or a repression that made any activity in the home impossible, cut off from the child even the restricted play-life there.

Since a child gets his best social contacts in play, it is not surprising that, of the seventy-seven children lacking contact with others, fifty-six were also shut off from play. The remaining twenty-one played, but alone or with adults in close supervision. Ten of them had no brothers or sisters to play with; two were excluded from association with others because of bad habits; nine did not get along well with other children.

Out of four hundred children, we found thirty-three who lacked an opportunity to learn the meaning of affection normally in daily life. Twelve of these were placed out in frequently changing homes or in institutions. Some of these had serious conflicts to remember in their broken homes. Thirteen were definitely disliked by father or mother, six others were victims of the unwholesome emotional attitudes of mentally abnormal parents, still others, loving both father and mother, were in constant conflict because of parental quarrels. Such children could hardly know the meaning of normal family affection.

An effort to learn why homes fail to furnish the essentials of good child care showed certain menacing factors at work. Predominant was friction between parents or relatives in the home, in fifty-one cases. Conflict of ideas about child training in thirty-five cases, although in nineteen of these the parents were quite amicable about their differences, made a division of authority serious for the child. Early exposure to sex knowledge or experiences was present in at least twenty-seven cases. In scattering instances bad conduct in the children, such as destruction of property, running away, and violence against others, could be traced directly to examples furnished in the home or immediate neighborhood. These instances are much more frequent in the older group of children. What the seeds are in early childhood which bear fruit in delinquency from eight or ten to twenty years is still largely unknown. The friction in the homes studied was, in half the instances, connected with drink, gambling, or lack of parental responsibility on the father's part; with mental defect or disease in one or both parents in eleven cases, and with temperamental differences between parents in ten. In fourteen families, strife had already resulted in a separation of parents, not always, however, with elimination of the absent parent from the child's circle of influences. A marriage to patch up illegitimate parenthood left seeds of conflict in seven homes. In eight cases the discord was between parent and child or, to an extreme and chronic degree, between one child and another; six were cursed by jarring relatives. Racial and religious differences between parents and a wide disparity in age made up among them eight more sources of irritation. Sixteen pairs of parents quarreled over methods of training the children, although in every case there was some other factor present, such as interference of relatives or a conflict between old- and new-world standards.

It is impossible to say how many of the four hundred children studied had been the victims of exposure to sex knowledge and experiences. We know

that sixteen were noted as sharing the room with their parents, where the habits of the latter made it unlikely that the child could escape such knowledge. Eight children were known to have had sex experience with brothers or sisters or companions. Carelessness at the time of the birth of another child resulted seriously for at least two children.

To view the failing or menacing home from another angle, we studied the handicaps of the parents represented. Two hundred and twenty-five of the children had parents who were prevented by ignorance from making a success of their parenthood. This does not mean ignorance of child training alone, but lack of general educational background so that new knowledge could find a foundation. They were not counted ignorant if they could think about their problems even crudely, and express their thoughts sufficiently to interchange ideas about them.

Forty-eight children had parents who were handicapped by physical illness, the fathers so as to be unable to work, the mothers so that housework and the control of the children were at times impossible. This does not include nondisabling syphilis or chronic poor health which gnaws away at one's patience and self-control. The mothers suffered most often by far from gynecological conditions, with heart disease and tuberculosis next in order. The fathers furnished only a quarter of the number of disabled parents, and most often with diseases of the digestive system or injuries to the spine.

Mental defect in parents had been diagnosed by psychological examinations in eleven cases, and informally in twelve more. Mental disease was known in eight cases and believed to be present in four more by the clinic physician. In addition, seventy-five children had one or both parents who were considered by the clinic staff distinctly neurotic-parents whose own mental difficulties made an effective relation to their children impossible. In all, mental or nervous disability in the parents was a disturbing factor in the lives of 110, or more than a quarter of all the children.

Aside from those whose parents were suspected of mental disability, eighteen children had one parent at least who was distinctly irresponsible in relation to the child. Seven of the mothers seemed indifferent to their children; five more were the victims of habits of loose living; two were young, and so dependent on their mothers as not to count in their own homes. Seven fathers indulged in bad habits and took their family cares lightly.

Is it possible to be too good a parent? Eighty-five children were considered by the clinic to be the victims of oversolicitude. There were certain conditions which seemed to accompany this misfortune fairly often. The child was an only child in nineteen cases, and the only boy in 23. The mother was neurotic in onefourth the cases. Loss of other children, widowhood of the mother, advanced years of the parents, unhappy married life, accounted among them for another quarter. One-fourth of the children had had much illness or had met with some injury.

A bit of racial background comes out in the study of oversolicitude in

parents. The Jewish mothers made up 58 per cent of oversolicitous mothers, or two and one-half times their proportion in the whole number of cases. There seems to be a good reason for this in the ideals of the Jewish community. Mothers are proud to tell the clinic worker of their untiring devotion to their children, especially in sickness, and loath to undertake measures recommended to cure a child of peevish self-absorption lest their neighbors think them "without a mother's heart." One of the educational tasks of the clinic is therefore to show this group of mothers, the most devoted in the world, how they may sacrifice to make their children wholesomely well, instead of rendering them unfit for joyous living.

What of the children themselves? One of the surprising things about the clinic work was to find the large proportion of quite normal youngsters who became patients solely because of abnormal homes and training. Thirty-two and one-half per cent showed some physical disease or defect, frequently enlarged tonsils or adenoids, or were in rather poor physical condition; only 6 per cent had a diagnosis of mental defect or disease; 13 per cent more were estimated by the social worker to have a poor personality make-up for social living, constituting them a special problem in adjustment.

The position of the child in the home seemed to have some, though not marked, significance. Forty-seven were only children, eighty had no rival children of their own sex in the family. One hundred and eight were the oldest, eighty-three were the youngest, twenty-four were adopted or placed-out children. Twenty-six were cursed by being the favorite child, usually of one parent-in three cases, of both. Eighty-five were regarded as peculiar by their families and usually advertised as such among their parents' friends.

The tragic fact about the homes represented in this study seemed to be that the children were not harmonious elements of a happy cooperative family, but combatants on a battle field where usually the laurels were pretty much on one side. In 209 cases they were with the children. The methods used fall into three classes, which we may call the method of violence, the method of stubborn resistance, and that of playing on the weaknesses of parents through appeal to sympathy or weariness or fear. A resourceful child might use all of them. One hundred and four relied prominently on noise, destruction, kicking, and striking, 109 on stubbornness, while 152 whined or cried their parents into submission. Twenty-seven of the 152 had developed some terrifying physical symptom which made it imperative that they be given their way. More than half of these had fainting attacks, or "blue spells" without physical cause, while others vomited, stayed awake at night, or otherwise awakened parental solicitude.

In what percentage of cases the parents were the victors is impossible to tell because of the difficulty of distinguishing between normal parental direction and the mistaken control that warps a child's life. Only those cases were listed where parental domination was so clearly unwholesome as to constitute a problem, being either cruel, a manifestation of parental bad temper, and hence

not a method of discipline at all, or else a control by fear. In the latter instance statistics mean little, since obedience is not a test of the child's being really controlled. Fear based on threats which amount to nothing sometimes evaporates, leaving a cynicism which may obey but leave its possessor quite the victor in the contest. However, we felt that twenty-two of the four hundred children were dominated by fears, of which the most common were those of punishment or the bogie man in some form; twenty-one by physical punishment, twenty-four by lying promises, and a few, seventeen, by sheer force of will or by emotional appeal to be good because mother was ill or for love of her. This latter form is capable of great abuse, as in the case of one fine lad with a good mother, whose need of wholesome play and companionship with other boys of his age was being placed in false conflict with his real love for his mother. The fits of stubbornness by which he reacted to the pull in two directions were still further used against him as evidence that he was not a loving son. Mother love may curse as well as bless. If it does not fit its dear one for other loves and sterner realities, it kills instead of giving life.

This study reveals a tremendous educational problem. If more than half the parents of these children were too ignorant to live understandingly in the world of common life, if 80.5 per cent of the children failed to find adequate home care, including training in conduct for living with other people, what can be done about it? Almost universally the parents were ignorant of some of the simple, common-sense principles of child training. In addition to trying to furnish a skilled diagnosis of what the real trouble might be underneath a bewildering complex of symptoms, the clinic was kept busy teaching such simple ideas as, "You cannot lie to your child and expect him to go on believing you," or, "Bribing is only payment for wrongdoing," or, "Fear controls for a little while, but either hardens the child or makes a coward of him in the end." These ideas ought to be as much a part of common knowledge as the use of milk for babies, and, if they were, would make a large part of the habit clinic work unnecessary.

When we, as a people, care supremely for the upbringing of our children, care enough to provide training for young people in parenthood as carefully as in reading, writing, and arithmetic, when we believe in play enough to see that no child misses it because of the accident of living in a city wilderness, when we learn enough about living together to prevent our quarrels from embittering our children's lives, or our foolish love from sapping their vitality-then perhaps we shall be fit to be the guides of the children of the future.

VIII. ORGANIZATION OF SOCIAL FORCES

HEALTH AND HOSPITAL SURVEYS: LOUISVILLE'S
CASE HISTORY, 1924

Haven Emerson, M.D., New York City

Introductory remarks. Before a health and hospital survey can be made, certain understandings should be arrived at between the agencies or institutions to be studied and the committee, group, or individuals who are to be responsible for the collecting and interpretation of facts, such as the following:

First, all facts bearing upon functions, costs, and amount of service shall be supplied willingly on request. The open-door policy is essential. Faultfinding "investigation" is not part of the undertaking.

Second, official and volunteer agencies, the public officers of government and the people, through the press or in other public manner, shall be informed of the objects and scope of the survey before it starts.

Third, the survey is primarily a fact-finding procedure for purposes of interpreting the community services to the people, and to permit of intelligent development of programs for protection of health and care of sickness, which will not be limited to one or another individual agency or institution.

Fourth, the survey is not to be thought of or used as a "selling campaign," although its findings may later contribute to such a purpose for fund-raising purposes.

Fifth, the attitude of mind of the community and its representatives must be favorable, or at least informed, welcoming and open-minded as to the need of analysis, possibilities of error or inadequacy, lack of proportion in its social performance of health and sickness services.

Sixth, the study, or at least the essential facts, conclusions, and recommendations, should be published.

Seventh, the cost of the survey should be published in some such terms as percentage of chest budget, health budget, or hospital costs, as well as in dollars and cents.

The survey I am requested to report upon is of health and sickness services in a large city. I must begin with the collection of facts and opinions. Reasons will be offered for the kind of facts collected. Most of the forms and schedules for collecting facts are to be found in published surveys.

The method of collection will be indicated. The facts which are usually available, even if not commonly correlated for use, and where they can be found,