we have an intuition that first impressions are lasting. Where there have been matters in dispute, however, the strategic position-second only in value to the first-is the last. In short, we must guard against the impression made by first and by last statements in an investigation.

In all this analysis of data the suggestions made in Part I in the discussion of inferences will be found useful. What is there said about the testing of inferences applies to their retesting by the case worker, and is so fundamental that it has seemed best not to restate in abbreviated form the conclusions of that chapter at the beginning of this. There are, however, many of the details in the later process of comparison-in the process of examining critically, that is, the gathered testimony-which are best summarized on the assumption that someone besides the case worker himself is to review a mass of evidence.

2. Suggestions for Comparisons Made by a Supervisor. What should a supervisor look for in a case record in which the work has reached the stage of evidence gathered but not yet compared or interpreted? For convenience of reference the treatment of this topic has been reduced to questionnaire form and added to the series of questionnaires in Part III, but every other questionnaire in this volume should be understood to have a relation to supervisory work and to the comparisons made in self-supervision. The questionnaire for supervisors summarizes material scattered throughout this volume and rearranges it under the heads of (a) the case worker's relations with client, (b) with client's family, (c) with outside sources, (d) the conduct of the inquiry as a whole, and (e) wider aspects of the inquiry.

Good supervision must include this consideration of wider aspects. We have seen that the habit of keeping in mind the bearing of each individual fact on general social conditions gives added significance to the statements in a record. This habit may also open broader avenues of usefulness. Every case worker has noticed how a certain juxtaposition of facts often reappears in record after record, and must have suspected that this recurring juxtaposition indicates a hidden relation of cause and effect. Or else he must have noted that some twist in the affairs of clients showed again 1 See p. 81 sq. See p. 449 sq.

and again a marked similarity of outline such as to suggest a common cause, though no rational explanation came to hand. It is here that the "notation of recurrence," as it is called, becomes a duty of supervisor and case worker. Not only should these repetitions be noted but they should be compared carefully. Some situations that seemed similar will be found upon examination to be different in essence, but the remainder, if they are likely to throw light on social conditions or on the characteristics of any disadvantaged group, should be submitted to those specialists in social reform who can make a critical and constructive use of them. The getting at knowledge that will make the case work of another generation more effective may be only a by-product of our own case work, but it is an important by-product.1 The wider significance of case work data is illustrated incidentally in the analysis of the Ames case, which follows:

3. The Ames Case. On page 84 will be found the face card of a family record of the Ameses, begun in 1909, together with a discussion of some of the inferences drawn from it by a case worker who had not read the record itself. This process of drawing inferences from a face card and then testing them by the record or by further inquiry will be found useful in review procedure.

Let us now see, without attempting to reproduce the Ames record, how a few of the suggestions in this section may be applied to the story of that family:

1 Dr. Adolf Meyer, addressing a group of after-care committees for the insane, just after having read some of their records, says, "I had to put a big black cross in my mind over the town of Waterloo. There is a town which evidently contains centers of infection, which the community cannot afford to tolerate, and which can be attacked if one has sufficient material against them. . . . The authorities and the good and bad people may not pay much attention to remonstrations until sufficient material accumulates and is plunged at the right time, and then you may be able to do something. These are difficult tasks, I know, but there is no way of doing anything by keeping quiet or by making abstract complaints."After-care and Prophylaxis, p. 16. Reprint of an article in the State Hospitals Bulletin, March, 1909, authorized by the State Commission in Lunacy, Albany, N. Y. Utica, N. Y., State Hospitals Press, 1909.

* Study of the original case record would be more satisfactory, for case workers will always disagree as to what is important and what is not in the making of a summary. On the other hand, a social case record which is fully adequate for study is such an identifiable thing that the writer has never been willing to publish one. The few that have been privately printed for class study only have been excellent teaching material, though even in the use of these few the danger of violating the confidences of clients has not been completely avoided, and the problem of reconciling their use with the highest case work ethics has been a puzzling one.

Thomas Ames is a tuberculous hatter of thirty-eight with a wife of twenty-eight and two children, girls aged six and nearly two. Mrs. Ames' mother lives with them. The family had been reported as in distress to a charitable woman, Miss Delancey, when she happened to be visiting some of their neighbors. After one visit to the Ameses, she sought, on May 10, the advice and aid of the nearest district office of the charity organization society. One of the society's case workers held the first interview in the home that same day, noting on the record that she was obliged to interview Ames, his wife, and his mother-in-law together.

Mr. Ames gave at this time his story of work at Caldwell's hat factory ever since his marriage, and stated that the tuberculosis dispensary had advised him to apply for admission to the state sanatorium, but that he could not leave his family. He was seeking work as an insurance solicitor, hoping in this way to become stronger. The mother-in-law was not working for reasons unstated. The church had helped but was too poor to continue, or so the family believed. Mrs. Ames had never been strong since the younger child's birth. She showed some hesitation about having any of her own or her husband's people seen. Mr. Ames, however, said that he understood the case worker's desire to consult them and furnished the addresses of his four brothers and sisters and of his wife's two sisters.

The outside visits were then made in the following order: Tuberculosis dispensary, Mrs. Ames' two sisters, her doctor, the school principal of the older child, one of Mr. Ames' brothers, and his two sisters, then the tuberculosis dispensary twice again, followed by an interview with Mrs. Ames alone. Only after all these visits had been made were the manager of the hat factory and the pastor of the church seen.

What did these outside visits reveal? An unusually simple family history, which for that reason is used here for illustration. The dispensary doctor was not found until the third visit to the dispensary, which, aside from sending a quart of milk daily, had had no contact with the home. The medical record showed that Ames' condition was grave, that he was running a high temperature and was unable to work.

Mrs. Ames' two sisters spoke in high terms of Ames' industry and kindness to his family. The older child was reported by the school principal to be quiet, well trained, and diligent, but "by no means bright." Mrs. Ames' doctor had known the family a long while, spoke well of them, but was vague about the wife's health, describing her as “always frail,” and did not state how long it had been since he had last treated her.

Joseph Ames and his wife had not realized before the seriousness of the situation. On learning it, they offered Mrs. Ames and her children a home if her husband would go to the sanatorium. (The case worker said on the spot that she thought the plan an excellent one, though the interview developed that both Joseph and his wife were sure Mrs. Ames should go to work and that she was "too high-toned.") Their sister, Clara, seen on May 15, was found to know the Ameses better than the other relatives of the husband. She dropped a hint that Ames was willing to go away, but that his wife was holding him back and urging him to find other work.

The case worker had had no intimation of this, but it proved the key to all the

treatment that followed. A private interview was had with Mrs. Ames. She could not believe at first that her husband's condition was as grave as represented, and moreover was worried as to what was to become of her home and her children. It was possible to convince her that Ames was a very sick man, and to reassure her as to her household. The explanation of Ames' attitude having been passed on to the dispensary, the doctor there was able to persuade his patient to apply for admission to the sanatorium.

It had taken ten days to accomplish this. Thereafter followed quickly visits to the two important sources of co-operation in the case-the employer and the church. Although Caldwell's had aided, the firm did not know that Ames had tuberculosis or was incapacitated for any work. They agreed, in the light of this development, to pay $5.00 a week until Ames could be admitted to the sanatorium. (The period of help was extended later to the date of Ames' return.) The pastor of the church agreed to supply whatever food was needed.

During an interval of some months before Ames could be admitted, Miss Delancey served as a regular visitor to the family, with the immediate object of suggesting the necessary precautions for the invalid. With a sleeping tent in the back yard, Ames actually made some slight gains at home before his five months away.

This social diagnosis and treatment, which was successful in the promptness with which it got at the heart of the difficulty-a personal as well as an economic oneand rallied the outside sources to meet it, had some weaknesses which a competent supervisor would quickly discover. Ames came back well enough to take and keep more healthful work under his old employers. But just after he went to the sanatorium in September, Mrs. Ames developed an incipient case of tuberculosis. Fortunately the infection was discovered in time; but the fact is there had been such concentration upon the problem of the sick man that preventive examinations of wife and children—a precaution more often neglected in 1909 than now, it is true-had not been made. And why was a woman described as frail left with no more definite diagnosis for four months? The opinions of the relatives on both sides of the house as to her health, her ability to work, etc., were set down in the record, but no competent professional judgment was procured.

Then, before the inquiry had been completed, the offer from the Joseph Ameses of a home with them for Mrs. Ames and the children had been accepted by the case worker as a definite solution without weighing the arguments for and against. Probably it was so received because it was the first concrete offer made. Its abandonment later may have been because other resources became available, and may have had no reference to the real objections to this solution on the score of health, incompatibility, the difficulty of re-establishing the home once it had been broken up, etc.

What does the school principal mean by her statement that Alice Ames is "a diligent student, although by no means a bright child"?

Even in so relatively simple a case as this one, a comparison of all the items of evidence, both by the case worker and by someone who did not know the Ameses, would have saved motion in useless

directions and have started it in helpful ones. A supervisor skilled in the notation of recurrence, moreover, would have learned from the study of other cases that not only in the hat factory where Ames worked but in certain branches of the whole industry did an unduly large proportion of tuberculosis cases have their origin. This feature of the case noted, all available data should have been placed at the service of students of occupational disease in its legislative and other aspects. Not satisfied with search in this one direction, the supervisor should have sought for possible causal factors of Ames' disease in his family history and his home sanitation.

At the same time it must be admitted that both case worker and supervisor might have made all these comparisons painstakingly, might have secured the necessary medical diagnoses of mother and children, and the mental examination of the older child, might have organized a committee to investigate the relation between hat making and tuberculosis, and might still have failed utterly in the social diagnosis and treatment of the Ameses. "They go through all their paces," said a social worker of certain trained assistants, "they attend to all the latest things listed in our modern social programs, and then miss, far too often, the most significant point in the whole case." This is another way of saying what Dubois has said they possess all the working machinery of diagnosis but do not know how to make a diagnosis.1 Painstaking comparison of all the items of evidence aids and leads up to interpretation, it often reveals the interpretation, but it cannot provide the imaginative insight which can make interpretation more than half of treatment.

III. THE INTERPRETATION OF MATERIAL

Ability to form a judgment is more important than ability to suspend judgment. We are between the horns of a dilemma here, for the diagnosis too promptly made, even when not erroneous, may be only the one-word diagnosis which roughly describes the general type of difficulty, and leaves undefined every individualizing particular. The delayed diagnosis, on the other hand, may miss the critical moment for effectiveness in treatment. With all the

1 See p. 347.