teristics of the immigrants to understand them in general, and with enough knowledge of the language to get the main points of the situation, interpretation will almost take care of itself.

2. Knowledge of the immigrant's language is a great help. It enables the health worker to use her interpreter intelligently; it also creates a feeling of confidence and appreciation on the part of the patient and of sympathy and readiness of approach on the part of the worker.

3. Experience in using foreign-language literature establishes two facts:

a. Where literature of any kind is to be given those not speaking English, it should be in their mother tongue.

b. Literature is comparatively ineffective except as a supplement to the spoken word. When so used, and when followed up by a personal conference with the professional worker, it helps to drive things home, to serve as a reminder, and to spread a little more widely the message given to the individual patient.

It is important that the persons preparing such literature be sufficiently informed about the subject matter and also have enough facility in the foreign language to present the ideas simply and interestingly. Such highly skilled persons are often beyond the command of a local organization, and this is one good reason why much of the foreign-language literature giving instruction in hygiene and in the care of various diseases should be prepared by national or state authori

ties who could make it available to an indefinite number of local agencies.

4. The children, because of their superior knowledge of English and of American customs, sometimes offer the readiest means of access to immigrant parents. Great caution, however, must be observed in utilizing children "to teach their parents," lest the disintegration of family life be encouraged.

5. Localization of field work, restricting one set of workers to a compact area with headquarters in the district, fosters familiarity and subsequent confidence.

6. To secure the co-operation of the foreign born themselves is one of the most important and difficult tasks confronting field workers.

7. The primary requisite for success in field work with the foreign born, the point upon which all other measures depend, is knowledge and understanding of the people, their backgrounds and characteristics.

XIV

THE HOSPITAL

THE hospital is an institution where patients are received whose illness requires that they remain in bed and receive more constant care and supervision than is possible in their homes. For the purpose of this study hospitals may be divided into two kinds:

1. The public-service hospital is a hospital, whether supported by public or private funds, which takes at least some patients as a service to the community and not merely in return for payment.

2. The proprietary hospital is run as a business enterprise. The term "private" should not be applied to hospitals of this second class because it is ambiguous, being used sometimes to mean supported by private as distinguished from public funds, and sometimes to mean maintained for private profit.

Hospitals are unevenly distributed throughout the United States. A disproportionate number are found in the larger cities and in the older communities of the East. The majority of these hospitals are of small size. There are 3,187 hospitals listed in the American Medical Directory of 1918 which, on the basis of information therein contained, have been tentatively classified as general hospitals of the first, or publicservice, class. One thousand two hundred and thirtynine of these, or 39 per cent, had 25 beds or fewer.

There were almost exactly the same number (1,246) with from 26 to 99 beds. Only 702 hospitals had 100 beds or more. The number of private proprietary hospitals is much larger, but the great bulk are small, having 25 beds or less.

In discussing the relation of the hospital to the medical care of the immigrant we are practically limited to the public-service group, chiefly to the institutions of 100 beds or more. The most highly developed examples of hospital service are found in the large hospitals, particularly in those which are affiliated with medical schools and are university or teaching hospitals.

In view of the fact that a large number of northern Europeans have settled in the growing industrial communities of middle size and in the small towns and rural districts, it is significant that the 66 medical schools of the country are nearly all located in large cities, that the number of medical schools is likely to diminish rather than to increase, and that hospitals established and maintained in intimate co-operation with these schools can reach only a very small fraction of the population in each state. These facts are fundamental to a consideration of hospital service for the immigrant.

IMMIGRANT ATTITUDES

The service that hospitals can render the immigrant is in part dependent upon his attitude toward the hospital. This is brought out by interviews with the foreign born, both doctors and laymen.

A Polish doctor says:

Poles are decidedly opposed to going to the hospital under any circumstances or to allowing their children to be taken. To go to the hospital is to die, they think, because in their experience it has always meant the last resort. Aside from this, they lack confidence in hospitals. The strangest stories gain currency among them about practices in the hospitals and the doctors can't reassure them. They actually believe that patients die of neglect or are killed by "black medicine."

A Russian doctor says:

Russians are afraid to go to the hospital; they have known little or nothing of them in the old country, and the experiences of people of their own nationality in the hospitals of this country have not served to give them any faith in them, for they do not understand the treatments. Exaggerated stories easily gain currency. The lack of the language makes them feel strange and helpless.

An Italian doctor says:

The masses of the Italian people have a deep-seated prejudice against hospitals. It would be difficult to find the cause of it. I cannot understand it; it is like many of the superstitions of ignorant people. They say people are abused, or neglected, or killed in hospitals. The younger generation is of course getting away from such notions, but still I have to deal with many cases at home when I know recovery would be much more certain in a hospital.

The immigrant's attitude toward the hospital of course depends partly on his background and partly on his personality and immediate circumstances. If he has come from a district abroad in which hospitals are distant places to which only desperately ill people are sent, naturally he comes to America with a different notion than if he had been brought up in a