culous patients found in them. One of the greatest helps from the Health Department comes from the daily receipt by each district office in the Charity Organization Society of the contagious disease bulletin and also the receipt of the monthly bulletin. The Health Department is also helpful in giving information about midwives, as from this department midwives' certificates are issued. As the tuberculosis clinics connected with the Health Department use the Social Service Exchange of the Charity Organization Society, it is always possible to know when a clinic is interested in a family known to the society.

III. SOCIAL RESPONSIBILITY FOR EARLY MEDICAL DIAGNOSIS Medical authorities are agreed that any way by which medical diagnosis could be had earlier than at present would add materially to the number of cures. It is at this point that the non-medical social worker might easily hold a strategic position, by cultivating a watchful eye for the possible indications in family and current history, in personal appearance and in mental attitude, of those physical and mental breakdowns that happen to have been preceded by social breakdown. The non-medical worker, if he is wise, will never attempt to make a medical diagnosis, even of the most tentative kind, but he will utilize promptly every opportunity to bring together the possible patient and the expert medical diagnostician. Early diagnosis is a very important element, for instance, in the cure of syphilis, cancer, stomach ulcer, and leadpoisoning, while the prevention of infant blindness is a matter of hours not days. This is no plea for a general interest in health campaigns, which is almost universal and often most in evidence in those very family agencies that are neglectful of their opportunities to cure and prevent in the individual case. The important thing to emphasize here is the daily exercise of our interest. by leaving no stone unturned, by making the concrete application in the detailed work of whatever kind for which we stand responsible to the community.

Comment on one of the case records of a large family agency reads as follows: "Visitor has certainly shown patience and sympathy, and has tried to align all available sources for relief. Is it not possible, however, that time and money might have been saved if a careful examination of the man had been made at once, instead of trying for two months to help him get work which he was physically unable to do?"

"I remember with shame," writes a supervisor of case work, "a case that I had myself years ago where a man who was thought to be very lazy really had intestinal

tuberculosis. In these days a good many case workers would be quick to see the possible significance of symptoms such as his and would arrange for a medical examination promptly, but there are hundreds of others all over the country who would not. We cannot emphasize too strongly, it seems to me, the importance of securing medical examinations in all doubtful cases, as one of the most important principles of social treatment."

A charity organization society secured surgical care for a woman whose health had been injured, according to the society's record, by running a foot machine in a factory. As soon as she recovered she returned to the old job, where she could make good wages, and her daughter was permitted to start at the same kind of work.

Any list of the particular things relating to health that are to be kept most in mind by the non-medical worker will change yearly with the rapid advances in medical knowledge and with the equally rapid gains in the public control of disease. Since the preparation of this book was begun, there has been a marked change in the matter of workmen's compensation (to take an illustration that is both industrial and medical), but the responsibilities and awkwardnesses from which these new compensation laws have released the social case worker will enable him to make his work for individuals tell all the better in the allied field of occupational disease.1 Social case work will continue to show, in its future development, this frequent throwing off on the one side and annexing on the other. To those who may be tempted to complain that too much is expected of the social case worker, this is the answer. His task contracts in a cheering way only as he deliberately extends it in directions that are carefully chosen and then steadily advanced.

Owing to the rapid changes just referred to, not even the most tentative list of health matters to be kept in mind by the social diagnostician can be given here, but medical men are beginning to write for social workers, and their statements should be studied carefully at first hand. There are excellent manuals relating to tuberculosis, and recently we have had a Layman's Handbook of Medicine prepared "with special reference to social workers" by Dr. Richard C. Cabot, in which, among many other things of use to us, he is at pains to name those diseases in which, owing to the

1 For illustration of the type of case work still needed in the compensation field, however, see Chapter XII, Employers and Other Work Sources, p. 248.

2 Cabot, Richard C.: A Layman's Handbook of Medicine. With special refer

ence to social workers. Boston, Houghton, Mifflin, and Co., 1916. € 3.2

importance of past history in their diagnosis, the social worker can be of especial service.

IV. METHOD

It remains to gather up, from notes made in the course of case reading, such criticisms and suggestions with regard to the relations of case workers to Medical Sources as will possibly help to strengthen social diagnosis on the health side.

1. Ask for Prognosis. It is not enough to learn the name of our client's disease; even more important are the medical predictions as to duration and probable outcome-the physician's prognosis. We should also be at great pains to learn what social treatment will hasten recovery and what will help him to avoid a recurrence of the trouble. In this way the medical prognosis may become the cornerstone of the social diagnosis.

2. Economize Resources. This lesson is needed at every stage of treatment and in the use of every source of information, but it is especially needed at this point by workers in the larger cities, for in these Medical Sources multiply very rapidly, and are sometimes consulted wastefully and heedlessly by the social agencies. The very willingness of doctors, hospitals, and dispensaries to serve is a temptation to the social worker. They should be consulted freely, of course, but should be chosen with care, and for better reasons than the social worker's own convenience. A knowledge of the special facilities and the limitations of medical agencies in the worker's own city is essential; and once consulted, these should be utilized to the full; should be given the benefit, that is, of whatever is known already, and should be given a free hand to make as complete a diagnosis as possible. The medical diagnosis given with encouraging promptness is not always the fullest or the best, and social workers should have a special respect for the physician who hesitates to pronounce judgment hastily.

Nowhere, perhaps, can the scientific axiom, "observations are not to be numbered but weighed," be more fittingly applied than to the following of medical dicta. The testimony of one physician who knows is worth the testimony of fifty who do not know. We should discourage the needless multiplication of Medical Sources, therefore, by consulting, at whatever cost of time and trouble to

ourselves, the very best available, and then should abide loyally by their findings.

In the small community, even the mediocre specialist may not be available for mental and nervous examinations, and it may devolve upon the social workers there-little fitted as they may feel themselves for the task-to interest one of the younger doctors to make special studies in this field. Many similar gaps remain to be filled; there are communities in the South where no physician has any special knowledge of the treatment of pellagra, and others, both North and South, where, even now, no expert diagnosis of a case of tuberculosis can be had.

But in the city of many physicians and medical agencies, how shall we discover who are the best available? Often doctors have been consulted before the social agency appears upon the scene, and it is necessary to turn to medical judgments already formed and to act upon these. Consequently it will sometimes be necessary to make inquiry about the standing of the doctor in a given case among his own fraternity. The etiquette of the social worker's relations to a reputable but relatively incompetent private physician who is in charge of a difficult case requiring the best diagnostic skill has yet to be worked out, but the patient's interests demand a not too easy withdrawal from a situation which calls for both tact and persistence. It is disheartening to read in social recordseven in those showing the deepest concern for the welfare of the client whose treatment is recorded-entries of hasty and contradictory opinions given by doctor after doctor, hospital after hospital, with blind faith in all on the part of the recorder, and with no consciousness of failure, apparently.

Dr. Cabot comments upon a social record submitted to him as follows: "The lack of medical co-operation, that is, lack (in the first place) of ability and (in the second place) of frankness on the part of the doctors concerned in the Boyle-Carey family, has been pointed out by various of our social workers at the Social Service Department, and doubtless by many others. But the point that I want to make about it is this: It may very well have been impossible to secure adequate medical co-operation, and the workers on the case may therefore have done everything that could have been done to avert the evils that came from the lack of such co-operation. But it is not at all evident that the workers were themselves aware that they were being checkmated and put on false scents so frequently owing to the shortcomings of the doctors. When a person is quite unavoidably balked by such means,

it seems to me that the records should show some indication of his rueful awareness thereof, just as, when a surgeon tells a patient that he should be operated on and the patient refuses, the surgeon is careful to make it clear in his record that the subsequent disasters are not his fault but are due to lack of proper co-operation."

3. Seek First-hand Information. This also applies elsewhere, but when the statements are as technical as medical diagnoses and prognoses are likely to be we must guard this point especially. In the gathering of medical evidence we must avoid both oral and second-hand reporting, whilst using every possible device that will save the time of the physician and his busy hospital and dispensary assistants. The written diagnosis is no substitute for a personal interview with the doctor, in which his suggestions as to social treatment and his fuller statement as to prognosis are procured; it saves many misunderstandings, however, and should not be omitted. The secretary of a state commission for the blind now asks for a written statement of diagnosis, and, when this is refused, indicates on the record that the diagnosis came by word of mouth only.

It will not always be possible to follow this rule, but it is quite possible to foreswear the gathering of medical information by hearsay. To ask a patient what the doctor said about his condition and write down the answer is to quadruple the chances of error, for the doctor may not have told him the whole truth, fearing that it would unduly alarm him; the patient may not have understood what was said; he may not remember accurately; or he may have reasons of his own for not telling all that he remembers. Some one or more of these objections applies to all evidence at second hand, and its use when the source is accessible is a sign of faulty technique.

A worker in a child-placing agency heard a rumor that Mrs. B, with whom twins had been placed to board, was tuberculous. Accordingly, fearing for the health of the agency's charges, she telephoned the charity organization society's district secretary, who had known Mrs. B. The secretary stated that Mrs. B had been treated at a certain hospital three years before for tuberculosis and that one of her children had had tubercular glands. Knew nothing more recent of physical conditions, but felt there was absolutely no danger at this time. Agreed with child-placing agent that it might not be a good place for a long residence. The twins were removed from the home immediately, though, save for Mrs. B's health, it was a suitable one. A case reader comments upon the record of this treatment as follows: "I find fault with this action, first because the hospital record was not consulted, and second, for the unsound deduction that the home might be safe temporarily but not per