Perhaps my most interesting observation is this: that while most of my fellow-patients, when questioned, would indicate a remote cause for the disease or some complicating difficulty, it seemed that in these same cases no efforts were being made to remove or mitigate these important obstacles.

Any sensible person must realize the advantage, as checks, of physical examinations and reexaminations, of microscopic examinations and re-examinations, of taking the patient's weight and repeating the step at intervals, of noting the calories of food consumed, of noting by weight the increase or decrease of expectoration, of making a daily temperature and pulse record. But not one of these or other similar operations are in any way curative. A patient declines or recovers quite regardless of them.

But treatment of the remote or complicating trouble might have a potent effect for good.

Let me cite a few of the cases I have noted: Case I. This man, though by nature of a buoyant disposition, brooded over the fact that two of his children had died of a disease closely allied with tuberculosis. He felt (and his wife added to his conviction) that he had caused the death of the children, though innocently.

Is it not possible that some intimate talks with the medical director would have revealed this mental trouble and soothed the tortured mind?

Case II. This young lady was a schoolteacher dependent upon her own efforts for a livelihood. As she saw the cost of treatment consuming her meagre savings she became more and more anxious for the future. Her anxiety was a disturbing element. Being a young woman of character, she applied to the sanatorium for clerical work, the position to be given her when her savings were gone. A position was promised her and her marked progress seemed to date from that time.

It will be noted that the cause and the remedy were discovered only through the decision of the patient and not from any initiative on the part of the sanatorium authorities.

Case III. This is the not uncommon case of a young woman in love and engaged to be married. The thought that she might not be able to enter into the relation for which she had promised herself weighed down her spirits to a degree which must have been a factor in causing her death.

Case IV. This is the all too common case of the young man who has indulged himself to excess in his worldly pleasures and who cannot resist even in the face of a serious disease like

Case V. This is rather a peculiar case. Here the remote cause was deafness. The patient's profession required the constant and accurate use of his hearing and the resultant strain in trying to overcome the defective hearing produced neurasthenia, from which tuberculosis followed. This case, though treated in several of our best sanatoria, refused to improve-the remote cause never receiving consideration. Only when by chance the patient isolated himself in a lonely cabin did he discover that the stillness soothed the weary nerves and as his nerves became healed his lungs began to show improve

ment.

It would seem to be an error for a physician or a medical director to assume that he has done enough when he tells his patients that they must discard any causes of worry or habits of life which are unhealthy or unwholesome. Because patients wish to get well would seem a sufficient reason for their never doing anything to retard recovery, but it is not.

That a rational human mind should impel us to do irrational things is one of the enigmas of the pychologists. And of all those who act irrationally the tuberculous patients lead. They are, with few exceptions, mere children. They require mental guidance. In most cases this leads to a most delicate and tactful form of psychotherapy. If a physician had but a limited time for each patient and had to choose between this work and the various examinations already enumerated it would seem that the work of father-confessor would bring the greater results.

As a humble layman I would suggest to my fellow-patients that there are no facts so personal or so delicate that they cannot be revealed to a good physician, and to good physicians, in turn, that it might be profitable to give more time in seeking out and trying to remove remote causes and complicating troubles.

These notes are among the first in the notebook. The last note is entirely irrelevant, but it is of great value. It is to the effect that the Autobiography of Dr. Trudeau is one of the most beautiful stories ever penned. It is so full of inspiration, contains so much of real happiness and pathos, in fact is such a human document, that to read it makes one proud to own the book and causes one to love the author as a brother. Every public library should have copies; every sanatorium library should have it on the shelves, and every one, layman or physician, will be uplifted through reading it.

In any public-health movement before effective constructive work may be performed it is essential that a knowledge of existing conditions be at hand. It was my particular piece of work to obtain that information for the Monmouth County Branch of the State Charities Aid and Prison Reform Association of New Jersey, covering a period of three months during the summer of 1915.

As a basis on which to make this survey it was decided that certain data be gathered from the vital statistics of the county. This necessitated visits to the various health officers of the cities, towns, boroughs and townships, including a trip to Trenton, and the remainder of the time was spent in an intensive study of home conditions in various districts.

Visits to Health Officers

There was practically no difficulty to get permission to see the records. In all but one instance my request was readily granted.

In discussing health conditions with the various inspectors of their communities, many of them had no health problems at all to consider. The invariable answer to my question was that health conditions were good. One officer, who is a physician, said that he considered the township healthy enough except for the fact that a winter resort nearby in an adjoining county was responsible for much of the sickness that prevailed in his township. This same man believes that a visiting nurse would be of inestimable value to the community. When asked if he would urge such a movement he hastily replied that it could not be done, for the people were too busy supporting their over-abundant number of

churches.

Another health inspector, who is also a physician, said that he had recommended in his report to the State Board of Health that a nurse be placed in his schools. He does not consider the piling up of records of physical defects every year among school-children of any consequence unless some effort is put forth to have these defects corrected. He believes that a school nurse would be of much assistance in getting these results.

There are but two trained health experts in Monmouth County and they are actively engaged with many of the vital health problems, such as pure-milk supply, reduction of infant

*The survey covered the entire county. Vital statisticts were gotten from all forty of the municipalities in the county-16 townships, 22 boroughs, 2 cities (Long Branch and Asbury Park). Ocean Grove is a newly-created borough, very recently set off from Neptune township of which it was formerly a part.-G. L. B.

The statistical tables accompanying the report are too extended to publish here.--THE EDITOR.

mortality, sewage and garbage disposal, purewater supply, and fly and mosquito extermination.

The other inspectors are men with no special training for the work, with the exception of one or two physicians who have kept abreast of the times. They are engaged in other occupations and give as little time as possible to health matters. Many of them have served for long periods of time, without acquainting themselves with modern health movements, and consider that. their duties are ended with the quarantining of a few houses and investigating a complaint or two.

Many communities have good health ordinances, but they are not enforced. No regular meetings of the boards of health are held in some townships, but only when an occasion arises. The health board of one township has not convened for over two years. It was not unusual to find that a health officer of one township would not know who was the health officer in an adjoining township.

To get this information meant not only a visit to the health inspector, for often he did not have the record, but to the clerk of the Board of Health, or registrator and the tax assessor.

To my question whether all births and communicable diseases were reported, a negative answer was frequently given. Two reasons were attributed for this failure: (1) carelessness of the physicians, (2) in some rural sections a physician is not called to attend the birth of a child nor to prescribe in cases of illness.

Method of Keeping Vital Statistics

The methods of keeping vital statistics are classified as follows:

1. Duplicate blanks of births and deaths in book form, exact copy of original.

2. Books made for the purpose and containing nearly all the information of the certificates. 3. Books made for the purpose, of the old style, containing very meager information.

4. Ordinary note-book with the births, deaths, and marriages all jumbled together.

5. A memorandum of the number only, written in the back of a book which was used for other purposes.

6. No duplicates kept at all.

In order to complete the vital statistics a trip was made to the State Board of Health at Trenton to secure them, but owing to a different system of compilation it was impossible to get them in the time at my disposal.

Study of Home Conditions

These visits were made in the homes of both town and country districts. I was guided in the selection of these places by a study of the vital statistics. They included those homes where deaths from preventable diseases had occurred, such as tuberculosis, pneumonia, typhoid fever, and deaths of infants under one year.

The following points were kept in mind while making these investigations:

(1) Length of time of illness; (2) cause, if known, of illness; (3) kind of nursing care patient received; (4) what precautions, if any, were taken; (5) any other members of family showing symptoms of disease; (6) sanitary conditions of home; and (7) cost of illness and funeral expenses. In every instance the information was freely given by members of the family, after I had explained my purpose.

Descriptions of a few typical cases visited will illustrate better than anything else I could say the health conditions in the homes.

Case 1..-The parents of a young man, twentynine years old, who died recently with tuberculosis, were called upon and they informed me that the boy had been ill and unable to work for two years. They believed that he contracted the disease from a "cold." The doctor came once in a while and left some medicine and instruc

tions about disposal of sputum. The nursing care was given by the mother. The patient remained in the house all the time, and as he did not like the windows open because it made his cough worse..they were kept closed. During the last stage of his illness the family were advised by someone to get Professor Hoff's Consumption Cure, which they did, and the mother firmly believes that had they obtained the medicine early enough the son would have been cured. She said that it did him lots of good in that it helped his cough. This stuff is put up in a two-ounce vial and retails at a dollar a bottle. They used in all fourteen bottles. The estimated cost of the illness and funeral expenses was five hundred and eighty dollars.

Case 2.-A colored woman who lost her son, thirty-one years old this January, said that he had never been strong since they came from Baltimore eight years ago. They did laundry work for a living and the boy did most of the ironing. She had called a doctor only once or twice when the boy had a hemorrhage. He received no nursing care except that given by his mother and was confined to his bed but two weeks. No precautions were used in regard to sputum. This house has not been fumigated since the boy's death. The woman's son-inlaw had died in the same house five years ago with "some kind of lung trouble.' The funeral expenses amounted to eighty dollars.

The

Case 3.-A mother, whose three-months-old baby had died with cholera infantum, said she had had no nursing care during confinement and had gotten up on the fourth day. She was not able to nurse her baby for any length of time because her milk soon disappeared, which she thinks was due to her getting up too soon. baby when born was fine and healthy, but as soon as she began giving it condensed milk it grew sickly. She took the child to three different doctors at different times and tried to follow directions in preparing the milk, but there was no one who could go into the home and show her exactly how to do it. The mother said she wished she lived in New York because she had a sister living there and the nurse came twice a week and showed her how to fix the baby's milk. The cost of illness and funeral expenses amounted to about seventy-five dollars. Two other children died in infancy, both fed on artificial food.

Case 4.-Another home near by was visited where a five-months-old baby had died under identical conditions. The sanitary conditions were of the worst possible sort. Two boys in the family are so choked up with enlarged tonsils that they breathe through their mouths constantly. The mother said she had received notice last winter from the school doctor that these children ought to have medical attention, but nothing was done, for lack of money. Four deaths of infants all under one year of age had occurred in this family. No estimate of cost could be obtained, as the bills have not yet been presented.

In none of the homes visited had any professional nursing services ever been given, with the exception of one case of pneumonia. A trained nurse was procured two days before the man's death.