation to our Supervisory Committee on Social Service, from which came all our financial support and counsel on development. T h e complexity of m y obligations was increased still further when, in 1 9 1 5 , Dr. Washburn appointed me to the position of Head Worker of the Social Service Department in the Massachusetts E y e and Ear Infirmary, of which he had been appointed director. T h e Infirmary, next door to our outpatient department, was closely associated clinically with medical care at the Massachusetts General Hospital, and this new affiliation gave an opportunity for more satisfactory cooperation between the social workers in the two institutions in the interest of patients served b y both. Meantime, I was in charge of the special course for medical social workers at the School of Social W o r k . These diverse obligations undoubtedly resulted in m y not giving all the time needed to any of them, but, through this diversified experience, I had learned an important lesson, „ namely, that I must delegate responsibility to others and must trust those to whom it was given. T h e accomplishments of those years were indeed due to the efforts of many, all eagerly devoted to the welfare of the patients.

12 Interesting tke D octors W E may well pause to consider the most fundamental concern of our workers—that of interesting the doctors in what we had to offer to care of patients, and so to them. "Why are the doctors indifferent to us? Isn't our work designed to make their treatment of patients more effective? Why are they so impatiently tolerant when we ask for prognosis of a patient's condition? We must try to plan ahead with the patient, and we need to know his hopes for improvement, his limitations for work." By such questions our puzzled workers implied, "Why do doctors behave like doctors?" There seemed to be characteristic patterns of behavior in the medical profession. When medical social workers came together, a frequent subject for discussion was how to get the doctors interested in social service for their patients. From the first it had seemed obvious to us that, if we were to fulfill our primary concern with the meaning of sickness to the patient and our purpose to help him remove obstacles that hampered medical treatment, we must work closely with the doctor. His medical plan for the patient was the basis for our service. This was accepted as one of our first principles, and therefore to some degree the doctors' purposes and ours were identical. Possibly it was because of our assumption of common purpose—before our work was understood by them, before we had made clear that we could safeguard the doctors' medical plan—that some of the doctors and nurses at first considered social workers to be intruders in the smoothrunning organization of the hospital. One thing sustained us, and that was the patient's eagerness for our help.

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So much for memories of the difficult early days; now for the lessons we learned as gradually we were accepted as part of the Hospital personnel—and for memories of our teachers. Early in our experience, we had the good fortune to work closely with three doctors of distinctive personality, each with characteristics that on superficial impression seemed to have nothing in common. Dr. Cabot, Dr. Putnam, and Dr. Washburn, newly appointed as Hospital Director, were the three. In those early years I would not have said that I was "working closely" with Dr. Washburn! As a matter of fact, I kept as far from him as I could, for I knew his critical feeling about social service, this "foreign body" that had invaded the precious organism of the Massachusetts General Hospital! Later I came to understand his austerity as a sort of military cloak, used to shield a shy and kindly person, and I have to dig deep into my memory to bring back that earlier impression of Dr. Washburn, who was to become one of our stanchest friends. The basis of our final understanding rested in my discovery that his first interest always remained the good of the patient and that he was a truly just person. His early skepticism was greatly to our good: we had to prove to him that we had something important to contribute to the care of the patient. It was obvious that we must find a basis for working with him. One spring day in 1908, I seized the chance to ask his help with a little patient whose home on Cape Cod was near Dr. Washburn's summer home. Mary was a charming Portuguese child who had had infantile paralysis which had been neglected. The doctor had ordered a brace for her leg. Mary's mother, who had come with her, could speak no English. Mary was interpreter. I knew little of resources on the Cape at that time and it occurred to me that here was an opportunity to enlist Dr. Washburn's interest. When I asked Mary if she knew Dr. Washburn, her face lighted up. "Oh, yes!" I took her warm little hand in mine and we went over to his office. I was apprehensive, Mary very eager. Dr. Washburn recognized her at once. After explaining

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the doctor's orders, I left the child with Dr. Washburn. When I returned a little later, he said, rather abruptly, "Send the bill to me," bade Mary a smiling "goodbye," and we left. I knew Social Service at the Massachusetts General Hospital had gained something that day. When Mary returned for her brace, she brought Dr. Washburn a bunch of trailing arbutus, which she delivered herself. " A little child" led us better to understand a big man with a kind heart behind an austere exterior. Dr. Putnam, as we have said earlier, was as eagerly interested as Dr. Cabot in our becoming established at the Hospital. With his brother, Dr. Charles Putnam, he was one of the group of friends, including Miss Frances R. Morse, John F. Moors, and Joseph Lee, who were active in support of our work and of other social services in Boston. Dr. Putnam was Professor of Neurology at the Harvard Medical School and chief of that service at the Hospital. The gentlest, most generous, and most tolerant of men, his capacity for seeing all around a question sometimes made Dr. Cabot impatient, since it often delayed action, but, when he thought the time had come for action, his courage was fearless and definite. This we were to witness during the controversy over Freud's ideas. It was Dr. Putnam who deepened our appreciation of what psychiatry was to offer toward better understanding of patients emotionally disturbed. Dr. Putnam also gave helpful advice when he found us disheartened over an accumulation of discouraging problems. He suggested our studying such cases as a series, analyzing the elements involved and thus getting a more objective point of view to determine whether there was not something we might do for the patients. For example, under his guidance we studied a group of one hundred patients with epilepsy. This was in 1915, when there seemed little we could do for such patients beyond seeing that they had their bromides or securing institutional care if ordered. Adult patients with epilepsy had great difficulty in getting and holding jobs; children were excluded from school. Often the diagnosis of epilepsy was

PIONEERING considered a disgrace, and patients shunned companionship. Their pitiable condition and the distress of their families taxed the worker's sympathies, for she felt rather hopeless herself. Our study was made jointly by Dr. Mabel Ordway of the Staff and our social worker, Margherita Ryther. Their analysis of ages, sex, nationality, degree of education and intelligence, frequency of attacks and duration of incapacity following attacks, vocation and employment record, gave a basis for discriminating consideration as to where to put our effort. Their report, 1 published in 1918, is a register of the many difficulties in the care of epilepsy at that time, a dark period now happily lightened by scientific advance in understanding the nature of the disease and its treatment. Dr. Putnam's humility before the complexities of human suffering, to which he was ever ready to give his utmost, made us feel very close to him, especially in our discouragements. He gave us courage for added effort, and directed it wisely. Then there was Richard Cabot, the indefatigable, the challenger of tradition, the utterly fearless leader in our pioneering, who gave us unstintingly of his time and thought. Anyone who knew Richard Cabot knew that "tact" was not a strong point in his character. But, what a bulwark of strength he was as we worked with him! W e could put all the cards on the table, argue, discuss, challenge him as he challenged us, and come out with courage to be up and doing. His frankness was a very good lesson for me. I was supposed to possess tact in interprofessional relations; on more than one occasion he made me see that my so-called "tact" was really hesitancy to be frank for fear of rebuff. I was not made of that sterner stuff that gave Dr. Cabot his courage to meet antagonisms and differences of opinion head-on. H o w Dr. Cabot hated the idea of placebos, which he contended, quite correctly, were designed to deceive the patients. He brought down on his head some violent criticism for his freely expressed stand on telling the truth to patients. Since he was sometimes blunt in expression, I suspect that many of his critics assumed that he would be likewise abrupt to the

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patient in answering his question, "What is really the matter with me, doctor?" But those who knew him best realized that it was his tender sympathy with patients that released them to put to him the question uppermost in their minds. He could answer the question more easily than many others because he gave his patients more than the diagnosis; he gave interpretation, and he stood by them while they were working through to acceptance of a serious diagnosis. I suspect that some doctors hesitate to answer this question because they dread the patient's emotional reaction, which they do not know how to handle. I suspect, too, that patients sometimes ask the question without really wanting to know for fear of a dire response. Similar situations pose ethical issues for social workers. One of the members of our social service staff was taking a patient, seriously ill with cancer, to a nursing home. As she sat beside the patient in the ambulance, she was asked, "Do you know Dr. Cabot? " "Why, yes, he started our social service." "Do you agree with his ideas?" The worker replied, "Not always," and then hesitated for she knew that the patient had not been told her diagnosis. "Why, what have you in mind?" Then the patient poured out her feelings. She said she was sure she had cancer, that the doctors would not tell her, that she had many responsibilities, matters to attend to if she was not to get well, and that she could have no peace of mind until this question was settled. I did not reprove the worker when she reported to me that she had told the patient the facts, helped her arrange for her will, and encouraged her to write out her wishes for the settling of her family affairs. Although in this case we acted in contradiction to our definite policy toward the doctors, not all cases so truly justified Dr. Cabot's convictions. It is well here to recall how recently has the veil been lifted from medical mysteries. In the early 1900's, patients were scrupulously sheltered from such diagnoses as tuberculosis

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(consumption, as it was called), diabetes, heart disease, pernicious anemia, and cancer. Since doctors desire above all to help their patients get well, it is easy to understand that, when they can feel little confidence in the outcome of treatment, they may retreat to just keeping such patients comfortable and turn their attention to those whose condition offers hope. At the time we began our service at the Massachusetts General Hospital, the treatment of tuberculosis by "rest, good food, freedom from worry" was being preached. This new concept tore the veil of secrecy from that disease and called the patient into partnership. Vivid still, however, are many experiences when tubercular patients were referred to us with the request to arrange for sanatorium care. We first asked the patient what the doctor had told him was the matter. "Why, he said I have bronchitis and need to go away for a while to rest." Not a very stable foundation for our discussion of his giving up his job and facing a year or two in a sanatorium, for making plans for care of the family, and for having the wife and children come to the clinic to see if they had become infected! Convinced that it was the doctor's responsibility to decide what the patient should know of his diagnosis—that he was the one to tell the patient, if we were to carry out his orders for care and remove obstacles to his medical plan—we persistently maintained that policy. But this medical responsibility, although theoretically recognized, was not always readily accepted; for the busy clinic doctor, time was part of the problem. We could gladly accept responsibility for seeing that the patient understood what he had been told, for there were often wide gaps between what the doctor said he had told the patient and what the patient understood. We realized that patients were often confused, that the terms used by the doctor were unfamiliar, and that to the patient the diagnosis was of less concern than the implications, gradually ramifying as he faced the facts in his situation. The indifferent doctor presented a separate problem, and

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his attitude was not easy for us to accept. W e saw that it was necessary for us to prove to him that we had something definite to contribute to his care of patients. As noted in an earlier chapter, Dr. Cabot, in his first annual report, likened outpatient procedures to the Mad Tea Party in "Alice." Alice was a favorite resort for me when I faced those difficult hurdles. Many years ago, the Department accepted the Dodo as a sort of mascot, and for years I had a Tenniel picture of him on my desk with the text: "The best way to explain it is to do it." This had been the Dodo's reply to Alice's query as to how to run a Caucus Race. Demonstration, with its validity as evidence, was accepted as our method. One day a younger worker came to me, utterly discouraged. I asked what was troubling her. "I just can't get Dr. B. interested to use social service in his clinic." I knew that her help was sought by most of the clinical staff and felt confidence in her ability. I asked her what Dr. B. ivas interested in. She had no idea, she had "never noticed any evidence of interest." So I suggested that she ask Mrs. Myers, our friendly and resourceful medical librarian, what Dr. B. was writing about. In an hour she came back, on tiptoes, her face beaming. "Oh, I have had the most wonderful time! Mrs. Myers gave me the most interesting articles to read. She says Dr. B. is a great authority on hysteria." Perhaps I had not adequately prepared her for work in that special clinic but I could now advise her clearly: "When the next patient with hysteria comes to the clinic, do the best job you ever did in getting significant social history. Then see that Dr. B. gets your record." By this means she demonstrated that social service had something to contribute to Dr. B.'s special interest, and gained another friend for us. There were other reactions to our efforts. I remember a visit from a member of the Ladies' Board of a New York hospital social service department, some years after our service was generally accepted. She said that one of the questions her workers wanted her to discuss was how to get the doctors interested in social service. I suggested, with a shadow of

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misgiving, I must admit, that we step out into the corridor and ask the first doctor we met. He happened to be Dr. Fritz B. Talbot, Chief of the Children's Medical Service, who had long been our cordial backer. I put the question to him. He hesitated a moment and said, " I guess it is because you interest yourselves in our hobbies." His "hobby" at the time was research into the energy metabolism of normal and abnormal infants. I should have been glad to have him tell of his early insistence that he needed social service in his clinic, where he had found that many mothers who brought children did not return as he had told them to. But at the time of my question he had just come from his special laboratory where he was studying a group of mongoloid (feebleminded) infants. His reply did not suggest the interrelation of medical and social care I might have wished, but he demonstrated a situation where we were of practical service. Dr. Talbot's purpose in his "hobby" was to contribute to scientific knowledge concerning metabolism in these defective children. His examination did nothing to correct the condition of the individual mongoloid child and it was our task to explain to the mothers why they were asked to bring their children to the clinic. W e listened to their tales of difficulties in care of the children. As we talked to them, we got some measure of the mothers' anxieties, of the effect on the care of normal children, and we gained knowledge of the lack of institutional care for feebleminded children under school age. This knowledge helped us to join in efforts to secure more adequate facilities. Friendly interest from the doctors was, of course, not enough for us. T o plan with them how best to help their patients get the most out of the medical care they prescribed was our aim. Dr. Cabot and Dr. Putnam had always been ready to give their time to discussion of individual cases, but we considered it indeed a step forward when, in 1913, Dr. Richard M. Smith of the Children's Medical Clinic suggested that we set aside a regular time for medical-social staff conferences. Dr. Cabot describes the plan in the eighth Social

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Service report: " O n c e a week in the Children's Clinic the physicians, social workers, nurses, and students (medical and social) sit down together to talk out one of the medical and social puzzles of the past seven days. T h e physician in charge of the clinic presides and presents the problems first from the medical standpoint; the social worker adds what she has individually learned of the case; then a plan for action is worked out. T h e weekly hour set aside for this conference serves to keep the physicians in touch with the quality of work done by their co-workers and assistants, to make clear to the social workers what the doctors are trying to do for the patients, to bind the whole group together as a team . . . and to pool the knowledge of all for the benefit of each." 2 Although this special medical-social conference lapsed after a few years, the plan developed later in several clinics. T h e clinical services to which social workers were assigned invited the workers to attend ward rounds, but this did not prove satisfactory when conferences were actually carried on in the wards, since discussion of the patient's personal problems in the open ward, with other patients near, might embarrass the patient. W h e n later the so-called "grand rounds" were held in the amphitheater, as they are at present, the medical social workers assigned to the special clinical service were usually in attendance and often asked to take part in discussion. This integration of clinical and social aspects of a case, which has developed in more recent years and is of major significance for the future of medical care, cannot be adequately dealt with in this story of our earlier years.

13

A Broad er οcope D U R I N G the decade 1910-1920, several developments in both the application and the better organization of social work in medical care of patients promised a broader scope for medical social service. T o be remembered among such developments at the Massachusetts General Hospital are: the organization of a special clinic for children with heart disease, to give inclusive attention to the many problems of the child and also to assist clinicians in ongoing research; the awakened interest in the relation of occupation to disease, given impetus by Dr. Edsall; and the effective cooperation of doctors, social workers, nurses, and community resources in tackling the problems arising out of epidemics and major disasters. The Children's Medical Service was the first urgently to request that a social worker be assigned to the clinic. One of the doctors once commented on such an arrangement: "The patients will not be aware where the medical work ends and the social work begins." The purpose was, indeed, to foster closer integration of the doctor's and social worker's services. Dr. Talbot had insisted that this was especially necessary in a clinic where the young patients could not give a clear history of their illness, or take responsibility in carrying out treatment, and where reports of conditions at home were of paramount importance. The first step toward meeting this need was taken in 1 9 1 1 , just a year after the clinic was started, when a half-time social worker was appointed; and in 1913, as already mentioned, Dr. Richard M. Smith had initiated the weekly medical-social staff conference of the clinic.

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As already noted, the study of attendance at this clinic, made in 1912, had disclosed rather shocking facts, such as the "one visit only" of 59 per cent of babies with digestive disturbances. T o correct that situation a member of the clinical staff was assigned to a newly formed unit, the Baby Clinic, and, through the generosity of Mrs. Elizabeth Andrews Mason and in appreciation of the work of Dr. Smith, the assistance of a full-time public-health nurse for home visiting and supervision of these babies was made possible. Our study had also disclosed the fact that the children with heart disease had maintained the highest rate of return visits. This fact, we believed, reflected the special attention given by Dr. Richard M. Smith and Dr. Richard S. Eustis to the study of heart disease in children and to their assignment of such patients to social service for supervision. The first of the special workers for the Children's Cardiac Clinic, Clara May Welsh, was appointed in June 1912. It is of significance for us to note that recorded among our volunteers, and as a member of our social service staff during 1 9 1 3 - 1 4 , is the name of Martha May Eliot, who in later years, as Associate Chief of the Federal Children's Bureau in charge of medical services, developed the program for Crippled Children. 1 Dr. Eliot appointed as consultant in medical social service Edith Baker, formerly of the Massachusetts General Hospital, to help develop the state programs for crippled children. Dr. Eliot has stated that her deep interest in the social aspects of medicine was first nourished in her experience at the Massachusetts General Hospital. In its work with the Children's Heart Clinic, the Social Service Department had, and still has, the devoted and consistent interest and support of the Committee on the Home Care of Children with Heart Disease. This group, made up of the wives of several of the clinicians and their friends, was organized in 1914 by Mrs. Fritz B. Talbot. Its purpose was to support social service in the Cardiac Clinic and to furnish funds and supplies needed in care of its patients. For two years the Committee maintained a small convalescent home

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for these children. But, as its name implies, it placed emphasis on care in the child's home rather than in an institution. These clinical pioneers in care of dispensary children with heart disease began at a time when there was considerable pessimism about the prognosis of the disease. A leading clinical authority had published his opinion that in his experience with dispensary patients a child who developed heart disease before ten years of age seldom survived his eighteenth year. In challenge to this statement, Dr. Talbot declared that heart disease in children is a "social disease and needs social treatment. The child and his family must be educated, his environment must be altered, and adapted to his limitations. He must be kept under supervision for a long period of time, not merely until he has recovered from the acute symptoms which bother him and which have made his family recognize the immediate necessity of a physician's care."2 Miss Welsh served in the clinic for five years. Out of her experience she developed discriminating judgment concerning institutional vs. home care for children: "I know of only five reasons which justify . . . care for a child with heart disease outside of his home: ( i ) when there is present a condition needing constant medical and nursing care; (2) when other illness in the family, usually that of the mother, makes home care impracticable; (3) when there is a large family of young children in a small home, so that anything like rest and quiet is impossible; (4) when there is persistent ignorance and lack of cooperation on the part of the parents; (5) actual criminal neglect on the part of the parents who are able to bear the burden." She reflected the firm belief of all of us that the next best place for a child after his own home is a well-selected foster home. Out of this conviction grew our policy of turning to community agencies that maintained foster homes. Beginning in 1914 we started a program of cooperation with the Children's Mission to Children. This association was begun cautiously on their part, but gradually led that agency to specialize largely in foster care of children under medical supervision.

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The story of the medical-social cooperation that developed through some thirty-five years in this clinic cannot be told here. The continuous association of Dr. Paul D. White with this program, beginning in 1914, furnished our department not only with wise guidance but with inspiring leadership and an opportunity possibly unparalleled. Careful follow-up of the children, to assure their attendance at the clinic, not only provided consistent medical supervision but also facilitated the very careful research in chorea, rheumatic fever, and heart disease carried on through many years by Dr. White and his associates. Several full reports of the medical and social service of the clinic have been published. In each progress report there has been no note of finality but rather a fuller understanding of the inevitable interplay of the medical, social, psychological, and economic aspects of the subject. Some of those associated longest with this clinic, notably Dr. White and Dr. T . Duckett Jones, have had a part in developing the national program for heart disease. The social, educational, and recreational service for the clinic was guided for some twenty-five years by Edith M. Terry, whose advice was sought by many, near and far, in the development of similar services.3 The work undertaken with Dr. Edsall on the problems of industrial diseases was begun in 1913. It was very active through the period under discussion, and must be separately set forth in a later chapter with a report on its current developments. The years 1916, 1917, and 1918 also brought to the Social Service Department major opportunities for demonstrating the application of medical social services in community emergencies. The poliomyelitis epidemic, the Halifax disaster, and the great influenza epidemic of the war years devastated thousands of families by the sudden onslaught of illness, death, and broken homes. The year 1916 will long be remembered by many hundreds of families for the tragedy of the extensive infantile-paralysis epidemic that shocked the people of Greater Boston and sur-

PIONEERING rounding communities. So numerous were its victims in this vicinity that the South Department of the Boston City Hospital was given over to the care of some 700 patients during the acute stage of the epidemic. Appropriate resources were quickly marshaled to organize means for meeting the immediate situation and to plan care for the future needs of the children who survived the epidemic. The State Commission on Poliomyelitis took leadership, working with the Harvard Infantile Paralysis Commission and drawing into council orthopedists with special interest in the disease, hospital administrators, visiting nurses, and medical social workers. T w o orthopedic clinics were authorized to establish special clinics for care of the patients, one at the Children's Hospital and one at the Massachusetts General Hospital. The City was districted and all patients at the City Hospital who were not under the care of private physicians were offered the facilities of aftercare treatment at one of the two special clinics, according to age, convenient geographical area, and transportation lines. It was arranged that the social workers at the City Hospital should interview the parents of children about to be discharged from the hospital ward, explaining the facilities for aftercare. The medical social workers of the two hospitals were given the names and addresses of the patients on their discharge from the City Hospital. A medical social worker visited the home promptly to make sure that, if the patient was not under the care of a private physician, the parents understood what was offered in care at the infantile paralysis clinics. This plan was established because, taking advantage of the emotional state of the community, several unscrupulous persons, posing as medical experts, were preying upon the ignorance and distress of parents of these afflicted children, visiting homes and distributing leaflets advertising quick cures of paralysis, "prepaid." Social workers visited such homes and explained the necessity for prolonged skillful care and offered to arrange for attendance at the clinics, if the parents so desired.

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Since many of the patients were helpless, special transportation was needed. This was provided by an ambulance and driver, through Mrs. John Hays Hammond. In cases already under the care of a family physician, the Hospital informed him of the special facilities of the clinic, should he wish to refer the child for care. Our new clinic at the Massachusetts General Hospital had 138 children referred for treatment, 121 of them under six years of age. A n additional worker was added to our department through the generosity of Mrs. Nathaniel Thayer. Every effort was made to keep the children under consistent care. Although this was a primary consideration, it was soon obvious that the parents needed much encouragement and guidance in the serious responsibilities so suddenly thrust upon them and that problems of schooling and suitable recreation must be arranged for these children so that they should not be further handicapped. At the end of 1917, our clinic at the Massachusetts General Hospital had increased to 193 patients, and continued to increase through the following years as the original patients were kept under care and new ones were added. Ethel W . Chase, the medical social worker in the clinic for many years, will be gratefully remembered by scores of the patients and parents as they were helped to carry through consistently and persistently the necessary but tedious plans of care. They were in most cases richly rewarded. Throughout this prolonged postepidemic period, the visiting nursing association gave excellent assistance, in general nursing care when that was needed at home, and by the addition to their staff of a physical therapist who supplemented clinic treatment by treatments at home when that was possible. A decade later these patients were still being followed, until every possible improvement had been assured. Service to the handicapped, under the developing program of rehabilitation, is discussed in a later chapter. The tragic explosion in Halifax Harbor in 1917, inflicting extensive physical injuries on hundreds of people, called forth offers of help from many quarters. The N e w England Chap-

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ter of the American Red Cross was one of the groups whose help was welcomed. Along with the familiar problems of disaster relief, the situation in Halifax presented a major need for surgical care. Six emergency hospitals were set up, where patients with serious eye injuries, severe ear disorders due to the explosion, fractures, injured limbs necessitating amputation, and other injuries were cared for. It was seen that social workers familiar with hospitals and skilled in dealing with sick people would be especially useful. Ruth Emerson and Edith Baker of our stafi were asked to join the group of medical social workers to render services in the six emergency hospitals. They helped with registration of the injured and cooperated with the local group of social workers who were dealing with the families of the patients, often homeless and destitute. So many of the patients were seriously injured that no hasty discharge plans could be made. A t the request of the Governor of the Province, Miss Emerson remained for several weeks, guiding the medical social work and helping to prepare a more permanent plan for aftercare of the victims of the disaster. On her return to the Hospital we were deeply involved in World War I, and she was asked to organize medical social service at the Chelsea Naval Hospital. So we lost her from our staff, but she was pioneering again in making application of the principles and methods of medical social service in hospitals caring for returned sailors. The influenza epidemic of 1918, so devastating to the troops in Europe and to the Army and Navy, soon spread to civilians and we witnessed one of the greatest scourges of modern times. It became especially vicious in its attack on patients who had had any previous lung infection; many with former tuberculosis had recurrences. All hospitals were crowded to overflowing. It was impossible adequately to care for patients who needed attention, and undertakers were pushed far beyond their capacity to give prompt attention to the dead. A State Emergency Health Committee rallied resources to help meet the situation. I was asked to organize medical social workers to help in the crisis.

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Hospitals were greatly overcrowded. Doctors, nurses, and all hospital personnel were overburdened. Medical social workers shared this stress and helped in a variety of practical ways. There was very great distress in homes of patients who could not be admitted to hospitals or those who insisted on remaining at home. As sickness and death wrought havoc throughout the city, the staff of the District Nursing Association was severely overburdened. These nurses sorely needed help to free them to care for the sick in families whose social problems were greatly complicated by severe sickness and death. In cooperation with Mary Beard, then director of the District Nursing Association, and with directors of social service departments of Boston hospitals, a group of medical social workers was recruited and assigned to the several districts of the Nursing Association to see that the acute social difficulties of the distressed families had attention from an appropriate source of help. Those who participated in this cooperative service will never forget the stark tragedy of the families, often broken by multiple deaths that created staggering problems for families where undertakers found it impossible for many days to care for the bodies of the victims. Nor could one escape the sense of how little any individual could do in face of the enormity of the disaster that had come upon the whole community. Yet the experience of facing together the realities of the situation made us more conscious of our interdependence, illuminated our common problems, and deepened our appreciation of the values of cooperative effort. That period gave reality to the War, to many who had considered it remote until our country became officially involved in 1917. A t the Massachusetts General Hospital the war years 1917 and 1918 were of major significance to the Social Service Department. Our Social Service Supervisory Committee was especially depleted when Dr. Cabot, Dr. Roger I. Lee, and Dr. Robert B. Osgood enlisted for war service in France. W e sustained further loss when Mrs. Nathaniel Thayer was appointed chairman of the Massachusetts Women's Committee of the Council of National Defense, and Mrs. Alice Hig-

PIONEERING gins Lothrop, who had helped us through many years, became the director of the Department of Civilian Relief of the N e w England Division of American Red Cross. But these two generous and faithful backers of our department were near at hand and could be consulted when we needed their advice. The enlistment of others of the medical staff, Dr. Paul D. White among them, resulted in substitutes and readjustments in the clinics, affecting our day's work. Some clinics were temporarily closed, such as the Industrial Clinic on the enlistment of Dr. Wade Wright. The department still had strong backing by such faithful friends as Dr. George R . Minot, Miss Frances R. Morse, and Dr. Richard M. Smith, who served as chairman in Dr. Cabot's absence. But in 1918 we suffered an irreparable loss in the death of Dr. Putnam, who from the very beginning had been a stanch supporter and an inspiration to our staff of workers. He built into the foundations of our department a basic appreciation of the psychological factors in sickness, and prepared the way for the contribution of psychiatry not only in medicine at the Massachusetts General Hospital but in social service as well. In this same year Sarah Evarts was appointed social worker in the Neurological Clinic. Dr. Putnam's hope that a special psychiatric service might be added to the Hospital in a plan of cooperation with McLean Hospital was thwarted by the World War and did not become a reality until 1931, at which time Sarah Evarts returned to us to develop the psychiatric social service in close affiliation with all units of medical social work. The year 1918 also marked the organization of the American Association of Hospital Social Workers, an action discussed for several years and precipitated by the precarious condition in which many social service departments found themselves. Depleted by loss of workers to war nursing service and to the Red Cross, they felt a strong urge to safeguard the movement through the comradeship that a professional organization afforded. H o w this came about is recorded in a later chapter. The following year marked a most significant change in

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the status of the Social Service Department at the Massachusetts General Hospital. The subject of the acceptance of the service as an official department of the Hospital had been discussed on several occasions. On Dr. Cabot's return from France the issue was raised again. The occasion was pointed up by the plan of the Hospital to make a special appeal for funds and the objection of the Trustees to a separate appeal by our Supervisory Committee for support of the Social Service Department. Negotiations ensued and the Supervisory Committee submitted the proposition that they would welcome the official recognition of the outpatient department of Social Service if the Hospital would assure a budget "of not less than the combined budget of the ward and outpatient departments . . . and that the present Supervisory Committee should be retained as an Advisory Committee." Dr. Cabot met with the Trustees for discussion of the issue. On October 17, 1919, the following vote was taken by the Trustees: "Voted that the Social Service Department be from this time forward considered an integral part of the Hospital, both administratively and financially, and that the present Supervisory Committee be continued and that due regard be given to its recommendations." In Dr. Washburn's history of the Hospital in reporting this action of the Trustees, he adds: "Thus, at last, after fourteen years of probation the Department became a definite part of the Hospital. It is only fair, however, to say that the most of the delay was due to questions of finance, not to any doubt as to the usefulness of the service." 4 The "doubts" were still clear in my memory, but I knew that we had won in Dr. Washburn a stanch friend but still a fair and constructive critic. Thus, our fortunes were cast with the Hospital and our financial support, along with the supplying of coal and electricity for a great institution, was to be considered their responsibility.

14 Accepted Officially I n his report for 1 9 1 9 - 1 9 2 1 , under the caption of "Formerly a Territory, now a State in the Hospital," Dr. Cabot commented on the Trustees' action in making Social Service an integral part of the Hospital. In the wards we had been officially recognized in 1914, but, as he stated, the outpatient social service "only by courtesy had been allowed, hitherto, to call itself a Department of the Hospital, since it was financed and managed independently. From 1905 until 1919, the Hospital allowed us space in the Outpatient Department, and light and heat necessary to carry on our work. W e bought our supplies and paid our workers with funds raised independently. . . The hospital authorities were quite right not to take in this new department, or to assume this extra expense on faith or by guess work. . . It was for the best that our Hospital waited to be shown in concrete ways why it was necessary to employ a group of women who were neither doctors or nurses, and who seemed at first quite out of place in a medical institution. "Meanwhile we have been relatively free to try experiments and make mistakes. . . The money raised by the Trustees for the permanent and well-established objects of the hospital could not rightly have been spent in groping and half-baked schemes. W e have dropped some of our undertakings. . . Experiments were quite properly and much more freely tried out because we were not using hospital funds." 1 Dr. Cabot does not mention a fact of which I was quite aware: that the freedom allowed us in the pioneering years had been granted because those in authority had confidence in

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those sponsoring the adventure, especially in Dr. Cabot himself, in Dr. Putnam of the clinical staff, and in Mrs. Nathaniel Thayer, a devoted member of the Ladies' Visiting Committee and from 1916 a member of the Hospital's Board of Trustees. In this three years' report, covering 1 9 1 9 - 1 9 2 1 , Dr. Cabot reminisced: " A f t e r the years of exciting and perilous adventure (1905-1908), those of us who had been actually in charge of the work selected a committee to supervise us." Remembering Dr. Cabot's reluctance when I urged the appointment of such a committee in 1907,1 have special pleasure in reporting these later comments. He was always rather skeptical of committees and the slower processes of group action. "Our original Supervisory Committee had included a group of physicians actively at work in the hospital. Their presence . . . has served two purposes. It kept the social workers clearly aware of what the doctors wanted and did not want of them. It also gradually showed the doctors the possibilities of social work as an aid to medical work." Dr. Cabot gave later recognition to another advantage of committee supervision. Dr. Washburn, Director of the Hospital, and then a vocal skeptic of the service, was a member: "His presence there helped us to bear constantly in mind the necessary administrative difficulties of the Hospital, so that we were less likely to make unreasonable requests or expect impossible things of so large and complicated an institution. On the other hand, the Director's presence at our committee meetings increased his knowledge of the definite and concrete ways in which medical social service could help the administration as well as the daily medical and surgical work of the hospital." I would add here that it was always my experience with Dr. Washburn that the good of the patients was his first concern. When he found that we, too, shared that object and had given evidence that we could help the patients, his support of our position in the Hospital's organization gradually grew. Concerning the other members of our Supervisory Committee, Dr. Cabot wrote: " W e had the good fortune to secure

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from the outset the active interest and regular presence at our meetings of business men, of one Trustee, and of trained and tried social workers from outside the Hospital. Their presence has made the Director and other physicians more conversant with the fact that there is a profession of social work, a body of firmly established and well-organized agencies who know their own business, as the doctors know theirs, and who in their own field are equally expert." Those "outsiders" to whom he paid tribute were Mr. J. A. Lowell Blake and Mr. Francis P. Sears, our treasurers, and Alice Higgins Lothrop, for many years the General Secretary of the Associated Charities, Miss Frances R. Morse, our very wise counselor, and Jeffrey R. Brackett, founder and director of the Boston (Simmons) School of Social Work. As Dr. Cabot looked back over these years, he wrote: "Our growth has been a matter of friendly give and take, both within and without the Hospital. [I may note that sometimes in the early years the "take" did not seem very friendly.] W e did not know at first exactly what we were here for. W e had to learn our limitations and our uses, in part from our failures, in part from friendly advice and instructions given by physicians of the Hospital. W e did not know exactly what our relations to the outside charities should be." But we knew we were appreciated by our colleagues in social agencies. Although most of our patients came from outside Boston, we often had patients from families under the care of Boston social agencies. Because we were in daily contact with patients and with the doctors, we could not only befriend the patients, often bewildered by the complexity of the institution, but interpret to the social agency the patient's condition and the doctor's advice. Throughout the years our experience made us constantly aware that we were representative of the growing profession of social work, and were ourselves being modified by the fact that the primary purpose of the hospital where we had chosen to function (surely a great social institution), was the medical care of the sick. This both determined the special character of our contribution to the medical care of

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patients and broadened and deepened the possibilities of medical care as the social responsibilities of medicine were thereby made more evident. Dr. Cabot spoke for us when he wrote: "Our Department has had something to teach but a great deal to learn. T o my mind . . . the main reason for such success as we have had is that our workers have been more ready to admit they were wrong than to put others in the wrong . . . the strength of our present position is that we still have, as we have had all along, plenty of wholesome give and take in the way of criticism, as well as cooperation." That we learned to recognize our mistakes as opportunities for educating ourselves was due in large part to Dr. Cabot's influence. He was always skeptical of "success stories" in social-agency reports and often challenged us to balance our successes with consideration of our failures and analysis of the reason for failure. W e never allowed a record to be closed with the too familiar phrase "patient uncooperative." Wherein had we failed? Dr. Cabot's favorite theme of learning from mistakes was brilliantly exemplified in his Pathological Conferences, which will receive comment in a later chapter. The process of adjustment to our new position as an official part of the Hospital brought us problems, as we had expected. W e were shifting from supervision by a benevolent Social Service Committee to direct responsibility to the Hospital Administration and were to take our place as one small department in a complex institution. It was fortunate indeed for us that by that time we had gained the confidence of the administrative officers as well as the doctors. It was fortunate, too, that the primary purpose of the Hospital—the medical care of patients—was our central purpose as well. W e had occasion many times to emphasize that fact. In Dr. Washburn's Annual Report for 1921, he stated our problem: "The Social Service Department, now an integral part of the Hospital, is of the greatest value and importance to us. It is a serious financial burden, however." W e were often reminded of this attitude on the part of the administration. Comments such as "the growth of social service is out

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of proportion to other departments of the Hospital," indicated no enthusiasm for the costs of expansion of our service, although that expansion was only in response to urgent medical demands. W e controlled our desire to inquire what the test of proportional growth might be. Although we still thought of ourselves as a new development in an old institution, we were also a service that had not yet reached logical growth. After the years of a possibly too generous support of our rapid development, it was inevitable that we, or at least I, should feel the tight rein of the administration. But every step in growth was taken only in response to demand from the medical staff for extending our service to more patients. In late 1921, I had word from Dr. Washburn that in the interest of economy all departments of the Hospital were to curtail their activities. W e were ordered to reduce our staff by two workers. After a sleepless night, I presented to a special meeting of our Social Service Advisory Committee my suggestion that, since we had expanded our service only on request from the doctors, it was suitable for us to place before them the problem of where our service to the patients or the assignment of our social workers might be curtailed. It was decided to put the question to the head of each clinical unit where our workers were placed. If we were to reduce our capacity to accept patients, the doctors must understand why and help decide how to select those patients who needed us most. As a result of this transfer of decision to the doctors, they sent to the administration a clear and urgent request that there should be no reduction of social workers, rather that there might be, as one doctor put it, " a reduction in drugs or xrays!" In my annual report to Dr. Washburn for 1922, I find the outcome of the ordered reduction: "Since the medical staff was reluctant to eliminate any of the staff of social workers, it was found necessary to drop one secretary and one stenographer. This necessitated a reduction in the recording of the work of the Department and a simplification of the methods of recording."

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As I look back on this memorable affair I recall that we considered the solution as having had two important effects. First, we knew that the doctors' reaction justified the soundness of our long-time policy to accept for service only patients the doctors asked us to serve and to assign no social worker to a clinical service except on medical request; primary responsibility for care of the patients thus remained with the doctors. Second, the reduction in stenographic help forced us to greater discrimination in recording; this in turn called for clearer thinking to determine the aspects of the patients' difficulties that needed our attention. An important reorganization of our work resulted from the change in our status. Until we were officially recognized in 1919, the social services in the wards and in the outpatient department were quite separate. The administrative order in 1908, excluding outpatient social workers from the wards, was definite. Since our outpatients were frequently recommended for admission to the wards, this separation had required that the social service for such patients be transferred to the worker assigned to the wards. This was confusing both to patients and to doctors, and certainly frustrating to us. So when the Social Service Department became an official unit within the whole hospital we were free to reorganize our services in keeping with our policies and the best care of the patients. The Administration had reorganized several clinical services between 1914 and 1920 to give continuity of medical care in clinics and wards; the head of each clinical service had been made responsible for the patient of that service throughout his care. This was established for the Children's Medical, Orthopedic, Neurological, Dermatological, Urological, and South Medical (Syphilis) Services. We, therefore, arranged for the social workers assigned to these special clinics similarly to carry through from clinic to ward. We became a part of the "clinical team," as the doctors called it; we kept in touch with those patients referred to us, in whatever division of the hospital they were transferred to for care.

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W H I L E we of the Social Service Department were seriously concerned with the details of adjustment to our new status at the Massachusetts General Hospital, other interests were pressing upon us. W e were being drawn into local community relations and were involved in several developments in the hospital field on a national scope. Of primary significance to us as medical social workers was the organization of the American Association of Hospital Social Workers in 1918. 1 The subject of national organization had been discussed for several years and local organizations had developed, notably the N e w York Conference on Hospital Social Service, organized in 1912, and the N e w England Association of Hospital Social Workers, formed a little later. The national organization in 1918 came about largely because of serious drains on the personnel of social service departments due to the war situation. The Red Cross call for nurses for Army hospitals and for social workers for Red Cross Home Service, and the newly developing social service for Army and N a v y hospitals, seriously depleted the socialservice departments in civilian hospitals. Those workers who felt responsibility to maintain the gains in this new application of social work to the medical field felt the need for holding together and looked to formal organization as a means to secure our gains. W e were encouraged in this by the expressed interest of the American Hospital Association. Dr. A. R . Warner, then superintendent of Lakeside Hospital in Cleveland, in an address before the Association in

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1918, on the subject of "Social Service and Hospital E f ficiency,"2 envisioned the hospital as a social institution in a broad sense. Accepting the idea of society's obligation to protect itself by helping the individual in need, he maintained that the hospital had an opportunity—an obligation—to broaden its concept of its own responsibilities toward the community. He suggested that all medical and social services to the sick, "between the incident of sickness and the return to normal life," might well be centered in the hospital; also, that this concept might contribute to preventive medicine by "preventing individual deterioration and hastening rehabilitation." He said that in the trend toward the role of the hospital in preventive medicine "the development of hospital social service departments has been the largest factor." T o sustain his suggestions of greater responsibilities for hospital social service, Dr. Warner offered a resolution, later acted on by the American Hospital Association, calling for more highly educated social workers to give leadership in this movement so intimately involving the interests of medicine and sociology and the developing profession of medical social work. Under the leadership of Dr. Warner, as president of the American Hospital Association in 1919, a nation-wide survey of hospital social work was authorized. A committee was made up of active medical social workers, nurses, hospital administrators, physicians, and representatives of the American Hospital Association, with Dr. Anna Mann Richardson of N e w York as field secretary. The purpose of the committee was "to study social service in hospitals and dispensaries throughout the country and to make recommendations as to standards, methods, or programs." Dr. Richardson later stated that there were 286 social service departments, so called, in hospitals in the United States and Canada, but based her report on a more detailed study of 60 social service departments scattered from coast to coast. Her report 3 covered evidence she had gathered concerning: " ( 1 ) Policies and practices of organization and financing; (2) the activities in the hospital

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or dispensary, and relations to community; (3) the workers, their number, training, salaries, habits of work, and problems they were facing." The organization of these departments varied greatly, being influenced by their origin; their financing also varied according to the interest of those sponsoring them. About half were organized as a department of the hospital and financed through the hospital budget. Others were supported by special committees or groups not otherwise associated with the institution. Their physical facilities were far from satisfactory; the space allotted had usually been designed for some other purpose, and was overcrowded, with little chance for privacy. About half of the 350 workers in these social service departments were nurses. In one-fourth of the departments there were no nurses; in twenty-five departments the staff was composed of workers with wide variation in training and experience. In this total group, in all its variations, Dr. Richardson states that there was one point of agreement, namely, that all workers, whether social workers, nurses, or teachers, wished for more adequate preparation. "As the possibilities of the work opened before them, they recognized their unpreparedness to meet wisely the many complex situations they were obliged to face. The hospital social workers now in the field almost without exception feel that their opportunities for service are bigger than their abilities. This results in an eagerness to increase their understanding and efficiency." Those who served on the committee appointed to consider Dr. Richardson's report will surely remember the spirited discussions that took place. Michael M. Davis, chairman of the committee, stated at the meeting of the American Hospital Association in Montreal where the report was presented: " W e all agree that it is not easy to agree . . . that this is a hopeful sign because in committees, generally speaking, the things we all agree upon cease to be interesting. The things we do not agree upon and really get into a friendly kind of row about, are the things which are in rather a developmental stage,

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with interests which attach to the developmental stage of anything." Out of the discussion of the findings of the survey and the personal experience and convictions of members of the committee, a report was submitted to the trustees of the American Hospital Association, embodying a statement of principles of organization, a definition of function, and suitable activities and policies. T h e moot question of education of personnel received the hottest discussion and was met by the recommendation that a special committee be appointed b y the trustees of the American Hospital Association to consider this subject. It was to give attention to "the elements which should be derived from training and experience; knowledge of the chief diseases, and health problems, primarily in their social implications; understanding of the social, industrial, and economic problems as they affect family life; knowledge of the purposes and activities of the chief public and private health and social agencies and of legal and community conditions which affect health; understanding of the traditions and customs of the medical profession and of medical institutions; ability to utilize both knowledge and personal qualities in attaining understanding of people and practical results in cooperation, guidance, and leadership." T h e committee to consider the education of social workers for hospitals was promptly appointed b y the trustees of the American Hospital Association. It consisted of physicians, nursing educators, hospital social workers and nurses, educators in general social service, and representatives of the American Hospital Association. T h e newly organized American Association of Hospital Social Workers was officially represented also. A t the same time the American Hospital Association expressed its interest in this new movement by the creation of a Service Bureau on Hospital Social W o r k , of which I was appointed director. This Bureau was designed to take over requests for information about social service as they came to the Hospital Association. A s I was at this time president of the American Association of Hospital Social

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Workers and a member of the Committee of the American Hospital Association, it was obvious that for me all these activities would be closely interrelated. The Committee on Training for Hospital Social Work was most fortunate in having Antoinette Cannon as half-time secretary. This was made possible by a grant from the Russell Sage Foundation to the N e w York School of Social Work, where she was in charge of the courses in medical social work. The report of this committee was a milestone in the development of medical social service, and had great influence on the whole future formulation of standards of medical social work and education of workers. From the point of view of the schools of social work, which were increasing in number, the report meant a rethinking of the curriculum. The basic education in social work was to be supplemented in a second year by teaching and experience that would prepare workers to function effectively in a medical setting and in association with a varied professional group. For those preparing for psychiatric social work an increase in the hours of psychological and psychiatric lectures was suggested, and, in the second year, practice in a mental hospital or child-guidance clinic. The activity of this committee, under the sponsorship of the American Hospital Association, gave great impetus to the newly organized American Association of Hospital Social Workers. In fact, the very name of the association, over which there was considerable discussion, was chosen under the influence of our friends in the American Hospital Association. The name was changed to the American Association of Medical Social Workers in 1934 as it became evident that our services had broadened out into other fields, notably that of public health. Although through this decade much of my time and interest were being given to the American Association of Medical Social Workers, that story has been written by the Association and need not be related here.

16 "We A nalyze O u r Function T H E decade 1920-1930 was a period of self-consciousness for medical social workers, and we at the Massachusetts General Hospital were keenly aware of our problems of growth. As participants in the survey by the American Hospital Association, which had revealed the extraordinary diversity of activities under the name of medical social work, and as members of the newly formed American Association of Hospital Social Workers we began to scrutinize our activities for their medical appropriateness, to analyze our functions in their relation to the other professions with which we were associated, and to criticize our organization and our relation to community agencies. I believe that throughout we emphasized that our purpose was, as always, that the patient might be better served. The medical social worker, in her special application of the growing profession of social work, was alert to influences that were working for clearer definition and better understanding of the particular field of the social case worker. During this period social work was in process of being differentiated into three characteristic phases: service to the individual, work with groups, and social reform. Social research was beginning to assert itself as a means of yielding the fruits of accumulated experience. We, at the time, were especially concerned with social case work in a medical setting. For us the parallels of careful case study and treatment in medicine and in social case work suggested that, if we were to increase our competence, we must be thoughtful in our techniques and methods and constantly critical of our-

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selves. Dr. Cabot often challenged us to answer the question, "In what is the social case worker expert?" W e were also influenced at that time by Mary E. Richmond and her writings. That she too was influenced by association with medicine will be evident from her book, Social Diagno sis,1 which was the most scholarly consideration of social case work that had been published thus far. Miss Richmond recognized that social work was still in process of development as a profession, and spoke for the thoughtful workers in this new field when she said that there was an "evident desire of social workers to abandon claims to respect based upon good intentions alone; we should meet halfway their earnest endeavors to subject the processes of their task to critical analysis; and should encourage them to measure their work by the best standards supplied by experience, standards which, imperfect now, are being advanced to a point where they can be called professional." Rather crude do the standards of that day seem to us now, as the art of social case work has come to be accepted. But Miss Richmond made the first contribution in an objective approach to analysis of social case work. Her deep appreciation of the contribution of medicine to social work, and her understanding of the strategic position of social service within the hospital had a profound influence on medical social work. At the time when Miss Richmond was scrutinizing "social evidence," to test its validity and to analyze processes leading to "social diagnosis," two prominent physicians were seeking some systematic method by which to register the "social diagnosis" as it related to the clinical situation. I well remember receiving a visit from Dr. Hugh Auchincloss of the Presbyterian Hospital in New York after he had had a stimulating talk with Miss Richmond. He was striving to improve the recording and classifying of medical diagnoses, so that records should be more readily available for study. Convinced that social factors influenced the medical situation and, therefore, medical treatment, he maintained that such

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elements in the patient's condition should be both a part of the medical record and so defined and classified as to be accessible for study with the medical diagnosis. Thus the interaction of social and medical factors could be better appreciated and applied. Dr. Auchincloss had gone to Miss Richmond to seek a terminology of social case work; Miss Richmond had to tell him that no such systematic classification existed. When he came later to Boston and talked with Dr. Cabot and me, we could give him no help beyond that of enthusiastic interest in his idea. Dr. Cabot was especially intrigued; he thoroughly enjoyed putting his ideas into an orderly 1, 2, 3 and a, b, c. Dr. Auchincloss persisted in his search and later secured the assistance of Miss Gordon Hamilton who, working with the Social Service Department of the Presbyterian Hospital, proceeded to analyze the factors in hundreds of case records and to formulate " A Medical Social Terminology." 2 Miss Hamilton succeeded in enlisting the cooperation of several other social service departments to analyze their records according to her plan and so pool with her such material as was thus accumulated. After considerable conscientious work by many medical social workers, it became evident that we could not arrive, in this way, at social diagnosis that would parallel medical diagnosis. Social problems presented themselves as symptoms and as parts of diagnosis, rather than as units that stood alone. Although the effort did not develop into a system, the medical social workers who were associated with Gordon Hamilton in this project were surely stimulated by contact with her keen, constructively critical mind. In 1917, Dr. E. Ernest Southard, psychiatrist, philosopher, pathologist, and director of the Boston Psychopathic Hospital, talked of a more systematic method of classifying social factors and problems. He approached the subject with a legalistic-biological parellel in mind, and suggested a tentative classification of what he called the "Kingdom of Evils"— Disease, Ignorance, Vice, Crime, and Poverty. His ideas were

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evidently nourished for some time in his fertile brain, for there later developed a book with the same title, written jointly with Mary C. Jarrett and published after Dr. Southard's untimely death in 1921. 3 Dr. Cabot, in commenting on these attempts at social analysis, insisted on a more positive emphasis on the patient's assets and the helpful element in his situation. He also questioned our interpretation of terms. When he saw "homelessness" and "maladjustment to environment" stated as summing up a patient's situation, he commented: "Certain men run away from home because homelessness is just what they desire." They do not want family responsibility—and as a patient mother of a large family once said about her wayward husband: "Family life is for thems as can stand it." "Maladjustment to environment" was an expression that always irritated Dr. Cabot, whose own spirit was often in revolt. He insisted that the phrase applied either to all sorts of evil or to none at all, that it described "the exultant rebel making ready to reform the world and the teamster bored at a classical concert." Although I maintained that if the teamster happened to be a Hungarian he might appreciate the concert more than I, we had to agree that "maladjustment" was a term too general to describe anything in particular. He said: " W e cannot even tell whether it is a blessing or a curse." In criticizing the urge to get our social data into some ordered system, Dr. Cabot cautioned us: "What characterizes the sufferer and his situation is a unique combination and interaction of such elements." He felt that from a social point of view "consumptives cannot be added up in columns so as to mean much, nor can the unemployed, nor the sex offender. T h e y are too different, each from each. But the young, rich, incipient, cheerful consumptives do form something like a group, whose fortunes and futures have much in common." He said we must always apply at least three qualifying phrases in any social analysis, "physical, somatic, and economic conditions," and note the interaction of these

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three factors. Life was not dull when he was at our conferences to challenge us! One of Dr. Cabot's assets for us was his capacity to be personal in his human relations with patients and then to be objective and analytical in discussing their problems. This capacity to balance feeling and thinking was educational to observers. H e challenged the criticism that there was too much sentiment in social service. Although he wanted us to have no sentimentality, he frequently said that a medical, nursing, or social service that did not have some sentiment was not service as he understood it. T h e most meaningful event of the decade, and disturbing to us in our day's work, was Dr. Cabot's resignation in 1921 from the Hospital clinical staff and from the Medical School. For those of us who knew of his early interest in philosophy and had witnessed his deep concern over public issues that arose during and after the war, the step he took in accepting the Professorship of Social Ethics at Harvard University was not really a surprise. W h a t was difficult to accept was the fact that he was no longer to be a daily familiar figure in the wards and clinic, free at almost any time to sit with us in conference over some immediate issue about which we wanted his clear-cut, quick judgment. W e did not always agree with him, but his discussion of the various aspects of a situation always helped us to clarify our thinking and gave us perspective. He was still to remain the chairman of the Social Service Advisory Committee, and was readily available when we called him. T h e Hospital trustees at their meeting in February 1921, regretting that they must accept Dr. Cabot's resignation, placed on record that "in doing so they ask that he will still continue the teaching and editorial work which he is doing for the Hospital [Pathological Conferences]. T h e y also desire to express in most emphatic form their deep appreciation of what the Hospital owes Dr. Cabot. Through his initiative and able and devoted labor there have been developed in the Hospital new and most valuable forms of usefulness which

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have had a powerful influence throughout this country and also in foreign lands. The Hospital Social Service which originated with him has been copied by leading hospitals far and wide, and his case records edited by him have found their way into distant lands as well as to all parts of this country. Further, Dr. Cabot has shown in his work a breadth of vision and self-effacing devotion which in themselves are an inspiration for the whole Hospital. The Trustees rejoice that Dr. Cabot will still continue his connection with the Hospital in instruction and editorial work." Several other events during the decade 1920-1930 affected the Social Service Department at the Massachusetts General Hospital. In his reports Dr. Washburn had for several years pointed out the need for a unit to meet the needs of people of moderate means. T o such a unit members of the clinical staff could bring private patients who, although unable to pay the rates at Phillips House, were not eligible for admission to the General Hospital wards. When the Baker Memorial unit was made possible in 1927, through the bequest of Mrs. Mary Rich Richardson, the doctors were asked to participate in plans for the scope and management of this enlargement of the Hospital's facilities. One of their stipulations was that in this new unit, as in the General Hospital, social service should be available to their patients—not to determine who were "people of moderate means" (that was the duty of the administration), but to provide service related to their medical care of such patients. Baker Memorial was opened for admission of patients in 1930, and Josephine C. Barbour, an experienced member of our staff, was appointed in charge of its social service. Through her demonstration of the uses of such service there, it soon became clear that the personal problems that complicate sickness in the Hospital's private units did not differ in kind, but rather in proportion, from those with which we were familiar in the General Hospital. Harassing financial anxieties were, if anything, more common and devastating among those on a higher economic level. This was especially true during the dark days of crisis of the early thirties. The

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aloneness of the aged, living in apartment hotels and at a loss when sickness comes and convalescence1 has to be arranged for, physical handicaps necessitating major adjustment, chronic disease with its prolonged and costly complications, broken families, illegitimate maternity with problems of adoption, industrial accidents, were all there. The greatest difference came in carrying out the medical plans for patients. If there were relatives near, it was often easier to arrange for aftercare; some responsible member of the family could make use of the accumulated experience and resourcefulness of the social worker. But many patients came from a distance, from other states or countries, and had no immediate relatives near. They needed the personal assistance and advice that were within the scope of our social service. We could give the patient, who often felt a helplessness, assurance that we could be called on to arrange the details for transportation by railroad or air for a recumbent patient, to secure legal help in executing wills, to counsel on legal procedures in cases of adoption, to deal with problems of immigration for the patient whose stay in this country, owing to unexpectedly prolonged medical care, threatened to extend beyond the limit of his visitor's permit. One rather unexpected type of question came to Miss Barbour early in her experience at Baker Memorial. Members of the medical staff began to request information and advice on community resources available for private patients coming to their offices. Many of their inquiries concerned procedures for use of institutions and of health and social resources. As it became evident that there was special need for a formulation of much of the information requested, a committee was formed in 1932 to prepare a pamphlet to inform physicians regarding these resources. The committee included Dr. George H. Bigelow, then Commissioner of Public Health, Dr. Dwight L. Siscoe, Dr. John P. Monks, Miss Barbour, and myself. Dr. Monks agreed to help secure the specific information and to test each item as it might apply in a doctor's private office. The resulting booklet, printed in 1933 under the title of Physician's Handbook, contained not only information on

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community resources in Metropolitan Boston but noted certain legal responsibilities. Until that time such information had not been available in any concise form for the doctor entering practice, namely, regulations for the reporting of diseases dangerous to the public health, of births, deaths, accidents, industrial injuries, and occupational diseases, of the dispensing of narcotics and the use of hypodermic instruments. The available resources in diagnostic and therapeutic facilities, especially those associated with communicable diseases, the convalescent and nursing-home services, and certain special resources such as those for the aged and the physically handicapped and for family counseling were included. This pamphlet, distributed to our clinical staff and to the social service departments of local hospitals through the generosity of an anonymous donor, was later sold to a wide circle of physicians. The need for such information in convenient form for ready reference was so evident that two years later the State Department of Public Health issued an official Handbook for Physicians that set forth the obligations of the medical profession in Massachusetts and listed many institutional resources. Subsequent editions have been issued. The year 1930 was of quite special significance to us. In that year a unit for psychiatry was allowed in the Neurological Service. Sarah Evarts, after four years with the Child Guidance Clinic in Colorado Springs, was appointed psychiatric social worker to serve in the new unit and to act as consultant to our general social-work staff. Thus we were enriched by generous give and take between the psychiatric and general social workers. The same year, 1930, marked the twenty-fifth anniversary of our Social Service Department at the Massachusetts General Hospital. We were now secure as an official part of the Hospital, with a staff of twenty-eight workers and an endowment of $68,000, which was to increase over tenfold in the next fifteen years. The annual meeting of the American Association of Hospital Social Workers was held in Boston in June, and a banquet was given in commemoration of this

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occasion with Dr. Cabot as speaker. His address on "The Meaning of Presence" was reminiscent of earlier days in the department and of his associates who helped to build the service. In his honor the Association presented a gift of $1000 as "The Richard C. Cabot Library Fund" for purchase of books for the Cabot Social Service Library, later to be placed in the Moseley Building next to the Treadwell Medical Library. The Social Service Advisory Committee, with the help of some three hundred fifty friends of the Hospital, also presented, in Dr. Cabot's honor, $30,000 as an "Educational Fund" for use in the department. At his request, this fund was designated especially for the professional advancement of the staff of the department. Harriett M. Bartlett, then on leave of absence helping Janet Thornton in the preparation of her book The Social Component of Medical Care,4 returned later to accept appointment as our Educational Director. Miss Bartlett was especially well prepared to review with us the educational responsibilities we were carrying for social students from schools of social work, student nurses, and medical students, and to help us improve our methods. She also guided us in staff development by means of a series of programs for discussion of the psychiatric implications in social case work and suggested opportunities for members of the staff to attend institutes related to our tasks. Miss Bartlett, while continuing as Educational Director on part time, was involved in important activities with the American Association of Hospital Social Workers, as chairman of a committee studying the suitable functions of medical social work® and later in presenting the first report on participation of medical social workers in teaching of medical students.6 Although our pioneering days were over, the future offered continuous opportunity to deepen and broaden the social aspects of social work in association with medical care. We were also to find a place in the rapidly developing field of public health—but these must be another story.

17 T k e I J ea JDecomes W i J espreao D U R I N G these same years of our pioneering at the Massachusetts General Hospital, our colleagues elsewhere were also in the process of developing social service departments in hospitals throughout the country. The idea of introducing into institutionalized medical care a service for patients whose illness is complicated by personal difficulties was so reasonable that it was readily accepted when understood. There was little argument against it beyond comments regarding the expense involved. The process of establishing the new element in the already highly organized institution was another matter. Some hospital administrators maintained that it might be done by volunteers without any qualifying argument as to the preparation of those who undertook to assume the serious responsibilities involved. In looking back over twenty years of experience, Mary E. Wadley, pioneer in social service at N e w York's great Bellevue Hospital, recalled the time in 1906 when she first heard of social service as initiated by Dr. Cabot and Garnet Pelton at the Massachusetts General Hospital: " M y first impression was one of wonder that no one had thought before of the need of such work . . . in all hospitals and clinics." She was well aware of the visiting-nurse service in the homes of patients discharged from the Presbyterian Hospital and of Dr. Chapen's program of foster-home care for sick infants. These visiting nurses presumably reported to the clinic doctors the conditions and problems they found in the homes of patients. Miss Wadley recognized the significance of Dr. Cabot's innovation in bringing into close association with

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him in his clinic a worker whose special task it was to deal with the social situations that complicated the patient's illness. Miss Wadley noted that he was "attempting to introduce social work as an integral part of medical care in hospitals." 1 In Baltimore Dr. Charles P. Emerson had already started his program for students from Johns Hopkins Medical School to serve as volunteers in the Charity Organization Society. His purpose was to make medical students aware of home conditions among the poor of the city who made up the clinic clientele, rather than to correlate medical and social care for patients. When Dr. Cabot, with his gift of vivid expression, reported on his plan, the practical value of introducing this new social element into medical care, and of doing so from inside the hospital, appealed to many doctors. The time was ripe for a cooperative idea such as Dr. Cabot's to take root, or at least to be planted. Social work was emerging as a profession, and schools of social work were being established to supply trained workers. Also, at the time that he faced frustration in his clinic work, Dr. Cabot was already familiar with the social service provided by various agencies in Boston. Earlier experience had prepared him for action. An interesting picture of Dr. Cabot as a young volunteer in the Boston Children's Aid Association has been recorded by William H. Pear. "On completing his college course with highest honors and later turning to medicine, Cabot found time, through the years between 1895 and 1900, to follow up an early interest in juvenile delinquents. With us he had an opportunity to study the content of the lives of boys who had come to be known to the courts, the group that had been made my special charge. He was keen for noting the effect of physical or environmental handicaps and was interested in possible means of counteracting them. He would say, 'We should understand all we can of the background— every feature of it; no telling where that may lead, maybe to new ways of treating the individual boy, possibly to getting at the background itself—social prophylaxis—to get into the home situation, perhaps heading off trouble for the next

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boy! . . I was constantly intrigued by the idea of exploring what he was referring to as background. . . "There was nothing surprising in the proposal with which he came to me one day. . . It was nothing less than his plan for establishing a new department for social service to patients at the Massachusetts General Hospital. And again it was with the backgrounds he was concerned, this time the backgrounds of the Hospital's patients; and it was quite characteristic, both the plan and his indifference to obstacles to be encountered." At Dr. Cabot's request, Miss Pelton spent some time with Mr. Pear before starting her work at the Massachusetts General Hospital, and she often turned to him for counsel.2 In 1906, in an address entitled "Foregrounds and Backgrounds in Work for the Sick" given at the 43rd Annual Meeting of the New England Hospital for Women and Children, Dr. Cabot reflected his experience in applying the principles learned from his social service with the Children's Aid Association. He confessed the hazards of absorption in the physical condition of the patient—"the clinical picture," as it is called—and in closing suggested queries for the clinician: "Am I using my eyes and ears, my sympathies and imagination as hard as I can? Am I searching for the deepest meaning, the widest bearing, the furthest connection of these facts? Am I seeing and helping as truly as I can the foreground and the background of my work?" This significant address was privately printed in 1906 and widely distributed.3 Publication and wide distribution of the "First Annual Report of Social Work Permitted at the Massachusetts General Hospital 1905-06" brought enthusiastic response to the ideas expressed and also contributions for support. Dr. S. T . Armstrong, Director of Bellevue Hospital, was one of the first hospital administrators to investigate the idea and introduce social service into his institution. Among clinicians to respond to Dr. Cabot's written reports were Dr. M. H. Fussell of the University of Pennsylvania Hospital in Philadelphia, Dr. Henry S. Favell of Chicago, Dr. Theodore Janeway, and Dr. Linsey R. Williams of Vanderbilt Clinic,

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N e w York. In a personal letter to Dr. Cabot, Dr. Williams wrote: "As a result of your experience in Social Service at the Massachusetts General Hospital much interest was aroused at Vanderbilt Clinic in your work. After plans were matured, a friend of one of the physicians advanced the money for the salary and expenses of a social worker for the year 1907. The expenses for 1908 for the nursing and social service have been raised by the physicians in the clinic. . . The men chiefly interested in our work are the busiest, and find little time to devote to supervision. . . T w o things are needed . . . the education of the Board of Managers as to the need of the work and supervision of the workers." Also interested in Dr. Cabot's activities, and a consistent supporter of medical social work over many years, was John M. Glenn, whose identification with the Baltimore Charity Organization Society and Johns Hopkins Hospital had brought him into close contact with Dr. Emerson and his work with medical students. When the Russell Sage Foundation was incorporated in N e w York in 1907, Mr. Glenn was appointed its first director, and he served in that capacity for twenty-four years. In 1908 he was drawn into discussion of ways to promote this new movement for social service in hospitals by a group which, in addition to Dr. Cabot, included Dr. Linsey R. Williams, William H. Allen of the Bureau of Municipal Research, and Dr. S. S. Goldwater, superintendent of Mount Sinai Hospital and president of the American Hospital Association in 1907-08. They discussed, through correspondence, the possibilities of engaging a doctor to promote the movement by enlisting the interest of trustees, administrators, and doctors and by offering to place a trained social worker in the hospital for a few months to demonstrate what could be accomplished through social work. This was in the early pioneering days when anything seemed possible! Fortunately wisdom prevailed—or possibly the means of carrying out the plan did not materialize. But it was then that certain facts became recognized. Dr. Goldwater wrote to Dr. Cabot his convictions that "even the most enlightened

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hospital boards are slow to undertake this new responsibility which the welfare work would put upon them, but when the work is actually begun in an institution, its nature soon arouses interest and its results raise up friends. . . A n organizer might, of course, pave the way for the reception of these demonstrators; but I should anticipate the best results from actual demonstrations to be made in hospitals by trained social workers." Dr. Goldwater's position as president of the American Hospital Association for that year gave his words added weight, and he was recognized as a man with vision and leadership in the hospital world. Those of us who were carrying the day's work were increasingly aware of the slow process of integrating this new idea into well-established conservative institutions with deep-rooted traditions and habits of thought and action. Doctors and administrators, absorbed in the immediate care of the sick patient, which obviously was the first responsibility, seemed to have little interest in what Dr. Cabot called that "background of community life out of which the patient has emerged and to which he belongs." In 1 9 1 1 , Mr. Glenn enlisted Miss Pelton to make a survey of the extent of the social service movement in the hospitals of the country. She gathered the first evidence of its spread into hospitals and clinics. W e were soon to discover that the term "social service" was adopted to cover great variety in activity—any effort to reach out into the community or to give personal service to patients—other than medical and bedside nursing care. But all these services were designed to help the patient. Some visiting-nurse services that had been provided by hospitals for some time as such were frequently referred to as "social service." The term was not defined, but Dr. Cabot had given it a meaning which, though vague, had a pioneering flavor that became popular. Miss Pelton's 1911 report listed forty-four "social service departments" in eight states and fourteen cities as far west as St. Louis. Seventeen of these forty-four were in N e w York City, where Mary E. Wadley had been an enthusiastic and

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devoted leader. One of the seven departments reported in Boston was Berkeley Infirmary, a small and useful dispensary in the South End. The one worker there acted also as admission officer, and the social concern for the patient permeated the medical care. Although social work had actually started at the Berkeley Infirmary one day before that at the Massachusetts General Hospital, this center, along with several on Miss Pelton's list, lapsed after a few years. But in the larger institutions, roots were being nourished, and the growth of the movement was rapid. Able and devoted women on boards of managers of the hospitals in New York gave backing to "social service" by way of financial support and volunteer service. With their help and that of some of the leading physicians the New York Conference of Hospital Social Service was organized in 1912, the first of the local groups to organize for mutual help and extension of the work. Membership was open to all who were interested. Dr. James Alexander Miller's leadership in work with tuberculosis patients brought strong support to the new organization. Through the generosity of Dr. E. G. Stillman a quarterly entitled Hospital Social Service was published to record meetings of the Conference and report phases of the work in various hospitals. It was the official organ of the Conference until it was discontinued in 1933. Meantime, at the Massachusetts General Hospital, many visitors from other cities and foreign countries made inquiries about the work. I remember the visit of Dr. Charles deBouchet of Paris in 1913 and his interest in having some of Dr. Cabot's reports translated into French. These in turn inspired Mme. Georges Getting to start social service in Professor Marian's wards for sick children in 1914. She was to become the devoted leader of the movement in France. Requests for consultations on initiating or developing social service in hospitals of other cities were received. I marvel now at my temerity in letting myself be considered an authority on hospital social service before we were officially accepted in our own hospital, but my days with the doctors

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and social workers with whom we had common interests in Philadelphia, Buffalo, and St. Louis taught me a great deal. Dr. Cabot and I were in frequent correspondence with England and Germany. It was evident that the idea of social service as supplementary to medical care was being rapidly accepted. Recognition of the necessity for training workers and a clear conception of what that training should be lagged behind. Insistent demand for workers resulted in the appointment of many who were inadequately prepared for their tasks. Nurses with no social training, social workers with no knowledge of hospitals, teachers with no other preparation plunged into dispensaries that were themselves poorly organized. I suspect that what helped dispensaries and social service to come through to something in which we can take pride today is that everyone concerned—administrators, doctors, and social workers—desired to give good care to the patient. It was a period when public-health movements and preventive medicine were developing and the usefulness of dispensaries was increasingly appreciated. The American Hospital Association was formulating standards for the many and varied groups in hospital administration, and in 1918 the first authoritative book on dispensaries was published.4 When the National Organization for Public Health Nursing was formed in 1912, there was considerable interest in identifying medical social work with this newly recognized sphere of nursing. For several decades visiting nursing in homes of "the sick poor" had been carried on in the larger cities. My own experience as a visiting nurse with the Associated Charities in St. Paul had given me an appreciation of the importance of this merciful service, and I welcomed the broadening of its scope into what Dr. C.-E. A. Winslow has called the most important feature in the public-health movement, for it was through the visiting nurses that the new knowledge of health measures could be practically applied. When the public-health nursing movement was officially launched in St. Louis in 1912, a special subcommittee on Hos-

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pital Social Service was appointed. This was called for by the fact that many nurses active in such departments recognized that they had interests in common with the new organization of public-health nurses. For a time I was chairman of that subcommittee. This was a period when several of us were trying to think out the special training needed to adequately prepare social workers for hospitals. The suggestion was urged by some that an abbreviated nursing training, supplemented by some social training, be developed through affiliation of a nurses' training school with a school of social work. But standards for nursing training had been built up laboriously since the days when doctors had protested the introduction of the "trained nurse" in hospitals. Compromise on these standards would be regrettable, especially since scientific medicine was developing rapidly and doctors were making demands for ever-higher skills in nurses to relieve them of special techniques. And those interested in the development of social work as a profession were increasingly aware of the opportunities and serious responsibilities involved in the practice of social work. Schools of social work were tending toward requirement of a two-year postgraduate course. The subject of the relative functions and training of nurses and hospital social workers was under lively discussion for several years. With others, I became convinced that our essential contribution to the dominantly medical institution was high quality in social service, that we must live up to the name we had so readily adopted. I was convinced that general social training was essential but that it should be supplemented by lectures in medicine and by experience under supervision in the medical setting. The contention that all social workers in hospitals should have nursing training spelled out to me an unattainable goal: the desirable four years of college, a three-years' nursing course, and two years of special training for hospital social work. Impossible to require! The first special education for social workers in hospitals was offered in 1912-13 by Simmons College School of Social Work. It was open to those who had had the basic year in

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social work, and required an academic year of ten months of practical work in a social service department, under supervision, combined with conferences and lectures at the School. During subsequent years hospital social workers met frequently in informal groups at the time of meetings of the National Conference of Social Work or the American Hospital Association. W e saw ourselves as a sort of hybrid group equally interested in identifying ourselves with both these organizations. A t the Conference of Social Work in Kansas City in 1918, the step was taken of organizing what we then called the American Association of Hospital Social Workers, to be known later as the American Association of Medical Social Workers. The meeting in Kansas City in 1918 was attended by thirtyfive hospital social workers and the new organization was designed as a means for "intercommunication among hospital social workers and to maintain and improve standards of social work in hospitals and dispensaries." Edna G . Henry, director of social service at the University of Indiana Hospital, was elected president. The years 1919 and 1920 marked significant gains for hospital social service. The new organization met during the 1919 sessions of the American Hospital Association in Atlantic City, and on the official program a special section on social service was noted. Dr. A . R. Warner, former superintendent of Lakeside Hospital in Cleveland and newly appointed executive secretary of the Association, came forward as a champion of social service in hospitals and dispensaries. His address on "Hospital Social Service and Hospital Efficiency" pointed up the serious need for better preparation of workers in medical institutions. Dr. Warner and Michael M. Davis, newly appointed director of the Service Bureau on Dispensaries and Community Relations, were responsible for the appointment by the Hospital Association of a committee to make a survey of hospital social service in this country. This survey 5 revealed—as had Miss Pelton's report of 1911—the great variety of activities

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carried on under the title of "social service." Following this report came authorization of a special committee, to include physicians, nursing educators, hospital social workers, and educators in general social work, charged with preparing a training program for hospital social workers. Antoinette Cannon was appointed its secretary, and through a grant from the Russell Sage Foundation was freed from a part of her work at the New York School of Social Work to give half time to the study. Her report was comprehensive. It provided the first statement of principles on the function and organization of medical social work and outlined a suggested curriculum for education in this special field.6 This report placed serious responsibilities on the new professional organization. These were accepted readily. The History of the American Association of Medical Social Workers, by Mary Stites, gives the steps in the growth of this vigorous professional association as it has responded to the more general recognition of the common problems of medicine and social work and of their interdependence for the effective care of patients. Following the formulation by the Association of "Minimum Standards to be met by a Social Service Department" as to function, organization, facilities, records, and personnel, these standards were recognized by the American Hospital Association and the American College of Surgeons. In 1928 this formulation was included in the approved standards for hospitals published by the American College of Surgeons. In the decade 1920-1930 social service was introduced into Army, Navy, and Veterans Administration Hospitals, through the American Red Cross. The introduction of a program for medical care in the Federal Emergency Relief Administration in 1933, and the passage of the Federal Security Act in 1935, brought demand for medical social workers in many local, state, and federal programs. The inclusion of social service as a part of the Federal Crippled Children's Services was accomplished through the leadership of Dr. Martha M. Eliot, who was then associate director of the Bureau and

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in charge of its medical services. For the responsible post of Consultant in Medical Social Service she chose Edith Baker, formerly of the Massachusetts General Hospital Social Service and director of social service at Washington University Hospitals in St. Louis. Under Miss Baker's able leadership the program for social service in most of the state programs for crippled children and maternal and child health has been developed. The medical social workers are usually appointed as consultants in the programs of state departments of public health, which are partially supported by federal funds. Medical social workers have gradually been drawn into services in tax-supported local and state clinics for tuberculosis, cancer, and venereal diseases, and programs for the prevention of blindness. The Federal Program for Civilian Rehabilitation, reorganized and broadened in 1943 under the Office of Vocational Rehabilitation, called for the inclusion of medical social workers in state programs. Opportunities far outstripped the supply of trained personnel. In making her survey of 1 9 1 1 , Miss Pelton had correspondence concerning the extent of the work of hospital almoners in England. Mr. Edgar S. Kemp, secretary of the Medical Sub-Committee of the London Charity Organization Society and also of the Hospital Almoners Council, had reported that qualified almoners were employed in ten London hospitals and in six provincial hospitals. "The almoner, as a rule, works among out-patients only. A t St. Thomas's Hospital and at Royal Free Hospital, however, some work is done among the in-patients." He added: "The danger at present is that women may be appointed who have not been properly trained for the work." The checking of "hospital abuse" was still a responsibility of the almoner. In 1913 the Wilhelmina Hospital in Amsterdam started the first medical social service in Holland, modeled on the work in the wards of St. Thomas's Hospital, which had been made possible through the Cicely Northcote Trust. Social service in the hospitals in France was greatly extended during the First World War, because of the burdens laid on the Red

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Cross by the influx of refugees. Dr. Cabot had gone to France in 1917 with Base Hospital No. 6, in charge of its medical service. About three months after the base hospital was established at Bordeaux, Dr. Cabot was lent to the American Red Cross Headquarters to develop clinics for the refugees. He found himself among old friends, for Homer Folks was head of Civilian Affairs for the Red Cross, and Edward T . Devine and Margaret Curtis were, in turn, Chiefs of the Bureau for Refugees. Dr. William Lucas, Dr. James Alexander Miller, and Dr. Alexander Lambert were rallied to work in the clinics. From Miss Curtis we have reminiscences of those days: "Dr. Cabot plunged right in to organize dispensaries for the refugees. He enlisted the very able Madame Getting as his assistant. . . Naturally the dispensaries included medical social service, and equally natural was the set-up for classes in social work.7 The Bureau for Refugees had been lucky enough to get Madame Fuster, a former teacher of the Ecole Normale, to give information to all the American social workers who came over for this civilian work. She gave each group what would now be called 'briefing' in such things as the government, duties, and titles of French officials, plus a short history of France and the technicalities of the relief of refugees, evacuees, and repatriees, which were essentials for all foreign workers. One of the textbooks was Miss Richmond's Social Diagnosis, and many of the chapters were translated into French." Dispensaries were established in many large cities, one in Dijon on the urgent insistence of a French girl who had seen the great need and had enlisted the volunteer service of two American Army doctors who wanted to improve their French! Miss Curtis tells us that "after the war a group of us from Boston who had been working in France organized a small committee to raise scholarships for French workers to come over to attend the School of Social Work. Madame Getting served as chairman of the selection committee in France." Dr. Cabot was chairman of the Boston Committee. Through the next ten years several French, Belgian, and Polish students

ï5

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spent a year at Simmons School of Social Work, under the auspices of this committee. During the early 1920's the Rockefeller Foundation provided for periods of experience for students from abroad who were interested in social service for hospitals. I remember such students from France, Czechoslovakia, India, and Poland. A t the request of the Rockefeller Foundation, Ida Pruitt, who had had social training in Philadelphia, spent a year (1920-21 ) in the Social Service Department at the Massachusetts General Hospital in preparation for establishing a social service department in the Peking Union Medical School Hospital in China. Miss Pruitt, who was born in China, spoke Chinese, and understood the people, did valiant pioneer medical social work in that country, fostering the training of social workers and the development of much-needed resources for social welfare. On her resignation in 1938, an assistant, trained by her, was appointed as chief of the department. Helen Shipps, who had spent some time with us at the Massachusetts General Hospital, went to Japan in the early 1930's, where she organized and developed medical social service at St. Luke's International Hospital in Tokyo, with the help of Dr. H. Hashimoto. Before she left Japan in 1941 she had been responsible for sending several Japanese workers to this country for additional training and experience. The first International Conference of Social Work was held in Paris in 1928, and for it Dr. Cabot prepared the first comprehensive report of the extent and development of medical social service throughout the world. 8 He reported that in 1924 there were 574 social-service departments in the United States, one in Hawaii. Canada reported ten departments in Montreal, Winnipeg, Toronto, Hamilton, and Vancouver. The yearbook of the Association of Hospital Almoners for 1927 recorded almoners working in nineteen London hospitals and in seventeen other institutions in England, Scotland and Ireland. Almoners were already established at Melbourne and Sydney in Australia. Medical social service for hospitals in Germany had been

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fostered by the establishment of the School for Social Work by Alice Solomon and by the organization of hospital workers as the Deutsche Vereinigung für den Fürsorgedienst im Krankenhaus, with headquarters in Berlin and two secretaries, Hedwig Landsberg and Anni Tüllman. They published a Bulletin which reported on various phases of the work. In 1928 came the report that the work had been extended to seventy-seven hospitals. In his report on France, Dr. Cabot stated that since the war social service, which had developed there through physicians in clinics rather than in hospitals, had extended to forty-seven clinics in twenty-eight hospitals and employed fifty-nine fulltime and ten part-time medical social workers. Workers were also established in Lyons and Marseilles. Since 1921 the social work in all the Paris clinics had been unified in an association known as Le Service Social à Γ Hôpital, managed by a volunteer committee, of which Madame Getting was chairman, and assisted by a contribution from the Ministry of Hygiene. Dr. Cabot's report also contains information about the development of medical social service in Austria, Hungary, Sweden, and Denmark, but since then, unhappily, there have been many changes in these countries. In 1933, Alice Solomon and Hedwig Landsberg were forced to retire. And most tragic of all, during the "Occupation" before the end of the Second World War, Madame Getting was seized in Paris, while presiding at a meeting of her committee, and has not been heard from since. At subsequent meetings of the International Conference of Social Work, in Frankfurt in 1932, London in 1936, and Paris in 1950, medical social workers from many countries have met and exchanged experience and strengthened bonds of fellowship. In these years, too, there has been exchange of visits. Miss Pruitt returned to this country periodically and gave us vivid pictures of her problems in China. Miss Shipps reported on her work at St. Luke's International Hospital in Tokyo and the transfer of the department to a trained Japanese social worker. Well-remembered by medical social

1

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workers in this country are the visits in 1924 from Miss Cummins, Lady Almoner of St. Thomas's Hospital, and from her successor, Cherry Morris, in 1935. A t the International Conference of Social Work in London in 1936, Antoinette Cannon presented a scholarly address, "The Uses of Medical Social Work," which gave a thoughtfull interpretation of the function of social work in medical institutions. After the Conference, the assembled medical social workers spent two memorable days with Dr. Cabot at Haywards Heath on a country estate, Elfinsward, placed at our disposal. As the subject for our discussion Dr. Cabot had posed "Our Failures, Their Cause and Cure." The opportunity for discussion and for recreation together forged still stronger bonds between workers in many countries. In reporting on this meeting, Theo date Soule tells of visiting a housing project in a country village. She expressed her enthusiasm over what she had seen to an English boy, who commented, "Well, in America, I suppose you are just developing." Miss Soule, then the president of the American Association of Medical Social Workers, remarked, "In medical social work, I know we are." And we still are! The years of the great depression and the war years were to see striking growth in the application of medical social work in public health and community services and a franker recognition of the contribution of psychiatry to medicine in all its branches and to social work. At the meeting of the National Conference of 1919, Mary C. Jarrett presented a paper on "The Psychiatric Thread Running Through All Social Case Work." 9 The validity of her thesis was readily accepted by many social workers. And that thread was to weave a pattern that has enriched the whole fabric of social work.

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18 A Special Privilege S O C I A L workers associated with doctors in teaching hospitals seem to me to have privileges above those who work independently in a social agency. First of all, the relation with the patient is simple; the patient has taken the initiative in seeking help when he is in pain. Although he may have some dread of hospitals, he has come with confidence that he will be helped. Usually, he has no sense of guilt or shame in being sick; even when his disease may have moral implications he feels safer in a medical setting than anywhere else. It has been my experience that the impersonal, unjudging attitude of the doctors produces the basis for keeping such patients under suitable care. In highly organized medical institutions, the "doctor-patient relation" often includes not merely a doctor but several doctors and the auxiliary personnel essential to modern medical care. If the interprofessional relations are cordial and each service is of a high order, the patient's confidence in the doctor broadens into confidence in the hospital itself. This confidence in the hospital is basically confidence in the medical profession and is deeply rooted in tradition. T o understand doctors and their reactions, it is well to consider how those roots in tradition have been nourished through the centuries and why we take it for granted that physicians worthy of the title are also worthy of the patient's confidence. Hippocrates, the great physician of 400 B.C., has been justly revered by the medical profession through the many subsequent centuries, for it was he who separated medicine from superstition and placed it on a scientific basis. Also, it was he

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who established a code of ethics for physicians, the principles of which have been so persistently recognized that the Hippocratic Oath, with slight changes in wording, is still taken by the graduates of many medical schools. In some of the phrases in that oath may be found an explanation of "conservative" attitudes that are characteristic of physicians. The first is the pledge of loyalty to the profession and of generosity to its members. The accepted principle that doctors shall make no professional charge for care of other members of the profession or their families may thus be explained. (Does this free them from experience with the costs of medical care? ) But the phrase that is both crucial for understanding doctors and far-reaching as well, is this: "Whatsoever I see or hear in the life of men which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret." It is this principle that lies at the root of our confidence in our personal physicians. But as a social worker pioneering with forward-looking doctors in movements for public health I was aware that this rigid principle was the cause of general resistance by doctors to extension of the list of reportable diseases. In 1907, when tuberculosis was "declared dangerous to public health" and therefore reportable, the doctors were a veritable wall of resistance. T o register a patient as having tuberculosis, a dread disease, was to them a betrayal of confidence. This feeling may have been exaggerated by the many instances in which the doctor had not told the patient his real diagnosis, a common situation in those years. The steady advance of public-health regulations and of preventive medicine have heaped upon the family doctor's shoulders many obligations that are not only burdensome in the required detail of reporting but sometimes disturbing to his conscience. The proposed addition of syphilis and gonorrhea to the list of reportable disease was fought bitterly. Its final form in Massachusetts of report by number only, so long as the patient remains under treatment, was a compromise

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with the doctor in his determination to protect his patients. The scrupulous protection of the medical records of patients by hospitals similarly rests in this deep conviction of the medical profession, and orders for reporting of disease had cautious acceptance by hospitals. The individualistic character of the physician's relation to his patient could not be changed to serve a broader sphere of human need without a struggle; to them protection of "the potential patient" seemed a rather vague purpose, with actual patients immediately under care. That these changes have taken place through the years and the medical profession has gained thereby in public confidence, is the highest tribute to the farsighted leaders who have pointed the way. Bewildering paradoxes present themselves in considering the characteristics of the medical profession. What seems to be solidly entrenched conservatism exists alongside a most free-minded spirit of research into new fields of knowledge. What is it that the medical profession seeks to conserve and what does it seek so eagerly to pursue along new paths? Its conservatism is often the butt of ridicule by laymen and social workers. When one is close to the practice of medicine in a modern medical institution, one comes to see this conservatism expressed as a fine screening process, a sifting out of false hopes in treatment, the cautious study of new discoveries, and a treasuring of methods proved sound in treatment. Because of their confidence in those who proceed by a careful balancing of the old and the new, pharmaceutical houses through the years have entrusted new drugs, which we call "miracle drugs," to conservative, reliable doctors who will carefully test a new remedy to determine its validity and dosage before it is put on the market for general use by the profession. I well remember when insulin was offered to Dr. F. Gorham Brigham to be used for diabetic patients in the Massachusetts General Hospital wards—under the strictest supervision until the correct dosage could be determined. W e who were familiar with the tragic picture of patients with diabetes watched the demonstration almost breathlessly. Mir-

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acle indeed! The same experience was repeated with Dr. Henry R. Viets in his use of prostigmine for patients with myasthenia gravis. Medicine is conservative, but has any other profession shown so steady a progress in opening up new means for relief of mankind? One notable characteristic of the fine type of medical men with whom I have had experience is that of learning from mistakes, by critical analysis of failure for the purpose of improvement in methods and skills. The Clinical Pathological Conferences instituted by Dr. Cabot at the Massachusetts General Hospital in 1910 are well known by medical men throughout the world. The plan for these weekly conferences at the Hospital grew out of the discovery by Dr. Cabot that a patient treated for what was diagnosed as "neurasthenia" had been found on autopsy to have had cancer. It was characteristic of Richard Cabot that this experience prompted him to action. With the cooperation of Dr. J. Homer Wright and later Dr. Oscar Richardson, pathologists of the Hospital, he selected the records of patients for whom there was an autopsy report. A secretary transcribed these records, omitting identifying data and diagnosis. At the weekly meeting of doctors and medical students, such an abbreviated record was provided, and the case was then discussed. Everyone in the group had opportunity to question or to commit himself as to diagnosis. After this preliminary discussion, Dr. Cabot called on the pathologist to present his findings as revealed by autopsy. Full discussion then followed to learn everything possible from any failure in examination, diagnosis, or treatment. T o observe these proceedings, as I did in those early years, with Richard Cabot presiding and Oscar Richardson presenting the results of his pathological findings, was not only educational but an inspiring experience. The obvious reverence of those two men for the human body and its mysteries, their humility before truth revealed, their eagerness to learn from errors in judgment were haunting lessons when faced with one's own limitations before the tragedies and life problems of patients.

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The Clinical Pathological Conferences, or Cabot Case Records, as they have come to be called not only in this country but in many foreign lands, are still carried on—a living tribute to Dr. Cabot. Dr. Alan Gregg, director of Medical Sciences for the Rockefeller Foundation, said of them: "The clinicopathological conference is the wonder and admiration of many of our foreign visitors, who see in it a candor and fearlessness altogether to the credit of American Medicine." 1 Medical social workers in a teaching hospital, aware of the astonishing progress of medicine in the past half century, cannot fail to be mindful of the tremendous significance of clinical research, not only as cumulative to the fund of medical knowledge but also as characteristic of the scientific mind. Scientific clinical research calls for concentration of purpose, open-mindedness to facts revealed, suspension of judgment until evidence is clear and sure, and readiness to share the fruits of labor when the search is completed. I well remember when Dr. Joseph C. Aub was carrying on his research into the nature of lead poisoning. The early clinical picture of lead poisoning was evidence of stippling of the blood; it had formerly been supposed to be a disease of the blood. How patiently Dr. Aub studied the condition of patients who came voluntarily into the research ward to help him in his search, which finally disclosed that the disease involved the calcium content of the body, and that the lead lodged in the marrow of the long bones. Some thousand cases were covered in an epoch-making research that revolutionized the medical treatment of lead poisoning. After the publication of Dr. Aub's book 2 based on this thorough study, I used to take my medical-social students to him to have him tell them what was involved in such painstaking accumulation of evidence—a good lesson for us who were sometimes too ready with statements of convictions out of limited experience. It was good discipline for us to have our theories met with the challenge, "What is your evidence?" Medical social workers in teaching hospitals, as they have demonstrated that they have something significant to offer,

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have been increasingly drawn into participation in clinical research. Much of social material does not lend itself to the specific tests available to the medical profession in the laboratory, but our accumulation of experience with patients living under serious emotional strain, a factor often not revealed in the course of physical examination, may present evidence highly significant in cases of digestive disorders or thyroid disease. Details of familial history, in diseases such as rheumatic fever and some of the obscure conditions involving the nervous system, often illuminate physical findings. T h e opportunity for social research in the field of public health is enormous, and it is only just being explored. T h e methods of medical research—the critical, questioning mind open to all avenues of approach, a readiness to retreat without regret or sense of failure if on the wrong track, suspension of judgment until there is ample evidence on which to base conclusions—these methods and attitudes of medical research, have much to teach us in social service. Those who have worked day after day in the atmosphere of a large modern hospital have witnessed the serious responsibilities that rest on the doctors. T h e y are aware of the absorbing interest of clinical medicine spurred by teaching and research, and do not find it difficult to understand why many doctors do not take an equal interest in the community problems with which social workers are deeply concerned. T h e clinician—because he is a physician—has humanitarian interests. T o secure his attention for the personal problems of his patient is not difficult, but the broader aspects of community medicine and public health may seem to him beyond his special concern. This apparent indifference may be explained by his familiarity with specialization; he would leave such matters to those whose primary responsibilities and special knowledge lie in these areas. Only in recent years have medical schools assumed, generally and officially, that medical education should include a study of the social aspects of medicine. Significant changes are taking place in medical education; there is a growing appreciation that medical schools

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must accept responsibility for preparing not only conscientious clinicians but those who can assume leadership in community problems of medicine and in the broad sphere of public health.

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I F consumption is ever to be eradicated it can only be done by preventive means and not by cure." These words, written by Dr. Lemuel Shattuck in 1850, more than three decades before the specific cause of tuberculosis was determined, express the social challenge to fight this great menace and suggest the optimism that was characteristic of the campaign against it a half century later. Pasteur's triumphant statement, that it was "in the power of man to cause all infectious diseases to disappear from the earth," became the battle cry when Koch made his momentous discovery in 1882 and the tubercle bacillus was recognized as one of mankind's greatest foes. That the pioneering attack on tuberculosis at the beginning of the century took the form of a campaign and that military terms were borrowed for publicity use was probably not a chance circumstance. The specific medical enemy— the tubercle bacillus—was known, and its social allies—ignorance, low standards of living, undernourishment, bad housing, unsanitary conditions of work, dirty, dusty streets—were recognized as fostering the spread of the disease. The campaign against it was purposeful and well planned, organized and led by courageous medical men, and supported by an enthusiastic army of public-spirited citizens. The strategy was to attack on several fronts. In order that the extent of the "great white plague" might be known, specific cases of tuberculosis were to be registered by doctors caring for such victims. Ignorance and fear of the disease were to be met by educating patients, their families, and the general

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public in its nature, transmission, and means of control. Public opinion was to be rallied to demand the correction of the contributing social conditions—slum clearance, decent housing, proper cleaning of streets, factory and sweatshop inspection, and installation of measures for health protection. Legislation was therefore pressing to make report of the disease compulsory, to establish sanatoria for the isolation and care of tuberculous patients, and to maintain clinics and public-health nurses for examination of those who had had contact with tuberculous patients. A new concept in medical treatment developed—the preventive measure of offering free examination to those suspected of having the disease. A medical-social evolution was in process. All these measures depended on publicity and the frank discussion of tuberculosis, and were directed not only toward educating the general public but quite specifically toward providing a clear understanding by the patients themselves. The established tradition of secrecy concerning a positive diagnosis of tuberculosis—a secrecy often maintained by the doctor toward the patient—was not readily dispelled. But the positive hygienic gospel of fresh air, good nutrition, pure food, decent standards of living for all, and hygienic surroundings for industrial workers aroused the enthusiasm of those who enlisted in the fight against tuberculosis, and there were a spirit of optimism and a high morale in the ranks. Many volunteered to help in this campaign to eradicate a dread disease that was taking many lives. This enthusiasm was in sharp contrast to the hard realities faced by the fearful patient when he learned that he had the disease. The medical advice, usually given with cheerful assurance by the doctor, meant to the patient the total disruption of his way of life. This pioneer public-health movement to combat tuberculosis was launched at an opportune time. In several cities medical men were calling attention to the fact that treatment of tuberculous patients in dispensary clinics was futile. The doctor could not see that such patients carried through the advice given, and it was obvious that their primary needs

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could not be met in the wretched and crowded tenements in which most of them lived. As we have already noted, social reformers also were denouncing the evils of low standards of living and were calling attention to the extent to which sickness was related to poverty, degeneracy, and crime.1 When, therefore, a Committee on Tuberculosis was appointed in 1902 under the vigorous leadership of Edward T . Devine, Secretary of the New York Charity Organization Society, an era of medical-social cooperation was launched. At the annual meeting of the Charity Organization Society in 1901, Dr. Herman M. Biggs, the leading spirit of the medical profession in fighting the disease in New York, had presented a report on "Tuberculosis and the Tenement-House Problem." Dr. Biggs and Mr. Devine recognized their common interests. Dr. Biggs was wise in seeking lay support, and Mr. Devine saw the strength of medical backing for the reforms he sought. Mr. Devine, a former teacher of economics, appointed secretary of the Charity Organization Society in 1898, and well to the fore in the reform movement, had firsthand knowledge of the social conditions among the people under care of the Society. In cooperation between the medical profession, social workers, and interested public-spirited citizens, he saw an irresistible force for improving the conditions of the poor in the great city of New York. It was at this time, also, that Dr. S. A. Knopf, then at the beginning of his notable career, presented his thesis, "Tuberculosis as a Disease of the Masses." This report stirred general interest, and was published by the New York Board of Health and widely distributed throughout the country. In the practice of social work a new attitude was emerging and modifying its philosophy. The earlier contention that the individual was in large part, and possibly wholly, responsible for any personal misfortune was giving way to both acknowledgment and deeper understanding of the obstacles with which he was faced and over which he might have no control. Mr. Devine in 1906 stated that the duty of the social worker is "to seek out and to strike effectively at those

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organized forces of evil, at those particular causes of dependence and intolerable living conditions which are beyond the control of individuals whom they injure and too often destroy." The battle was on! Massachusetts had had a long history of interest in tuberculosis. Dr. Henry Ingersoll Bowditch, back in 1857, was advocating out-of-door living for his tuberculous patients. One such patient, in his old age, told of Dr. Bowditch's advice to him "to go to Minnesota to live an outdoor life. . . Avoid drugs, hotels, hot stoves, plastered rooms; you can get all these in Boston and die; yet if you and your young wife have the pluck to go where and to do as I tell you, you can live, and live in good health and in a community of immense promise. Do not fear this cold-air treatment, it is the coming cure for your trouble." When the antituberculosis campaign in Massachusetts was taking form early in the century, there were already such men as Dr. Vincent Y . Bowditch, Dr. E. O. Otis, and Dr. Charles Millet eager to give professional backing to volunteer efforts. In 1903, with their encouragement, antituberculosis societies were organized in Cambridge and in Boston. The Boston Society for Relief and Control of Tuberculosis was already active under the stimulating and enthusiastic leadership of Alexander Wilson, a far-sighted social worker who, like Edward T . Devine, saw the serious need for improving the general conditions of life in the wretched tenement-house districts of the city. Mr. Wilson played a major role in arousing public backing for the cooperative efforts of social agencies and medical and public-health leaders toward reform. It was he who secured the participation of the Associated Charities and the eager and keenly intelligent interest of its secretary, Alice Higgins, in gathering evidence of the extent of tuberculosis in the families under their care. As a student in the School of Social Work in the autumn of 1906, I was assigned for practical experience to the Roxbury District of the Associated Charities. Here I heard of the many families being sent to the agency by doctors and nurses

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of the newly established clinics for tuberculosis patients. W h e n a study of tuberculous families was proposed I volunteered to help. A n d this is what I found. One hundred families in the Roxbury District were known to have included a recent patient with tuberculosis. In these families, fourteen mothers and fifty-six fathers had already died of the disease; ten mothers and eight fathers were ill with it at the time of the study. In these families there were 289 children under twenty-one years of age. In cooperation with the visiting nurses it was arranged to have these children examined at the clinic. Nineteen of them were found to have active tuberculosis and were placed under care. W e were shocked to find the prevalence of the scourge in our district. I shall always remember the conference held that winter, at which reports of all the districts were presented concerning the problems of families in which tuberculosis had been found. N o one had a true picture of the extent of the disease in Boston at that time, but here was plenty of evidence to spur the antituberculosis movement. T h e problems were far beyond the capacity of private agencies. It was obvious that the major responsibility for an effective program must be assumed b y public authorities, and that this could come about only if public opinion demanded it. M y personal interest in tuberculosis had been well founded during the previous summer when I was in charge of a camp for children of the poorer district of Minneapolis who had been exposed to the disease. Especially I remember four-yearold Willard whom the visiting nurse had found lying on the foot of his mother's bed as she lay dying of tuberculosis. Brought to the camp, situated in pleasant woods on the bank of the Mississippi River, Willard did not at first share our enthusiasm for bringing him out into the country, into fresh air and sunshine where he could have plentiful good food and play with other children. H e cried for his mother, whose death he had not comprehended. T h e sunshine hurt his eyes; he bent his arm to shut out the light. (I was to learn later that he probably had phlyctenular keratitis.) T h e milk made

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him sick and he didn't like the quiet, or probably he missed the city noises. He avoided the other boys; they were too rough. Willard taught me many things, but especially he gave me a deep desire to do what I could to help fight a disease that could so scar a child's life. That Willard left the camp with rosy cheeks, having gained in weight, gave zest to my desire. After I joined the social service group at the Massachusetts General Hospital, I was to become very familiar with the manifold problems presented to patients with tuberculosis. During that first year, 287 patients with the disease were referred. One of the first patients, I recall, was referred from the medical clinic to me as a social worker to place under care in a sanatorium. She was a young mother with three children, whose father had deserted them, leaving her to work for their support. This was long before there was public provision for "Mothers' Aid." (The philosophy of social work then seemed to be that public aid was grudgingly given to families deserted by the father, since it would tend to relieve the father of a sense of responsibility.) The mother's medical record showed me that two years before she had been treated for "bronchitis," one year before for "pleurisy," and now she was sent to me to make some plan for her in face of a diagnosis of advanced tuberculosis. W e were fortunate enough to secure institutional care for the mother, for the last weeks of her life. That the story did not end there was typical of the involvements of the problems turned over to us through the years. On her deathbed this mother had secured the promise of her younger sister to care for the children after she was gone. This the devoted sister did, with some help from her brother and practical help and consistent interest for years on the part of the Social Service Department of the Hospital. The sister gave up her plans for marriage, her fiancé not being willing to share the responsibility for care of the children. The sister, now in her late seventies, with a chronic heart disease, is unhappily living out her loneliness in a crowded boarding home with other old women, supported by Old

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Age Assistance. She has spanned the growth of medical social service at the Hospital from its early opportunities with tuberculous patients only to confront us with the current problems of old age and chronic illness. In the early days of the antituberculosis campaign, Dr. Charles Millet was especially identified with , the movement against sending tuberculosis patients to the West and South in search of health. His early advocacy of outdoor living for tuberculous patients here in Massachusetts was cause for much criticism. Meantime, such states as Arizona, California, and New Mexico were protesting against the floods of tuberculous patients from northern states that overwhelmed the relief agencies when these patients found themselves destitute in a strange place, alone, and many of them in a dying condition. The idea of seeking climate as the sole remedy for tuberculosis has so long been discarded that it is something of a surprise to turn back to the record of the first decade of the campaign and find authoritative advice on "Climate and Tuberculosis." For instance, in 1906, the Boston Medical and Surgical Journal advocated Tucson as a desirable winter resort for tuberculosis. "Tucson is a growing town in a growing country. Many persons who are not very sick have found employment in the mines in neighboring mountains or in the business houses of the town. For the persons with visible symptoms the outlook is not so good as there is a disinclination to employ those who may be a menace to other employees."2 For several years after our social service department was established we had occasional requests to send tuberculous patients to the Southwest. Through the evidence accumulated by the National Society for Relief and Control of Tuberculosis we were able to report to the doctors concerning the sad fate of most patients who left their homes in search of cure on the basis of climate. Meanwhile the possibilities of successful treatment in Massachusetts were being demonstrated. In addition to promoting facilities for care of patients in sanatoria, day camps, and classes, a vigorous educational cam-

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paign was carried on. One of the most spectacular methods was the Tuberculosis Exhibit. This had official sanction in a legislative act of 1905, authorizing the State Board of Health "to cause a public exhibition to be made of the various means and methods used or recommended for treating and preventing tuberculosis, now recognized as a communicable and preventable disease." Some 25,000 people attended this state exhibit when it was held in 1906. This was followed by smaller local exhibits under the sponsorship of local antituberculosis societies. I remember helping at the one arranged by the Cambridge Society, in which bad and good tenement living conditions, dirty and clean workrooms, were depicted side by side. Life in the sanatorium was pictured, and general information on control of the disease was presented. Posters displayed facts about good nutrition, and talks on healthful living and educational leaflets were provided. A t the Exhibit, I spent my volunteer period at the microscope, demonstrating a slide with a specimen of sputum that showed the tubercle bacillus and telling about the antispitting law. W e had offered prizes for the best compositions written by school children, who had been sent in large numbers to see the exhibit. One child seemed to get the idea of my demonstration for he wrote: "One thing I saw was a germ. It was a little red hair running through a spit that an unmanly gentleman put on the sidewalk." W e were humbled, however, when another child wrote, "Tuberculosis was started in 1882 by Dr. Trudeau who had it in the aderondacs and since then it has become very popular." I wished I might go about the schools to tell the children of the heroic life of that great man. It is my memory that Dr. Edward L. Trudeau had had much to contribute to the optimism by which the antituberculosis movement was inspired. At least he was an inspiration for many of us. I remember the deeply moving experience of seeing and hearing him at the meeting of the International Congress on Tuberculosis in Washington in 1908, when the vast audience greeted him with reverence and enthusiasm. In

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his presidential address at the Congress of American Physicians and Surgeons in 1910, he chose as his subject, "The Value of Optimism in Medicine." 3 Looking back over his life, he said he had always had a large fund of optimism. "Sometimes it was about all he had." "Optimism," he continued, "is a product of a man's heart rather than his head; of his emotions rather than his reason; and on that account is rather frowned upon by many physicians whose scientific training naturally leads them to depend solely upon the qualities of the intellect and look with suspicion upon any product of the emotions. We doctors are too apt to look upon brains as a criterion of his [a doctor's] chances of achievement in life and to . . . deprecate those qualities which are closely related to his emotions as rather likely to mislead and hamper him in his career. And yet optimism is a prominent factor in anything a man may achieve in life. It is a mixture of faith and imagination, and from it springs the vision which leads him from the beaten paths, urges him to effort when obstacles block his way, and carries him finally to achievement when pessimism can see only failure ahead." Dr. Trudeau then paid tribute to Richard Cabot as one of those physicians whose imagination and enthusiasm had disturbed the habitual routine of dispensary practice by his introduction of social service, "which so strongly reflects his faith and his ideals." Fifty years ago, "consumption" was the more familiar term for tuberculosis. And consumption was a suitable term to describe the emaciation of the hectic patients who sat on the benches in the corridor of the Outpatient Department of the Hospital. The phrase "ravages of tuberculosis" was used frequently in the antituberculosis campaign, and in the clinics we saw the vivid picture—many weak, emaciated men and women in advanced stages of the disease, coughing with copious sputum, waiting patiently and anxiously to see the doctors. Many of these pathetic patients could scarcely walk and were aided by relatives and friends who had brought them, hopefully asking that they be sent to Rutland Sanatorium since

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they had heard that patients who went there were cured. W e social workers knew what the verdict would be: "Only early cases are sent there." A t Rutland in 1898 the first state sanatorium specifically designed for such a purpose, the Massachusetts Hospital for Consumptives and Tubercular Patients (later called Rutland Sanatorium), was formally opened. Intended originally to care for patients in advanced stages of the disease, its purpose was later stated as for early cases only. The change was by way of demonstration, to encourage an optimistic attitude on the part of the public as to the possibility of successful treatment of the disease if discovered and placed under care in its early stages. For several years doctors from Rutland Sanatorium came to the Outpatient Department at the Massachusetts General Hospital two afternoons a week to examine patients recommended for admission to the Sanatorium. They were checking to ensure admission of incipient cases only. It fell to us social workers to encourage the patients and families during the additional hours of waiting for the final verdict. W e also saw that they had milk and crackers from the "Patients' Lunch Counter" that we had persuaded the Hospital to provide for such patients, weary with much waiting during the ordeal of the morning clinic. W e knew that the policy of admission of early cases only to the Rutland Sanatorium was wise but, when we were faced with patients who had been refused admission, we were often distressed—all patients refused admission to the Rutland Sanatorium were promptly referred to Social Service for some other plan. The resources for care of patients with advanced tuberculosis were few and many of those coming to our attention were too ill to be accepted in the tuberculosis classes described in an earlier chapter. Makeshift arrangements were carried out for some with tents on roofs or balconies and with home supervision and hygienic instruction by medical social workers or visiting nurses. Our most distressing experiences came from those patients

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who refused to accept the diagnosis made by skilled clinic physicians. On visiting such patients at home to find out why they had not returned to the clinic, we too often found that they had, on the advice of a friend, gone to some practitioner who had assured them that they had "bronchitis" or "bronchial asthma" or even "stomach trouble." Since such information came to us from the patient, we often suspected that in many instances the doctor had chosen to withhold the truth from him. W e had been through that experience with some of the clinic physicians. Since the patient had chosen to go to a private physician we could do nothing but stand by and see him throw away his golden opportunity for recovery and later drag himself back to the clinic to plead for help when it was too late, when all savings had been spent in vain search for health, and when the disease had a fatal hold. All who were interested in the tuberculosis campaign in Massachusetts were stanchly back of the state program proposed by the State Commission on Tuberculosis of which Dr. Arthur T . Cabot was chairman. W e joined forces in urging the legislature to appropriate funds to build the additional sanatoria, for nothing seemed so important as provision for segregation of the infectious patients. When the sanatoria were finally opened, we felt that great progress had been made in our fight for the control of the disease. But medical social workers in the hospital clinics where so many patients were discovered were to find that their special service to the patients was again needed at just this crucial point of persuading patients to accept institutional care. T o the patient, this wise policy of segregation meant isolation from all that had meaning to him; isolation from his family, his friends, his work—all that made up his habitual way of life. To give up his responsible active role, weighted with significance to him, and to accept a plan involving months, possibly years, of institutional existence was usually a major emotional operation. Even when we did succeed in getting patients into a sanatorium, we found that they did not always stay there. All

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sorts of natural human longings led them to desert the perfect hygienic surroundings of the institution, over which we had been enthusiastic. A mother in intolerable distress over her child, who she is sure needs her care, cannot eat or sleep. The father who gains weight and feels some return of vigor is sure he can go to work again, to support his family, although the doctors insist he is not yet fit to work. The "good" patients, who readily accepted the passive roles, were later to prove the most difficult when return to normal activity was advised. Dr. Cabot once described them as having "lost their moral backbone" from prolonged idleness. Psychological problems began to loom large in the tuberculosis campaign. Prolonged physical rest, prescribed for these patients, which formerly was the only accepted means of treatment, often tended to create habits of idleness and dependency that defeated, in part, the purpose of treatment—to return the patient to self-sufficiency. Several special services were added to the institutional provisions, such as occupational therapy, largely for its diversional values, and libraries with books to feed the mind and stimulate varied interests. The newer surgical procedures, when successful, have not only a physical but a psychological benefit—one may add, an economic value also. The State Commission on Tuberculosis made a wise move when it proposed that local sanatoria be built for care of patients in advanced stages of tuberculosis and that a state subsidy be granted on a per capita basis of $5.00 a week if the care met established requirements. Thus patients who could be visited by their families might be more willing to remain under care. Another provision was that of local clinics with public-health nurses who could arrange for examination of those who had had contact with infectious patients. The public-health nurse soon became the most essential factor in the tuberculosis campaign as she established her function in "case finding" and in hygienic teaching in the home. The care of patients was a major interest in the first decade of the antituberculosis campaign, but the broader aspects of the fight were also receiving attention. Public-education pro-

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grams were being developed in the schools and posters were placed conspicuously in factories and various public places. Slum clearance, better housing, and clean streets were urged persistently in the interest of fighting the spread of tuberculosis. One of the most effective legislative acts called for as necessary to control of tuberculosis was establishment of factory, sweatshop, and tenement-house inspection. This was conceived as an educational program but authority was given for action in cleaning up working conditions that were deemed dangerous to public health. The inspectors were specifically charged with studying the extent of tuberculosis in the state, the health of minors employed in factories, and the sanitation of factories, slaughterhouses, public buildings and tenements in which clothing was manufactured. This meant working closely with both state and local boards of health. This act, approved in 1907, had the strong backing of those working in the tuberculosis campaign. Dr. Harry Linenthal, a member of the outpatient staff of the Massachusetts General Hospital and later actively interested in the Industrial Clinic with Dr. Edsall, was a pioneer in inspection of clothing factories and tenement-house workrooms. W e in the Social Service Department had occasion to consult with him on conditions that came to our attention. The shocking conditions he found in sweatshops were vividly reported and dealt with effectively and courageously. Many tuberculous patients were brought under treatment. More decent conditions of work were secured for many and, one may add, cleaner garments were placed in the shops for sale to unsuspecting customers. Dr. Linenthal once reported that his protest to an employer against the workers' spitting on the floor of a tenement workshop brought the rejoinder: "What do you expect? This is not a parlor or ballroom. Where do you expect them to spit?" Measures for protection of workers against tuberculosis meant more decent conditions for all workers. Tuberculosis has some features that distinguish it from other chronic diseases. Its infectious nature, which presents

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a serious public-health menace, has brought about community measures for treatment and control that were revolutionary when they were first proposed. Frank discussion of the diagnosis and nature of the disease and of the part the patient must play in treatment were the means of dispelling much of the former mystery about disease. The general knowledge of the hazards of infection, however, tended to attach a stigma to the victim of tuberculosis. I have known patients to whom the idea of being a possible menace to their families was a source of deepest distress. Physical treatment of the tuberculous patient has undergone considerable change in recent decades. Improvements have been made in methods of detection of early symptoms. Sheltered workshops have made their contribution to the discharged patient. Sanatorium care has been improved in several ways. There is a trend toward better integration of the professional services that aim to safeguard effective treatment and help to restore the patient to the community. Many of the state sanatoria and those for the Veterans Administration caring for tuberculous patients have appreciated the value of having social service available within the institution to act as a link between the patient and his family. The social worker finds useful opportunities in discussing with the patient his anxieties, in encouraging his cooperation in treatment, and in listening to his complaints, which, if expressed, are often resolved. There is a growing appreciation of the psychology of being a patient. Restoration of the discharged patient to community life is having attention. Vocational counseling in the light of the patient's physical limitations and capacities, and opportunities for special training, give promise of a better future to many a patient. The state Rehabilitation Programs sponsored and in part supported by the Vocational Rehabilitation Office of the Federal Security Agency should be more effectively related to sanatoria for tuberculous patients. A t the half-century mark the early optimism about the eradication of tuberculosis does not seem warranted. But the death rate of this dread disease has been drastically reduced.

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The fight has been worth while for what has been accomplished in better standards of living and work and in publichealth education. Popular backing of the national and state tuberculosis associations has promoted a broad program of education and research and given support to the activities of the official health authorities in extension of facilities and improved legislation.

20 H a z a r d s f o r t k e I n d u s t r i a l Λλ^οτκ er I N our pioneering days we were frequently aware of the hazards to industrial workers through exposure to fellow workmen in highly infectious stages of tuberculosis. Health measures for factories and workshops were meager indeed at that time, but 1907 became a year of major significance for several advances in public-health measures. It was then that legislation was passed requiring the State Board of Health to "declare those diseases that were dangerous to public health," hence reportable by doctors to the Board. Tuberculosis was among them. Another important legal provision was the establishment of a system of factory inspection and the appointment of health inspectors for tenements and workshops where any branch of clothing manufacture was carried on. 1 Dr. Harry Linenthal, of the Massachusetts General Hospital staff, whose pioneer work has already been referred to, was appointed inspector of clothing-trade workshops in Metropolitan Boston. M y interest in the subject of occupation in relation to disease was sharpened by a visit in 1909 from John B. Andrews, then secretary of the American Association for Labor Legislation. He came to ask if I could help him get some information about early cases of phosphorus poisoning in match workers in Massachusetts. He told me that the earliest match factories were established in Massachusetts. Had we had any patients with "phossy jaw"? I had never heard of such but I was to learn. Mr. Andrews was gathering data on the subject for Senator Esch, who was sponsoring federal legislation to prohibit the use of white phosphorus, the deadly dangerous

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substance then used in the manufacture of matches. Mr. Andrews had gathered evidence of some 150 cases of "phossy jaw," and had found reference to the statement that the first match factories were established in Massachusetts about 1838. Had the Massachusetts General Hospital any records of such cases? I appealed to Mrs. Grace Myers, our most efficient Record Librarian. Through her diagnosis catalogue, she soon located the record of one Francis Choate, who in 1851 was admitted to the Hospital for treatment of "Necrosis of the Jaw." His record stated that he had "worked for 12 years in manufacture of matches, dipping cards of matches into phosphorus. The room in which he worked would be filled with the fumes of it and he used to sit with his head over the vessel from which it came. He says not many men can stand the work, because of bronchial irritation which it excites . . . [The patient's] teeth have dropped out. Half a dozen fistulous openings along the jaw. Masses of dead bone protrude into the mouth from toothless jaw." The medical record further stated that the patient, upon discharge, "was advised to go to the country and return at a later date." A record of his readmission a few months later gave a hideous picture of his condition and of his death at the Hospital. Here was historic evidence to add to Mr. Andrews's 150 current cases of "phossy jaw." The Esch bill was passed in 1912, sixty years after Francis Choate's death. Thereafter a harmless ingredient was substituted for the white phosphorus, and "phossy jaw" in the manufacture of matches was consigned to industrial history. The Congressional Record of the hearings on the Esch Bill had called it "one of the most loathsome diseases of our civilization." This record of Francis Choate haunted me, possibly because the Workmen's Compensation Law was being hotly discussed in Massachusetts at that time. It became operative in 1912. Most of the early compensation acts made provision for "industrial accidents" only; they did not at first compen-

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sate for industrial diseases. Fortunately, the Massachusetts Act included the words "personal injury by accident," and in 1914 the courts interpreted the law to cover industrial diseases. The test case was that of a man who had optic neuritis as a result of standing over poisonous coal-tar gases; he was judged to have received a personal injury. Another case stirred my interest. A girl with the diagnosis of chlorosis was sent to me from the Female Medical Clinic by Dr. Roger I. Lee, because she had told him she could not pay the 35 cents for Blaud's pills, the specific remedy for her type of anemia. In talking with the girl, very frail and undersized for her twenty years, I learned that she was employed as a "sealer" in a raincoat factory. Not understanding what a "sealer" was, I asked her to describe her work. She told me that she used naphtha cement to seal together the seams of ladies' raincoats, that the room was "closed," as moving air dried the cement too fast, and that the smell "took" her appetite. She was the oldest of three children whose father had deserted them and she and her mother supported the family. The mother was away all day and the younger children were in school and "took care of themselves." It was obvious that this patient needed more than the Blaud's pills. In working out a plan for her, with her mother and a local family society, we consulted Dr. Lee. He became interested and suggested that we study with him the condition of industrial workers who came to the medical clinic during the next six months. A special worker was assigned to this study. Although we found no striking instances of special hazards, we did become more aware of the life of the working girls and the importance of considering the working conditions of our patients as well as their situation at home.2 For the Social Service Department, and for this growing interest in the relation of occupation to health, the coming of Dr. Davil L. Edsall to the Hospital Staff in 1912 was most opportune. His broad knowledge of the subject made a lasting impression on many clinicians with whom he was associated. He had written the chapter on lead poisoning in the re-

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vised edition of Oliver's Occupational Diseases, and I had had some correspondence with him on the subject while he was still in Philadelphia. His coming gave direct stimulus to our consideration of occupational diseases. One of Dr. Edsall's first questions concerned the extent of lead poisoning among the patients. As no such inquiry had earlier been made, I undertook an analysis of the cases registered in the Hospital's diagnosis catalogue during the previous five years, 1907-1912. I found 147 such cases recorded but the designation of occupations was inadequate or missing. In only 37 cases was there any description of the occupation or the source of the poisoning. The note "painters" was not more specific, and that of "rubber workers" was without meaning to me until I had later observed the job of "mixer" in a rubber factory, when I accompanied Dr. Edsall on a visit to the place of employment of one of our patients who was in the Hospital ward with lead poisoning. One of the first things Dr. Edsall did was to require that in taking medical histories more specific information be recorded about the patients' work. He pointed out that a note of "laborer," "shoe factory," "factory worker," had no real meaning. If we were to have a clue to occupational hazards, we must know not only the specific occupation within the industry, but the processes in the occupation. Our ignorance was the more obvious as we realized that in our social records a man's work, although it took up most of his waking hours, had been noted for what it meant in wages at the end of the week. With encouragement and guidance from Dr. Edsall, we undertook a systematic search for occupational diseases in our patients. One of the Massachusetts General Hospital nurses, Susan Holton, had had experience in our department in the course of her training, and had shown a keen interest in this subject. With the generous gift of a friend, we employed Miss Holton for the task. She first familiarized herself with the chief industries of Massachusetts, and with Dr. Edsall's guidance made a study of the occupations and processes known to have

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hazards to health. That the medical record made during physical examination should give a more accurate designation of occupations was of primary importance. This was pointed out to medical students who took the patients' initial histories and, at Dr. Edsall's suggestion, Miss Holton gave them instruction in the noting of specific facts concerning occupation and industry. Each day after the clinic Miss Holton reviewed the records from the Male Medical Clinic and selected cases that suggested exposure to hazards such as "strains, poisonings, fumes, dust or extremes of temperature." Patients who reported hazardous exposure were seen by Dr. Edsall or Dr. Linenthal. We knew we could count on Dr. Linenthal's cooperation, as we had long since discovered his broad interest in industrial hazards. With his help and in consultation with Dr. Alice Hamilton and at Dr. Edsall's request, a special "occupation" card was prepared, to be filled out for all industrial workers and attached to the medical record. It called for a full description of the processes of the occupation, designating any special strains, poisonings, or other hazards to which the patient was exposed. We soon found that many patients did not know what specific materials they were handling nor the dangers to which they were exposed, unless it was an obvious one, such as excessive dust or very heavy lifting. The "mixers" in the rubber factory, for instance, although they knew that they were handling dusty powder, did not know that it contained litharge, an oxide of lead. In reporting the first fifteen months of our joint study, Dr. Edsall pointed out that 482 patients were found to have 916 exposures to hazardous conditions. There were 193 cases of exposure to lead, in which 104 patients showed definite symptoms and 89 had "border-line symptoms."3'4 In the course of gathering information we had widespread correspondence on general industrial-health questions. From Italy, a letter from Dr. Devoto, Director of the Industrial Clinic in Milan, is to be remembered. He stated that in his experience.

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besides the marked cases of industrial diseases, he had found that "unhygienic work imparts to ordinary sickness a special physiognomy." The industrial history sometimes determined diagnosis. There was the patient who had been coming to the medical and neurological clinics for a long time complaining of vague symptoms of excessive nervousness, fleeting memory, lack of control of his voice. No organic basis had been found for his condition and he had been considered "neurasthenic." The new occupation card, when added to his medical record, described his work as a gilder in a picture-framing factory, where he worked over pots of benzol and benzine. The patient was then seen by Dr. Edsall, who pointed out that the diagnosis had become clear; a report of benzol poisoning was made to the State Board of Labor and Industries. After change of work the patient's symptoms gradually subsided. I remember another case in which change of work was the basic treatment. An iron molder, seen in the Orthopedic Clinic, complained of severe back pain. Tuberculosis of the spine was first suspected, but an x-ray showed no disease of the bone. On reviewing with the doctors the exact motions of lifting repeatedly required in the course of his job, the specific muscle strain was explained. His special skill as an iron molder was an important asset to the patient, but this was safeguarded by his employer who, when interviewed, agreed to shift him to the lighter job of core caster. And there were several skilled chocolate dippers who had developed eczema from constant contact with sugar; for them also, the medical advice of "change of work" was in the nature of treatment. For four years we worked under Dr. Edsall's guidance in this study of the relation of disease and occupation among our patients, increasing our understanding of the broad scope of this subject. W e had opportunities to visit some of the chief industries in the state and note the response of employers with whom Dr. Edsall discussed the hazards in certain industrial processes. He had an extraordinary gift for making clear,

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without rancor, that the good of the employee was in the best interest of the employer. As Dr. Cabot once said of him, "Dr. Edsall is not only wise, but he looks wise"; his council whether in clinic or factory was impressive. Clear in my memory of the factory visits are the shiny new protective devices on machinery, seen after the Workmen's Compensation Law became effective in 1912. Since an employer's rates of insurance were in direct relation to the accident rate in his factory, it was in his interest, as well as that of the employees, that every possible protective measure should be taken to prevent injury to workers from being caught in the whirling wheels or revolving rollers of machinery. B y 1916, both in the Hospital and among certain industrialists, interest in the study of industrial disease had increased to the point where special funds, raised through the initiative of Dr. Frederick C. Shattuck, were given to the Hospital to establish an Industrial Clinic, under Dr. Edsall's supervision. Dr. Wade Wright, who had recently completed his internship, was placed in charge and gave to it his full time, assisted by a medical social worker, Helen Bradfield, and a secretary. In the Hospital's Annual Report for that year, we find reference to the Industrial Clinic: " T o the Clinic are referred all cases from either the House ( W a r d ) or Out-Patient Department, which are reportable to the State Board of Labor and Industries, and all reports of industrial diseases are made through the Clinic. A large number of Workmen's Compensation cases is reviewed because of the importance of studying the incidence and causes of industrial accidents and the economic and social problems so frequently involved." 5 This was an ambitious program, as all pioneering ventures are likely to be. But I remember my great feeling of satisfaction at the time in the thought that at last the Industrial Clinic was to be a permanent unit in the Hospital, relating itself to all the clinics and services where industrial workers came for medical care. But, like many good things, the clinic was abandoned with the coming of the W a r and the consequent loss

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of personnel. It was closed in June 1917, after Dr. Wright's enlistment in War Service with our many doctors in Base Hospital No. 6. T o some of us it seemed rather ironical that, as war came to our country, it became imperative, for the production of war materials, to preserve the health of industrial workers. T o that end there developed a great demand for physicians and nurses in industrial plants. With the closing of our Industrial Clinic, two of our workers, Marie M. Wright and Miss Bradfield, were promptly engaged by the Commission on Labor of the Advisory Commission of the Council on National Defence for a special study of industrial fatigue. Although we noted a dropping off of these professional services after the war, they had created a new specialization in medicine and nursing, and progressive industries mindful of the value of attention to the health of employees recognized the industrial physician and industrial nurse as essential. In 1920 the Industrial Clinic was reopened, with Dr. Wright again in charge and Elizabeth McShane as industrial social worker. The cost of the Clinic, except for provision of quarters and ordinary supplies, was borne by the Department of Industrial Hygiene of the Harvard School of Public Health. In 1923, Dr. Edsall resigned from the Hospital to become Dean of Harvard Medical School. Miss McShane also resigned in that year. In 1924, because of ill health, Dr. Wright resigned, and the inevitable happened. Deprived of the vital leadership and deep personal interest of some strong clinician, the Clinic struggled along for a few years but was abandoned in 1928 and its quarters were taken over by other services. The weakness in organization of the Industrial Clinic was its dependence on Dr. Edsall's leadership. It had not been carried on long enough to secure roots in the clinical services or the Hospital's organization. Dr. Edsall's transfer to the Medical School did, however, stimulate industrial research in the laboratories there, and his influence lingered among certain individuals at the Hospital. Most prominent among these was Dr. Joseph Aub, whose epoch-making investigation into the

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basic nature of lead poisoning was carried on in the Research Ward of the Hospital.6 One lasting element of those days may be found in "Instructions in History Taking for Clinical Clerks" in the medical wards. The section on "Occupational History" is much the same as that formulated by Dr. Edsall in 1914. Dr. Washburn, in his history of the Massachusetts General Hospital, comments concerning the regrettable closing of the Industrial Clinic in 1928, as follows: "The study of industrial disease, especially in manufacturing communities like ours, is of great importance. With the use of newly discovered processes and chemical substances, their effect on employees needs careful evaluation. It is pleasing to note that the reëstablishment of this Clinic is being considered."7 But again war intervened. It was not until 1947 that reëstablishment of a clinic for study of disease related to industry was again seriously undertaken. The Occupational Medical Clinic was actively opened in February 1949, with Dr. Harriet L. Hardy in charge. The Clinic is strengthened by Dr. Hardy's affiliation as Associate Physician in charge of Occupational Medicine at the Massachusetts Institute of Technology and as Consultant Physician in the Division of Occupational Hygiene of the Massachusetts Department of Labor. This time the clinic is established on a broader base of various interests and with vital leadership. May it indeed become recognized as the essential adjunct of clinical medicine and social research, as it most certainly should be.

21 Attitudes

Change

T H E year 1950, as a half-century mark, has been the special occasion for taking account of progress significant in our cultural development. Many assume that the greatest advances of the times have been made in science, especially in the contributions to medicine and man's well-being. This view has been suggested in an earlier chapter. Others acclaim what science and the ingenuity of man have done toward creating labor-saving devices that free us for leisure and enjoyment for other uses of our energies. Each sees the changes most significant to his special interests. T o those who believe that, in so far as we know the truth, the spirit of man may be freed, one of the great changes brought about in this half century has come with the gradual lifting of the veil of mystery that surrounded medicine and, more especially, with the tearing away of the taboo against discussion of sex. W e are now permitted a fuller understanding of the role of our emotions in human relations and in disease and treatment. Many of our accepted patterns of behavior are deeply rooted in customs and religious teachings, and the process of bringing to light for objective consideration the many psychological factors involved has been painful and confused. Because of this, public education has been slow to impart fundamental understanding of the emotional aspects of our lives. The reasons for this reluctance are obvious, if we consider the overhanging moralistic censorship that has shrouded the subject of sexual differences and relations. While no one questioned the wisdom of the dictum that the proper study of mankind is man, yet there long remained an

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assumption that much that science had revealed concerning the functioning of our bodies and especially the role of our emotions was not proper for disclosure through public education or for open discussion for the sake of deeper understanding. Among the general public of today many credit—or blame— Sigmund Freud for the change that has come about. But the forces that made change inevitable were many and various. Men well known in the medical profession, through patient research into the nature and causes of those diseases that had come under the "conspiracy of silence," gradually disclosed evidence on which a great public-health campaign could be launched. Schaudinn, Neguchi, Wassermann, and Ehrlich were in the forefront of those who gave to medicine specific information for the control of syphilis and gonorrhea, two diseases which through the ages had cursed mankind. But in Victorian days these momentous scientific contributions were not permitted public discussion, and disclosure of their significance to society demanded a high quality of courage on the part of those who promoted the so-called "social-hygiene movement" in its early beginnings. The anticipated antagonism of the public toward facing the situation frankly is suggested in the guarded title, "The Society for Sanitary and Moral Prophylaxis," under which the movement was initiated by Dr. Prince Morrow in 1905. Freud was already putting forth his theories on the role of sex in nervous disease, but no one would have dared to publicize his ideas outside medical journals. Although he was gathering adherents, many in the medical profession were loath to recognize the Freudian theories, as already mentioned. T h e y indulged in the most scathing abuse of the saintly Dr. James J . Putnam when he sponsored Freud's visit to Boston and his appearance at the twentieth anniversary of Clark University in 1909. These were still times when, as Dr. Oliver Wendell Holmes wrote in 1870, in "Mechanism in Thought and Morals," our deeply rooted prejudices, "ashamed to confess themselves, nudge our talking thoughts to utter

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their magisterial veto." 1 However, as in the tuberculosis campaign, courageous medical men, supported by laymen of equal courage, tackled the difficult problems confronting them. They were convinced that only through a vigorous campaign toward public-health education, and by the provision of facilities for medical care, could there be hope for the eradication and prevention of the so-called "venereal disease." It would seem that the hospital should be the strategic base for such a campaign. Yet hospitals and dispensaries have not always been ready to offer treatment to patients with syphilis and gonorrhea. One of the rules of an early dispensary in Boston was "that persons suffering from venereal disease or from the effects of alcohol should not be treated by the dispensary, as being the victims of their own sensual indulgence." And the archives of the Massachusetts General Hospital disclose considerable argument on the part of its trustees for excluding patients with syphilis from admission to the wards. Under the date of October 30, 1822, Drs. Jackson and Warren wrote to the protesting committee of the trustees on the subject, expressing a different view: "It is not surprising and it is not at all to be lamented that public opinion not only attaches infamy to those afflicted with this disease [syphilis] but also an apprehension of danger in communicating with them. From both considerations prudent and virtuous men might at first view of the subject be led to think such persons improper inmates in a public institution of so respectable character as our Hospital. We must confess, however, that the more intimate acquaintance with this subject to which our professional duties have led us, has induced in us a different opinion. . . There may be sufficient objection to the admission into the Hospital of women affected with the disease, allowing exceptions in favor of those only whose characters are such as will bring no disreputation on the institution. But in regard to men, it will, we think, be found that those affected with this disease are not generally more vicious, not less deserving our sympathy, than a large proportion of those who resort to a hospital for relief from other disease. . . It

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is only from a conviction of the benefits which a hospital . . . can afford to a miserable class of sufferers, that we are induced to plead their cause." 2 The subject evidently continued under discussion by the trustees and medical staff, for in 1839 it was voted that patients with syphilis "should be received only in urgent cases, and should always be charged double the usual rates of board." This attitude toward the admission of such patients into the hospital wards persisted throughout the nineteenth century. The self-sufficient hospitals of that time did not concern themselves with the hazards to public health involved in their refusal to offer institutional isolation to syphilitic patients in a highly infectious stage of the disease. It was to be many years before hospitals awakened to their community responsibilities on this subject. Only when science contributes its knowledge as to the nature and specific cause of a disease, discovers a definite means of diagnosis, determines the period of infectiousness, and establishes specific treatment—only then can an active publichealth campaign for aggressive attack on the disease be successfully instituted. The obstacles that had to be overcome in the antituberculosis campaign have already been discussed. Syphilis presented a much more difficult proposition, because of the highly charged condemnatory attitude generally held toward those found to have or suspected of having "venereal disease." This attitude was not readily modified in spite of insistence by medical specialists that a large proportion of the patients so afflicted were not responsible for their infection. A point of view not uncommon within even recent decades was expressed by a Chicago hospital in 1919, when a public-health officer, asking that a special clinic for treatment of syphilis should be established in the outpatient department, was met by the argument that "if it were known that they had a disease like syphilis in the hospital, many of its substantial and private patients would be offended." Jane Addams, in an address in 1907 before the American

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Hospital Association,3 tells of a volunteer from Hull House who, on asking to see a patient in the ward of a public hospital, "where the wrecks of womanhood are cared for," was treated with scornful insult by the admitting officer, who evidently assumed that "nobody could be coming on an errand of humanitarianism to see this woman because she needed someone to hold her to a purpose." The use of the term "venereal disease" was doubly unfortunate; first, it had the connotation of immorality on the part of every patient so afflicted, and second, it confused two distinct diseases. The scientific terms used in medicine are supposed to be accurate and specific in definition. Yet these two quite distinct diseases, syphilis and gonorrhea, which have no common scientific basis in cause, symptoms, or treatment, are still designated as "venereal disease." The term is a relic of the days before the etiology was known, and it has unfortunately been retained by those promoting the public-health movement for education and care of the unfortunate victims of these diseases. Our pattern of alphabetical designations has possibly led to the use of " V D " with some loss of the earlier implication of the term. Anyone who has had experience with the tragic situations of patients with accidental infection, and especially with babies with ophthalmia neonatorum of gonorrheal origin, seriously regrets the condemnatory attitude that generally obtains toward victims of these infections. One of the saddest sights of our pioneering days in medical social service was that of the newborn baby brought to the Massachusetts E y e and Ear Infirmary with neglected, although preventable, eye infection, and doomed to blindness. The Infirmary, closely associated with the Massachusetts General Hospital since its establishment in 1827, had added a special ward in 1898 for the isolation and care of babies with ophthalmia neonatorum, thus offering its skilled facilities for the prompt care of those tragic patients brought to its doors. But at that time there was no legal requirement either to report the disease or to protect babies from infection, although in 1881 Professor

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Credè of Leipzig had made the wonderful announcement that a single drop of a weak solution of silver nitrate, dropped in the eye of the newborn, would destroy the germs of ophthalmia neonatorum and not injure the eye. The lay campaign for prevention of blindness in Massachusetts found ready response at the Infirmary. In 1902, under the valiant leadership of Miss Annette P. Rogers, the Association for Promoting the Interests of the Blind was organized. This Association, and the temporary State Commission for the Blind appointed in the next year, gave support to a law passed in 1905, requiring that anyone in charge of an infant whose eyes show an unusual discharge within two weeks of birth must report this fact to the Board of Health within six hours. (Legal requirement of reporting by physicians, as such, was not promulgated until 1909.) In 1904 Miss Rogers had secured the permission of the Infirmary to have a study made by Dr. Anna G . Richardson of the medical records of patients with ophthalmia neonatorum. Dr. Richardson, in her survey of ninety-two records of babies admitted to the special ward in thirteen months, soon demonstrated that hospital records must be supplemented by social information if they were to be useful in promoting preventive measures. But she secured enough evidence of prevalence and of neglect in reporting infections of babies' eyes to stir the ardent efforts of those interested to tackle a preventive program against ophthalmia neonatorum. In 1907, two years after social service at the neighboring Massachusetts General Hospital was established, social service at the Infirmary was started with the backing and financial support of the Association for Promoting the Interests of the Blind. Catherine Brannick was appointed as social worker for the stated purpose of discovering " b y investigation and individual work among patients whether something might be done to supplement the medical work for the prevention of blindness." From the strategic position of the desk for admission of patients, Miss Brannick soon found opportunities for serving these expressed purposes through friendly rela-

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tions with the patients, who readily confided to her their anxieties and their personal difficulties in carrying out treatment. " N o one to stay with the children"; " T o o far to come as often as the doctor says"; the expense of travel; fear of operation—all these comments came in response to her friendly receptiveness and her ready accessibility.4 The report of the first year states that a review of five years of admission of babies to the special ward for ophthalmia neonatorum showed that of 577 cases, 117 on admission had already developed involvement of the cornea, with resultant injury to eyesight. A plan was promptly worked out between the Infirmary and the newly appointed permanent Commission for the Blind (1906) by which all cases of ophthalmia neonatorum coming to the attention of the Infirmary were to be reported, through its Social Service Department, to the State Commission for the Blind. For several years there were over one hundred patients annually so reported. Progress in prevention was slow because of the necessity for an extensive general educational campaign concerning the disease, its cause, its prevention, and the resources for treatment. The frequent distressed comment of heartbroken mothers, "I didn't know," "The doctor didn't tell me," gave impetus to the movement. The education of the doctors to their part in the campaign was fostered by the special Committee on Ophthalmia Neonatorum of the American Medical Association, with Dr. F. Park Lewis of Buffalo as chairman. These pioneers, doctors and laymen working together, were rewarded for their devoted efforts by the practical elimination of this disease, which for centuries has been one of the chief causes of blindness. In retarding the public-health campaign against "venereal diseases" the "conspiracy of silence" has much to answer for. Reluctance to allow public discussion of the subject was not confined to laymen; the medical profession, in large part, long resisted the suggestion that syphilis and gonorrhea be reported to the Board of Health. As has already been suggested, it is of interest to speculate to what extent this was

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due to the deep-rooted ethical convictions that the medical profession had held through many centuries. "Whatsoever I see or hear in the course of my profession . . . if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets." The hesitancy of many doctors to accede to the insistence of those concerned with public health—and with the potential patient—that communicable disease should be reported as a basis for control and prevention, resulted in much controversy. Dr. Cabot characteristically expressed himself on the subject. He challenged the doctors on their insistence that their first and only loyalty was to the individual patient rather than "to the community that trusts and maintains them."6 The issue was not so simple to most doctors as it seemed to Dr. Cabot. This is expressed in a letter to him from one of his admiring friends at the Hospital: "Have just finished your experiments in righteousness and truth, smoked a cigarette with feet in a chair and am impelled to say that the article strikes me as making for the truth, in an age that won't yet bear it, but I am with you in the endeavor to tell the truth as we know it, more than most men do. But I would like to have you, if you wish really to give a truthful impression of your attitude toward patients, write more of the same and take up some really thorny problems which fall to the lot of those physicians who have to deal with 'unrespectable diseases,' with mothers whose daughters have had abortions, wives whose husbands have syphilis, mothers who write you long letters about first-borns, and then see how the truthful experiment works." The Boston Medical and Surgical Journal in 1909 commented editorially on the report of a medical institute that had "adopted an amendment to its code of ethics releasing physicians from professional secrecy regarding private affairs of patients or their families when such secrecy or silence results in injury or infection of innocent persons." The editor's comment was that here "is apparently another attempt to solve by legislation a problem which can be worked out

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only by slow development of professional and public opinion . . . Questions of truth-telling and concealment by physicians have within a few years been warmly discussed, though not settled. Such discussion is valuable in that it leads to the expression of all points of view; but there is doubt as to the present wisdom or profitableness of formulating any official dogma on the subject." 6 Slow indeed was progress, but courageous men and women gave serious thought to the steps that might be taken. Legislation, however, had to await the support of public opinion. Dr. Prince Morrow was still pursuing the purposes expressed in the Federation for Sex Hygiene. He had gathered a purposeful group about him and in 1913 they accomplished the merging of this group with the National Vigilance Association to form the American Social Hygiene Association. Charles William Eliot, the former president of Harvard University, who had been interested in Dr. Morrow's efforts to awaken the public to the relation of sex education to both private and public health, was elected president of the new organization. He served a short term as president, and remained vice-president throughout his life. The prestige of Dr. Eliot's sponsorship of the movement was a milestone in the campaign. The many state organizations later organized to promote the social-hygiene campaign have patiently and consistently pursued the educational program for promotion of adequate care of syphilis and gonorrhea, but in recent decades, with the increase of public facilities for care, the emphasis has been on the more positive program for rallying forces toward the further support of wholesome family life and the preparation of youth for family responsibilities. Leaders in medicine who understood the urgency of a more aggressive attack on the devastating venereal diseases were gathering evidence of the results of neglect of the subject. T o promote a campaign of prevention, facts were published concerning the extent of syphilis of the nervous system among patients in mental institutions, the death rates of babies born

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of syphilitic mothers, heart disease of syphilitic origin, and congenital deafness and defective eyesight due to this cause. The First World War disclosed the extent to which these diseases disabled the troops and presented the greatest loss of time, and an aggressive attack on the menace was initiated. Special clinics were beginning to be established in civilian hospitals, although some hospitals still refused to admit patients to the wards. Progressive state departments of public health, making use of established clinics in voluntary hospitals, designated them as "state" venereal-disease clinics and provided funds for support and free medicine for patients during the infectious stages. This was the case at the Massachusetts General Hospital in 1918. Social service was incorporated into the syphilis clinic when it was started in 1914, and Ora Mabelle Lewis, the social worker assigned, maintained that an impersonal friendliness without any moralistic attitude toward the patients was the best guarantee for holding the patient to consistent treatment. In those days the early remedies called for months and years of consistent attendance at the clinics. Confidence once established usually led to opportunities for helpfulness to the patient in other ways; many a complicated family situation was disclosed that needed skillful counseling and practical help. Dr. George Hoyt Bigelow, Massachusetts Commissioner of Public Health from 1923 to 1932, gave courageous leadership to development of the public campaign in the state. His appointment of Dr. Neis A . Nelson as director of the program was the occasion of instituting a vigorous educational plan not only for the public but for doctors as well. Their reluctance to report syphilis and gonorrhea was somewhat modified when in 1928 the law stated that patients should be reported by number rather than by name and to the State rather than the local Board of Health. Dr. Bigelow contended that it was difficult to make effective use of the known medical information on the nature and treatment of the diseases because of the associated taboo that

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lingered. Private lectures were more possible to arrange, but newspapers were reluctant, in fact refused, to carry any information that included use of the words syphilis and gonorrhea. In 1934, a rent was made in the shielding curtain when a scheduled radio talk by Dr. Thomas Parran, Jr., Commissioner of Public Health of New York State, was canceled at the last moment. In a series of talks, "Doctors, Dollars, and Disease," broadcast under the sponsorship of the National Advisory Council on Radio in Education of the Columbia Broadcasting System, of which Dr. Parran was a member, he had been scheduled to speak on "Public Health Needs." He planned to present a scientific basis for the control of syphilis, but at the last moment the officials of the System refused to allow him to use the word "syphilis" over the air waves. He promptly resigned from the Council with the result that the ensuing public protest was given notice in several newspapers. It was as Surgeon General of the Public Health Service that Dr. Parran in 1936 "blasted into the public's consciousness that gonorrhea and syphilis are prevalent diseases which seriously menace the public health."7 His fiercely frank article, "Why Don't We Stamp Out Syphilis?" was printed in the Reader's Digest for July 1936, as condensed from his article, "The Last Great Plague T o Go," which appeared in the Survey Graphic for July 1936. The deed was done. A furore arose, in a mixture of protest and commendation. The bars were down. Earnest and serious thought was given to a national campaign of medical care, public education, and research into more adequate methods of treatment. The movement was well launched for treatment of these diseases with public facilities, supported by informed community backing. And so at last the hospitals joined the campaign and participated in the aggressive program to encourage patients to come to make use of the facilities for their care, vying with each other as to the most effective methods of follow-up of patients who failed to return for care—a far cry from the protesting edict of 1822.

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The moralistic attitude of the general public was to be met by social education. One of the special arguments for establishing social service within the hospitals was the frequent presence there of the unmarried mother in the maternity wards, and especially of the unmarried pregnant girl in the clinic. "Every year a score of unmarried girls come to the Hospital to find out whether they are pregnant," wrote Dr. Cabot in an early report of social service at the Massachusetts General Hospital. "Is the doctor's duty done when he has stated the fact? . . . W e have for years answered (theoretically) 'yes.' That is, when the physician remembered it and was not too busy, he generally gave the girl the address of one of the 'rescue homes' in the city. Whether she could or would or did go there, and whether it was well that she should go there, was rarely if ever looked into, so that I have no means of judging whether any tangible good resulted from our intentions in these puzzling cases."8 Similarly Dr. Cabot asked what is the responsibility of the doctor toward the girl who comes with justified fear but is found to have escaped pregnancy. And what of the women, married or unmarried, who are found to be infected with a "venereal disease?" Is medical care, if she chooses to accept it, all she needs? Answers to such questions as these have helped to mold the policies and procedures of clinics as new medical knowledge, changing attitudes, and public-health measures and organized programs have wrought their revolutionary changes in the community relations of hospitals and dispensaries. Although the "scarlet letter" had been abandoned, and the name of the "Refuge for Repentant Females" had been discarded before our new century dawned, the public in general still retained a highly condemnatory attitude toward illegitimacy. Out of pity most of the larger communities had established "Magdalen Homes," "Houses of Refuge," and "Leagues of Compassion," often with a firm policy of admitting only girls "guilty of first offense." For those "guilty of second offense" the only institution open to them was often

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the almshouse. Social workers of that day reflected somewhat the moralistic attitude of the public in their conviction that "the girl who had gone wrong" must pay for her misdeeds by assuming personal responsibility for her child. Care of the baby would awaken her maternal feelings, and the child, an outlet for her love, would "save" her. This was also in general the point of view of the "rescue homes." In Dr. Cabot's second report, for 1906-07, we find such questions as these: " W h y do we limit the sex problems to women? W h y are we doing nothing to combat immorality and venereal disease in men? Simply because we have as yet no idea how to attack the problem." And the social worker's later comment: "One cannot even prosecute the men in cases such as I deal with, except by that very fact putting upon the girl an amount of disgrace and publicity which she is unwilling to go through; yet society condemns the girl, brands the child, and receives the man into its midst." Some question was being raised about the real value of institutional care for the unmarried pregnant girl. Dr. Cabot expresses this problem in the same report quoted above. "In such a 'home' the girl is usually idle or very inadequately occupied and has much time to talk over with others in the same condition their experiences of good and evil, which may be either more or less extensive than her own." In his first report he had stated: " V e r y few of these girls are prostitutes. Some of them differ very little morally from the 'average' man or woman. T h e y are simply less fortunate; yet they find themselves branded as outcasts, sinners, and disreputable women. If their condition is made known, family and friends hiss shame and reproach at them. Fearing to confide in the family, they are all the more cut off from the ordinary sources of sympathy, advice, and guidance, all the more in need of help from without." 9 "It has become increasingly clear," he wrote in 1907, "that we must do this work through our own agents, and we intend to put the whole time of one worker upon it and make a thorough study of the best methods of caring for these girls."

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The selection of Jessie Donaldson Hodder for this difficult task was most fortunate for the patients who came under her thoughtful and devoted care. Fortunate, too, were her associates, who felt the influence of her generous and illuminating attitude toward the girls "who had gone wrong." It was characteristic of Mrs. Hodder, in her first report concerning the girls with venereal diseases, to include these words: " W e must meet them as sick persons, not as 'sinners.' Whatever their state of mind, whatever the causes of their starting on this life, we must meet them where they are and learn all they have to teach us before we can be sure of what we have to teach them. T o get on a friendly footing with them is difficult. They know that they are 'respectable' until they are 'found out' and so it depends upon our attitude toward them whether they accept our help—for their good and the community's." Although Mrs. Hodder came through the experience of her four years in our Social Service Department with firm general convictions, she considered each patient according to her individual circumstances and need. She saw these girls, pregnant or infected, who were sent to her by the doctors, for what they were: the spirited adolescent who had sought emancipation from the rigidity of puritanical parents; those feeble of mind and a prey to flattering attention of the moment; the simple trusting one, under the spell of a love betrayed, and overwhelmed by the situation in which she found herself; and, of course, the "tough" one, full of defiance. I remember her passionate anger when she found a terrified child of twelve, whose insane mother had put her in a house of prostitution. And how she scorned shams and false values! "What will people think?" The outcry of the distraught father of the girl frequently distressed her own forthrightness. Her idealism of motherhood, as such, led her to heroic efforts to lift these girls as unhappy, unmarried mothers, to the self-respect that she believed might come from facing reality and from loyalty and devotion to their children. Although she did not often achieve

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her goal, she was more successful than most social workers of the day. I recall a beautiful Irish girl, who used to come to see Mrs. Hodder, her baby in her arms, her head high. This, after months of anguish and final awakening, and a return to her mother and her neighborhood. With careful guidance this girl had secured a responsible position where her intelligence and reliable work received suitable recognition. In her neighborhood, her reputation was such that when, one day, the father of her child taunted her as she passed, he was promptly pounced upon by the young men near by and pommeled unmercifully. No officer of the law interfered. Unhappily there are few communities that meet the situation so courageously and honestly, giving the "illegitimate mother" and her child a fair chance. Farseeing as she was, Mrs. Hodder did not believe that marriage was necessarily a solution of the problems of these girls facing maternity. Her first annual report states that, of the forty-seven pregnant girls under her care, "seven were married to the father of the child, because they love each other." She saw no other basis for a successful home. As was inevitable for such a gifted personality, Mrs. Hodder was sought for service in a wider sphere. The secret of the high quality of her work in the Social Service Department of the Massachusetts General Hospital, as later in her brilliant record of twenty years (1911-1931) as Superintendent of the Massachusetts Reformatory for Women at Framingham, was in her own character. This Dr. Cabot later summarized as "full of vision and faith, by suffering matured, enlightened, disciplined, softened, fired, by religion anchored and assured." Under Jessie Hodder's wise and spirited leadership the old prison at Framingham was itself "reformed," with activities for the women indoors and out in the fields, a library, and the introduction of beauty in music and drama and pictures. "Prisoners," she said, "were sent to institutions to use their time, not just to serve it." Mrs. Hodder's experience as a worker in medical social service was reflected in her introduction of doctors and psychiatrists in the study of the women

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as well as in their care, and of the greatly improved hospital facilities she secured. Patients needing careful clinical study or major surgery were usually sent to the Massachusetts General Hospital for care. Mrs. Hodder's influence reached far beyond Massachusetts and this country to international groups, carrying forward more constructive methods of dealing with women in revolt against society. Under various workers the Social Service Department at the Massachusetts General Hospital carried on the work so well begun by Mrs. Hodder, and concerned itself with the special baffling problems of these patients. Farsightedness is not characteristic of youth nor, for that matter, a common human trait, as we live largely in our present preoccupations. The unmarried mother, whatever her circumstances, is brought squarely up against two problems, those of her future and of having inevitably to live with her past. Kindly attention may be provided for her through her "emergency" period of pregnancy and the delivery of her child, but the problem of her future years and the life of her child are stark realities that have not had the consistent attention they call for. And what are the life stories of children deprived of the security of legal parents and a true home? Some studies have been made, but for these children there can be no simple answer any more than a general answer can be given to the problem of what to do for children stranded by the divorce of legal parents. The only agreement among those who have devoted themselves to such social problems is that prevention must be sought. In recent decades childhood security has been generally accepted as basic for growth to wholesome maturity. Recognition of the insecure social position of the victim child may have had more influence than we realize in the increase in adoptions of such babies born to illegitimate parents. Around these children many of the states have thrown legal protection, through careful safeguarding of their welfare, present and future, by individual attention to guidance into family security through selection of suitable adopting parents and the establishment of definite legal status. Social workers

FRUITS OF EXPERIENCE in public and voluntary social agencies fostering family and child welfare have seen the tragic results of faulty adoption of children and have welcomed the trend toward legal safeguards and careful consideration of individual cases. Such precautions are now required in several states where legislation requires licensing of agencies that may arrange adoptions. The two World Wars have brought urgent need for serious recognition of the problems of illegitimacy—and a realization that they are not confined to any one economic level of society.

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absent-minded friend of mine once confessed his reluctance to go again to the Lost and Found bureau at the railroad to inquire for his umbrella, because he was sure that the attendant there had classified him "as the man who always leaves his umbrella in the train." We do not like to be classified if some inadequacy is thereby implied. "The handicapped" is one of those classifying phrases that may stir our sympathies but it takes on true meaning only in specific application to an individual. Handicapped for what? If for a full and rich life, sensitive to current affairs in the world and with hours filled with service to others, the term seems inappropriate to apply to such an individual as Miss Alice Kimball, who, paralyzed at the age of 59 years by a spinal injury, yet lived for twenty-five years, an inspiration and practical help to her family and friends. The triumph of a great and free spirit over pain and physical limitation led others to forget her handicap. In recent decades a striking change has come about in our reactions to this term and in our constructive measures to meet our obligations relative to this problem. The negative connotations of the word "crippled" and "handicapped" have become less suggestive of finality, and the term "rehabilitation," although still somewhat vague in its usage, is gradually taking on a constructive significance. Broader responsibility has been acknowledged in the medical care of those with physical disabilities due to injury, disease, or congenital defects, to the end that the patient may regain in fullest extent his function as a normal person. The healing of the wound no longer meets

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the obligation of surgical care; "stump healed" is not a suitable discharge note on the record of a patient who has had an amputation. Many years ago a nurse superintendent of a hospital serving a wide agricultural area appealed to me for suggestions as to what might be done for a six-year-old boy. The doctors said they had done all they could, and the boy was living on at the hospital. He had had both legs amputated following a mowing-machine accident on his father's farm. The doctors now reported him ready for discharge. The nurse superintendent said, "I can't bear to send him home this way, to crawl around on his stumps. He ought to have artificial legs. But what can I do?" This happened long before there was any federal or state supported Crippled Children's Program, and long before the rehabilitation centers, as we know them now, had been conceived. In those days it was largely a matter of chance whether some interested person could secure private resources to supplement the hospital care of such patients as this little boy, or whether the hospital had a social service department designed to work with the doctors to arrange suitable aftercare plans for the patients. As a strategic center for relief of the sick and disabled, the hospital—the modern hospital of our big cities—offers a vantage point for witnessing major changes in medical care. The evolving concept of rehabilitation of the handicapped through the past half century is illustrated in the growing complexity of equipment for adequate service and the variety of specially trained personnel that have been added as aides to medicine. As scientific research has yielded deeper knowledge of diseased joints and muscles and favorable conditions for restoration of body tissues, the age-old physical properties such as heat and water and exercise have been critically restudied for their specific uses. New professions have been created, such as that of physical therapist, complementary to medicine, to make possible a program of interprofessional cooperation for effective treatment of many diseases formerly consigned for custodial care in chronic hospitals.

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There has come about, also, the realization that treatment for restoration of function should be started as soon as possible after injured patients are brought under care—for psychological as well as physical reasons. Some measure of these changes is suggested as we read early reports of the Social Service Department of the Massachusetts General Hospital. Always mindful of the psychological effects of illness on the patient, Dr. Cabot wrote, in 1912: " A handicapped man is something like a broken bone. A broken arm in splints wastes in a few weeks to skin and bone. After the bone has knit, we have to overcome the effects of disuse on the stiffened joints and atrophied muscles, and combat the flabbiness due to the splint's external support. Now the enforced idleness, the machination of lawyers, the support by relatives and sympathetic coddling given the handicapped man in the months just after his injury, sometimes affect his moral and mental fiber as splints affect the tissues of a broken arm, his energies run down, his morale becomes atrophied; he is flabby and looks to society to support and protect him like a splint." It is clear that medicine did not then generally recognize such psychological symptoms as a natural complication of physical injury, with attendant lowered vitality and helplessness, and that these must be dealt with constructively in the course of proper treatment. In his conception of social service as complementary to medical and nursing care, Dr. Cabot in 1912 urged us to deal with these psychological aspects whenever he found that patients' needs were not met. He wrote: "The injured patient's mind . . . must be exercised during convalescence, if he is not to degenerate. The proper occupation of ward patients is still a virgin field for social work in hospitals. . . Preventive work of this kind would, I believe, materially diminish the yearly quota of 'traumatic neuroses' or mental twists following injury, neuroses which occur with organic injury and disease as well as in their absence." Many social service departments of that time recognized the need for patient occupation, and, to foster the patients' interest, simple programs of diversional occupation were often

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started with volunteer help. They were the forerunners of the now essential and much broadened function of the occupational therapist, whose profession was well established following the First World War. Dr. Cabot saw the need for more than diversion, important as that was. "These mental habits have to be broken up like the adhesions around an unused joint, or stretched by training and exercise. This is a painful process and may be resented, yet it is one of the chief duties of the worker for the handicapped and should be begun by those in charge of the patient convalescent in the hospital ward." The later emergence of physical therapy as a specific service essential to restoration of function in joints and muscles, and its constant emphasis on patient participation, illuminated for me my recollection of the old "Zander Room," the MedicoMechanical Department, as it was called, at the Massachusetts General Hospital, with its many extraordinarily ingenious machines imported from Sweden, each designed to exercise some joint or muscle while the patient sat passively submitting to the process. Shoulders, ankles, fingers, knees, hips, elbows were given motion according to medical orders. No slightest exertion on the part of the patient! Ingenious, yes, but wholly unmindful of the values, both physical and psychological, of the patient's participation in effort. But during World War I the overwhelming problems of injured soldiers stimulated orthopedic surgeons to devise new constructive methods for treatment of injured joints and muscles. The old Zander apparatus at the Massachusetts General Hospital was consigned to a storeroom. Although recorded as a war economy, I suspect that there were deeper reasons for the abandonment of this sterile form of therapy. Early case reports of our medical social service note the frequent referral of patients for "change of work" to an occupation suitable to some physical handicap. For the cardiac patient, "light work" was often suggested and frequently when more specific instructions were requested by the social worker, the doctor might suggest the job of "watchman."

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But we soon found that watchmen do more than sit and watch! They often carry heavy responsibilities: night watchmen especially might be required to walk much of the night about a factory, tend coal furnace fires (no automatic oil furnaces in those days), and be prepared to act quickly in emergencies. Watchmen at railroad crossings were exposed to all kinds of inclement weather. "Light work" was found to be an illusion. Much more specific instruction as to the physical limitation of the patient from the medical point of view was necessary. And, too, much more accurate knowledge on our part was required as to the specific industrial processes involved in performing a given occupation. Probably most important of all, it was essential to secure some estimate of the patient's interests and capacity for the occupation suggested. Stimulated by Dr. Theodore C. Janeway of New York, the leading spirit in establishing a special bureau for physically handicapped patients, Dr. Cabot, in his report for 1907, expressed the need for such a bureau to which we might refer our patients. We were beginning to get some idea of the scope of the subject of employment for those unable to compete in the open market, but did not then realize how many different specialized skills, closely integrated, were later to be considered essential for adequate service to the handicapped. In the years that followed, through a series of successes and failures, it became obvious to us that the work of placement of handicapped patients required specialized knowledge. Meantime in several cities relief-giving agencies had established bureaus for the handicapped, such as that under the Charity Organization Society of New York, and in 1911, in Boston, the King's Chapel Committee for the Handicapped was organized. The Committee employed Grace S. Harper, an experienced social worker, as secretary. An earlier chapter has told of her help to us and how she was given headquarters in our department at the Hospital, although the work was supported entirely by and under supervision of the King's Chapel Committee, of which Dr. Cabot and I were members. Miss Harper worked closely with the staff of the department,

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and taught us many things. For one thing, she was as concerned to satisfy the employer as to secure an opportunity for the patient. In preparation for her service, she had visited many factories, noting processes that might be performed by workers who could use only one hand or foot, those requiring no standing on the job, those that required special training, and opportunities for work as apprentices. In those days, before the workmen's compensation legislation had gone into effect, employers were more ready to allow interested people to visit their factories. Miss Harper found several employers who were willing to try out the applicants she might send them. And, as she was scrupulously careful not to try to place a handicapped patient of whose ability she was uncertain, she secured the genuine interest of several employers who helped to restore handicapped patients to self-support. Although vocational guidance had not then attained the professional status we accord it today, the patients' special interests were taken into account in seeking employment for them. I remember a young Italian with double amputation of his legs, who, while convalescing, told of his cherished wish to be a tailor. Miss Harper found a neighborhood tailor who agreed to talk with the patient. While still in the ward, the young man was given lessons in tailoring, and his special aptitude for the trade was assured as he worked under the tutelage of the friendly tailor. At his discharge he left the hospital with two artificial limbs, paid for in part by his family and in part by the King's Chapel Committee, and also with the opportunity to enter a tailor shop as an apprentice. Miss Harper taught us that we should discriminate as to the capacity of patients for work, and should recognize that many handicapped persons could work under ordinary conditions and without special training, if the right job were found; others could work under ordinary conditions if they were trained for selected trades or processes within trades. There were also those, with special abilities, who, although they could not yet physically endure the long hours and hard con-

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dirions of competitive industry, could work in a protected environment. For these the so-called "Sheltered Work Shops" were later devised. Some of these shops, notably in New York City, were especially established for patients with heart disease or those convalescent from tuberculosis. For the incapacitated, work for its therapeutic value was not to be forgotten. The rehabilitation centers of today would not accept such classification as we social workers then used, since much progress has been made in reducing the handicaps themselves by modern methods of treatment. Our patients, also, taught us much. From Lucy Hogan I learned, among other things, that, when a patient has fought through to an acceptance of limitations, there may be for him a real sense of freedom within the limitations. Surely here was a free spirit, lifting the solemn atmosphere of a whole ward to one of cheerfulness and activity. On several of her many periods of hospitalization, I watched with interest and amusement her quiet technique of getting any patient who could participate to fold gauze for the nurses or make some other use of idle hands. She once called me to her bedside and whispered that she wished the nurse would move her down the ward next to an especially doleful woman. This was done, and later she told me with great amusement that she had found out what was the matter with the woman. She had confessed to Lucy: "It makes me so sad—the way you are." Evidently she had seen Lucy Hogan only as a patient in a wheel chair, minus both legs, and was mystified by the busy hands and gurgling laughter that was so infectious. "What did you say to her, Lucy?" "Oh, I said I'd much rather have my trouble than hers. Mine is outside where I can see it." Many other handicapped patients were served through Lucy, for with Miss Harper's help she was established in a dressmaking shop, where for a few years her dream of an opportunity to employ and teach dressmaking to other crippled patients was realized. Here several handicapped girls were prepared for self-support, but the War disrupted the plan. Lucy found a permanent refuge in a convent in New Hamp-

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shire, where, except for occasional periods of hospitalization, she lived for twenty-five years, teaching sewing to groups of girls and to a few other handicapped women who were accepted under this friendly roof and supervised by a wise and understanding Sister. General interest in employment of the handicapped showed a marked increase before and during the war years. Several agencies sprang up in the larger cities, fourteen in N e w York alone. The Bureau for the Handicapped, maintained by the Hospital Social Service Association of N e w York, was designed as a resource to serve handicapped patients from thirtythree N e w York hospitals. It specialized on placement in jobs, not in training. Considerable attention had been given by cardiologists to classification of patients with heart disease, to indicate their capacity for work. This was a period during which many states passed legislation for compensation for industrial accidents. Anyone with imagination, witnessing the tragedies that resulted from accidents to industrial workers brought to emergency wards of our hospitals, could not fail to be aroused to urge every measure to prevent these cruelties and to meet some of the problems of the victim and his dependent family. "Compensation" seemed an inadequate term in many situations, but the money was a great help. One result of the new laws came as something of a surprise at first. The fact of the operation of the workmen's compensation laws made most employers refuse to employ people with any handicap, since, in most states, the insurance rates for an industry increased in proportion to the number of accidents. Some employers were to discover that an intelligent man, although physically handicapped, if carefully placed in a suitable job might be an especially valuable and steady employee. In 1916, the first city-wide survey of "Education and Occupations of Cripples," conducted under the auspices of the Welfare Federation of Cleveland, was reported on by Lucy Wright, of the Massachusetts Commission for the Blind, and A m y Hamburger, of the Social Service Department of the

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Massachusetts General Hospital.1 This illuminating report on 4,186 handicapped persons dispelled the conception that handicapped men and women must necessarily be economically dependent. Numerous instances were cited of those with serious handicaps who, triumphant over their limitations, inspired the declaration: "It is what's left and not what is gone that matters." The term "cripple," which was commonly used at that time, was defined as referring to those with defects of the skeleton and skeletal muscles, and it was assumed that such patients were commonly the concern of the orthopedist. One can only surmise how much greater would have been the scope of this survey had our present inclusive interpretation of the handicapped been the basis. As it was, the diagnoses of infantile paralysis and bone tuberculosis were given as the chief causes of crippling among children, and industrial accidents the chief cause among adults. Happily, bone tuberculosis is now a comparatively rare disease and industrial accidents have been reduced, probably owing to workmen's compensation legislation and the extension of protective devices. In the Cleveland survey special attention was given to the crippled children, to problems of their schooling and training, and the pro's and con's of institutional care. A broad program, based on the medical, educational, vocational, and other needs of the handicapped was suggested, with close cooperation of the agencies interested in various phases of the subject. This report and several others, such as those of the Russell Sage Foundation, the Institute for Crippled and Disabled Men, and the Survey of Cripples of New York City, inaugurated by some forty organizations and hospitals engaged in work for the crippled in Greater New York (1919), were evidence of the mounting interest in the subject. In reading these reports today, one can recognize a steady progress toward a broader appreciation of the complexity of the problems that affect the patient's daily life, his education, work, and opportunities for satisfactions in life. But to date the program seems to have

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hitched along with emphasis first on one phase and then on another. Vocational guidance, which was developing within the educational systems in many states, was gradually being adapted to the needs of the handicapped. Facilities f o r vocational training were increasing. But an inclusive program that comprehended integration of the various and specialized services now recognized as essential was lacking. Some such program, however, was envisioned in the Cleveland Report in these prophetic words: "Adequate provision, probably by hospital extension work, should be made for the rehabilitation of newly made cripples; and for the beginning of their reeducation and even vocational training, when that is contributory to their treatment, in the larger sense, as, f o r instance, to provide artificial limbs and to furnish such occupation and training as is possible during convalescence and will prove a bridge to reëmployment. " 2 Out of the tragedies of the First W o r l d W a r came a determined effort to give to our injured servicemen all the skilled care possible, under the leadership of "the best care an army ever had." Phenomenal advances were made, especially in orthopedic and plastic surgical care, in improvement of prosthetic appliances, and in occupational and physical therapy. Vocational guidance and training were also available. T h e National Civilian Vocational Rehabilitation A c t of 1920, stimulated in part by the demonstration of the A r m y program, was fostered by those dealing with victims of industrial accidents. T o those administering workmen's compensation laws, it had been apparent that many injured workmen could not return to their former occupations and needed training for jobs suitable to their limitations. T h e weakness of this act was the lack of a carefully integrated medical service. While compensation to the injured industrial worker provided medical care, this was not so organized as to relate well with the vocational program, which was usually administered under state departments of education. N o r was there provision for ade-

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quate medical care for the injured nonindustrial civilian. These weaknesses in the plan were not met until the Office of Vocational Rehabilitation, reorganized in 1943 under the Federal Security Agency, then made possible a rounded program for medical, surgical, psychiatric, and hospital care with physical therapy, coordinated with medical social service, vocational counseling and training, placement, and followup to assure a suitable adjustment to the job. Artificial limbs, braces, hearing aids, when needed to supplement the patient's capacity, are provided. This program, long sought by those interested in the handicapped, is dependent on adequately trained personnel not overburdened by a too heavy load of work, and on adequate appropriation of funds. In these needs it is at this time short of fulfillment in most states, although valiant efforts are being made by those charged with carrying out the service. As with all public provisions for social welfare, the quality of service and the adequacy of support depend on the will of the general community and the interest of the various professional colleagues involved. Unfortunately, many citizens forget that public services, created by the will of the people, are their responsibility and not merely a target for criticism. The magnificent work and consistent, broad, purposeful provisions of the Baruch Committee on Physical Medicine, organized in 1944, has established a record that is a signal illustration of what may be the uses of voluntary support, intelligent interest, and leadership in service to humanity. The generous grants to medical schools for education in the supplementary skills in rehabilitation of the injured and also for research, have given a great impetus to promotion of rehabilitation programs under both public and voluntary auspices. General medicine, surgery, especially orthopedic and plastic skills, and psychiatry in its growing understanding of the emotional life, have great richness of resources that may be applied to rehabilitation. And medicine's contribution should be basic and her leadership assured in a well-rounded program for rehabilitation. But to the support of medical care that leader-

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ship must rally all the contributions of the related skills and professions that are now known to be essential to secure for the patient his fullest physical, mental, social, vocational, and economic usefulness.3 To most people the crippled child makes a special emotional appeal. In this democracy of ours, we have accepted the principle that every child should receive proper support and protection and opportunity to develop to his fullest capacity. That we fall short of these expressed ideals and stated convictions does not mean that they are not vital forces in reaching our goals,4 but among our crippled children are thousands who have been denied the natural right of childhood to healthful growth and development, the blessings of sight and hearing, carefree play, and the security of home life. Our desire to make up to these children for the losses they have suffered has been disciplined by the realization that for them, as for all the handicapped, sympathy must be constructive for the child, not merely an emotional indulgence for ourselves. The realities of limitation should be recognized and capacities for growth and freedom -within limitations should have devoted attention. But there is no call for patience in the face of known means of prevention of handicaps or for the pursuit of remedial measures for the best treatment and care possible for each child according to his need. All the surveys discussed earlier emphasized the importance of special attention to crippled children. Of the adults reported on many had been crippled in childhood. Through the decades the National Society for Crippled Children, incorporated in 1921, has aroused the sympathies of the public in the plight of the crippled children and has developed, especially in recent years, constructive efforts through leadership for branch organizations in many states. The National Foundation for Infantile Paralysis, incorporated in 1938, has directed its efforts toward every phase of this still unconquered disease that especially menaces childhood. Included in its program are direct care of patients, establishment of facilities for treatment, the support of research into the causes of

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the disease and methods of treatment, and education of personnel. The generally aroused determination to give care to the crippled child prepared the public to accept, in 1934, the establishment of the Federal Crippled Children's Program, by means of which grants were made to states for the administration of clinics for their treatment and supplementary care. The program is now operating in the forty-eight states, the District of Columbia, Hawaii, Alaska, Puerto Rico, and the Virgin Islands. Since it is estimated that there are at least half a million crippled children in these broad lands of ours, all these efforts, public and voluntary, are needed. The considerable evidence that they are working effectively together is a hopeful indication of the soundness of this phase of social welfare. The place of the medical social worker in the program either for direct service or as consultant is secure. The definition of the "crippled child" is being gradually broadened to include not only the obvious orthopedic cripple but those with congenital defects, such as harelip, cleft palate, and absence of limbs, the blind, the deaf, those with defective sight or hearing or speech, and, more recently, such chronic diseases as rheumatic fever or heart disease, epilepsy, and motor difficulties such as cerebral palsy. So special and unique are some of these pathological conditions, and so much in need are they of further clinical study, that we are witnessing an extraordinary increase in attention by the medical profession in one or another of these problems, expressed in a variety of organizations, national in scope, each with focus on some chronic disease that handicaps mankind. And since it is the public interest that they should be dealt with intelligently and constructively, financial support by the public is sought. Concentration of attention is necessary in some phases of development of these complicated problems. At this time there is more emphasis on the medical aspects of both the problems and the search for more knowledge. Since chronic disease has very special social implications for the individual and for society, one might wish that more attention be given to study

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of the social aspects of each of these special subjects. W e , the public, should be informed about the purposes of these medical-social movements and be patient with the multiplicity of appeals, recognizing that we have with us a manifestation of the breaking down of the age-old barriers between the medical profession and the lay public. And we must recognize that, while asking for financial support, the medical profession itself is giving most generously of time and special knowledge in promoting these campaigns. Meantime our interest in promoting the application of available knowledge to the service of the handicapped should not falter. Inspiration for pushing forward well-rounded programs for care of the handicapped can readily be found in the lives of our fellow citizens who, through their own courageous efforts and the resources established for their help, are demonstrating the capacity of the human spirit to triumph over physical limitations.

23 T k e P a t i e n t T e a c h es T H E threefold purpose of the Massachusetts General Hospital—to care for patients, to give instruction, and to study disease—is characteristic of general hospitals associated with medical schools the country over. W e have seen how advances in medical science during this half century have changed the hospital care of patients. The same influences have wrought changes in the other two purposes to no less degree. In fact, the three purposes are intimately interdependent. This will be evident as we look more closely at the development of the hospital as an educational institution. In its early days the teaching purpose of the Massachusetts General Hospital was limited to the instruction of students of medicine. Lectures were given them by staff physicians, and they were permitted to "walk the wards" and observe the older doctors in their diagnosis and treatment of patients. This is a far cry from medical teaching as developed in the hospital of today. Facilities for elaborate and exact laboratory techniques now supplement the observation of symptoms, which was in the past the chief method of study of the patient, and one that required great skill. As newer professions, such as nursing, developed to work with and supplement medicine, the hospitals took on responsibility for instructing such groups, especially in applied technical skills. Pioneers in nursing paved the way for this profession most courageously. But as its leaders sought persistently to raise the quality of nursing in our hospitals, they often had to work against opposition from the doctors themselves. As medical examination and treatment developed into specialized

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and elaborate techniques, the doctors were sometimes slow to pass over to nurses many of the procedures that had formerly been performed by doctors only. The statement of a former house officer at the Massachusetts General Hospital illustrates the degree of change in the accepted function of the trained nurse, since her introduction in the early seventies. Dr. Edward Waldo Emerson told me that he could remember when the clinical thermometer was considered too delicate an instrument to be entrusted to a nurse! Nurses have so completely demonstrated their essential value to good medical care of hospital patients that only by turning to the historian can we recall the heroic struggle they experienced before their profession became established. Courageous groups of women in those early seventies initiated schools of nursing affiliated with hospitals, in which the essential practical experience was centered. A training school for nurses is now usually an organic department within a hospital, and the hospital assumes the medical instruction of its pupils, provides teaching of principles of nursing, and supervises practice. Even in the present trend toward university-sponsored schools of nursing, practical experience with patients on hospital wards is still the major element in their educational programs. A similar development, though at a comparatively recent date, has taken place for the professional dietitian, for the feeding of patients has evolved from "invalid cookery" into the well-recognized field of therapeutic dietetics. The hospital dietitian in a teaching hospital now carries responsibility not only for the proper feeding of patients in the hospital, but for instruction for clinic patients as well, where, for example, diabetes and gastrointestinal diseases are treated. She has been drawn into the practical teaching of nurses as well as of student dietitians who, in established schools, have had basic education in the theoretical aspects of the subject. As the science of nutrition has developed and so changed the treatment of many diseases, dietitians in some hospitals are also drawn into instruction of house officers serving in wards.

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It was in this generous atmosphere of teaching that the Social Service Department at the Massachusetts General Hospital found itself rather naturally developing educational responsibilities. An earlier chapter has noted that, from the establishment of social service at the Massachusetts General Hospital in 1905, pressure was brought upon the department to accept apprentices and to prepare them as "trained workers" in this rapidly growing practical field of social service. In 1912, this apprentice method was abandoned, and our department adopted the policy of offering practical experience only to prospective medical social workers in affiliation with a school of social work from which they were receiving basic courses of instruction in professional social work. From this beginning, and under the leadership of the Simmons College and N e w York Schools of Social Work, specialized education for medical social workers has developed. After its organization in 1918, the American Association of Medical Social Workers accepted as one of its chief purposes the promotion of education of personnel for this new field of service. The full story of the development of professional education for social workers, as applied to medical care and public-health programs, is presented in the History of the American Association of Medical Social Workers, by Mary Stites.1 There are now ( 1 9 5 1 ) in this country twenty-one accredited professional schools of social work that offer postgraduate education in medical social service. In every instance these schools are affiliated with hospitals that have a wellestablished social service department, in which the practical application of classroom teaching is carried on under supervision. So we see that gradually, as the concept of adequate medical care has evolved and other professions have been drawn into collaboration with medicine, the teaching function of the hospital has expanded beyond the original commitment to teaching medical students. T o a considerable degree the hospital may be credited with sharing in the creation of new related professions. In some teaching hospitals one finds, aside

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from those already mentioned, students of hospital administration and of occupational and physical therapy and those preparing for posts as record and reference librarians or as medical artists. In every instance the special professional instruction is supplemented by a program of experience with patients and with doctors and nurses. I have witnessed this development of the hospital over four decades, and as I face the task of presenting something of the great service of one of them, the Massachusetts General Hospital, in its broad educational role, I want first to register appreciation for what I have learned in these years. My teachers have been patients, doctors, my associates, the administrators, and those colleagues outside the hospital who have helped me to see the institution more objectively than one can by submerging oneself in the highly absorbing experience of just being a part of the hospital family. And every day, in spite of the routine of many technical procedures carried on in a hospital, there is uniqueness in the human drama which keeps one ever alert. Of all these teachers, the patients have me most in their debt. But one of the first lessons came from my good friends in the medical profession. As pioneers in the home supervision of the Hospital's tuberculosis patients for whom there was no adequate sanatorium care, the department was working over its methods of teaching the patients and their families the details of hygiene they should follow. As I had great respect for the contributions of science to medicine, I was eager that our teaching should be scientifically sound. So I sought out three friends—a clinician, a psychiatrist and a physiologist— and begged them to review with me each item of hygiene that we were attempting to teach: food, exercise, bathing, sleep, rest, fresh air. As a guide to our volunteer home visitors to the patients, I planned to prepare a pamphlet with clearly stated directions on each item. I specified that I was determined that our teaching must be scientifically sound. Well, before these good honest scientific friends had finished with

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me, I had unlearned many things and realized that truth was difficult to arrive at! As to food, they told me that there was a lot of nonsense published and taught concerning food. (This was in 1907, before much was known about body chemistry or modern dietetics.) But they said it was important that one should enjoy his food—this when under medical orders we were urging resistant patients to eat a dozen eggs a day, even if they disliked them! As to sleep, people differ so much in their individual needs of sleep, they said, that they could not be definite about that. Each must learn how much he found necessary for refreshment. And the amount differed with age. Bathing, they said, was very important from an aesthetic point of view, but there was no evidence that it was essential to health. It was important to keep clean any abrasion in the skin, but there were plenty of instances, so they said, of people living to old age without bathing. Surely, I thought, I could get evidence that abundance of fresh air was essential to health. W e were making elaborate arrangements for our tuberculous patients to sleep outdoors, and I myself had done so just to show the patients it could be done. But the physiologist stated that the capacity of the lungs to absorb oxygen was limited, and that an effort to increase that capacity by outdoor sleeping was futile. And again, they said, there were plenty of cases of old people who had never opened their windows at night. What about exercise? (These were the days of "chest weights and dumbbells" and mechanical exercises.) Walking, they said, was probably the best general exercise. It was unself-conscious and, therefore, the best way to exercise if one enjoyed it or could make it incidental to some purpose other than just walking. But, they added, since exercise increased respiration, it was well for tuberculous patients to abstain from active exertion because rapid respiration might hamper the healing of lesions in the lungs. These comments of 1907 are

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of special interest in the light of our present greater knowledge based on scientific research that has given backing to modern dietetics and the new specialty of physical medicine. Of course, my pamphlet of "scientifically sound" teaching of personal hygiene for tuberculous patients was never written. W e compromised on various items that seemed empirically useful in the light of common sense, and we learned not to be too positive in our guidance of patients except as, step by step, science established such facts as diet and insulin in diabetes and the feeding of liver in pernicious anemia. One thing I learned was that hygiene was not the basis for a patient's happiness. And, too, that a passion for cleanliness was sometimes evidence of a pathological state! In 1912, Miss Sara E. Parsons, then Superintendent of Nurses at the Hospital, came to ask if our department could accept selected students from the Nurses Training School for an experience of three months, "so that they can understand where these patients come from and what they have to go back to on discharge from the wards." She was sure that the students would become better nurses if they understood the patients' problems at home. W e recognized this request as a by-product of our demonstration of what we had to offer to care of the patients and readily lent ourselves to sharing experience with the nurses. The early plan, that the student nurses visit patients' homes, become aware of the social and health agencies and institutions with which we were working, and attend legislative hearings on proposed health measures at the State House, gave enlightening experience to them. Thus began an association between the Nurses Training School and the Social Service Department that proved mutually helpful over the years. Some of the nurses became so interested in social service that we had to make clear that the brief period in our department was not to be interpreted as preparation for this field of service. Social service departments elsewhere were also enlisted by nurses' training schools to give experience to student nurses. Meantime, public-health nursing was growing rapidly and

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influencing nursing education. Gradually the National League for Nursing Education took note of these trends, and it formed, with the American Association of Medical Social Workers, a joint committee to work on this subject. This committee outlined a program for nurses' training schools to indicate the uses of medical social workers as teachers of the social aspects of nursing. These programs have been reviewed from time to time. Essential in all our instruction has been the use of case teaching, to illustrate the many complicating personal problems that individual patients must face when sickness comes. By presenting in actual circumstances what it means to have a mother sick and out of the home, or to lose the weekly wage of the father of a family, or to face the difficulties of a mother of five who must keep one child with heart disease happy and quiet in bed for a long period, our case teaching helped the nurses to understand better why a patient may not easily accept the role of illness. As they came to understand the function of social service, the nurses in their turn became very helpful in bringing to the attention of the doctors and social workers those patients whose anxieties suggested that social service might be needed to effect recovery. The forces that changed the medical treatment of patients, and resulted in institutional medical care for a large proportion of the sick, markedly affected the education of medical students. As an earlier chapter has emphasized, absorption in the rich contributions of science, together with the development and organization of specialization in the hospital, tended to dim the clear picture of the patient in his usual setting of family and community. It should be noted that medical schools that had affiliation with a program of home care of patients, such as those mentioned in Chapter 3 and also those at Tufts and Boston University Schools of Medicine, offered to students exposure to the environmental factors in illness of dispensary patients. Great teachers of medicine in highly organized hospitals in this country early saw the shortcomings in the preparation

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of medical students for their future careers, and in several notable instances sought to make some correction. Earlier reference has been made to Dr. Osier's interest in the problem and to his influence on Dr. Charles P. Emerson, who led a group of medical students, members of the Johns Hopkins University Y.M.C.A., to volunteer as home visitors in districts of the Baltimore Charity Organization Society. Concerning these beginnings, Dr. Emerson wrote in 1930 (in a personal letter to me): "Our work in Baltimore began in 1901 . . . as a Hopkins Medical School Y.M.C.A. problem, but before the year was over it was a Medical School problem. Our effort was to find some way of getting the medical students in touch with patients in their homes, believing that they could not understand the problems in the wards if they knew nothing about the patients' problems at home." Because of the close identification of the Johns Hopkins University and the Charity Organization Society, Dr. Emerson had no difficulty in arranging with the district office of the Society nearest the hospital to organize a special board, with Dr. Emerson himself as chairman, to guide this venture. The students were assigned as home visitors under the district supervisor, Helen B. Pendleton. So great was their interest that, after two years, Dr. Emerson reported: "This movement had grown so that the work was divided into three districts (Committees). . . Thirty-three per cent of the medical students were active volunteers. . . From the first, we were primarily interested in the broader medical education of our students." When Dr. Emerson later became Dean of the Indiana Medical School ( 1 9 1 3 ) , he arranged to create within the Department of Sociology of the University a division of social service under the able direction of Edna G . Henry, a welltrained social worker, assigned to have charge of social service to the dispensary patients. He conceived of this practical work with patients as an opportunity for social instruction for student nurses and medical students in "environmental medicine." He spoke of the dispensary as offering "a social laboratory for the Department of Sociology."

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Vivid in my memory is a visit made to Dr. Emerson and Miss Henry in 1 9 1 3 , when I attended one of the clinics that demonstrated this interrelation of medicine and social work. Dr. Emerson presented at the clinic a patient with chlorosis. T h e student who had been assigned for a home visit to the patient reported that the girl worked in a laundry, where she stood all day on a wet floor and fed wet clothes into a mangle. She took a cold lunch to the laundry and, outside of working hours, helped with housework at home. She slept with her grandmother, who had "a prejudice against night air." Several other patients were presented. A f t e r each case presentation Miss Henry would further develop the social implications of the case and bring up pertinent points for discussion. In each instance a medical student reported on the work and home conditions of the patient in a manner bearing testimony to Dr. Emerson's contention that "the social aspects of the case should permeate the entire handling of the case and not be considered in any way separate." T h e value of social service in a teaching clinic is stated by Dr. Emerson in the reports of the Indiana University Social Service Department for 1 9 1 1 - 1 9 1 3 : "If the Social Service Department helps one patient, then one patient has been helped; but if this department teaches one medical student how best to help that patient, then it has indirectly helped many of the patients whom this student may later treat." 2 T h e use of a social service department for sociological research is also considered. Dr. John S. Billings, of Rush Medical School, was another of the great teachers of that time who did not accept the limitations that were pressing on medical education and crowding the curriculum by demands for teaching the fields of scientific interest. I remember seeing him pace the platform at a meeting of deans of medical schools, where speaker after speaker had advocated increase of teaching time for one and another of special clinical fields. " H o w can we hope to produce the resourceful physician in four years if we accept all these additions to the curriculum?" A t the Massachusetts General Hospital, the Social Service

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Department was drawn into the teaching of medical students by Dr. David L. Edsall in 1913. A n account of our early experiences in "The Uses of Social Case Work in Teaching of Medical Students" was presented by Grace S. Harper of our staff at the meeting of the National Conference of Social Work, in Baltimore in 1915. 3 Methods changed through the years but case teaching, familiar to the student in clinical instruction, was especially adapted to this social teaching. And the patient himself in the uniqueness of his situation, although apparently passive, was the real teacher. W e learned early that the students were sensitive to the attitudes of their medical leaders toward sharing the teaching conference with us social workers. There was a time when I suspected that the unfailing courtesy with which we were accepted as a group of women serving the patients did not necessarily lead to our being welcomed as instructors! We soon arrived at one of the cardinal principles of our part in teaching of medical students: the conferences must always be obviously in charge of the clinical teacher, so that it was made clear that the social implications of the patient's situation were important in the consideration of his medical problem and were an integral part of it. This principle was easily established in the fortunate succession of Dr. Edsall, Dr. George R. Minot, and Dr. James Howard Means, who over the years guided the social conferences for students at the Massachusetts General Hospital. It was during the time when Dr. Edsall handed on to Dr. Minot the responsibility for carrying on these weekly social conferences that we were asked to help revise the instructions for medical history taking. I treasure the memory of hearing Dr. Minot present the subject from the medical side. He dealt with each item in the patient's history, with his gift of meticulous discrimination of the importance of each as a factor in accurate diagnosis. Introducing the patient's social and environmental situation as bearing on medical history and plan of treatment, he turned to me to present and illustrate methods of interviewing patients and relatives and securing pertinent

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social information, through which to better understand attitudes of the patient. I remember presenting my experience with an Italian girl with tuberculosis who had refused to go to the sanatorium available to her. In this her family excitedly agreed. On looking into the situation we had discovered that a sister had died from advanced tuberculosis soon after admission to this same institution, a fact that had not come to light in the medical history. In our association with Dr. Minot, I remember his making us more aware of our need to learn from our medical associates a more careful discrimination as to what in our field was significant to the medical understanding and care of patients. Also, I came to appreciate the discipline of reserving judgment until the facts were assembled, tested, and related and carefully integrated with the medical information. Much of all this has, since those earlier days, been absorbed into accepted methods and principles of professional social work. It was, indeed, a great privilege to work with a man who, though so scientifically minded, was at the same time acutely sensitive to the human values involved in the care of the sick. And it was with a sense of our responsibility in the medical care of the patient that we social workers shared in making a revised outline for history taking that should include specific social data to supplement medical findings. Probably the most satisfying conviction that came out of experiences shared with these medical teachers was that the quality of care of patients in a teaching hospital is held high because of the teaching. Its purpose is to demonstrate to the students the best that progressive medicine can give to diagnosis and treatment. The presence of alert, questioning students helps in this. And the effect on the students of the example of their leaders in carefully weighing point after point is instructive. The influence of attitudes and habits of behavior is frequently very striking. I have often been thankful that my experience fell in a hospital where I could witness the practice so well expressed in Dr. Means's instructions to his students in the little brown pamphlet on "The Amenities

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of Ward Rounds," with its dignified and sensitive understanding of the point of view of the patient. Our teaching of medical students was throughout the years based on the "case method," a method with which they were familiar in their medical education. A t first we selected clinic or ward patients with whom we were working and whose situation was the source of social complications in their sickness or physical handicap. W e presented a series of such cases, calling attention to specific social problems and their general medical implications. The weakness of this method was that we prepared the cases for presentation, that the students did not necessarily know the patients nor take much part in active discussion. As fourth-year students having their first vital experience in direct and responsible contact with patients, their interest was naturally focused on acquiring specific clinical techniques in examination and diagnosis. When Dr. Means took over responsibility for the program of clinical teaching on the medical wards in the early 1920's, we critically reviewed with him our part in the program and tried out a variety of methods for helping the students to become more acutely aware of the social elements in the patients' condition and the community resources for supplementing medical care. Since 1932 the general plan has been to have each student assigned to the medical ward complete a medicalsocial study of some patient whose initial medical history he has taken. The student is encouraged to interview relatives, consult with the social worker, visit the patient's home if this is practical. (Since Massachusetts General Hospital patients come from all over N e w England, home visits are not often feasible.) The student then prepares a written report of the patient's situation, bringing out specific social, psychological, and environmental aspects of the case and noting the general implications of the particular problems involved. He is called upon to present his case study at a medical-social conference presided over by the clinical teacher and attended by the student group and the supervisor of social service. Free discussion is encouraged and many a lively give-and-take develops as the

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students take over controversial questions raised in relation to the case under consideration. The question is often asked of the student, "What would you do if this were a patient in your private office?" A review of some 600 of these case studies reveals a wide range of difficulties the patients must face: unemployment and broken homes due to sickness, old age and its problems, alcoholism and drug addiction, marital friction, a variety of reactions to the necessity for dependence on public support, problems of immigrants facing deportation because of dependency arising out of illness, industrial disease, and often the costs of medical care. Attitudes in great variety are revealed, from emotional dependency to belligerence in accepting physical handicap. Taken chronologically, the case records reveal changing attitudes on the part of the students and reflect the special pressing problems of the times. Free discussion of the social issues as raised by these cases has developed notably under the leadership of Dr. Means and his assistants, Dr. John P. Monks and Dr. William W . Beckman, and with the active participation of Dorothy Kellogg, supervisor of social service. The purpose is to help the students to think for themselves on current issues that are related to their responsibilities. Observing the development of this plan, one may trace a growing skill in the integration of medical and social study, diagnosis, and treatment plan. In fact, this teaching is no longer isolated in a definite hour of instruction. It permeates the daily practice in the wards, and there the students witness, almost as a commonplace, the interweaving of medicine, psychiatry, and social service for the patient. This does not imply that all goes smoothly with regard to the general adoption of such integration. The issues involved are too closely identified with vital questions of the day to expect calm sailing. W e shall see in a later chapter that social workers have been drawn into clinical teaching in several other medical teaching centers. At the Massachusetts General Hospital, the Social Service Department from the first participated in the teaching of other professional groups only on request. Even so, I think that, in

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our desire to strengthen ties in our interprofessional relations and to identify ourselves with the teaching purposes of the institution, our staff sometimes became involved in extra responsibilities beyond its capacity to carry them with satisfaction. Sometimes we entered a teaching program by chance. Such was the case with Dr. Cabot's special interest in offering a clinical year to theological students. It was because of his eager desire to offer an opportunity that should expose students of theology to the hospital community that Dr. Cabot asked us to take this new project under our wing. The idea of offering experience to prospective ministers of religion by direct contact with the sick, now well sponsored by the Institute of Pastoral Care, was early associated with the name of Rev. Anton T . Boisen, who, following a personal experience, became deeply interested in fostering among the clergy a better understanding of the spiritual welfare of patients with mental disorders. In 1925, with the cooperation of that extraordinarily uninstitutionalized superintendent at the Worcester State Hospital, Dr. William A. Bryan, Mr. Boisen initiated at that hospital clinical pastoral training for theological students. Dr. Cabot, always alert to the spiritual needs of the patients and knowing of Mr. Boisen's venture, sought to apply the idea in a general hospital. In consultation with that saintly man, Dr. Alfred Worcester, he developed a plan which he proposed should be tried out at the Massachusetts General Hospital. He formulated his ideas in an article entitled " A Plea for a Clinical Year in the Course of Theological Study," 4 maintaining that this period would offer an opportunity to apply religious belief "to encourage, console and to steady human souls and to learn from them as well as from failures in attempting to help them." 5 Dr. Cabot knew from his own experience that in a responsible relation to patients the theological students could learn much from them, as to visiting the sick, attendance on those who face dreaded operations, the problems to be faced in fatal disease, consolation of the be-

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reaved, and all the personal complications of sickness that beset patients and their families. It seems especially significant that Dr. Cabot's original idea was to have these theological students accept the humbler but serious responsibilities of acting as orderlies, to assist the nurses and the trained orderlies in the simplest tasks of bathing and feeding patients, to accompany them to the operating room, and thus to identify themselves with the patient at a critical moment in his hospital experience. They also witnessed an autopsy, that they might better appreciate why families were sometimes asked that to add to medical knowledge such examination be permitted. The Social Service Department was asked to give to these students some talks on the hospital as we saw it through the patients' eyes, and to relate our experience in our work and in the complex interprofessional relations of the institution. W e also discussed with the group serious community problems disclosed in our contact with patients, problems of civic responsibility and those involving moral issues that seemed to us important for spiritual leaders in the community to appreciate. Our original and informal relation to this educational program for theological students at the Massachusetts General Hospital never became a formal affiliation of our department. It soon seemed more suitable to have it allied with the nursing service, but we saw that the plan offered a priceless opportunity not only to the theological students but to graduate clergy also. It was of value according to what the student himself brought to the experience. This was, of course, true of all of us who had the privilege of working in contact with patients. The Art of Ministering to the Sick, written by Dr. Cabot and Rev. Russell L. Dicks, who for four years was in charge of these theological students, has become a valuable guide not only to ministers but to all who would better understand the sick in their spiritual needs.® In these specific ways the teaching function of the hos-

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pital has expanded, but its organized educational activities by no means encompass the teaching that goes on naturally within its walls day by day. The patients themselves learn much from their personal experience in the hospital, as they are taught their part in carrying out treatment and aftercare orders. No member of the medical staff, regardless of his status, questions the educational value of his daily association with patients in his concern for their care. Not only is medical knowledge furthered within the hospital; much is learned about human nature, its frailties, its capacity for heroism and courage. Of all this the patient is probably not fully aware, although occasional patients, especially those in a hospital where medical research is carried on, know and take satisfaction in knowing that, under the care of thoughtful physicians, their condition reveals information both valuable to their own treatment and helpful to others in similar distress. From our colleagues in the medical profession, we medical social workers learn many valuable lessons. One of these is the humility and the receptiveness with which the best of them seek to learn from experience. Knowledge of any disease is enriched by the variation of symptoms and response to treatment observed in accumulated experience with many patients. But special richness of opportunity for human relations is the lot of the medical social worker. Her daily experience in a hospital brings her into close association with a great range of humanity—with professional colleagues pursuing their special activities, with the many men and women whose work in the background keeps the institution going—but most of all with the patients, whose wide range of personalities and circumstances represent accumulated problems in the community. Yet each patient's situation is as unique as the fingerprint. Exposure to such experience offers, to those who can meet each day with imagination and a student's eagerness, a rich opportunity for growth in knowledge and in wisdom.

24 jMedicine and S o m e S o c i a l Trend* H I S T O R I A N S of the far future, looking back at the general advance in social welfare in this country during the first half of the twentieth century, may well note remarkable changes in organized care of the sick, for these five decades saw the emergence and firm establishment of that unique institution, the modern hospital, with its assembled resources of scientific medicine. T h e y will note that, in its early firmly stated purpose of care "for the poor only," the hospital, formerly rather isolated from the community, has become the indispensable resource for all sick persons, regardless of their economic situation. Played upon by forces both social and scientific, the hospital has been probably the least static of our social institutions. Earlier chapters have pointed out that the phenomenal industrial development, the unrestricted immigration through several decades, and the growth of urban living, attendant upon our growing so-called prosperity in the latter part of the nineteenth century, brought many hazards to health and welfare. Resultant conditions in community living in their turn brought about a stirring of the social conscience that introduced many reforms. Science applied itself to the study of disease and sought the causes of sickness as rooted in the habits of life and the crowded environment of masses of people. Clinical medicine moved out positively into the field of public health. T h e term "preventive medicine" was coined and given meaning as to sanitation and the early detection of communicable diseases. Concern for public health has become, in large part, an

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accepted community responsibility. Education of the general public about diseases that call for the practice of personal hygiene, or that can be controlled by health authorities, has become a policy of branches of government charged with the protection of our health. The doctors who, fifty years ago, were pioneers in educating people to the nature of that dread disease, tuberculosis, and in enlisting the victims themselves in frank participation in practical measures of treatment, built better than they knew. They established a structural pattern that could bridge the gap between the medical profession, with its rapidly increasing knowledge of control of diseases, and the masses of humanity for whom sickness was complicated by ignorance, fear, poverty, superstition, and unwholesome conditions of living and working. The now familiar term, "the modern hospital," suggests consistency in character as a solidly integrated unit. But the hospital of today is not just a hospital. Many characteristics must be taken into account in considering this focal medical institution. Hospitals vary greatly in architecture, bed capacity, administration, technical facilities, limitation on admission, and, most of all, professional personnel. A great teaching hospital is the epitome of resourcefulness in technical medical care, and the most complex and highly organized of our modern institutions. In its avowed threefold purpose—to care for patients, to teach, and to carry on medical research—at its best it represents a veritable constellation of services, professional and administrative. It is a demonstration of unity in diversity, of cooperation in a common aim—the adequate care of the sick. Within it are assembled not only nurses and doctors. Not only is medicine represented with all its elaboration of specialties—surgery, medicine, neurology, psychiatry, and their many subdivisions such as orthopedics, cardiology, urology, plastic and neurosurgery and a score of others. There also are the pathologist, radiologist, biochemist, pharmacologist, psychologist, social worker, dietitian, occupational and physical therapist, librarian, medical artist, laboratory technician. T o support all these groups, who serve the patient more

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directly, there must be many others with skill and experience— the administrators, accountants, bookkeepers, chefs, engineers, painters, plumbers, laundry and housekeeping personnel. And because of such complexity of organization, our larger hospitals have introduced the hostess at the entrance of the hospital, and the director of personnel and employment. As the importance of cooperation between the community and the hospital has become better appreciated, the public-relations officer has also been added. Careful study of the steps of steady development of the large teaching hospital, with its aim to make available every resource of medicine and promote scientific advance, will show, I believe, that no specialized service has been added except when the better clinical care of the patients or more efficient management of the institution has made evident the need f o r it. Is it any wonder that medical care has become very costly and that it poses problems for the hospital management as well as for the patient? These problems, both economic and medical, also involve social policy in our community living. A n d always this highly complicated institution poses human problems, of both a personal and a social nature, to the patients who receive its benefactions. It is not surprising, therefore, that this complex organization, so truly human in its purpose, is, nevertheless, bewildering to the sick person. H e comes to the hospital at a time when personal attention and simplicity in human relations are especially desired. T h e very ill patient may find comfort in the impersonal efficiency with which the various elements in the organization get into action for his care. But for many patients, especially those who come fearfully and for the first time— or from a simpler habit of life in a rural community—the strangeness and busyness about them may yield little satisfaction. I suspect that in most patients' minds there lingers a picture of the old-time doctor-patient relation, a personal, friendly situation, in which doctor and patient were the only essential elements in the unit of medical care. But medical care has become more complex and the changes wrought by specializa-

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tion, delegation of responsibilities to nurse, house officer, technician, and other assistants, are not readily accepted by the patients. The present substitution for the old relation seems to arouse nostalgia not only in patients; doctors, too, protest that above all we must save the doctor-patient relation intact. The specialized organization of the hospital is here to stay, however, and that it is necessary and desirable in serious illness seems to be well accepted—rather especially by the medical profession itself. As to public reaction the patients, educated in the values of expertness, foster specialization in seeking "the best," and are usually unmindful of its limitations. Specialization calls for sharp focus of attention and interest, a deepening rather than a broadening of vision. But artists know that background is essential to the primary focus of a picture, and the clinical picture is usually a complicated one, for it is often a composite. In highly organized medicine the problem of the specialist is both to keep a true focus on the patient and to appreciate that in each picture the background is unique. Anyone who brings imagination and human understanding to experiences with sick people, knows that the role of patient is a difficult one to play with self-confidence and dignity. T o endure helplessness, discomfort, and pain, when physical and spiritual energies are at a low ebb, taxes our usual independence in the management of our personal affairs. The privacy in which we usually live is interrupted, and we seem to be shorn of our maturity. What is it then that we want of those entrusted with our care at such a time? Is it not, first of all, assurance that we are receiving the best of care? If this assurance is given with kindliness, our confidence is reinforced. Sickness often breeds a childlike sensitiveness to friendliness. The careless abruptness of any one among the confusing many whom the patient must meet may shake his confidence in the hospital. Unreasonable, yes; but reasonableness is not a characteristic attribute of the sick person, as most of us secretly know. What then is the essential value in the treasured doctor-

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patient relation that we should retain in spite of the conditions of medical care in the big hospitals? I believe it is the element of confidence that lies at the heart of medical care—confidence that frees the patient to make use of the services he has sought and to accept such responsibility" as may fall to him to make treatment effective. T h e hospital itself must become the recipient of the patient's confidence. It is on such accumulated confidence that a hospital secures its reputation of service to the community and receives the support of the general public. T h e interprofessional relations made necessary by the highly organized medical care of today in our large hospitals can be effective for the patient only when based on confidenceconfidence of the patient and of the various professions in one another. It was in recognition of the complex and rather impersonal organization of our hospitals and dispensaries that medical social workers were introduced into these expanding institutions. Furthermore, they were charged with giving attention primarily to "the meaning of sickness to the patient and his family." In its pioneering days, the purpose of hospital social service was sometimes interpreted as "humanizing the institution." Medical social workers in general have, I believe, kept their focus clearly on the patient. It has been their concern constantly to deepen their understanding of what the patient's experience means to him in the personal complications of his sickness. But keeping the hospital "human" cannot be the task of any one group; it must be the consciously shared responsibility of everyone who has contact with the patient in the course of his treatment in the institution. T h e medical social worker contributes her special knowledge and understanding, and shares with the rest of "the team"—and must help to give the patient the assurance that all are so sharing—in carrying through a unified medical service. For many years my desk at the Massachusetts General Hospital was so placed that I could readily see the entrance to the emergency ward. It is a rigid rule of the Hospital that this parking place be kept free. N o obstacle must impede a direct

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approach to this entrance when the ambulance with some tragic burden rushes up. Behind that door, at any moment of day or night, medical care must be immediately available to any patient in urgent need. No moralistic question is asked whether he is "worthy," no delaying inquiry is made as to his economic status. He is a patient in immediate need of care. That is enough. At a later time less important matters may be considered, but a need that may pose the question of life or death is the focus of prompt attention. The medical profession has led us to take such readiness for granted, and those who truly represent the profession deeply resent any failure to fulfill its best traditions of service. Complete facilities for emergency care are characteristic of thousands of hospitals throughout our country. Like many of the blessings provided for our welfare, we readily accept the familiar resources provided by medicine, without appreciating their significance. But surely there is deep significance in the devoted attention of doctors and nurses to the saving of human life. This may be seen daily in hospital wards all over our land. W e accept their unquestioned devotion to the seriously sick as a mark of our civilization, and seldom stop to think what it really means. And, as surely, their interest is not to preserve a mere biological existence, for how tragic it is when the high skill of medicine leaves the patient nothing but heartbeat and no capacity for human response. This determination to spare no effort to save life must arise from the deeper significance of our need to hold fast to the meaning of life itself. And in this we all share in understanding, for it is our relatedness to everything in our conscious world that gives life meaning. W e do not need profound philosophers to tell us that essential to us is our feeling for family and friends, our enjoyment of participation with others in the use of our God-given capacities, in work and in play, in our love for what to each of us is beautiful and desirable. So the purpose of medicine itself, as well as of medical social work, may well be restated as that of giving conscious atten-

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tion to the "meaning of life for the patient," and not merely "the meaning of sickness." So it is that medicine is surely deeply involved in the social organization of our life, and that, if there is meaning in the phrase "doctor-patient relation," this meaning implies the recognition of the patient as a social being who lives in a network of relations, and not in the chance isolation of sickness. Both the patient's health and his sickness are of present concern to the medical profession in its broad scope of service. But what of the "modern hospital," our present-day institutionalized expression of medical care? Although the large teaching hospitals, with which we have been especially concerned, serve many thousands of patients in wards and clinics, they are themselves only a small proportion of the total number of hospitals, so-called, in our country. There is no agreed definition of "hospital," by which to compile a national statistical measure of the establishments where sick people are assembled for care. In many instances it is difficult to distinguish between what may properly be designated a hospital and the semi-institution that takes on characteristics of a boarding or nursing home. Through legislative measures and by the publishing of authoritative statements of standards for hospitals, important steps toward better organization and standards have been taken in recent years. Through voluntary action by the American Hospital Association, the American College of Surgeons, and the Council on Medical Education and Hospitals of the American Medical Association, standards for physical plant, for organization, and for the professional qualifications of personnel and equipment have been declared and modified from time to time as advances in medicine require them. Official recognition by these medical organizations has become desirable to the lay managers of modern institutions. In 1950, there were in our country 6,431 "recognized" hospitals, of which 4,518, with â total bed capacity of 419,871, were nongovernmental in management. The desire of the medical profession, especially those concerned with public

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health and hospital management, to establish hospital standards is reflected in the legal requirement by many states for the licensing of such institutions as may be publicly recognized as hospitals of good standing. And the licensing and supervision of nursing or boarding homes for care of the sick is now required by several states. Through such legislation, the public, which is ourselves, can identify good facilities in case of illness. It was in the spirit of such legislation that we were long ago given medical protection through the licensure of doctors for practice and the registration of nurses—and more recently, in many states, of nursing attendants. H o w well does the public understand the significance of these standards and protective measures? T h e public is the consumer and may accept or reject community facilities, good or poor. T h e education of people in preventive public-health measures, in discriminating use of facilities, and in provision for financing possible periods of illness, has difficulties to overcome. Health is not appreciated fully until we lose it. Sickness is not normally desirable; people who "enjoy poor health" are judged by psychiatrists to be in a pathological state! Nevertheless, we should confess that most of us are somewhat childish in our lack of farsightedness in matters of health. Most of us, if we were honest with ourselves, would acknowledge sympathy with the man who, in an interview with the admitting officer of a hospital, was asked if he could manage to pay ten dollars a week. He replied, yes, he guessed he could but he didn't like to spend his money that way! H o w are we, as laymen, to attain greater maturity in our attitude toward medicine and public health? T h e increasing use of the institution for care of the sick has been a distinctive trend in our half-century, and is a marked change from the past century's special uses of the almshouse for its destitute and its "sick poor." There are many reasons for this ever-growing tendency to ask the institution to serve us in our most vital human experiences. Today—and in all economic groups—births, death, care of the chronically sick and the aged invalid are, in our cities at least, extensively

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institutionalized. Fifty years ago, such experiences were to a large extent considered to be the intimacies of family life and were met in the home. What is the social significance of these trends? How have they affected the home as a place where life's values are seen most clearly and where personal responsibility should be developed? And what does institutional living mean to those who must experience it? While rejoicing over the rapidly increasing institutional resources in our communities, and urging further increase, should we not pause to evaluate the social assets and liabilities involved? In our country in 1946, 82 per cent of births took place in hospitals. In some states, nearly 95 per cent of births occurred in institutions. Since pregnancy cannot be considered in itself a pathological state, I presume, we may ask why this overwhelming preference for welcoming a new life in the hospital rather than in the home. Does good prenatal care so frequently indicate such hazard to mother and child that every professional facility for their physical safety must be at hand? Or is it largely a matter of convenience to doctor, to patient, and to family? Is it our modern housing, restricted in size and lacking in privacy? It is a mixture of all these, I suspect. At any rate, these facts indicate that the hospital has social as well as medical uses. But do these reasons for resort to the institution add up to better obstetrical care? This is a question that has personal concern for the public as well as for the doctors. Anyone familiar with the maternity wards in our hospitals knows that, by the use of modern anesthetics and new obstetrical methods, Nature's more leisurely ways are often speeded up. In his interest to promote closer cooperation between those concerned with the birth of children and their care through infancy, a pediatrician asked a skillful and efficient obstetrician if he might attend some deliveries with him. "Agreed! I'll be at M. hospital tomorrow afternoon. There will be a case at two, one at three, and another at four. Come at your convenience." Speed and skill, yes! Only by institutionalizing childbirth could such a schedule be set. Saving time for the doctor? Saving time for impatient waiting relatives

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and probably painless for the mother? Insistent demands from patients, who now know the resources of the institution and of skilled medical care, have undoubtedly influenced this situation. But some thoughtful doctors are asking questions about these trends. So are some prospective mothers. Here is an indication of the growing conviction on the part of the lay public that the uses of medical knowledge are no longer the prerogative of the medical profession alone. It is, therefore, of prime importance that general health education should be sound. The extent of public information on health and medical subjects is another of the phenomenal developments of recent decades. Popular magazines now publish frank discussions of subjects that fifty years ago would have found the printed page only in medical journals. Much good has come with the many channels for health information, for an educated publichas shared with medical men in greatly reducing infant mortality, in preventing many serious illnesses, and in assuring early treatment of diseases that were formerly leaders in mortality statistics. The net result of these methods of publicizing medical information and the promotion of preventive health measures has brought about a striking increase in life expectancy in this country—from 49 years in 1900 to 67 in 1950. This wellrecognized social phenomenon of increase in the life span has brought about a rather rapid evolution in our thinking, one that has resulted in social action that has affected our economy. Although most individuals give little thought to the inevitable fact of old age for themselves, the plight of our great masses of old people—deprived of work, forced into dependence, subject to increased infirmity and chronic illness—has stirred the emotions and imagination of the general public. As a result the granting of financial aid to the aged has become, in the past thirty or forty years, the public policy of all units of government across the land. But economic assistance is only one lesser aspect of this problem of the aging population. The public welfare au-

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thorities, responsible for administering our programs of oldage assistance, have long realized that aid to the aged involves the further problem of the care of great numbers of the infirm and of those chronically sick. With prolonged life, the incidence of many of the chronic illnesses characteristic of advancing years, such as arteriosclerosis, arthritis, heart diseases, and diabetes, have numerically increased. So great have become the numbers of the chronically sick that hospitals of all kinds feel this burden. The special hospitals designed for such patients are overcrowded and the so-called nursing home has come into prominence as a partial resource. Unhappily, much of the care for the chronically sick has been custodial rather than constructively medical. The concept of rehabilitation is far from realization in the care of our aged. The American Public Welfare Association, a voluntary body deeply interested in the development and maintenance of sound principles and effective administration of our public welfare services, was responsible for initiating a significant attack on the mounting burden of chronic illness. Recognizing that the public assumption of old-age assistance was leading into the broader field of medical care for the chronically sick, the Association undertook studies of the scope of the problem. Following their preliminary assembling of evidence of the ramifications of the subject, the national Commission on Chronic Illness was formed in 1946 to merge by its organization the interest and efforts of the following voluntary organizations: The American Hospital Association, the American Public Welfare Association, the American Public Health Association, and the American Medical Association. The commission established a rallying point for the many and varied expressions of concern with this subject, and provided an opportunity for a broad and concerted approach to study of causes and prevention of chronic illnesses, and promotion of a program of suitable facilities for care. Although the interest of the Public Welfare Association was initially stirred by the extent of chronic disease in the aged, the new Commission faced the subject as affecting all

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ages. Many local social and medical groups have felt concern with the problem for a long time. Community-service organizations in several cities have organized special committees to bring together various institutions and social agencies especially concerned with the subject, to pool experience, and to foster social experiments toward more suitable ways of dealing with the problems locally. Leaders in medicine especially interested in such chronic diseases as arthritis, rheumatic fever, heart disease, and infantile paralysis have looked to an informed public for support for research and for educational campaigns for care and prevention. The important point in these trends is that in the plan of the Commission on Chronic Illness, and in all the concerted action in interest of the subject, there is a frank recognition of the interdependence of health and social welfare—and so of the medical profession, those active in organized social services, and the general public in solution of our common problems. The program of the 1951 International Conference on Gerontology in St. Louis, where representatives of some fiftytwo nations gathered to discuss and exchange experience on the various problems of the aged—its medical, social, economic, and psychological factors—was a striking and heartening example of multiple professional interdependence and of the necessity of citizen participation in a constructive attack on a common human problem. That this principle, upon which medical social service was founded, continues to prove sound is again implied by the declaration of the World Health Organization in its definition of health as "a state of physical, mental, and social well-being." Health for the individual and the community can be achieved only by their recognized alliance under this principle.

25 Σ acing N e w F r o n t i e r s P R E V I O U S chapters have suggested how medicine has been influenced during the past five decades by the constant advance of medical science and by the more recent demands made upon the profession through the phenomenal development of public health and the expansion of public interest and understanding. Within this time the once sheltered position of the private practitioner, long accountable only to his conscience for fulfilling ethical responsibilities to individual patients, has shifted to one especially exposed to the community obligations that have been created for all of us by truer understanding of the nature of disease and the possibilities of prevention. Naturally coincident with the extraordinary advances in methods and techniques for the study and treatment of disease, an insistent demand for equivalent improvement in medical education made itself felt. In 1910, Abraham Flexner's study of medical education, published under the auspices of the Carnegie Foundation for the Advancement of Teaching, 1 brought about the closing of many "eclectic" and second-rate medical schools. His criticism, fearless and constructive, resulted in improvements even in the best of the schools. Hospitals, always an essential factor in medical education, came in for censure, too, and the movement for reform in medical education resulted in the formulation of standards not only for curricula but also for facilities for teaching in laboratory and clinic. Within a few years the American Hospital Association and the American College of Surgeons established authoritative standards for hospitals, and the Council on Medical Education

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and Hospitals of the American Medical Association issued annually a public list of those hospitals suitably equipped for the postgraduate training of "interns and residents." But technical instruction was not considered sufficient to prepare students of medicine for the responsibilities that society was placing on their shoulders. The profession began to call for recognition of quite another aspect of medical education. It contended that focus on the scientific study and diagnosis of disease tended to divert attention from the patient as a person and to present him as a vehicle for a disease. By its provision of clinical specialization and elaborate technical equipment, the hospital in its turn was hampered in fulfilling its underlying purpose in the care of the sick. It was toward the solution of this dilemma that Dr. Cabot had suggested the introduction of social service. Laymen who mourn the "good old days of the family doctor" see that changes have come but, confused by them, often fail to understand that medicine is still in process of evolution. Even the most conservative member of the most conservative profession may regret but can scarcely deny that a vital process of growth is going on. T o conserve the values of the past is an unquestioned responsibility of medicine; not less important is an openmindedness to change that will extend the beneficence of better medical care for the sick and safeguard the people's health. Along with a vanguard of the profession, the public has taken a hand in pressing upon medicine major questions of public policy and procedure. In 1932, the publication of the five-year study of the Committee on the Costs of Medical Care brought forward for widespread public discussion the problems of making medical care available to all the people. This report, Medical Care for the American People,2 leads a long series of publications that record the highly controversial issues in which the medical profession and the public have been involved during the two succeeding decades. Meanwhile, many changes reflect the influence of public opinion

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on medical practice and show the "resistant flexibility" of the medical profession. The layman who looks objectively at our half-century cannot fail to note how various are the directions from which medicine has been subjected to attack after attack from social forces and from within its own ranks. He may well marvel at—and give thanks for—the stability shown by this great and beneficent profession through the centuries. The vitality of the roots that have nourished it maintain its capacity to grow in whatever directions the demands of service to mankind may indicate. It was to be expected that changes in the interpretation and practice of medicine should become of concern also to educators seeking to prepare for their future responsibilities the young men and women who choose medicine as a profession. As one looks back at the half-century, one cannot fail to observe that, whenever there was evidence that further frontiers must be explored, a vanguard of courageous members of the medical profession has pushed on toward them. The public should understand that, although the forward march toward public health is beset with obstacles, they can be overcome if the public and medical leaders are guided by the outstanding principle of our democracy, easy to state but difficult to realize—equality of privilege. In such an equality medical care according to need should be available to everyone, and any program for carrying out such a purpose should respect the integrity of the individual. Not only the patient but the physician as well should receive this recognition. The successive upheavals of two world wars and a major economic depression have been in themselves factors that brought to the fore the social aspects of medicine. As an earlier chapter has noted, several teaching hospitals in this country had drawn medical social workers into cooperation with their clinical teaching, so that the social and environmental conditions that affect the hospital patient might be fully presented. Among these were the hospitals associated with

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medical schools at Harvard, Pennsylvania, Tulane, Vanderbilt, Western Reserve, and Yale Universities and at Tufts College. The American Association of Medical Social Workers, giving serious consideration to the educational responsibilities undertaken by its members, appointed a committee to study the extent of such teaching and the methods in use. In 1939, the Association published a ten-year report on The Participation of Medical Social Workers in Teaching of Medical Students.3 This report was prepared by Harriett M. Bartlett, then educational advisor in the Social Service Department at the Massachusetts General Hospital. The chief recommendation of this study was "that participation of a social service department in the teaching of medical students should not be undertaken unless there is a well-established department with adequate facilities for such teaching, and that primary responsibility for this teaching should rest with the medical school and that the social workers should not take part except at the request of teachers in the medical school." In 1943, the Association of American Medical Colleges officially invited the Association of Medical Social Workers to participate in a joint study designed to gather information concerning "the teaching of the social and environmental aspects of medicine, to analyze the data obtained, to evaluate methods in use, and to offer recommendations based on the conclusions drawn from the study." The joint committee appointed to carry out the study was under the co-chairmanship of Dr. J. A. Curran and Eleanor Cockrill, with Miss Bartlett as secretary. The report was based on information gathered from sixty-one medical schools. In about one-third of these, social workers were sharing in the teaching, but few had official recognition from the medical schools. One notable exception was Elizabeth P. Rice, who as director of the Social Service Department of New Haven Hospital developed a comprehensive and well-integrated program with the Yale Medical School. This committee, in its consideration of its purposes, made two fundamental assumptions: ( 1 ) "There are three major

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features of illness—physical, emotional, and social; these are so intimately interwoven in the pattern of disease that they must be considered together rather than as separate entities; all three must be included in the curriculum if medical education is to provide the student with the knowledge and skills necessary to fulfill the aims of medicine." (2) "The medical student should learn to recognize and understand the social factors in every case, to evaluate them in relation to the medical problem, and to assume responsibility (himself or through others) for the relevant problems as a part of diagnosis and treatment." The report of this committee was published in 1948 under the title Widening Horizons in Medical Teaching.* During the iç^-o's these broad considerations of the field of medicine and public health were commanding the attention of the medical profession and those concerned with trends in protective health measures. Conspicuous in promoting discussion of the subject was the activity of the Committee on Medicine and the Changing Order appointed by the New York Academy of Medicine. This committee was made up of doctors in the special fields and included teachers of medicine, nurses, dentists, economists, social workers, and laymen. A series of public lectures was presented at the Academy, and the committee authorized several publications based on these lectures and on problems facing medicine in these times.8 Essays on psychosomatic medicine, medical social work, psychiatric social work, and rehabilitation were included as "Medical Addenda" in the group of publications.® In seeking to demonstrate that social work had its special contribution to make to the advance of medicine in its care of the hospital patient, and to record how social work won its recognition in the medical field, this book has not given suitable acknowledgment to what the process—and the difficulties—of that demonstration did for medical social work itself. Nor does it indicate how the growth of social awareness on the part of the public has brought about a broader scope for

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social workers. The spirit that fostered the development of preventive medicine may be seen to have expressed itself also in organized efforts to prevent social ills by way of such constructive activities as those designed to safeguard family life and to prevent delinquency. Social workers, disciplined by experience, were evolving a more positive social philosophy. All pioneering that has a firm purpose is sure to be a disciplinary experience. Our discipline, as social workers in a hospital, came first of all in our own recognition that we must justify our inclusion in an already rigidly organized institution, inhospitable to our ingenuous offers to improve the smooth-running order by which its admirable service was being carried on. W e shared with the doctor and the hospital a common purpose, to provide effective care of the patient to the end that he be returned to his place in family and community life as readily as possible. W e found that everyone about us had a clear-cut function to perform. W e realized that we too must determine our function and establish its effective interprofessional relations. It was of invaluable benefit to us to be closely associated with a scientifically disciplined, humanitarian profession. W e observed that its habitual procedures were guided by principles that we could apply in our service to individual patients: careful search for relevant facts in each case, weighing of evidence, suspension of judgment until all facts are in hand, and treatment based on knowledge of the total situation. These principles combined to present a method to emulate—and, we may add, a method now familiar to all skilled case workers. That objective attitude—nonjudgmental but not lacking in warmth of feeling—which the highest type of doctor and nurse bring to their relation with the sick was to be admired. T o observe the man of science was in the nature of discipline. He sets up his experiments to test his hypothesis. If it is proved, that is a fact. If it is disproved, that is a negative fact but a valuable one, nevertheless, since it shows that he is on the wrong track. And evidence to him

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must rest on verification many times over—a good lesson for pioneers in social research, and one to remember in later days when change in growth again calls for analysis and self-analysis. This book has dealt chiefly with the pioneering experience of introducing social service at the Massachusetts General Hospital. It has also taken account of the rapid growth of a demand for the inclusion of such services in organized medicine during years when hospitals and dispensaries were themselves undergoing extraordinary development, especially in their community relations and obligations. As medicine moved out into the field of public health, medical social workers were called into participation in a new setting and their special knowledge and skills were applied to programs in which individual patients were served, as in the nation-wide program for crippled children established through the Federal Children's Bureau. In state public-health facilities for maternal and child health and in programs for medical care of recipients of public relief, medical social workers are acting as consultants. More recently schools of public health have appointed them to the faculty. A t the mid-century mark, medical social work is established as a professional service in several hundred hospitals and dispensaries, and in institutions for medical care in the Army and the Veterans' Administration. Soon after its organization in 1918, the American Association of Medical Social Workers appointed a committee on education, which has consistently concerned itself with this subject for many years, since 1926 with an educational secretary, Kate McMahon. T w o years of postgraduate education with approved curriculum and acceptable practical experience in the social service departments of accredited hospitals is now offered by 25 of the 57 schools of social work that have membership in the Association of Schools of Social Work. While medical social work was developing its professional role within organized medical care, other social services were being created. Trained workers were assigned to courts, schools, and churches, their function modified somewhat by

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the institutional setting within which service was rendered to individuals in need. Cftarity organization societies, which had pioneered in many social reforms, revised their function to focus attention more clearly on service to safeguard family life. Social settlements in congested areas of the larger cities concerned themselves with relations among community groups of different cultural, economic, religious, and social backgrounds with the purpose of fostering helpful mutual understanding, especially in times of social tension. Psychiatry, stimulated by experience in the First World War, drew social workers into its special field and with them gave impetus to the child-guidance movement of the 1920's. The influence of the mental-hygiene movement toward a more general understanding of human motives and emotional life and the influence of psychiatry on social work as a whole are immeasurable. As the number of social and health agencies increased, recognition of their common purposes led to organization of community councils in cities throughout the country. Under a variety of names, such as Community Chests and Councils, these have become familiar to millions of generous Americans through the public educational campaign that accompanies their yearly appeal for voluntary support of local social services. The annual meetings of the National Conference of Social Work, called the National Conference of Charities and Correction when it was organized in 1872, provided a forum for discussion of general and immediate social problems through the years. A t the meeting of the conference in Baltimore in 1915, Abraham Flexner spoke on the subject, "Is Social Work a Profession?" 7 He commented on the fact, well known to the assembled group, that the term "social work" was loosely used and ill-defined. He recognized its altruistic motivation, a characteristic essential in all professions, but he questioned whether it had yet attained other necessary characteristics, such as clearly defined objectives and standards, definitely formulated and educationally communicable techniques. Flex-

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ner's challenge to our emerging profession in 1915 deeply stirred those leaders who were concerned with the education of social workers in classroom and by practice. The schools broadened and improved their curricula and their standards of related practice. In 1920 they drew together to form the American Association of Schools of Social Work, for exchange of experience and more concerted action in improving educational facilities. N o w in its thirty-second year, the Association has a membership of 57 colleges and universities. After the devastating economic depression of the '30s, a social security program was developed by our government to provide public assistance to the aged, dependent children, and the blind. All these agencies, local, state, and federal, call for competent administration and personnel well prepared for their responsibilities. The overwhelming problem of educating such personnel is suggested as one thumbs through the 600 pages of the Social Work Year Book ( 1 9 5 1 ) , which presents short authoritative descriptions of the nation-wide organizations, public and voluntary, that express our concern with human welfare. 8 A wide variety of experience is needed for carrying out these services. Recent events have demonstrated that those concerned with social-work education have continued to be aware of the seriousness of their responsibilities. In 1948, the Association of Schools of Social Work, determined to meet more adequately the need for a supply of well-prepared workers, joined with a number of other organizations concerned with social-work education and practice, to create the National Council on Social Work Education. The Council saw that the whole subject ought to have critical and free-minded study under leadership that could objectively examine the present status of social work as a profession, the education provided for the responsibility entailed in social work in these times, and the interdependence of education and practice. Under a grant from the Carnegie Corporation, the Council secured the services of Dr. Ernest V . Hollis, of the United States Office of Education, and Alice L. Taylor, social worker and educator,

256

FRUITS

OF

EXPERIENCE

to make the study. Their report to the Council, Social Work Education in the United States, was published in 1951. 9 This report again calls for careful analysis of the basic functions of social iVork, its scope, purposes, and philosophy. It is a challenge not only to the educators but to all social workers. If accepted for all that it can mean to our profession, it may well have an impact on social work as great as the Flexner report of 1910 had on medical education. Speaking at the meeting of the National Conference of Social Work in 1951, Miss Bartlett, herself a member of the Council, said in discussion of the report: "As we consider the implications of the Study we see that in the past social workers have been too concerned with segmental, specific, and immediate interests. We have done too much acting and not enough thinking. T o attain our full growth we must not only be able to grasp the intellectual concept of a united profession but also to go through a change of feeling which will place togetherness ahead of separateness. We must learn to think and act together in a sustained way toward common objectives. I believe that this report has come at the very time when this readiness is developing and may offer a needed channel."10 So we see that both medicine and social work today face responsibilities to promote better education for the social obligations of their professional personnel: medicine, old and disciplined, but with courageous leaders who see a widening range for public service in clear view; social work, young and vigorous, facing the necessity definitely to clarify its special function and standards and bring its aims into sharper focus as a basis for a comprehensive educational program. Both professions face issues that involve public policy: medicine, for leadership in making its service available to the people, both in care of the sick and in promotion of health; social work, doing its part in tackling obstacles to the realization of our declared ideals for decent standards of life and equality of opportunity for all. In a democracy, progress in public welfare can come only through community action; the general public

FACING NEW FRONTIERS

257

has a vital share in charting the course. It is the steadiness of our forward march, not necessarily its speed, that will attest our belief in the principles of democracy. Although this book, according to its purpose, looks back over the known years so that the yesterdays and the progress of medical social service may have an available record, I hope that it may also have one of the values of history, to give a basis for looking to the future. A t this time we social workers who have long been associated with medicine must share with the whole profession the responsibility to face new frontiers and a wide horizon.

Notes an a Ref erences In d ex

Ν otes and R e f e r e n c e s C H A P T E R ι. A DOCTOR'S M E S S A G E ι. President Lefavour of Simmons College in his annual report for 1904 states that at the prompting of "persons most closely connected with administration of charities of this city" and after "Harvard University signified its willingness to contribute to the movement," Simmons College Corporation agreed to cooperate in the establishment of a school for social workers. A joint administrative board was appointed, consisting of President Eliot and Joseph Lee for Harvard, President Lefavour and Miss Frances R. Morse for Simmons, with Miss Annette P. Rogers, Robert A. Woods and Thomas B. Fitzpatrick. Men students registered at Harvard, women students at Simmons. This informal affiliation continued until June 1916, when Harvard withdrew. The University contributed $2000 a year for the twelve years. Later Simmons established a formal affiliation with Tufts College. C H A P T E R 2. T H E E N G L I S H HOSPITAL A L M O N E R ι. Helen D. Bosanquet, Social Work in London (London, 1914); Frank J. Bruno, Trends in Social Work As Reflected in the Proceedings of the National Conference of Social Work, 1874-1946 (New York: Columbia University Press, 1948). 2. Β. E. Astbury, "Hospital Almoning: How it all Began," The Almoner, I, No. 6 (September 1948). C H A P T E R 3. F O R E R U N N E R S I N T H E U N I T E D S T A T E S ι. Adelaide Dutcher, Philadelphia Medical Journal, VI, 1030-1032 (1900). C H A P T E R 4. A PERIOD OF SOCIAL A W A K E N I N G ι. Dorothy Giles, A Candle in her Hand (New York: Putnam, 1949). 2. W . R. Stewart, The Philanthropic Works of Josephine Shaw Lowell (New York, 1911). 3. Edward T . Devine, When Social Work Was Young (New York: Macmillan, 1939). 4. Jane Addams, "The Layman's View of Hospital Work among the Poor," Proceedings of American Hospital Association, IX, 57-63 (1907). 5. Richard C. Cabot, "The Meaning of Presence," Address on Occasion of Twenty-fifth Anniversary of Social Service Department, Massachusetts General Hospital, 1930, privately printed.

262

NOTES AND

REFERENCES

C H A P T E R 5. A PHYSICIAN T A K E S A C T I O N ι. Richard C. Cabot, Social Work, Essays on the Meeting Ground of Doctor and Social Worker (Boston, 1919); based on lectures given at the Sorbonne, Paris, 1918, published under title Essais de Médecine Sociale (Paris, 1918). C H A P T E R 6. W E BUILD ON FIRM F O U N D A T I O N S ι. Nathaniel I. Bowditch, History of the Massachusetts General Hospital ("not published"; printed by John Wilson & Son, Boston, 1851); George E. Ellis, History of the Massachusetts General Hospital, A Continuation, 1851 to 1872; Grace Whiting Myers, History of the Massachusetts General Hospital, ]une 1872 to Dece?nber 1900 (printed by Massachusetts General Hospital, 1929); Frederic A. Washburn, The Massachusetts General Hospital, Its Develop?nent, 1900-1935 (Boston: Houghton Mifflin, 1939). 2. Josiah Bartlett, "Dissertation on Progress of Medical Science in the Commonwealth of Massachusetts," Address before the Massachusetts Medical Society, June 1810. 3. Myers, History of the Massachusetts General Hospital, pp. 10-11. 4. Bowditch, History of the Massachusetts General Hospital, pp. 177-178. C H A P T E R 9. W E CHOOSE OUR ADVISORS ι. Richard C. Cabot, Social Service and the Art of Healing (New York, 1909). 2. Ida M. Cannon, Social Work in Hospitals (New York, 1913; rev. ed., 1923). C H A P T E R H. S E E K I N G OUR SPECIAL R O L E ι. Ninth Annual Report, Social Service Department, Massachusetts General Hospital, 1914. 2. Ibid. 3. Ibid. 4. M. M. Davis and A. R. Warner, Dispensaries (New York, 1918). C H A P T E R 12. I N T E R E S T I N G T H E DOCTORS ι. Margherita Ryther and Mabel Ordway, "Economic Efficiency of Epileptic Patients," Journal of Nervous and Mental Disease, X L VII, No. 5 (May 1918). 2. Eighth Annual Report, Social Service Department, Massachusetts General Hospital, 1913. C H A P T E R 13. A B R O A D E R SCOPE ι. Dr. Martha M. Eliot was appointed Chief of the Children's Bureau of the Federal Security Administration in 1951.

NOTES AND REFERENCES

263

2. Fritz Β. Talbot, Richard S. Eustis, Clara May Welch, and J. Herbert Young, "Symposium on Endocarditis in Childhood," Boston Medical and Surgical Journal, CLXXIII, 348-357 (1915). 3. Paul D. White, Edward F. Bland, Edith M. Terry, and Virginia B. Ebert, "Convalescent Care of Children with Heart Disease due to Rheumatic Fever. Report of Five Year Study," New England Journal of Medicine, C X X L V , 627-638 ( 1941). 4. Washburn, The Massachusetts Getterai Hospital, p. 462. C H A P T E R 14. A C C E P T E D OFFICIALLY ι. Report of Social Service Department, Massachusetts General Hospital, 1919-1921. C H A P T E R 15. A PROFESSION R E C O G N I Z E D ι. Mary Stites, History of the American Association of Medical Social Workers (in preparation). 2. A. R. Warner, "Social Service and Hospital Efficiency," Proceedings, American Hospital Association (1918), pp. 171-174. 3. "Report of Committee Making a Survey of Hospital Social Service," Hospital Social Service, III, 1 (1921), reprinted as Bulletin No. 2$ of the American Hospital Association (Chicago, 1921); "Report of the Field Secretary to the Committee of the American Hospital Association Making a Survey of Hospital Social Service," Hospital Social Service, III, 22 (1921), reprinted as Bulletin No. 24 of the American Hospital Association (Chicago, 1921). C H A P T E R 16. W E A N A L Y Z E OUR F U N C T I O N ι. Mary E. Richmond, Social Diagnosis (New York, 1917). 2. Gordon Hamilton, " A Medical Social Terminology," Hospital Social Service, X V (1927). 3. Elmer Ernest Southard and Maiy C. Jarrett, The Kingdom of Evils (New York, 1922). 4. Janet Thornton, The Social Component of Medical Care (New York: Columbia University Press, 1937). 5. Harriett M. Bartlett, Medical Social Work, A Study in Current Aims and Methods in Medical Social Case Work (Chicago: American Association of Medical Social Workers, 1934). 6. Harriett M. Bartlett, The Participation of Medical Social Workers in the Teaching of Medical Students (Chicago: American Association of Medical Social Workers, 1939). C H A P T E R 17. T H E IDEA BECOMES W I D E S P R E A D ι. Giles, A Candle in Her Hand, p. 186. 2. William H. Pear, " A Little Journey in Remembrance," The So-

2Ó4

NOTES

AND

REFERENCES

dal Worker (Boston: Alumni Association of Simmons College School of Social W o r k , July 1944). 3. Richard C. Cabot, "Backgrounds and Foregrounds in Medical W o r k , " chap, i in Social Service and the Art of Healing ( N e w York, 1909), p. 31. 4. Davis and Warner, Dispensaries. j . Bulletins No. 23 and 24, American Hospital Association. 6. "Report of the Committee on Training f o r Hospital Social W o r k , " Bulletin No. 55 of the American Hospital Association (Chicago, 1923). 7. Richard C. Cabot, Social Work. 8. Richard C. Cabot, "Hospital and Dispensary Social W o r k , " Hospital Social Service, XVII, 269-320 (1928); presented at International Conference of Social W o r k , Paris, 1928. 9. Mary C. Jarrett, " T h e Psychiatric Thread Running T h r o u g h all Social Case W o r k , " Proceedings of National Conference of Social Work (1919), pp. 5 8 7-593· C H A P T E R 18. A SPECIAL P R I V I L E G E ι. Washburn, The Massachusetts General Hospital, p. 117. 2. Joseph C. Aub, Lead Poisoning (Baltimore, 1926). C H A P T E R 19. A SOCIALLY C O N S T R U C T I V E DISEASE ι. Edward T . Devine, Misery and its Causes ( N e w York, 191 r). 2. Boston Medical and Surgical Journal, CLV, N o . 12 (September 190ό), 307-308. 3. E. L. Trudeau, Transactions of the Congress of American Physicians and Surgeons Eighth Triennial Session ( N e w Haven, 1910). C H A P T E R 20. H A Z A R D S F O R T H E I N D U S T R I A L W O R K E R ι. H a r r y Linenthal, "Sanitation of Clothing Factories and Tenement-house Workrooms," chap, iv in E. A. Locke, ed., Tuberculosis in Massachusetts (Boston, 1908), pp. 28-36. 2. Sixth Annual Report of Social Service Department, Massachusetts General Hospital (1911), pp. 21-28. 3. Eighth Annual Report, Social Service Department, Massachusetts General Hospital (1913), pp. 9-10; Ninth Annual Report, Social Service Department, Massachusetts General Hospital (1914), pp. 18-22. 4. Eleventh Annual Report, Social Service Department, Massachusetts General Hospital (1916), pp. 30-31. 5. Annual Report, Massachusetts General Hospital (1916), pp. 48-50. 6. Aub, Lead Poisoning. 7. Washburn, The Massachusetts General Hospital, pp. 391-395.

NOTES AND REFERENCES CHAPTER

il. A T T I T U D E S

z6s

CHANGE

ι. Oliver Wendell Holmes, "Mechanism in Thought and Morals," Phi Beta Kappa address at Harvard, 1870. 2. Washburn, The Massachusetts General Hospital, pp. 303-305. 3. Jane Addams, " T h e Layman's V i e w of Hospital W o r k among the Poor." 4. Massachusetts E y e and Ear Infirmary, First Annual Report of Social Service Department, 1907-08. 5. Richard C. Cabot, " T h e Doctor and the Community," American Medicine, V I I I , 7 3 1 - 7 3 2 (1904). 6. Boston Medical and Surgical Journal, C L X I , 64 (1909). 7. Neis A . Nelson and Gladys Crain, Syphilis, Gonorrhea and Public Health ( N e w York: Macmillan, 1938), p. 1. 8. Second Annual Report, Social Service Department, Massachusetts General Hospital ( 1 9 0 6 - 0 7 ) , pp. 26-27. 9. First Annual Report, Social Service Department, Massachusetts General Hospital ( 1 9 0 5 - 0 6 ) , p. 19. CHAPTER

22. " I T ' S W H A T ' S

LEFT THAT

COUNTS"

ι. L u c y W r i g h t and A m y Hamberger, Education and Occupation of Cripples, Juvenile and Adult, A Survey of All the Cripples of Cleveland, Ohio in 1916 Under the Auspices of the Welfare Federation of Cleveland ( N e w York: Red Cross Institute for Crippled and Disabled Men, 1 9 1 8 ) , Series II, N o . 3. 2. Ibid., p. 78. 3. Caroline H . Elledge, The Rehabilitation of the Patient (Philadelphia: Lippincott, 1948). 4. Reports of White House Conference on Children, 1930. Section I, "Medical Social Service," pp. 1 3 1 - 2 7 1 ; also Sections III and I V , A and B, "Handicapped Children" ( N e w Y o r k , 1932). CHAPTER

23. T H E P A T I E N T

TEACHES

ι. Stites, History of the American Association of Medical Social Workers. 2. Indiana University, Report of the Social Service Department for 1 9 1 1 - 1 9 1 2 and 1 9 1 2 - 1 9 1 3 , pp. 45, 73. 3. Grace S. Harper, " T h e Uses of Social Case W o r k in Teaching of Medical Students," Proceedings of National Conference of Social Work (Baltimore, 1 9 1 5 ) . 4. Richard C. Cabot, "Adventures on the Borderland of Ethics, A Plea for a Clinical Y e a r in the Course of Theological S t u d y , " Survey, L V , 275-277 (1925). 5. Richard C. Cabot, Adventures on the Borderland of Ethics ( N e w Y o r k , 1926), chap, i, pp. 1 - 2 2 .

266

NOTES AND REFERENCES

6. Richard C. Cabot, and Russell L . Dicks, The Art of Ministering to the Sick (New York: Macmillan, 1936). C H A P T E R 25. F A C I N G N E W F R O N T I E R S ι. Abraham Flexner, Medical Education in the United States and Canada (New York, 1910). 2. Medical Care for the American People. Report of Committee on the Costs of Medical Care (Chicago: University of Chicago Press, 1932).

3. Bartlett, The Participation of Medical Social Workers in Teaching of Medical Students. 4. Widening Horizons in Medical Education. A study of the Teaching of Social and Environmental Factors in Medicine. Report of Joint Committee of Association of American Medical Colleges and American Association of Medical Social Workers (New York: Commonwealth Fund, 1948). 5. Medicine in the Changing Order (New York: Commonwealth F u n d , 1947).

6. Medical Addenda, Related Essays on Medicine and the Changing Order, 194η (New York: New York Academy of Medicine, Committee on Medicine and the Changing Order, 1947). 7. Abraham Flexner, "Is Social Work a Profession?" Proceedings, National Conference of Charities and Correction (1915). 8. Social Work Year Book, 1951 (New York: American Association of Social Workers, Inc., 1951). 9. Ernest V . Holies and Alice L. Taylor, Social Work Education in the United States, A Report of a Study Made for the National Council on Social Work Education (New York: Columbia University Press, 1951 ). 10. Harriett B. Bartlett, " T h e Significance of the Study of Social Work Education," The Welfare Forum (New York: Columbia University Press, 19J1), pp. 61-72.

Index Adams, Samuel Hopkins, 41 Addams, Jane, 37, 39, 40, 191-192 Adoptions, 137, 203, 204 Aged, social problems of, 137, 242, 244-246 Allen, William H., 143 Almoner. See Hospital Almoner American Association of Hospital Social W o r k e r s , 32, 118. See also American Association of Medical Social W o r k e r s American Association of Medical Social W o r k e r s , 118, 126, 130, 131, 139; history, 221, 2jo American Association of Schools of Social W o r k , 253-255 American College of Surgeons, 241, 2 47 American Hospital Association, 37, 38, 44, 84, 99, 126-131, 146, 148, 149, 245, 247; early purposes, 38; Service Bureau on Dispensaries, 148, 241 ; Service Bureau on H o s pital Social W o r k , 129 American Medical Association, Committee on Ophthalmia N e o n a torum, 194; Council on Medical Education, 241, 248 American Public Health Association, 2 45 American Public W e l f a r e Association, 245 American R e d Cross, 116, 118, 149, 151 American Social Hygiene Association, 196 Andrews, J o h n B., 179-180 Armstrong, T . S., 49, 85, 142 Astbury, Β. E., 16 Aub, Joseph, 161, 186 Auchincloss, H u g h , 132-133 Australia, Hospital Almoners in, 152 Baker, Edith, 116, 150

Baker Memorial Unit, M.G.H., 136137 Baker, Ray Stannard, 40 Baltimore Charity Organization Society, 30, 32 Barbour, Josephine C., 136-137 Barnett, Canon, 12 Bartlett, Harriett M., 139, 250; quoted, 256 B.irtlctt, Rev. John, 52, 54 Bartlett, Josiah, 52 Baruch Committee, 215 Beard, Mary, 117 Beaton, Laura, 77 Beckman, William W . , 231 Bellevue Training School for Nurses, 35 Benzol poisoning, 184 Berkeley Infirmary, 145 Bigelow, George H., 137, 197 Biggs, H e r m a n M., 43, 44, 166 Billings, J. S., 227 Blackwell, Elizabeth, 24-27 Blake, J. A. Lowell, 82, 122 Blind, Association for Promoting Interests of, 193; Commission for, 193-194 Boisen, Rev. Anton T., 232 Boston Almshouse, 52-53 Boston Associated Charities, 67-69 Boston Children's Aid Society, 46, 141 Boston Dispensary, 28-29, Î5> 76, 98 Boston School of Social W o r k . See Simmons School of Social W o r k Boston Society f o r Relief and Control of Tuberculosis, 39, 167 Bowditch, H e n r y Ingersoll, 167 Bowditch, Nathaniel I., 55-56 Bowditch, Vincent, 167 Brackett, Elliott G., 72-73 Brackett, Jeffrey R., 30, 82, 92, 122 Brackett, Miss Minnie, 73 Bradfield, Helen, 185-186

INDEX

268

Brannick, Catherine, 193 Brigham, F. Gorham, 159 British National Health Insurance A c t (1911), 20

British National Health Services Act (1948), 20

140

Brogden, Margaret, 32 Bryan, William Α., 232 Burleigh, Edith N., 78-79 Burrage, Katharine, 78-79

Charity Organization Movement, 43, 45. 67, 254

Cabot, Arthur T . , 70, 174 Cabot, Richard Clarke, 4-5, 6, 8, 20-

21, 33-34. 44. 49-5 1 . 5 8 -59. 63-64, 75. 8j, 95-96, 120, 133, 140, 143144, 175, 199-200, 202, 207-208,

248; address to Ν . E . Hospital, 142; advisor to School of Social Work, 93; analyzes function of Social Service, 96-97, 132, 134; appeals for support of Social Service, 47; appointed to M.G.H. Staff, 46; committee on training for social service, 92; characteristics, 4, 103-105,

133-135,

142,

19J; institutes Clinical Pathological Conferences, 123, 135, 160-161; establishes clinical experience for theological students, 232; Educational Fund presented, 139; experience with Boston Children's Aid Society, 46, 141; International Conferences of Social Work, 152, 154; interest in music, 5; interest in philosophy, 4, 5, 133; resignation from Hospital Staff, 135; tribute from Hospital Trustees, 135-136; twentyfifth anniversary of Social Service Department, 139; war service, 117-118, 151

Cabot Social Service Library, 139 Canada, medical social work in, 152 Cancer, 105-106

Cardiac Clinic, i n . See also Heart Disease Carnegie Corporation, 255 Carnegie Foundation for Advancement of Teaching, 247 Chapin, Henry Dwight, 29, 44, 49,

Cannon, M. Antoinette, 78, 130, 154 Cambridge Tuberculosis Association, 69

Chase, Ethel W., 115 Chesley, Annie L., 82 Children's Medical Clinic, 76; medical-social case conferences, 108, 109; cardiac clinic, i n ; social worker assigned, 110 Children's Mission, cooperation with, 112

China, medical social service in, 152 Choate, Francis, 180 Chronic illness, 137, 245-246 Cicely Northcote Trust, 18 Clark University, twentieth anniversary, 79 Clarke, W . Fairlee, F.R.C.S., 12-13 Cleveland Welfare Federation, survey of cripples, 213 Clinical Pathological Conferences, 123, 135, 160-161

Cockrill, Eleanor, 250 Codman, Ε. Α., 98 Cole, Rebecca, 25 Commissioner of Charities of N e w York City, request for study of social service, 90 Committee on Home Care of Children with Heart Disease, 1 1 1 Coolidge, Algernon, 98 Crippled Children's Program, Federal, 150, 206, 217, 253 Cummins, Anne E., 18, 20, 154 Curran, J . Α., 250 Curtis, Margaret, 151 Daniels, Annie S., 26 Davis, Michael M., 85, 98-99, 128, 148

Day, Elizabeth Richards, 85, 98 deBouchet, Charles, 145

INDEX de Forest, Robert W., 44 Denison, Edward, 10 Devine, Edward T., 36, 151, 166-167 Dewson, Mary, 47 Diabetes, 106, 159 Dicks, Rev. Russell, 233 Dimock, Susan, 27 Dispensaries, use and "abuse," 11, 13, 39. 44. 15°; growth, 99 Dutcher, Adelaide, 31 Edsall, David L., 86, 93, 110, 113, 176, 181, 183-184, 228 Ehrlich, Paul, 189 Eliot, Charles William, 196 Eliot, Martha May, h i , 149 Emerson, Charles P., 31-32, 85, 141, 143, 226-227 Emerson, Edward W., 220 Emerson, Ellen T., 2nd, 70 Emerson, Ruth V., 89, 116 Emmanuel Church, 32 Emotional aspects of illness, 46, 7780, 175, 177, 207-208, 237-238 Epilepsy, study of, 103-104 Esch, Senator, 179-180 Eustis, Richard S., h i Evans, Mrs. Glendower, 47 Evarts, Sarah, 118 Factory inspection, 42 Farmer, Gertrude L., 6, 65 Favell, Henry S., 142 Federal Children's Bureau, 37, i n , 253 Flexner, Abraham, 247, 254, 256 Floyd, Cleaveland, 69 Folkes, Homer, 44, 151 Food, protection of, 40-41 Foreign-born patients, 37 France, medical social work in, 153 Freud, Sigmund, 79-80, 189 Fussell, M. H., 142 Galen, 22 Germany, medical social work in, '53

269

Gerontology, International Conference on, 246 Getting, Mme Georges, 145, 151, 153 Gilman, Daniel C., 30-31 Glenn, Helen, 85 Glenn, John M., 30, 84, 143-144 Glenn, Mrs. Mary Wilcox, 30 Goldwater, S. S., 38, 99, 143-144 Gonorrhea, 190, 192, 196-198 Gorham, John, 53 Green, John Richard, 10 Gregg, Alan, quoted, 161 Halifax Harbor disaster, 115-116 Hamburger, Amy, 212 Hamilton, Alice, 28, 183 Hamilton, Gordon, 133 Hammond, Airs. John Hays, 115 Handbook for Physicians, 137, 138 Handicapped, social service for, 75, 188-218 Hardy, Harriet L., 187 Harper, Grace S., 75, 209-211 Harvard Infantile Paralysis Commission, 114 Harvard School of Public Health, 186 Harvard University, relation to Simmons School of Social Work, 261 Harvey, William, 22 Hashimoto, H., 152 Hawes, John B., 2nd, 69-70 Heart Disease, 76, 106, 110-113, 246; institutional vs. home care, 113 Henry, Edna G., 85, 148, 226-227 Higgins, Alice. See Lothrop Hippocrates, 157—158, 189; oath of, 158, 195 Hodder, Jessie Donaldson, 82, 201203 Hoe, Mrs. Robert, 26 Hogan, Lucy, 211 Hollis, Ε. V., 255 Holmes, Oliver Wendell, quoted, 189 Holt, Ed., 5 Holton, Susan, 182-183

270

INDEX

Hospital Almoner, 8, 15-16, 18; duties, 16-17; principles to guide, 14 Hospital Almoners' Council, 18 Hospitals: Bellevue, 35, 49, 8j; training school for nurses, 35, 8j Boston City, 114 Chelsea Naval, 116 Johns Hopkins, 30-32 London's Voluntary, 10 New England, for Women and Children, 27-28 N e w Haven, 250 New York Infirmary for Women and Children, 24-27 New York Post Graduate, 29, 49 Peking Union Medical School, 152 Presbyterian, 133, 139-140 Royal Free, 8, 13, 16, 19, 150 St. George's, 18 St. Luke's International, 152 St. Thomas's, 16, 18, 20, 150 University of Minnesota, 90 University of Pennsylvania, 85 Washington University, 150 Wilhelmina, ijo House of Lords, hearings, 11; Select Committee, 15—16 Housing Reform, 42-43, 91, 166 Howard, Herbert B., 63 Hurd, Henry, 31 Huxley, Thomas, 12 Hygiene, teaching of, 222-224 Indiana University, Department of Sociology, 226 Industrial Clinic, 118, 176, 182-183, Infantile paralysis epidemic, 1 1 3 - 1 1 4 Institute of Hospital Almoners, 18 International Conference of Social Work, 20, 152, 154 Jackson, James, 53-54, 190 Jackson, Miss Marian, 68 Janeway, Theodore, 142, 209 Japan, medical social work in, 152

Jarrett, Mary C., 134, 154 Jenner, William, 22 Jones, Daniel Fiske, 82 Jones, T . Duckett, 113 Kellogg, Dorothy, 231 Kelly, Florence, 41-42 Kemp, Edgar S., 150 Keyes, Alicia, 79 Kimball, Alice, 204 King's Chapel, 75; Committee for the Handicapped, 209-210 Knopf, S. Α., 43, i66 Koch, Robert, 164 Landsberg, Hedwig, 153 Lathrop, Julia, 37 Lead poisoning, 161, 181-182, 187 Lee, Joseph, 103 Lee, Mrs. Roger I., 98 Lee, Roger I., 117, 181 Lewis, F. Park, 194 Lewis, Ο. M., 197 Linenthal, Harry, 176, 179, 182 Loch, (Sir) Charles Stewart, 8, 1220, 36; Secretary to London Charity Organization Society, 12; Royal College of Surgeons, 12; quoted, 14, 19 London Charity Organization Society, 8, 10, 12-13, 16-17, IJO; medical committee, 12; purposes stated, 10 London Family Welfare Society. See London Charity Organization Society Lothrop, Alice Higgins, 68, 118, 122, 167 Lowell, Mrs. Josephine Shaw, 35 Lyman, Ella. See Mrs. Roger I. Lee McLean Hospital (Asylum), 55-57 McMahon, Kate, 253 McShane, Elizabeth, 186 Marfan, Professor, 145 Mason, Mrs. Elizabeth Andrews, 111 Massachusetts Commission on Tuberculosis, 70

INDEX Massachusetts Conference of Social Work, 5 Massachusetts Eye and Ear Infirmary, 100, 192-194 Massachusetts General Hospital, 3-5, 20, 24, 33-34, 46, 48, J I - J 9 , 63, 69, 82, 84, 90, 126, 140, 143, i4ï, 159, 180, 190, 208, 254; emergency ward, 239; Ladies' Visiting Committee, 3, 84, 88-89; Outpatient Department, 47, 64, 72, 98, 100, 102, 114, i i j ; purposes, 219; teaching functions, 219, 222, 228229, 233-234; training school for nurses, 89, 93, 224; Trustees' tribute to Dr. Cabot, 119 Social Service Department, "permitted," 63, 83; partial recognition, 87; position of Chief created, 87; official acceptance, 119; educational responsibilities, 89, 91-94, 100, 139, 221, 223, 228233; Supervisory Committee, 8 1 82, 87, 89, IOO, 121, 122 Massachusetts Reformatory for Women, 202 Means, James Howard, 228-231 Medical education for women, 24 Medical frauds, 41 Medical history, 22-23 Medical Schools; Boston University, 225; Harvard, j8, 93, 250; Indiana University, 32, 226; Johns Hopkins, 32, 226; Tufts, 225, 250; University of Pennsylvania, 250; Yale, 250 Medical-social terminology sought, * 33 Medical social work, education for, 93, 100, 130, 147-148; seeking special role, 96-97; survey of, 127-130; uses in disaster relief, 1 1 5 - 1 1 6 ; uses in epidemic, 117 Medicine, complexity of organized, 236-237; contribution of science, 23; contribution to social work, 131—132, 160-162, 252; education for, 247-2jo; ethics of, 157-158,

271

189, 195, 240; specialization, 236238; trends, 23, 246-249 Miller, James Alexander, 145, 151 Millet, Charles, 167, 170 Minot, George R., 118, 228-229 Mongoloid infants, 108 Monks, John P., 138, 231 Monksville, Lord, 16 Moors, John F., 103 Morris, Cherry, 18, 154 Morrow, Prince, 189, 196 Morse, Miss Frances R., 92, 103, 118, 122 Musser, John, 85 Myers, Mrs. Grace, 107, 180 National Conference of Charities and Correction. See National Conference of Social Work National Conference of Social Work, 42, 84, 90, 254, 256 National Foundation for Infantile Paralysis, 216 National Organization for Public Health Nursing, 146 National Society for Crippled Children, 216 Neguchi, 189 Nelson, Neis Α., 197 Neurasthenia, 78, 79 Neurological Clinic, 77 New England Association of Hospital Social Workers, 126 New York Academy of Medicine, 25' New York Charity Organization Society, 35, 43-45, 209; committee on tuberculosis, 43, 69, 166 New York Conference on Hospital Social Service, 89, 126, 145 N e w York School of Social Work, 45, 130, 221 Nursing, 3, 29, 35, 49, 92-93, 117, 146147, 220, 224-225, 242 Occupational diseases, 179-180, 182184 Occupational therapy, 208

INDEX

272

Ophthalmia neonatorum, 192-194 Ordway, Mabel, 104 Orthopedic Clinic, 72-73, 75 Osgood, Robert B., 72, 82, 117 Osier, Sir William, 31, 226; letter to Dr. Cabot, 33 Otis, E. O., 167 Parran, Thomas, Jr., 198 Parsons, Sara E., 224 Pasteur, Louis, contribution to medicine, 22 Pear, William H., 141-142 Pelton, Garnet I., 48, 63, 140, 142, 1 4 4 - 1 4 J , 148, IJO

Pendleton, Helen B., 30, 32, 226 Perry, Ralph Barton, 5 Phosphorus poisoning, 179-180 Physical medicine, 215 Poliomyelitis, Massachusetts Commission on, 114 Pratt, Joseph H., 32, 69 Preventive medicine. See Public health Provident dispensaries, 13, 16 Pruitt, Ida, 152-153 Psychiatric social work, 118, 130, 138, 251 Psychiatry, influence of, 80, 103, 118, 'Ϊ4ι 2 I 5 Public health, 3, 6, 22, 24, 26, 31, 36, 39-40, 42-43, 69, 7 0 - 7 1 , 91, 114, 116, 1 3 8 - 1 3 9 , 146-147, 1 5 8 - 1 5 9 , 1 6 2 - 1 6 3 , 164-178, 187, 189-199, 217, 222, 224, 236, 242, 244-246, 249, 2 5 1 , 256

III, 150, 179235253,

Putnam, Miss Elizabeth, 47 Putnam, James J., 64, 77-79, 81-82, 92, 102-104,

r

°8> " 8 , 121

Rehabilitation, Federal program, 150; vocational, 177, 150. See also Handicapped Rice, Elizabeth P., 250 Richards, Elizabeth V . H. See Day Richardson, Anna G., 193 Richardson, Anna Mann, 127-128

Richardson, Mrs. Mary Rich., 136 Richardson, Oscar, 160 Richmond, Mary E., 30, 84, 132-133, '5>

Riis, Jacob, 42 Rockefeller Foundation, 152, 161 Rogers, Miss Annette P., 193 Royal College of Surgeons, 12 Royce, Professor Josiah, 4-5 Russell Sage Foundation, 30, 84, 86, 93, 130, 149

Rutland Sanatorium, 172-173 Ryther, Margherita, 104 Schaudinn, Fritz, 189 Schools of Social work. See American Association of Schools of Social Work, New York School of Social Work, Simmons School of Social Work Schuyler, Louise Lee, 35 Sears, Francis P., 122 Shattuck, Lemuel, 164 Sheppard, G. F., 16 Shipps, Helen, 152-153 Simmons School of Social Work, 56, 91-93, 100; foreign students, 151-152; special course for medical social service, 100, 147, 221, 261

Siseo, Dwight L., 137 Smith, Richard M., 76, 108, 110-111, 118

Social aspects of illness, teaching medical students, 31-32, 225-231; teaching nurses, 224, 225 Social Hygiene movement, 189 Social settlements, 254 Social Work Education, National Council on, 255 Social work, professional development, 4, 9, 45; education, 45, 92, 254-256

Social Work Year Book, 255 Soule, Theodate, 154 Southard, E . E., 5, 133-134

Speedwell Society, 29-30 State Charities Aid Association, 35

INDEX Steffens, Lincoln, 40 Stewart, Mary, 16-17 Stillman, E. C., 14J Stites, Mary, 221 Syphilis, 190-192, 195-198; resistance to reporting of, i j 8 Talbot, Fritz B., 76, 107-108 Talbot, Mrs. Fritz B., h i Tarbeli, Ida M., 40 Taylor, Alice L., 255 Tenement work shops, 26, 91, 176 Terry, Edith M., 113 Thayer, Mrs. Nathaniel, 64, 82, n j , II7

'. 1 2 1

Theological students, clinical experience, 232-233 Thornton, Janet, 139 Tippet, Alice O., 84, 86, 88 Trudeau, Edward L., 171-172; tribute to Dr. Cabot, 172 Tuberculosis, 43, 69, 70, 106, 164179; bacillus discovered, 164; classes, 69; climate, 170; Massachusetts Commission, 170, 174175; reportable, 158, 179 Tiillman, Anni, 153 Tyson. See Helen Glenn United States Sanitary Commission, University of Minnesota Hospital, request for consultation, 90 Unmarried pregnancy, 82-83, '37» 199, 201, 203 Vanderbilt Clinic, 142 Veiller, Lawrence, 43 "Venereal disease," 82, 190, 192, 196

2

7 3

Veterans' Administration hospital, social service, 253 Viets, Henry R., 160 Vocational guidance, 212-214 Vocational Rehabilitation, Office of, z'J Wadley, Mary E., 49, 85, 90, 140-141, 144

Wald, Lillian, 44, 49 Warner, A. R., 99, 126-127, 148 Warren, John Collins, 53-54 Washburn, Frederic Α., 82, 84, 86, 88, 92, ioo, 102-103, "9> I2I > I24> 136, 187; quoted, 123 Wassermann, August von, 189 Webb, Beatrice and Sidney, 12 Welsh, Clara May, 111-112 White, Paul D., 113, 118 Wiley, Harvey W., 40 Wilkie, Mrs. John L., 49 Williams, Linsey R., 142-143 Wilson, Alexander, 167 Winslow, C.-E. Α., 146 Worcester, Alfred, 232 Workman's compensation, 180-181, 185 World Health Organization, definition of health, 246 Wright, J. Homer, 160 Wright, Lucy, 212 Wright, Marie M., 186 Wright, Wade, 118, 185-186 Yerkes, Robert M., 5 Zakrzewska, Marie, 27 Zander apparatus, 208