Stanfield’s Introduction to Health Professions 7th Edition

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vii
NOTE FROM THE AUTHORS
and physical therapy, and an associate’s degree for support
personnel in the same field. Physical therapy and occupa-
tional therapy assistants trained at the associate’s level are
being used to support the work of professionals because of
the lower cost for their services.
Information technology is changing the way health care
is delivered as well as the way consumers manage their health.
Electronic health records that are accessible by professionals
regardless of physical location are cost effective and improve
the quality and safety of health care. Many patients now have
access to lab values and other text results through a patient
portal within the electronic health record. Technology also
makes it possible for patients to do more self-monitoring
and to communicate results back to their physician, nurse, or
caseworker. For example, blood glucose and blood pressure
can be monitored by the patient and the results transmitted
to the health care provider.
Nanna Cross, PhD, RDN, LDN
Dana C. McWay, JD, RHIA, FAHIMA
Careers in the healthcare field are growing more rapidly
than other careers because of longevity and advanced tech-
nology that has increased the number of elderly needing
health care. Within health care there is a career for nearly
everyone—from entry-level positions as a home health aide
that require no prior training to being employed as a physi-
cian that requires 7 to 8 years of college plus an internship to
enter a career.
This text is designed so that the instructor can select indi-
vidual chapters for a course. Most college texts are organized
to be followed from the beginning of the book through the
last chapter. By contrast, instructors using this text can select
only certain chapters based on the course objectives since each
chapter is written to be understandable and comprehensive as
a standalone. Key terms unique to health care are defined in the
glossary at the end of the text and are listed at the beginning of
each chapter so students can refer to the glossary as needed.
WHAT ARE THE LATEST TRENDS
IN THIS MARKET?
The trend is to require a master’s degree or above for
entry-level professional degrees such as occupational therapy

viii
Now in full-color, the seventh edition of an Introduction to
Health Professions provides comprehensive coverage of all
the major health professions. This product is designed for
students who are interested in pursuing a health-related
career but are still exploring and have not yet decided on a
specific career. The Seventh Edition outlines more than 75
careers and touches on every major facet of the field, in-
cluding a description of the profession and typical work set-
tings; educational, licensure, and certification requirements;
salary and growth projections; and Internet resources on
educational programs and state requirements for licensure
and/or certification. In addition, this resource provides a
thorough review of the U.S. healthcare delivery system,
managed care, healthcare financing, reimbursement, insur-
ance coverage, Medicare, Medicaid, and the impact of new
technology on healthcare services. Information on career
preparation and development are also included. All chapters
are updated to reflect current demographics and new policies.
HOW IS THIS BOOK
ORGANIZED?
The new edition of this text has been reorganized into five
sections
• Part I—The Healthcare System in the United
States. This section provides an overview of the
healthcare system in the United States, with sep-
arate chapters on categories of health services,
financing health care, the impact of aging on de-
mands for healthcare providers, health care reform,
and medical and information technology.
• NEW! Part II—Jobs and Careers. This section fo-
cuses on career planning and career development.
• NEW! Parts III through V contain chapters on in-
dividual careers that are organized so that students
will be able to quickly identify a particular career
of interest. Each chapter is organized to follow the
same general format, making it easy for students to
explore many different health careers. Each chapter
follows the same format with a description of the
profession and typical work setting; educational,
licensure and certification requirements; salary and
growth projections; and Internet resources on ed-
ucational programs and requirements for licensure
and/or certification. For example, in the chapter
on dentistry, the career is described based on the
education and training requirements from most
education—dentist—to least education—dental
assistant. For each career within the dentistry pro-
fession, the student has access to the usual respon-
sibilities, work setting, salary, and expected demand
for that career. Each chapter lists Internet resources
to explore educational programs as well as state
requirements for licensure and certification options
for advancing in the profession.
• Part III—Healthcare Practitioners and Tech-
nicians. This section is the core of the prod-
uct and contains 20 chapters directed at health
careers that involve direct patient contact and
care, ranging from diagnosis to treatment
to education and counseling and medical or
surgical interventions.
• Part IV—Healthcare Support Personnel. This
section contains five chapters directed at health
careers that support or supplement other
health professionals in providing ongoing care
for patients—medical and nursing assistants,
personal, home, and psychiatric aides; medi-
cal information technology; and massage and
recreation therapy.
• Part V—Health-Related Professions. This
section focuses on health-related profession-
als who usually do not have direct contact
with human patients but often have an im-
pact on human health—veterinary medicine
and occupational health and environmental
sciences.
PREFACE

ix
Nanna Cross, PhD, RDN, LDN has worked as a faculty
member in dietetic and physician education programs
teaching clinical nutrition courses and supervising dietetic
interns in clinical practicums. Dr. Cross worked as a clinical
dietitian at the University of Missouri Hospitals and Clinics
and as a consulting dietitian for Home Care, Hospice, Head
Start and Long-Term Care facilities.
Dana C. McWay, JD, RHIA, FAHIMA is both a lawyer and
a health information management professional. She works as
an adjunct faculty member at Saint Louis University in the
Health Informatics and Pre Law Studies programs. She serves
as the Clerk of Court for the U.S. Bankruptcy Court for the
Eastern District of Missouri, an executive position responsible
for all operational, administrative, financial, and technological
matters of the court. She has worked as both a director and as-
sistant director of medical records in a large teaching hospital
and a for-profit psychiatric and substance abuse facility. She is
a past Director on the Board of Directors of the American
Health Information Management Association and serves as a
voting member of the Institutional Review Board at Washing-
ton University School of Medicine, from 1992 to present.
ABOUT THE AUTHORS
Special Thank you to our Ancillary Authors:
Gaynelle Schmieder RN, NCMA, BSN, M.ED.
Assistant Professor and Lead Faculty/Health Care Professions
Program Director/Medical Assisting Technology ACE Faculty Liaison
Pennsylvania Highlands Community College
Johnstown, PA
Tammy Calpin MSN, RN, CSN, NCMA
Instructor, Medical Assisting/Practicum Coordinator
Pennsylvania Highlands Community College
Johnstown, PA

x
Professional
Professional
Profiles
Name: Amanda, RN, ADN
Job Title: Charge Nurse
Education: Associates in Nursing; enrolled for BSN
Q: Tell us about your career progression .
A: After graduating from nursing school, I hired
on at a local hospital with 113 beds and soon after
found myself a charge nurse on a 31-bed high acu-
ity telemetry unit. Diagnoses of our patients varied
from congestive heart failure, myocardial infarction,
cardiomyopathy, and many chest pain rule outs that
resulted in other various outcomes.
I recently took a position on a 40-bed medical floor
as a free charge nurse. My job now allows me to fo-
cus on the hospital’s quality indicators and outcomes.
I get to round on patients in the morning to deter-
mine the needs of my colleagues and the floor. I love
the role I am currently in because I can advocate for
patients by discussing the care they are receiving and
learning ways to improve our delivery.
Q: What challenges you about your
profession?
A: Nursing has been a very challenging yet fulfilling
career for me. It has allowed me to develop a profes-
sional skill set, build relationships with patients, and
learn on a daily basis from my peers. I have recently
become engaged in community events while sitting
on the Young Professional Advisory Board in my
county. I have had many great opportunities while
working as a registered nurse and look forward to
many to come.
Q: How have you demonstrated
professionalism in your career?
A: Over the years, my career has presented me with
many opportunities to grow as a professional. The
hospital has a clinical development program that al-
lows nurses to put together a portfolio representing
their work over time. There are many requirements
including service in the community, continuing edu-
cation, awards or recognition from patients, and par-
ticipation in committees or improvement events that
take place in the hospital. Developing this portfolio
and committing to the work that it entails encour-
ages me to view my job as a nurse as something much
more. Nursing is a profession and has been elevated
to that over time. As a nurse, I feel it’s my obligation
to continue to engage myself into my community
and help represent what the profession of nursing is.
Q: Without disclosing protected health
information, describe an ethical challenge
you’ve faced and how have you
addressed it .
A: As a nurse I often am witness to ethical dilemmas
within the acute care setting. When taking care of an
elderly patient who had decided to go on hospice,
I witnessed many family members who came in to
visit who were not in agreement with the patient’s
decision. Over the course of a few days the patient
had become very weak and unable to communicate.
Many family members began to demand that the
decision to start hospice care be reversed and that
[hospital staff] resume treatment for the patient’s
cancer. When involved in caring for large families
and patients with terminal illness, it is important to
advocate for the patient. At times, it can be emo-
tionally taxing, and your own beliefs may not agree
with those of the patient; however, it’s important to
keep your own beliefs out of it. Ultimately, in this
particular situation, my patient had paperwork that
reflected his wants and needs for end-of-life care. He
had made a decision to die peacefully, and my job
was to allow him just that. We called a chaplain in to
comfort the family and help them understand that
the patient was clear about his wishes. In this case,
the family just needed support to accept his wishes.
Death is hard for all parties involved, but as a nurse,
my first priority was advocacy for my patient.
Q: Describe the continuing education
requirements for your profession .
A: Continuing education is mandated each year and
can be different from unit to unit. My floor must par-
ticipate in a skills lab that ensures that we are profi-
cient in a number of clinical skills. We must also ob-
tain eight hours of continuing education hours that
we can do online or take classes within the hospital.
Throughout the hospital, there are multiple types of
equipment to safely transfer patients who need as-
sistance with ambulation, so every year we have to
demonstrate proficiency in safe patient handling. It
is also mandatory to keep up to date a BLS [basic life
support] card and in some areas ACLS [advanced car-
diac life support].
91
LEARNING PORTFOLIO
Study Points
1. Career development stretches beyond what is needed
initially to enter into a healthcare profession.
2. Training for healthcare students includes similarities
across disciplines, referred to as a common core of
knowledge.
3. Healthcare professionals who act in an accountable
and ethical manner in the workplace and maintain a
steady composure in the face of adversity demonstrate
professionalism.
4. Codes of ethics are common across virtually every
healthcare discipline.
5. Healthcare professionals who breach confidentiality
not only damage their relationship with the patient,
they may also violate the law and professional require-
ments.
6. Many healthcare practitioners contribute to the suc-
cessful treatment of patients through health teams.
7. Malpractice is professional misconduct.
8. Continuing education is an integral part of career de-
velopment.
Issues for Discussion
1. At one time or another, most everyone has encoun-
tered someone who has acted in a less-than-profes-
sional manner. Discuss with your instructor and
classmates examples you have experienced of this
phenomenon. Describe what actions you think
should have been taken in these examples that could
have turned the non-professional situation into a pro-
fessional situation.
2. Math anxiety has played a role in discouraging per-
sons from pursuing entry into the health professions.
Brainstorm with your classmates and instructor the
reasons math anxiety exists, considering whether
timed tests and the risk of public embarrassment play
a role. Discuss what actions can be taken to lessen or
eliminate math anxiety.
Enrichment Activities
1. Safety of healthcare professionals is an important
function of the job. Research the Internet for the rates
of injury to registered nurses, physicians, nurse’s aides,
dietitians, physical therapists, respiratory therapists,
and housekeeping staff. Create a chart comparing the
types and rates of injury among these healthcare pro-
fessionals.
2. Codes of ethics exist in virtually every healthcare
profession. Research the websites of any of the pro-
fessional associations listed in subsequent chapters to
see what they include in their code of ethics. Create a
chart identifying the similarities and differences be-
tween the codes of ethics of various professional as-
sociations.
3. Continuing education is usually a central tenet of a
professional association. Research the websites of any
of the professional associations listed in subsequent
chapters to see what types and how much continuing
education activity is required over a specified period
of time. Create a chart comparing this information for
each profession chosen.
References
1. Material related to the common core of knowledge arises
from two sources: The National Health Science Stan-
dards, National Consortium for Health Science Education
(2015) available at: http://www.healthscienceconsortium.
org/wp-content/uploads/2015/07/NATIONAL-HEALTH-
SCIENCE-STANDARDS-May-2015f1-PE2.pdf and Health
Science Alignment – Common Core Mathematics, Depart-
ment of Elementary and Secondary Education, State of Mis-
souri (2011) available at: http://dese.mo.gov/sites/default/
files/HealthSciMath.pdf.
2. Tarasoff v. Regents of University of California, 529 P.2d 553
(Cal. 1974), reargued, 551 P.2d 334 (Cal. 1976).
3. Corn v. French, 289 P.2d 173 (Nev. 1955).
4. Katsetos v. Nolan, 368 A.3d 172 (Conn. 1976).
Career Development
98 CHAPTER 8
NEW FEATURES
Learning Portfolio
At the end of each chapter, this review section includes: Study
Points, Issues for Discussion, and Enrichment Activities.
All sections are thoroughly updated to reflect current training
requirements, responsibilities, and salaries, as established in
the Occupational Outlook Handbook 2016-2017 Edition.
Interviews with Professionals
Including Frequently Asked Question/Answer section.

xi
New Careers
Includes nine new careers!
• Podiatrist (Chapter 9)
• Orthotics and Prosthetics (Chapter 17)
• Exercise Physiologist (Chapter 19)
• Substance Abuse and Behavioral Disorders
Counselor (Chapter 20)
• Genetic Counselor (Chapter 22)
• Community Health Worker (Chapter 23)
• Board-Certified Behavior Analyst (Chapter 23)
• Phlebotomist (Chapter 29)
• Massage Therapist (Chapter 30)
THE LEARNING AND
TEACHING PACKAGE
The Learning Package for
the Student
Students can review the Learning Portfolios at the end
of each chapter. For the first eight chapters of the text, the
Learning Portfolio includes Study Points, a brief summary
of the chapter content. All chapters also include Issues for
Discussion and Enrichment Activities designed to be used by
the student for self-study and exploration.
The Teaching Package for
the Instructor
Teacher resources include the Learning Portfolios at the end
of each chapter, which are designed to be used by both the
student and instructor. In addition, the following items are
part of the Instructor’s Teaching Package:
• Test Bank for each chapter
• PowerPoint slides for each chapter
• Instructor’s Manual with the following components:
–
– Chapter Overview
–
– Lesson Objectives
–
– Resources
–
– Suggested Lecture Outline
–
– Discussion Questions
–
– Suggested Learning Activities
–
– Homework
Bloom’s Taxonomy
The Learning Package for the student and the Teaching
Package for the instructor are designed to incorporate
Bloom’s levels of learning from the lowest level of knowl-
edge to the highest level of evaluation. The learning and
teaching packages that accompany the text encourage go-
ing beyond the content of the text. The text is expected to
be a starting point.
New Features

xii
Darlene Martin, MEd, ATC
Liberty University
Kristen L. McHenry, MS, RRT-ACCS
Director of Cardiopulmonary Science Program Assistants
Professor – Department of Allied Health Sciences
College of Clinical and Rehabilitative Health Sciences
East Tennessee State University
Jahangir Moini, MD, MPH
Professor of Science and Health
Eastern Florida State College
Cindy Mulder, MSN
Instructor
University of South Dakota
Amy Nelson, MS OTR/L, MT(ASCP)
University of South Dakota
Dr. Dennis Palkon, PhD, MPH, MSW
Professor and Director of Management Programs/Health
Administration/Business
Florida Atlantic University
Bonita Sasnett, EdD
East Carolina University
Erin Sayer, PhD
Chief Academic Advisor – School of Biological Sciences
University of Nebraska – Lincoln
Karen Bakuzonis, PhD, MSHA, RHIA
Chair Health Informatics Department
Ashford University
William Ballard, MA, MEd
Academic Advisor College of Business
Florida Atlantic University
Dr. Barry Brock
Academic Coordinator/Health Services Administration
Barry University School of PACE
Dr. Kenneth L. Campbell, MPH, MBA, MA
Adjunct Professor
Department of Health Sciences at Chicago State University
Adjunct Professor and Interim Community Health Worker
(CHW) Program Director at City Colleges of Chicago
Cook County System Operations Analyst
Cook County Health and Hospitals System (CCHHS) and
Cook County Department of Public Health (CCDPH)
Karen Collins Gibson, MSA, RHIA, FAHIMA
Delaware County Community College
Nicole L. Hatcher, PH.Sc, MPAS, PA-C
Assistant Professor
Howard University
Andrea Koepke, PhD, RN
Dean – College of Health Professions
The University of Findlay
Barbara Marchelletta, CMA (AAMA), CPC, RHIT, CPT
Program Director – Allied Health
Beal College
REVIEWERS
Figure: © Shutterstock/Sebastian Kaulitzki

Nurse with tablet: Getty Images/iStockphoto; OR: Shutterstock/xmee;
Dog: Shutterstock/DuxX; Man in lab: Getty Images/iStockphoto;
Dentist: Shutterstock/foto infot; Spine: Shutterstock/Sebastian Kaulitzki
The Healthcare
System in the
United States
PART ONE

Figure:
©
Shutterstock/Sebastian
Kaulitzki

U.S. Health Care
Objectives
After studying this chapter, the student should be able to:
■
■ Discuss the changes in health problems of the population in the United States over the past 150 years.
■
■ Identify expected future changes in the health of the population that will influence healthcare needs and
career opportunities in health care.
■
■ Explain the role of the government in the expansion of health care.
Key Terms
Acute infectious diseases
Affordable Care Act (ACA)
Applied behavior analysis (ABA)
Autism spectrum disorder (ASD)
Avian influenza
Centers for Disease Control and
Prevention (CDC)
Chronic illness
Children’s Health Insurance
Program (CHIP)
Clinical preventive services
Ebola virus
Electronic health records (EHRs)
Epidemics
Globalization
Health Exchange
Health information technology
(health IT)
Health outcomes
Human Genome Project
Infant mortality
Infectious disease
Life expectancy
Lifestyle
Longevity
Medicaid
Medical technology
Methicillin-resistant
Staphylococcus aureus (MRSA)
National Prevention Council
Sepsis
World Health Organization (WHO)
© stefanolunardi/Shutterstock
3
CHAPTER 1

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Introduction
This Seventh Edition differs from the first six editions for two reasons. First, three new chapters have been
added: Chapter 6: Medical and Health Information Technology, Chapter 8: Career Development, and
Chapter 22: Genetic Counseling. Second, discussion questions and enrichment activities have been added
to each chapter. The impact of healthcare reform legislation on healthcare delivery systems and careers has
been incorporated into this edition.
HISTORICAL EVENTS
IMPACTING HEALTH CARE
Controlling healthcare costs and increasing access to health
care were policy priorities for President Barack Obama
with the passage of the Affordable Care Act (ACA) signed
into law on March 23, 2010.1
Some of the reasons for the
rising costs of health care are the use of expensive medical
technology and prescription drugs, reimbursement sys-
tems that reward the volume of medical services instead of
outcomes, inadequate preventive services, the aging of the
population, and the increased prevalence of chronic dis-
ease, as well as high administrative costs.2
Healthcare costs
have been a concern of the government because growth
in healthcare costs exceeded growth of the United States
economy beginning in the 1970s and 1980s at a high of 10%
to 12% with a drop between 2010 and 2012, when health-
care spending was comparable to growth of the economy at
3%.3
Another critical issue that needs to be addressed is the
inefficiencies and disparities in the current system. Com-
parisons with other countries and across states show large
variations in spending without commensurate differences
in health outcomes.4
The most significant change in health care in the United
States in the past five years is the number of individuals who
have access to health care with the implementation of the
ACA. At the end of 2014, 15.6 million people had health in-
surance through either a private health insurance carrier or
a Health Exchange. Total enrollment through a Health Ex-
change totaled 6.7 million in 2014 and 11.7 million in 2015.5
Also, between the summer of 2013 and January 2015, there
was a 19% increase in the number enrolled in either Med-
icaid or the Children’s Health Insurance Program (CHIP)
for a total of 11 million additional low-income children and
adults with access to health care.6
Even with greater access
to health insurance—an estimated 30 million people con-
tinue to be uninsured—the majority of the uninsured are
low income with poor health who live in states that opted
out of Medicaid expansion under the ACA.7
Greater access
to health care increased demand for providers (physicians,
nurses and other healthcare workers), hospitals, outpatient
clinics and home-care services. The healthcare environment
has become more competitive, in large part because of the re-
quirements for hospitals to improve both the quality of care
and efficiency as a result of the ACA.
The United States will need to continue to improve the
efficiency and quality of health care and reduce disparities in
access to health care for all Americans. With that premise, we
begin this chapter with a look back at healthcare issues and
treatments developed in the past 150 years. Much of the ma-
terial from the sixth edition of this text is still relevant. The suc-
ceeding chapters have been updated to reflect the anticipated
changes and demographics of the 21st century, and the chang-
ing nature of health care and opportunities for health careers.
A LOOK BACK
Since the dawn of recorded history (and undoubtedly be-
fore), human beings have suffered sudden and devastating
epidemics and diseases. In the United States in the second
half of the 19th century, the most critical health problems
were related to contaminated food and water and inadequate
housing, and sewage disposal. A countrywide cholera epi-
demic and a yellow fever epidemic killed more than 30,000
people between 1853 and 1858.
By 1900, infectious disease epidemics had been brought
under control as a result of improving environmental con-
ditions. Cities developed systems for safeguarding the milk,
food, and water supply, and health departments began to grow,
applying case findings and quarantines with good results. The
major epidemics that had caused deaths had been eliminated
in the United States, and the pendulum swung away from
acute infectious diseases and toward chronic conditions.
Pneumonia, tuberculosis, diarrhea, and diphtheria ac-
counted for one-third of all deaths in the 1900s. The most im-
portant factor in the decline in mortality in the 20th century
was essential hygiene, supported by home and workplace
improvements and attempts to improve the environment.
Better hygiene accounted for approximately one-fifth of the
reduction in mortality.8
Another reason for the falling death rate was the improve-
ment of nutrition, which led to an increase in the resistance
to diseases. Once sanitation improved, lack of food and the
resulting malnutrition were largely responsible for infectious
diseases. Nutritional status is a critical factor in a person’s re-
sponse to infectious diseases, especially young children. Ac-
cording to the World Health Organization (WHO), the best
“vaccine” against common diseases is an adequate diet.
With epidemics behind them, the scientific community
began working on better surgical techniques, new treatment
U.S. Health Care
4 CHAPTER 1

methods, new tests to facilitate accurate diagnoses, and the
treatment of individual diseases. The number of hospitals
grew rapidly, and medical schools flourished. Within a few
years, medical care and patterns of disease had totally changed.
The arrival of antibiotics in the 1940s and the implementation
of childhood universal vaccination in the 1950s for measles,
mumps, rubella, and polio signaled the end of the dominance
of acute infectious disease (FIGURE 1.1).8
By the late 1940s, chronic illnesses such as heart dis-
ease and cancer accounted for nearly half of the deaths in
the United States. By the 21st century, the development of
new drugs to control risk factors for heart disease, for exam-
ple, drugs to control hypertension, cholesterol, and diabetes,
reduced death from heart disease by 28% between 2003 and
2013. During this same time, deaths from cancer also de-
creased by 15% (FIGURE 1.2).9
FIGURE 1.1 Universal child immunization beginning in the 1950s
dramatically reduced death from infectious disease in the
United States.
© Ilike/Shutterstock
FIGURE 1.2 Death rate for selected causes.
Data from National Center for Health Statistics.
The introduction of antiviral therapy in the 1990s re-
duced the death rate from the human immunodeficiency
virus (HIV) by 80%.10
The effectiveness of new treatments, including drug
therapy, increased life expectancy over a 30-year period be-
tween 1980 and 2013; life expectancy increased from 70 to 76.4
years in men and from 77.4 to 81.2 years in women (FIGURE 1.3).
Infant mortality rates fell to a historically low level of
5.96 per 1,000 births, a 13% decline between 2003 and 2013.9
Longevity and an increased number of elderly have in-
creased the prevalence of chronic and degenerative diseases
associated with aging, including hypertension, diabetes,
chronic kidney disease, and osteoporosis, as well as Alzhei-
mer’s disease and other forms of dementia.11
The downside to
improvedhealthcareandlongevityisthatone-thirdofthepop-
ulation above 65 has multiple chronic conditions. Treatment
for chronic conditions in the elderly accounts for two-thirds of
total healthcare costs in the United States. In the future, phys-
ical and cognitive decline associated with aging will require
personal assistance from family or paid caregivers and health
services from a variety of health professionals. In addition, by
2050 the population will also be more ethnically and racially
diverse: one-third will be Hispanic non-white, one-third Af-
rican American, and one-third white.11
These changes will in-
fluence the environment for new healthcare workers and the
diversity of those needing care.
A LOOK FORWARD
Medicine must now confront the diseases and health prob-
lems that are greatly influenced by the local and international
environment. Globalization and ease in international travel
increase the risk for infectious diseases. In the United States,
viral gastroenteritis is the most common viral infection and
salmonellosis is the most common bacterial infection—both
Heart disease
CVD
Cancer
Influenza and pneumonia
Diabetes mellitus
0
100
200
300
400
500
600
700
1950 1960 1970 1980 1990 2000 2010 2013
Per
100,000
Population
5
A Look Forward

examples of healthcare workers involved in preventing the
spread of infectious disease.
Most diseases of today are associated with personal
lifestyle. Individuals can take responsibility for most life-
style factors such as physical activity, eating habits, smoking,
drinking alcoholic beverages, using illicit drugs, personal hy-
giene, and so forth. However, healthy communities are nec-
essary to support individuals in achieving a healthy lifestyle.
Disparities in health are related to lack of access to healthy
food, safe housing, space for regular physical activity, educa-
tion, employment, and health care. The National Prevention
Council established seven priorities for preventive services to
improve the health and quality of life for all Americans of all
ages and to address health disparities (TABLE 1.1).16
Two lifestyle factors associated with a high risk for
heart disease and cancer that can be changed are smoking
organisms cause foodborne illness.12
Newly recognized
infectious agents have caused substantial public health con-
cern and investment. These include influenza H3N2, avian
(bird) influenza, and Ebola, and some particularly virulent or
drug-resistant bacterial strains, such as methicillin-resistant
Staphylococcus aureus (MRSA). Influenza and pneumonia
remain major causes of death, particularly among persons 65
years of age and older, and HIV/AIDS continues to spread.
Although most infectious diseases are now prevented
with vaccines and improved methods of infection control,
new organisms continue to appear from mutations and
transmission from wild animals or insects to domesticated
animals and sometimes to humans. For example, in 2015
cases of avian flu were identified in Europe and China; in
the United States, entire commercial poultry flocks required
culling or removal of infected turkeys and chickens—and
sometimes an entire flock was destroyed to prevent further
spread of the disease, at great financial cost to the poultry
business.13
The 2014 Ebola epidemic in West Africa, the largest in
history, spread to the United States by healthcare workers
employed in West Africa. The Centers for Disease Control
and Prevention (CDC), the U.S. government agency that
monitors infectious diseases, developed infection-control
measures for hospitals treating infected patients in the
United States. WHO and the CDC also deployed teams of
experts to West Africa to implement infection-control mea-
sures to prevent further spread of the disease in Africa.14
MSRA increases the risk for surgical infections,
pneumonia, and sepsis in hospitalized patients and requires
stringent infection control measures to prevent spread of the
bacteria causing the infection from patient to patient and
among healthcare workers (FIGURE 1.4).15
Epidemics of infectious disease require a team of ex-
perts to track and contain diseases to prevent epidemics in
both humans and animals. Physicians, nurses, veterinari-
ans, medical laboratory technologists, epidemiologists, and
public health officials at the local, state, and federal level are
FIGURE 1.4 Methicillin-resistant Staphylococcus aureus (MRSA) is
a common cause of skin infection.
FIGURE 1.3 Life expectancy by year and sex.
Data from National Center for Health Statistics. Health United States, 2014:With Special Features on Aged 55–64.Hyattsville, MD. 2015.
0
10
20
30
40
50
60
70
90
100
1900 1950 1980 1990 2000 2013
Life
Expectancy
at
Birth,
in
Years
Year
46.3
65.6
70 71.8 74.1 76.4
48.8
71.1
77.8 78.8 79.3 81.2
Male
Female
© Joseph Dilag/Shutterstock
U.S. Health Care
6 CHAPTER 1

and obesity.17
The good news is that the rate of smoking has
dropped by more than half since 1970, when 45% of adults
over 18 years of age smoked compared to only 18% in 2013.
However, obesity rates continue to rise—only 30% of adults
20 years of age and older were at a healthy weight between
2009 and 2012.9
For the future, the predominance of chronic illness as the
major threat to health raises many issues. The public concept
of health is that intervention by the doctor and early discov-
ery of disease will prevent or cure disease, when in fact health
is determined mainly by lifestyle. Optimal treatment for pre-
venting chronic illness requires health care that is long-term
and continuous, yet health care in the United States is often
delayed until a chronic disease has been diagnosed. Although
behavioral and environmental influences are the greatest con-
tributors to poor health, surgery and drugs are regarded as the
core of health care. The current method of financing health
services emphasizes payment for specialized services—for ex-
ample, surgery or cardiac rehabilitation—instead of preven-
tive care, which may include referral to a dietitian for nutri-
tion counseling to lower weight and blood cholesterol levels.
Funding for health care has traditionally focused on treatment
of chronic disease, such as hemodialysis treatment for chronic
kidney disease—often the result of untreated or poorly con-
trolled hypertension or diabetes. What is needed in health
care is a redistribution of resources for the prevention of dis-
ease, care of the acutely ill who require immediate treatment,
and ongoing care for those with chronic diseases.
Preventive healthcare services improve health by pro-
tecting against disease, lessening the impact of disease, or
detecting disease at an early stage when it is easier to treat.
As a result of requirements to include preventive services by
insurance plans purchased through Health Exchanges un-
der the ACA and coverage by Medicare, clinical preventive
services are being utilized by more Americans. For exam-
ple, immunizations and cancer screening—e.g., mammog-
raphy and colonoscopy—are the most common preventive
services. However, utilization remains suboptimal for some
services. In 2013, only 70% of children 19 to 35 months of
age received a combined vaccination series protecting them
against nine infectious diseases. Only 41% of adults 18 years
and older received the influenza vaccine, and only 60% of
adults over 65 years of age received a vaccine against pneu-
monia.9
IMPACT OF TECHNOLOGY ON
HEALTHCARE SERVICES
Technology has made many new procedures and methods
of diagnosis and treatment possible. Advances in medi-
cal technology have improved the survival rates of trauma
victims and the severely ill. Clinical developments, such as
infection control, less-invasive surgical techniques, and ad-
vances in reproductive technology, improve the quality of
life. Drug therapy for managing chronic conditions—cancer,
heart disease, and diabetes—has extended life for many
Americans. Prescription drugs for treating mental illness
have allowed many to live in the community instead of be-
ing hospitalized.10
Between 2007 and 2010, nearly half of all
Americans took one or more prescription drugs. Factors that
have contributed to greater use of prescription drugs are the
growth of drug coverage by private and government health
insurance—Medicare Part D (drug plans) was introduced in
2006—and the ACA of 2010 made drugs more affordable.10
The continuing surge of technological advances is not
without problems. Medical technology can also prolong life
for the critically ill, unresponsive patient who has little or no
chance of recovery. Services such as mechanical ventilation,
kidney dialysis, parenteral (tube) feeding, and other means
can keep even comatose patients alive. For the healthcare
system, dying can be extremely expensive.
The high cost of technology affects the financial struc-
ture of the entire healthcare system. These increased costs are
visible in the form of higher health insurance costs, higher
costs for hospital stays, government payments to the sys-
tem, and total medical bills. This advanced technology has
not only increased medical costs, but also created a social
and ethical problem. Because of limits in funding, advanced
treatment is not available to all people. The poor, who may
need it desperately, have no access to it.
The incredible growth of technology has affected all the
health professions. Students entering the health field today
recognize that they must excel academically and master
technical skills. Less time is spent learning personal, non-
technical aspects of care. This value system is reinforced by
professionals, peers, and administrators, and by the public
as well. Excellent technical performance has become a stan-
dard, at the cost of the personal, human touch.
The federal government plays an increasingly powerful
role in the direction of health care. It dominates the health-
care system by virtue of its expanding monetary support of
technology and services, and because it sets the rules for the
provision of health care.
As health services enter the 21st century, it becomes
apparent that the social philosophy of the 20th century is
TABLE 1.1 National Prevention Strategy
Priorities for Reducing Death and Major Illness
Tobacco-free living
Preventing drug abuse and excessive alcohol use
Healthy eating
Active living
Preventing injury and violence
Reproductive and sexual health
Mental and emotional well-being
Data from National Prevention Council. National Prevention Strategy.
June 2011. Internet: http://www.surgeongeneral.gov/priorities/pre-
vention/index.html
7
Impact of Technology on Healthcare Services

high healthcare costs. New technology makes it possible
to identify genes for these brain diseases—Alzheimer’s,
Parkinson’s disease, epilepsy, ASD, traumatic brain in-
jury, and psychiatric disorders such as schizophrenia and
depression—as well as capture images of the brain to de-
velop treatment for such diseases.20
Awareness of the need
for pain control and freedom to make choices about treat-
ment for those with life-limiting illnesses is beginning to
shift the focus of both patients and physicians from cura-
tive therapy to quality of life and greater use of palliative
and hospice services.21
Health information technology (health IT) is chang-
ing the way healthcare workers practice their profession,
and even more changes are expected in the future. First
steps were using Electronic health records (EHRs) in hos-
pitals that linked data from physicians, pharmacy, clinical
laboratories, and imaging as well as documentation by all
health professions. EHRs make it possible for multiple team
members to schedule a patient-team conference regardless
of physical location. Remote monitoring of patient clinical
data—for example, blood pressure and blood glucose—al-
lows healthcare workers to provide care after the patient is
discharged from the hospital. Sharing of EHRs among dif-
ferent providers for the same patient—hospital, emergency
room and outpatient clinic—has the potential for improv-
ing patient safety by avoiding drug interactions and reduc-
ing costs by avoiding duplicate laboratory tests.22
The federal
government uses data to monitor outcomes such as hospi-
tal readmission rates and surgical complications, as well as
healthcare costs.
SUMMARY
To improve the health of all Americans, it is critical to con-
tinue collecting data on all components of health; document-
ing trends in risk factors, health status, and access to and
utilization of healthcare services; and disseminating reliable
and accurate information about the health of our popula-
tion. Equally important is gaining an understanding of the
healthcare needs and utilization patterns of population sub-
groups, especially with changes in access to health care with
healthcare reform. Such insights will enable policy makers
to set program priorities and allocate target resources most
effectively. Healthcare and population trends and healthcare
reform will affect all health professionals in every career and
will change the practice of medicine as we know it.
Because there is no single “U.S. healthcare system,” the
many ways in which health care is delivered can be puzzling.
This should not be surprising, given the historical perspec-
tive of health services, the diverse subsystems in operation in
the United States, and the dynamics of social and technolog-
ical changes.
FIGURE 1.5 Autism spectrum disorders (ASD) affects 1 in 68
children in the United States.
© JGA/Shutterstock
obsolete and is moving toward a philosophy that holds
society, through the government, responsible for organizing
and maintaining adequate health care for all people. Health
care was once considered an individual matter, but it is now
considered a right to which everyone should have access.
TRENDS THAT WILL IMPACT
HEALTH SERVICES AND
HEALTH CAREERS
Changes in disease patterns and methods of diagnosis and
treatment impact the demand for health services and health-
care workers. The Human Genome Project has identified
gene mutations that transmit risk for disease and response
to drugs used to treat disease. The lower cost of genetic test-
ing and coverage by health insurance have made it possible
for this technology to be available for more people. This new
information allows a physician to ask patients for a family
disease history and order DNA testing to target preventive
measures specific to the disease. Genetic counselors play an
important role in counseling patients about DNA testing to
identify risk for disease as well as treatment interventions.18
Public health research shows that more and more chil-
dren are being diagnosed with Autism spectrum disorders
(ASD) with 1 in 68 children in the U.S. being given this di-
agnosis. Children with ASD are often treated by a team of
health professionals, including occupational therapists,
speech therapists, and applied behavior analysis (ABA)
therapists (FIGURE 1.5).19
Many diseases of the brain cause disabilities that
impact productivity and quality of life and contribute to
U.S. Health Care
8 CHAPTER 1

LEARNING PORTFOLIO
Study Points
1. As a result of the 2010 Affordable Care Act (ACA),
more Americans had access to health insurance through
Health Exchanges, Medicaid, or the Children’s Health
Insurance Program (CHIP). As a result of new Health
Exchanges, 6.7 millionAmericans obtained health insur-
ance in 2014 and 11.7 million were enrolled in 2015. An
additional 11 million low-income adults and children
received health care through Medicaid or CHIP in 2015.
2. Health problems during the 1800s were related to
contaminated food and water and inadequate sewage
disposal resulting in epidemics and deaths from chol-
era and yellow fever.
3. Both longevity and infant mortality statistics im-
proved with improvement in sanitation and universal
immunization; by 1950, the principal causes of death
changed from infectious diseases to the chronic dis-
eases of heart disease and cancer.
4. By the 21st century, the decrease in death rates among
the elderly was significant. These declines were related
to improved drug treatment for heart disease and can-
cer and lower smoking rates.
5. The consequence of improved longevity is a greater
number of elderly with multiple chronic and degenera-
tive diseases; treatment for these conditions account for
two-thirds of total healthcare costs in the United States.
6. Clinical preventive services (cancer screening and
immunizations) are more accessible because of pro-
visions of the Affordable Care Act, but not all Ameri-
cans take advantage of these services.
7. New infectious diseases of domesticated animals and
humans continue to emerge and require monitoring
and infection-control measures to prevent epidemics.
8. Over 50% of the causes of death are related to per-
sonal lifestyle choices: diet, physical activity, tobacco
and alcohol use, illicit use of drugs, and motor vehicle
traffic fatalities.
9. Greater use of prescription drugs are the result of
drug coverage by private and government health in-
surance—Medicaid, CHIP, Medicare, and the ACA.
10. The Human Genome Project will increase under-
standing of diseases of the brain needed to develop
improved methods of diagnosis and treatment.
11. Health information technology (health IT) improves
communication and efficiency in providing health
care and will increasingly be used by the government
to monitor the quality and cost of healthcare delivery.
12. Factors that will influence current and future health-
care occupations are changes in disease patterns and
treatment and access to health care.
Issues for Discussion
1. Discuss changes in access to health care in the United
States as a result of the Affordable Care Act of 2010.
2. Discuss how the causes of death have changed since
1900 in the United States. Discuss three major factors
that have contributed to this change.
3. Discuss the role of government in providing access to
health care through legislation and financial support
of health care and technology.
4. Discuss the pros and cons of requiring all children to
receive immunizations as a prerequisite to enrolling in
school.
5. Discuss the role of Health information technology
(health IT) in monitoring the quality and cost of
health care in the United States. What are the advan-
tages and disadvantages of using HIT?
Enrichment Activities
1. Methicillin-resistant Staphylococcus aureus (MRSA) is a
cause of skin infection in the community, for example in
high schools and day care centers. Review information
from the CDC (MRSA in the Community: http://www.
cdc.gov/mrsa/community/index.html) to learn how
MRSA can be transmitted in the community setting.
2. Use obesity prevalence maps from the CDC (Obesity
and Overweight: http://www.cdc.gov/obesity/data/
prevalence-maps.html) to learn more about obesity
in the United States, including the state in which you
live. Which states have the highest rates of obesity,
and which states have the lowest rates of obesity?
3. Explore CDC Vital Signs to learn more about differ-
ences in cigarette smoking across states and different
groups within the United States (Tobacco Use & Sec-
ond Hand Smoke. CDC Vital Signs. September 2010:
http://www.cdc.gov/vitalsigns/TobaccoUse/Smoking/
index.html). Learn more about the health risks of
smoking and secondhand smoke.
4. Learn more about the role of genomics from the
CDC’s Healthy People 2020 website (http://www.
healthypeople.gov/2020/topics-objectives/topic/
genomics). Which diseases have a strong relationship
to genomics, and how can this information be used by
consumers and physicians to prevent disease?
5. Review the article Global Health in the Clinical Labora-
tory (Critical Values. 8:24-27, April 2015: http://www.
ascp.org/Newsroom/Critical-Values.html) to learn how
Emory University in Atlanta, Georgia prepared to accept
and treat patients traveling from West Africa who were
infected with the Ebola virus. What special isolation pro-
cedures were used?
Learning Portfolio 9

LEARNING PORTFOLIO
References
1. Office of the Legislative Counsel, U.S. House of Representa-
tives. Compilation of Patient Protection and Affordable Care
Act. 111th Congress, 2d Session. May 10, 2010. Internet:
http://housedocs.house.gov/energycommerce/ppacacon.pdf
2. Goodman DC, Brownlee S, Chang C-H, Fisher E. Regional
and Racial Variation in Primary Care and the Quality of
Care Among Medicare Beneficiaries. A Report of the Dart-
mouth Atlas Project. Hanover, NH: Dartmouth Institute for
Health Policy and Clinical Practice Center for Health Policy
Research; 2010. Internet: http://www.dartmouthatlas.org/
downloads/reports/Primary_care_report_090910.pdf
3. Peterson-Kaiser Health System Tracker. How Has Health
Spending Changed Over Time? Menlo Park, CA: Kaiser Fam-
ily Foundation. Internet: http://www.healthsystemtracker.
org/chart-collection/how-has-health-spending-changed-
over-time/?slide=5
4. Goodman DC, Brownlee S, Chang C-H, Fisher E. Regional
and Racial Variation in Primary Care and the Quality of Care
among Medicare Beneficiaries. A Report of the Dartmouth Atlas
Project. Hanover, NH: Dartmouth Institute for Health Policy
and Clinical Practice Center for Health Policy Research; 2010.
Internet: http://www.dartmouthatlas.org/downloads/reports/
Primary_care_report_090910.pdf
5. Levitt L, Cox C, Claxton G. Data Note: How Has the Individual
Insurance Market Grown under the Affordable Care Act? Menlo
Park, CA: Kaiser Family Foundation. May 12, 2015. Internet:
http://kff.org/health-reform/issue-brief/data-note-how-has-
the-individual-insurance-market-grown-under-the-afford
able-care-act/
6. Artiga S, Rudowitz R, Gates A, Snyder L. Recent Trends for
Medicaid and CHIP Enrollment as of January 2015: Early
Findings from the CMS Performance Indicator Project. Is-
sue Brief. March 31, 2015. Menlo Park, CA: Kaiser Family
Foundation. Internet: http://kff.org/medicaid/issue-brief/
recent-trends-in-medicaid-and-chip-enrollment-as-of-
january-2015-early-findings-from-the-cms-performance-
indicator-project/
7. Garfield R, Young K. Adults who Remained Uninsured at
the End of 2014. Issue Brief. January 2015. Menlo Park,
CA: Kaiser Family Foundation. Internet: http://kff.org/
health-reform/issue-brief/adults-who-remained-unin
sured-at-the-end-of-2014/
8. National Center for Environmental Health; National
Center for Health Statistics; National Center for Infectious
Diseases, CDC. Achievements in Public Health, 1900–1999:
Control of Infectious Diseases. MMWR 1999; 48:621–629.
9. National Center for Health Statistics (NCHS). Health,
United States, 2014: With Special Features on Adults Aged
55-64. Hyattsville, MD: NCHS; 2015.
10. National Center for Health Statistics. Health, United States,
2013. With Special Features on Prescription Drugs. Hyatts-
ville, MD: NCHS; 2014.
11. Centers for Disease Control and Prevention. The State of
Aging and Health in America 2013. Atlanta, GA: CDC;
2013.
12. Smith KF, Goldberg M, Rosenthal S, Carlson L, Chen J,
Chen C, Ramachandran S. Global Rise in Human Infectious
Disease Outbreaks. J R Soc Interface. 2014; 11(101):20140950.
13. Centers for Disease Control and Prevention. Avian Influ-
enza in Birds. Internet: http://www.cdc.gov/flu/avianflu/
avian-in-birds.htm
14. Centers for Disease Control and Prevention. Ebola (Ebola
Virus Disease). April 28, 2015. Internet: http://www.cdc.
gov/vhf/ebola/outbreaks/2014-west-africa/index.html
15. Centers for Disease Control and Prevention. Methicil-
lin- resistant Staphylococcus aureus (MRSA) Infections.
April 2014. Internet: http://www.cdc.gov/mrsa/healthcare/
index.html
16. Office of the Surgeon General, U.S. Department of Health
and Human Services. National Prevention Strategy. June
2011. Internet: http://www.surgeongeneral.gov/priorities/
prevention/index.html
17. Ortman JM, Velkoff VA. An Aging Nation: The Older Pop-
ulation in the United States. Current Population Reports.
P25-1149. Washington, DC: U.S. Census Bureau. May 2014.
Internet: https://www.census.gov/prod/2014pubs/p25-
1140.pdf
18. National Human Genome Research Institute. The John Hop-
kins University/National Human Genome Research Institute
Genetic Counseling Training Program. Internet: http://www.
genome.gov/10001156
19. Centers for Disease Control and Prevention. Autism Spec-
trum Disorders (ASD). February 24, 2015. Division of Birth
Defects, National Center on Birth Defects and Develop-
mental Disorders. Internet: http://www.cdc.gov/ncbddd/
autism/facts.html
20. National Institutes of Health. Brain 2025: A Scientific Vision.
The Brain Initiative. June 5, 2014. Internet: http://www.
braininitiative.nih.gov/2025/indes.htm
21. National Hospice and Palliative Care Organization. NHP-
CO’s Facts and Figures: Hospice Care in America. Alexandria,
VA: NHPCO; 2014.
22. Sochalski J, Weiner J. Health care system reform and the
nursing workforce: Matching nursing practice and skills to
future needs, not past demand. In: The Future of Nursing:
Leading Change, Advancing Health. Washington DC: IOM
(Institute of Medicine)/The National Academies Press; 2011.
Design Credits: Spine: © Sebastian Kaulitzki/Shutterstock
U.S. Health Care
10 CHAPTER 1

Categories of Health
Services
Objectives
After studying this chapter, the student should be able to:
■
■ List direct health services provided by the federal government.
■
■ Compare financing and governing of private, public, and volunteer healthcare facilities.
■
■ Identify the four broad types of health services in the United States.
■
■ Compare the population served by federally funded primary care health centers and free clinics.
■
■ Name health agencies within the U.S. Department of Health and Human Services (HHS).
■
■ Summarize the six major points of the Patient Care Partnership.
■
■ Describe public health and mental health services in the United States.
Key Terms
CHAPTER 2
Affordable Care Act (ACA)
Almshouse
Ambulatory care
Behavioral Risk Factor Surveillance
System (BRFSS)
Civilian Health and Medical
Program of the Department of
Veterans Affairs (CHAMPVA)
Commissioned Corps
Community hospital
Diagnosis and treatment
Disease prevention
Essential hospitals and health
systems
Federally funded primary care
health centers
Healthcare facilities
Health promotion
Health Resources and Services
Administration (HRSA)
Hospital system
Indian Health Service (IHS)
Informed consent
Mental health services
© Jim Parkin/Shutterstock
11

OVERVIEW OF THE U.S.
HEALTHCARE SYSTEM
The healthcare industry is a complex system of diagnos-
tic, therapeutic, and preventive services. Hospitals, clinics,
government and volunteer agencies, pharmaceutical and
medical equipment manufacturers, and private insurance
companies provide these services. In terms of jobs in the
healthcare industry, hospitals employ the largest percentage
(39%), followed by offices of health practitioners (26%) and
nursing and other residential facilities (20%). Home health
services and outpatient, laboratory, and other ambulatory care
settings make up the remaining healthcare jobs, at 8% each.1
The focus of this chapter is hospitals and outpatient or
ambulatory care provided by both private and government
institutions, as well as the federal agencies responsible for en-
suring the health and safety of all Americans under the U.S.
Department of Health and Human Services (HHS) through
research and financial support. Chapter 4 includes long-term
care—nursing home care and other supportive living facilities.
The federal government provides very few direct health
services, preferring to support new, improved services by
providing money to fund expanded services, for example
through the Affordable Care Act (ACA). The exceptions are
the health services of TRICARE, through the U.S. Department
of Defense (DoD), the Civilian Health and Medical Program
of the Department of Veterans Affairs (CHAMPVA), and the
Indian Health Service (IHS). The federal government has no
authority to provide direct services; this is a function of the
private sector and the states. The federal government is in-
volved, however, in financing research through the National
Institutes of Health (NIH) and individual health care for the
elderly through Medicare as well as healthcare for the low-in-
come uninsured through Medicaid. The federal government
also funds loans and scholarships for students in the health
professions through the Health Resources and Services
Administration (HRSA). The most important federal agency
concerned with health affairs is the HHS, with 11 operating
divisions, including eight agencies in the U.S. Public Health
Service and three human services agencies.2
Congress plays
a key role in this federal activity by making laws, allocating
funds, and doing investigative work through committees.
The healthcare system offers four broad types of ser-
vices: health promotion, disease prevention, diagnosis and
treatment, and rehabilitation.
CATEGORIES OF HEALTHCARE
SERVICES
Health promotion services help clients reduce the risk of
illness, maintain optimal function, and follow healthy life-
styles. These services are provided in a variety of ways and
settings. Examples include hospitals that offer prenatal nutri-
tion classes and local health departments that offer selected
recipients prenatal nutrition classes plus a food package that
meets their nutritional requirements (the Women, Infants,
and Children [WIC] program). Classes at both places pro-
mote the general health of women and children. Exercise and
aerobic classes offered by city recreation departments, adult
education programs, and private or nonprofit gymnasiums
encourage consumers to exercise and maintain cardiovas-
cular fitness, thus promoting better health through lifestyle
changes.
Disease prevention services offer a wide variety of
assistance and activities. Educational efforts aimed at involv-
ing consumers in their own care include attention to and
recognition of risk factors, environmental changes to reduce
the threat of illness, occupational safety measures, and pub-
lic health education programs and legislation. Examples of
public health programs are a smoking cessation class offered
through the hospital or the local department of public health
or a lead abatement program for older homes offered to
homeowners by the city health department. An example on
the individual level is women participating in screening for
breast and cervical cancer. It is evident that preventive mea-
sures such as these can reduce the overall costs of health care.
Diagnosis and treatment of illness have been the most
used of the healthcare services, most often provided in the
hospital or ambulatory care setting. Diagnosis of illness
involves physician visits and, if necessary, laboratory tests,
x-rays, and other technology to make a diagnosis; examples
of treatment are surgery, physical and speech therapy, and
medications. Recent advances in technology and early diag-
nostic techniques have greatly improved the diagnosis and
treatment capacity of the healthcare delivery system—but
the advances have also increased the complexity and price of
health care (FIGURE 2.1).
Rehabilitation involves the restoration of a person to
normal or near normal function after a physical or men-
tal illness, including chemical addiction. These programs
take place in many settings: homes, community centers,
Mental Health Parity and Addiction
Equity Act of 2008
National Association of Free &
Charitable Clinics (NAFC)
National Center for Health Statistics
National Institutes of Health
Network
Patient Care Partnership
Private hospital
Proprietary hospital
Public hospital
Refugee
Rehabilitation
Social Security Act of 1935
Social Security Act of 1965
TRICARE
U.S. Department of Defense (DoD)
U.S. Department of Health and
Human Services (HHS)
U.S. Public Health Service (PHS)
Vital statistics
Voluntary hospital
12 CHAPTER 2 Categories of Health Services

rehabilitation centers, hospitals, outpatient clinics, and long-
term care facilities. Rehabilitation is a long process, and both
the client and family require extra assistance in adjusting to
a chronic disability. Common conditions requiring rehabili-
tation are physical injuries such as strokes and head injuries,
hip and knee replacement surgery, and mental conditions
such as alcohol or drug addiction.
HEALTHCARE FACILITIES
A wide variety of healthcare facilities are available. These
facilities, the places where persons involved in the healthcare
industry work, are broadly summarized in this chapter but
are individually detailed elsewhere. This discussion of the
numerous healthcare fields should assist students in select-
ing a career and becoming knowledgeable about their chosen
fields.
Expansion of the healthcare system and professional spe-
cialization has resulted in an increase in the range and types
of healthcare settings. Medical care settings include offices of
health practitioners, nursing and residential facilities, home
health services, and outpatient clinics, laboratories, and
ambulatory services as well as the primary inpatient setting—
hospitals. Public health settings are usually community-based
and may be voluntary organizations, such as the American
Cancer Society, or government-supported entities, such as the
city, county, or state public health department.
Clients requiring diagnosis and treatment can find
health care in physicians’ offices, ambulatory care centers,
and outpatient clinics. In addition, there are freestanding
immediate-care clinics staffed by physicians or located in-
side a pharmacy and staffed by nurse practitioners or phy-
sicians’ assistants who provide immunizations and treat mi-
nor, acute illnesses such as colds, cuts, or sprains. Although
physicians in office practice focus mainly on the diagnosis
and treatment of specific diseases, many clinics and ambula-
tory centers offer health education and rehabilitation as well.
For example, outpatient cardiac rehabilitation centers pro-
vide classes on nutrition and stress management and the use
of exercise equipment to increase strength and endurance
while monitoring heart function. Other health professionals
who provide rehabilitation services are physical therapists
for physical rehabilitation and psychologists, social workers,
and behavioral counselors, who provide therapy for chemi-
cal addiction and mental illness.
Community-based agencies provide health care within
defined neighborhoods. Such diverse facilities include fed-
erally supported health centers, adult daycare centers, home
health agencies, crisis intervention and drug rehabilitation
centers, halfway houses, and various support groups. All
work in a wide variety of ways to maintain the integrity of
the community.
Federally funded primary care health centers serve
high-need communities designated as medically under-
served areas or populations—the largest comprehensive
safety net of primary and preventive care in the country. The
health centers are supported by the HRSA within the HHS
and are public and private nonprofit healthcare organiza-
tions governed by a board, most of whose members are in
the community being served by the health center. The cen-
ters serve medically underserved populations/areas or spe-
cial, medically underserved populations, such as migrant
and seasonal farmworkers, the homeless, or residents of
public housing. The health centers provide a medical home
for low-income individuals, racial and ethnic minorities,
and other underserved populations in both rural and urban
communities. Health centers manage patients with multiple
healthcare needs and use key quality improvement practices,
including health information technology—nearly 90% of
the centers use electronic health records.3
The health centers
provide services to patients regardless of their ability to pay;
however, many patients are enrolled in Medicaid, Medicare,
or the Children’s Health Insurance Program (CHIP), and
the health centers receive reimbursement for services from
these federal government programs. Other patients may
have insurance through the ACA Healthcare Marketplace
or other insurance outlets. Comprehensive medical, dental,
pharmacy, and behavioral health services are available at the
health centers. A multidisciplinary team of physicians, phy-
sician assistants, nurses and nurse practitioners, midwives,
social workers, health educators, and behavioral health and
other providers staff the health centers.
The first health centers were established in 1962 for
migrant and seasonal farm workers, and by 1964, two neigh-
borhood health centers were opened in the Boston area. As
of July 2015, there were more than 1,300 health centers that
operated in 9,000 service sites that provided care to nearly
23 million patients in all states within the United States, the
District of Columbia, Puerto Rico, the U.S. Virgin Islands,
and the Pacific Basin. As a result of the ACA (which provided
funds to expand the health centers and increased access to
health insurance coverage), the number of centers increased
by 300 and the number of patients served increased by 23
million. In 2014, one in every 14 Americans received health
care through one of the health centers; 50% of those receiving
FIGURE 2.1 Diagnosis and treatment is the most-used healthcare
service.
© thomas koch/Shutterstock
13
Healthcare Facilities

Exploring the Variety of Random
Documents with Different Content

"I owe you," said Bob, in a bland voice, "ten shillings. Here's the
money. Do you want to earn a ten-pound note, which might swell
into fifty? There's a gentleman friend of ours who would stand that,
and more perhaps, for services rendered."
"What kind of services?" inquired Crawley, pocketing the ten
shillings.
"Information. Truthful and accurate information. The ten pound
note sure. That much we guarantee, and wouldn't mind giving half
on account. The fifty-pound almost as sure. Here, let me speak to
you aside."
They walked a little way from us, and I did not interrupt their
conversation, which lasted some twenty minutes. At the end of that
time Bob left Crawley to say a few words to me.
"Go back to the inn," he said, "you and Sophy, and wait for me.
Will join you there in an hour or so. Crawley and I going to have a
drink."
I obeyed him without wasting time in asking questions, and
Sophy and I returned to the inn. It was a disappointment that a
telegram from Emilia had not arrived. But before Bob made his
appearance an incident occurred which profoundly agitated me. I
was sitting at the table, making, as was usual with me, a record of
what had happened, in the doing of which I had occasion to take
some papers from my pockets. Among these papers which I placed
on the table was the photograph of Gerald Paget which I had found
in M. Felix's room, his name being written on the back. While I
wrote, Sophy remained quiet. The girl has a discretion; she knows
when to speak and when to hold her tongue. My writing done I took
up the papers to put them in my pocket, and in doing so the
photograph dropped to the ground. Sophy stooped and picked it up,
and was about to give it to me, when her eyes fell on it.

"Well, I never!" she exclaimed. "If it ain't the pickcher of Number
One!"
"What?" I cried.
"It is," she said, looking at it with absolute tenderness. "It's the
image of 'im, though he's older now than when it was took; but it's
'is face as clear as clear can be."
"Sophy," I said, rising in my excitement, "are you mad? Do you
know what you are saying?"
"'Course I do. It's Number One I tell yer. I'll take my Bible oath on
it!"
"You must be dreaming," I said. "This is the portrait of a
gentleman who died many years ago."
"If he's dead," she persisted, "he's come to life agin, like Mr. Felix.
It's Number One's pickcher, and nobody else's."
She was so positive that I was confounded by the possibilities her
statement opened up, supposing her not to be mistaken. Nothing
that I said could shake her conviction.
"I know 'is face as well as I know your'n," she said. "I can't be
mistook. It's the pickcher of Number One."
At this juncture Bob entered the room. Anxious as I was to hear
his news I first explained the incident to him, and it was an
additional surprise to me when he ranged himself on Sophy's side.
"I accept everything," he said. "No villainy too monstrous for
Peterssen. Corroborative evidence handy. Crawley!"
The man was outside in the passage, and at the summons he
came in.

"Know this portrait?" asked Bob, handing it to him.
"Of course I do. It's Number One. How did you get hold of it?"
"Never mind. Are you positive it is his portrait?"
"I'll swear to it."
"That will do. Go and get something to eat, and be ready when I
call you. Mind, no drinking."
Crawley gone, Bob turned his attention to me.
"Before I tell you arrangements entered into with Crawley, finish
about this picture. Sophy says, portrait of Number One. Crawley will
swear it. I believe it--name of Gerald Paget back of picture.
Deduction--portrait of Gerald Paget. Further deduction--Number One
and Gerald Paget same person. Startling--but Peterssen and M. Felix,
damned scoundrels, pair of them. No villainy too monstrous for
them. In circumstance of Number One and Gerald Paget being same
person, his solution of Peterssen's power over M. Felix. What does
lady we are working for overhear? Overhears Peterssen threaten to
ruin M. Felix; overhears him refer to a pleasant partnership in
Switzerland nineteen years ago. Overhears him ask M. Felix if he has
forgotten his brother Gerald. Not idle words. On the contrary, deeply,
darkly significant. To my mind, quite clear--and convincing. Splendid
links of circumstantial evidence. Gerald Paget alive instead of dead,
additional reason for M. Felix's disappearance. Threatened not on
two sides, but on three. Peterssen--Gerald Paget--Gerald Paget's
wife. Desperate fix for M. Felix. Your opinion, Agnold?"
"Coincides with yours, Bob. Light is truly breaking in upon this
mystery."
"Right you are. Now to explain Crawley. Have taken him in our
service--for one month, certain--thirty shillings a week. Matters
brought to satisfactory conclusion, promise of passage to America,

with few pounds in his pocket. No doubt M. Bordier will do what we
wish, and indemnify us. If not, won't ruin us. Agreed?"
"Agreed."
"I come now to Peterssen and Tylney House. Briefly. Things been
going wrong for some time past. Peterssen in pecuniary difficulties.
Dunned on all sides for money owing. Tradesmen threaten to stop
supplies. Last night, Peterssen in frightful rage. Door of private room
locked. Key missing. Door forced open. Something stolen from room.
Crawley doesn't know what. We do. Sophy, otherwise Maria,
nowhere to be found. Row between Peterssen and Crawley.
Peterssen accuses Crawley of treachery. Crawley calls him another.
At midnight Crawley hears bell ring. Peterssen answers it--admits
visitor. Crawley doesn't see him. Visitor sleeps there--is there this
morning--but Crawley can't catch sight of him. Keeps himself dark.
Crawley sent on bogus errand. Occupies him three hours. Returns to
find visitor gone, Peterssen gone, Number One gone. Note left for
Crawley from his master. Concern burst up. In note, small sum for
wages due. Not half what is due. Crawley furious, but helpless. I
have enlisted him. He is to assist us to track Peterssen. That's all."
"Bob," said I, "Peterssen must be hunted down and brought to
justice."
"He must," said Bob, "and shall be."
"There is some fresh villainy hatching," I said. "If possible we
must prevent it. You will stand by me?"
"To the end," said Bob.

CHAPTER LIV.
OBTAIN AN EXPLANATION FROM EMILIA.
It was now between five and six o'clock, and we did not wait for
the night to pass before we commenced the task of hunting Dr.
Peterssen down. The immediate result, however, was unsatisfactory.
Indefatigable as we were we learnt nothing, and Crawley proved to
be rather in our way than otherwise. Dr. Peterssen's movements
must have been cunningly made indeed to so baffle us. We went to
the railway station, but the station-master was positive that three
such men as we described had not taken tickets for any place during
the day. He could have identified Dr. Peterssen; of Peterssen's
patient or of M. Felix he had no knowledge.
"There isn't much traffic here," he said, "and we know pretty well
who comes and goes."
"But strangers sometimes pass through," I observed.
"That goes without saying," he responded.
"They might have travelled separately," suggested Bob.
"They might," said the station-master.
"It is hardly likely," I said aside to Bob, "that this would be the
case. If Peterssen and M. Felix have come together again, Peterssen
would not lose sight of his villainous partner; and neither of them
would lose sight of the gentleman they have wronged."
I consulted the time-table. There was no other direct train to
London that night, but a train passed through, without stopping, at
11.40. I inquired of the station-master whether it was possible for
the train to stop a few seconds to take me up to London, and he

answered that it could be managed. Having arranged the matter
with him I left the station, accompanied by Bob and Sophy. Crawley
lingered behind; he had a flask with him, out of which he took
frequent drinks. I had already arrived at the conclusion that he
would be of little assistance in tracking Dr. Peterssen, but as his
evidence might be valuable in the event of our hunting Peterssen
down I thought it advisable to keep him about us.
"What is your idea?" asked Bob, as we walked from the station to
the inn.
"If I do not receive a satisfactory letter or telegram from London
before eleven o'clock," I replied, "I shall go on to London to see
Emilia."
"For what purpose?"
"To gain some information of M. Bordier. Something may come of
it--I cannot say what; but to remain inactive would be fatal to our
chances."
"Peterssen has a good start of us," said Bob. "He has given us
check."
"But not checkmate, Bob. I have hopes that it remains with us to
score the game."
Neither telegram nor letter had arrived for me at the inn, and a
little after eleven I was at the station, awaiting the train. It was
punctual to time, and stopped just long enough to enable me to
jump in. Then we whirled on to London, which we reached at three
o'clock in the morning. At such an hour a visit to Emilia was out of
the question, and I had perforce to bide till morning. The delay gave
me opportunity for a few hours' sleep, and at nine o'clock I was in
the presence of Emilia. Although she received me with signs of
perturbation I observed a change in her. Her eyes were brighter, and

there was a certain joyousness in her manner which I was glad to
see.
"You have had good news," I said.
"I have," she replied, "the best of good news. But what brings
you again to London so unexpectedly, dear friend?"
I thought of the secret in my possession which identified Dr.
Peterssen's patient, Number One, as Gerald Paget, whom she had
mourned as dead for nineteen years. But I did not dare to whisper it
to her lest I should inspire delusive hopes. The proof had yet to be
established, and until that was done it would be best and most
merciful to preserve silence.
"I come entirely upon your business," I said, "and I wish to get
back at once."
"How good you are to me!" she murmured. "Never, never can I
repay you for all your kindness."
"We will not speak of that. But you can give me some return now.
I think I may truly say that I deserve your confidence."
"Indeed, indeed you do."
"I sent you a telegram yesterday."
"Yes, I received it."
"I expected one from you."
"I am sorry," she said, "but I had nothing to communicate, and M.
Bordier desired me neither to write nor telegraph to anyone till he
saw me. I was bound to obey him with so much at stake."
"Yes, I understand all that. He is aware that I am a reporter on a
newspaper, and he fears I shall make improper use of information. I

cannot blame him, but he is mistaken. Did not M. Bordier return to
London yesterday?"
"No."
"He gave you instructions, then, by letter."
"By letter and telegrams."
She took from her pocket a letter, and two telegrams in their
familiar buff-colored envelopes, and, after a little hesitation, handed
me the latter.
"I cannot think I am doing wrong in letting you see them," she
said.
The first telegram ran: "I have good news, the best of news. Keep
a good heart. Julian unites with me in love to you and Constance."
"His son is with him?" I asked.
"Yes," she replied. "Poor Julian!"
In my last interview with her, two days since, she had referred to
Julian Bordier in the same pitying tone. I had not then asked for an
explanation, and I had not time now. The moments were too
precious to waste in questions which did not bear immediately upon
the matter in hand. I read the second telegram: "We may be absent
a day or two. Meanwhile send no letters or telegrams to any person
whatsoever. I particularly desire to avoid publicity of any kind. To Mr.
Agnold, who has so generously and kindly befriended you, I will give
a full explanation when we meet. Our united love."
For a moment or two I was nettled, but I very soon got over the
small feeling. Had I been present when M. Bordier surprised Bob
Tucker in the inn and found the document in the secret drawer of
the desk, he would doubtless have taken me into his confidence. It

was natural that he should look upon Bob in a different light, for the
probable reason that he supposed him to be a professional
detective.
"M. Bordier," said Emilia, "repeats the injunction in his letter. I
could not but obey him."
She read from the letter words to the same effect as the second
telegram.
"You infer," I said, "from these communications that M. Bordier
places no obstacles in the way of your daughter's union with his
son."
"Yes," she replied; "it is my happy belief. My heart is lighter than
it has been for months. I have endured what seemed to me an
eternity of sorrow, but that has passed, and Heaven's light is shining
upon my life."
She was transfigured. There was indeed a heavenly light in her
eyes, and her manner was as that of one who had been raised from
deepest woe to supreme happiness.
"I rejoice with you," I said, cordially. "Is it a breach of confidence
for me to ask from what part of the country M. Bordier has written
to you?"
"His letter bears no address," she said.
"Does he give you no information of what he has done and is
about to do?"
"None."
"Nor of any discovery that has been made?"
"No."

She looked at me wistfully; I took her hand. As to certain matters
there was on my part no motive for secrecy. Why should I withhold
from her even for an hour that which would strengthen the new-
born hopes which animated her? To a heart so sorely bruised as hers
had been, to one who had borne suffering so sweetly and patiently,
it would be cruel to keep back the least word of comfort, and I
narrated to her all that had taken place between M. Bordier and Bob.
She was greatly excited when I told her of the recovery of the desk,
of M. Bordier's search for the secret drawer, and of his subsequent
discovery of the hidden document.
"It is the copy of the marriage certificate," she cried.
"That is my impression, and now I can relieve your mind of
another discovery. It is our firm belief that the man who assumed
the name of M. Felix lives."
I gave her our reasons for this belief, and made her acquainted
with Bob's theory of the seizure which threw M. Felix into a state of
unconsciousness and insensibility, and which was simply pronounced
to be death. She was profoundly agitated, and the grateful tears
flowed down her face.
"I have been distracted by a horrible fear," she said, "that I was
the indirect cause of his death. Surely Heaven sent you to my aid on
the night we first met. Without you I should not have dared to
move, and indeed whatever steps I might have taken must have
proved futile. Through you and your friends, Dr. Peterssen is
unmasked, and my honor established. How I long to embrace that
brave girl, Sophy! No reward can be too great for her, and M.
Bordier, I am sure will do all in his power to advance her. Dear
friend, dear friend! My words are weak--my heart is full."
She pressed my hand and kissed it, and she promised to let me
know everything upon M. Bordier's return. I did not tell her why I
was anxious to return to the village with as little delay as possible,

but I incidentally showed her the photograph which I had found in
M. Felix's rooms. Her tears bedewed it, she kissed it again and
again.
"It is my dear husband's portrait," she sobbed. "His name is in his
own handwriting. Dear Gerald! They would have had me believe you
false. Heaven forgive them for their treachery to you, to me!"
She begged me to leave the picture with her, but I was compelled
to refuse; I needed it to track Dr. Peterssen and his patient. Of
course I kept my reasons to myself, and I promised her that I would
only retain the portrait a short time, and that it should soon be hers.
"I do not exactly know," I said, "where I shall be during the next
few days; I may be travelling from place to place, but I shall
continue to telegraph to you wherever I am; in order that you may
communicate with me."
"But why do you go away again?" she asked; "you have
discovered what you wished; nothing more remains to be done."
If she but knew, I thought, how different would be her desire--
how she would urge me to fly, how she would implore, entreat, and
urge me on!
"Much remains to be done," I said, "Dr. Peterssen must be found;
he must not be allowed to escape."
"Leave him to Heaven's justice," she said.
"That will overtake him; but man's justice shall also be meted out
to him. Would you leave Leonard Paget also in peace?"
"I would," she replied.
"He has squandered your fortune, but there may be some small
portion left. It must be recovered; it will serve as your daughter's

dowry."
"She needs none. M. Bordier and Julian will be content to take her
as she is; and for me--has not happiness shone upon me in the
darkest hour of my life? Let both those men go their way."
"No," I said, firmly, "my mission is not yet ended, and you, if you
knew all, would not seek to restrain me."
She looked at me questioningly, and I accounted for my rash
remark by saying, "There are public as well as private duties, my
dear madam, and I should be false to my trust if I neglected the one
for the other. I should like to shake hands with your daughter before
I go."
She went from the room and returned with Constance, who
received me cordially. As they stood side by side, their lovely
countenances irradiated by thoughts of the bright future in store for
them, I was glad to know that I had had some small share in their
better fortune.
"It is something to have done," I said to myself as I hastened to
the station, "to have assisted to bring joy to the hearts of two good
women; this in itself is ample reward. Then, old fellow, you have
gained two earnest and sincere friends. One of these fine days you
shall go to Switzerland, and be witness of the happiness to which
you have contributed. And if you can restore to the one a husband,
to the other a father----"
I rubbed my hands and stepped on gaily. The mystery of M. Felix
had engaged and engrossed me for a considerable time, but I was
never more interested in it than I was at the present moment. "I will
not desist," thought I, "till the end is reached. A bitter ending for the
snarers, a sweet ending for the snared."

CHAPTER LV.
TREACHERY.
"News, Agnold!" cried Bob, when I joined him in the country.
"Bravo!" I said, "out with it."
"Three men answering to the description of those we are seeking
were seen yesterday on the road to Monkshead."
"Where is that?"
"Thirty-two miles from here, as the crow flies."
"Who gave you the information?"
"Crawley. The fellow is of some use, after all."
I was not so sure, but when I questioned Crawley he was so
precise and circumstantial in his account that I saw no valid reason
to discredit him. He had received the news from a teamster, he said,
who had passed the men on the road. Were they walking? Yes. How
did the teamster know they were going to Monkshead? They were
on the high road. How far from Monkshead? About ten miles.
"I have asked questions," said Crawley, "of every stranger who
has passed through the village, and this was the only one who could
tell me anything at all."
"Did you describe Dr. Peterssen's appearance to him?" I asked.

"Yes, and he said it was something like another of the men."
"Did you describe the third?"
"How could I, when I never saw him?"
I had put the last question as a test of Crawley's truthfulness; if
he had answered otherwise, the doubts I had of his veracity would
have been strengthened.
"You believe he is speaking the truth, Bob?" I asked my friend,
Crawley being out of hearing.
"What reason has he to tell lies?" asked Bob, in return.
"To show that he is doing something toward earning his wages."
"That's cutting it rather fine," said Bob. "You are giving Crawley
credit for intellect; I think he is not overstocked in that respect. Can't
afford to throw away a chance, Agnold."
"Certainly not, and this chance shall not be slighted. But we will
not risk everything upon the hazard. My plan is this. Crawley, Sophy,
and I will go to Monkshead on a voyage of discovery. You shall
remain here to take advantage of anything that may turn up. I will
keep you posted as to our movements; you will keep me posted as
to yours. Blessings on the electric telegraph. You will repeat all
telegrams that arrive for me to such places as I shall direct, retaining
the originals in case of miscarriage. Do you agree to all this?"
"I must," said Bob, "though I would rather go with you."
"There would then be no one left in command here, and we
should be burning our ships."
"All right. You are welcome to Crawley. Must you take Sophy?"

"I must. She is the only one in our party who is familiar with M.
Felix. If we hunt Peterssen down, M. Felix will most likely be with
him, and Sophy is at hand for the purpose of identification. Should I
have reason to believe we have struck the right trail, I will wire to
you, and you can come on to us. Say agreed, old fellow."
"Agreed, old fellow."
After that Bob and I were closeted together for an hour, setting
down all our arrangements in black and white; then I prepared to
depart.
"Good luck, Agnold," said the faithful Bob. "Send for me soon."
"As soon as I can. I want you to be in at the death."
I spoke these words lightly, with no notion of their ominous
significance, and a carriage and pair having been got ready for us,
Crawley, Sophy, and I took our seats in it, and bowled along to
Monkshead. We arrived there at noon on the following day, and at
the post-office I found two telegrams sent by Bob, one from himself
saying that stagnation was the order of things, the other a copy of
one forwarded from Emilia in London, in which she said that she had
not heard from M. Bordier, and expected that he was on his way to
her. The whole of the afternoon I was engaged in the attempt to
discover whether any persons answering to the description of Dr.
Peterssen and his companions had made any stay in Monkshead. I
learnt nothing of a satisfactory nature, and, thoroughly exhausted, I
was discontentedly refreshing the inner man, Sophy sitting at the
same table with me, when Crawley, who had been out making
inquiries, came in with a man who looked like what he was--a tramp.
"Here's a fellow," said Crawley, "who can tell us something."
"If I'm paid for it," said the tramp.

"You shall be paid for your trouble," I said, giving him a shilling.
"This is on account. You shall have another if your information is
satisfactory."
"He has tramped from Deering," said Crawley, "and passed the
parties we are looking for."
"How far off?" I asked.
"A matter of forty miles," replied the tramp.
"Were they riding or walking?"
"Two was riding, one was walking."
"What was the conveyance?"
"What do you mean?"
"Were they riding in a carriage?"
"No, in a cart; top of sack of hay."
"What is the man who was walking like?"
His description enabled me to recognize Dr. Peterssen; it tallied
with that given to me by Emilia, Bob, and Sophy.
"And the two men riding on the hay?" I asked. "Can't be so sure
of them," said the tramp; but his description warranted the belief
that they were Dr. Peterssen's patient and M. Felix. As to the latter I
consulted Sophy, and she said it was something like M. Felix.
"How do you know," I inquired, "that these men were travelling in
company?"
"'Cause two of 'em--one as was walking and the other as was
riding--was talking to one another."

"Did you hear what they said?"
"No, I didn't."
He had nothing more to tell me, and he took his departure after
receiving his second shilling.
I turned to Crawley and asked him how he had picked up the
tramp.
"I was having half a pint at the Staff's Head," replied Crawley,
"when he came in. Seeing he was a tramp, stood him a pint, and
asked him where he'd come from. From Deering, he said. Then I
asked him whether he'd met anybody in particular on the road, and
he said nobody; but when I spoke of three men in company, and
gave him an idea of what Dr. Peterssen was like, he brightened up
and told me what he told you. I thought you had better see him, so
I brought him along."
I nodded and said we would start for Deering in the morning, and
Crawley went to the bar to refresh himself. Now, whether I was
influenced by my original latent suspicions of Crawley, or by the non-
success I was meeting with, one thing was certain. I was not entirely
satisfied with Crawley, and my dissatisfaction was not lessened by
the fact that I could find no valid reasons for mistrusting him. Later
on it will be seen whether I was right or wrong in my impressions,
but, as will also presently be seen, the trail I was following up,
whether it were true or false, led to important results, the mere
remembrance of which will abide with me as long as I live.
We did not reach Deering till late the next night. The post-office
was closed, and I could not obtain the telegrams which I had
directed Bob to forward till the morrow. As on the previous day,
there were two--one from Bob with no news, the other from Emilia
expressing anxiety regarding the continued silence and absence of
M. Bordier. I myself considered it strange, and I sympathized with
Emilia's unexpressed fears that she had been buoyed up by false

hopes. Things altogether were looking gloomy; we seemed to be
drifting without a rudder, and my experiences in Deering tended still
further to discourage me. There were no traces of the men I was
seeking, and after dispatching letters and telegrams to Bob and
Emilia, I seriously discussed with myself the advisability of returning
to London and awaiting news of M. Bordier. Sophy broke in upon my
cogitations.
"I've found 'em out," she said, with a flushed face. "That there
Crawley is taking of us in, you see if he ain't. He's been telling a
pack of lies with 'is 'ay cart and 'is tramp. He's got 'old of another
cove, and is bringing of 'im 'ere. I 'eerd 'im telling the chap what to
say to yer. I'm mum. 'Ere he is."
Sure enough there entered Crawley with another tramp, who told
me a plausible story of having met Dr. Peterssen and his companions
some thirty miles off. The fellow played his part fairly well, and when
I refused to give him money, began to bully. I soon silenced him,
however, by threatening to give him into custody on a charge of
conspiracy, and he slunk away without another word, but with a
secret sign to Crawley, which I detected. Crawley would have
followed him, but I had got between him and the door.
"You miserable sneak," I said, "your game's at an end. So, you've
been coached by your scoundrelly employer, Peterssen, to deceive
us, and I was fool enough to be taken in by you. What have you to
say about it?"
He looked at me slyly, but did not speak.
"You are frightened that you may criminate yourself, but you have
done that already. I can prove that you have robbed us of money
under false pretences; I can prove that you have entered into a
conspiracy against us. Do you know the punishment for conspiracy?
It is penal servitude, my friend. You wince at that. Honesty would
have served your interests better, my fine fellow. Had you not

behaved treacherously you would have been made for life. And now
you will find that you have fallen between two stools. You think that
Dr. Peterssen will reward you. You are mistaken. He has promised
you a sum of money for misleading us. You will not get a penny of it.
You fool! Better for you to have trusted straightforward gentlemen
who had the means, and had the will, to richly reward you, than a
scoundrel like your master, who has used you as a tool. You are to
report the success of your treachery to him personally. Where? In
London? Go to him there, go to the address he gave you, and try
and find him. As he has rogued others, he has rogued you. Before
you are many hours older, you will learn that honesty would have
been your best policy."
The play of his features proved to me that all my shots were
faithful and had struck home. I gave him a parting one.
"I will put the police on your track. You are a marked man from
this day, and you and your master will have to answer in the criminal
dock for the crimes of which you are guilty."
I had moved from the door, and he, seizing the opportunity,
darted through it and was gone.
"Fine words!" I exclaimed. "Much good they will do!"
"Never mind," said faithful Sophy. "You gave it 'im 'ot, and no
mistake. You frightened 'im out of 'is life; he'll shy at every peeler he
meets."
"It will not help us," I said, in a rueful tone. "We are at a dead-
lock."
"Never say die," said Sophy, cheerfully. "That ain't a bit like yer."
Upon my word her encouragement put fresh life into me, and I
grew less despondent. Determined to leave Deering as quickly as

possible, I went to see about a trap, and here I met with another
disappointment. I could not get a trap till the following day.
"We shall have to wait until to-morrow, Sophy," I said. "So let us
make ourselves comfortable. I wonder if there's a local newspaper
about. I will read you the news if there is; it will help to pass the
time."
Upon what slender foundations do momentous issues hang! A
pregnant proof of this truism was at hand. There was no newspaper
printed at Deering, but at Fleetdyke, the nearest place of
importance, was published a small daily sheet called the Fleetdyke
Herald. The landlord at the inn at which we put up did not take in
the paper, but it happened that a traveller, making pause there, had
left behind him two copies of as recent date as yesterday and the
day before. These the landlord brought in to me, and I sat down to
entertain Sophy, who prepared herself for an hour of great
enjoyment.
"What things in a newspaper do you like best, Sophy?" I asked.
"Perlice Courts," she replied, "when I gets the chance of anybody
reading 'em out--about once in a bloo moon, yer know."
"Police Courts it shall be," I said. "I have a fancy for them myself."
So evidently had the Editor of the Fleetdyke Herald, who seemed
to make it a special feature of his paper to gather the police-court
news of a rather wide district around his locality as an attraction to
his subscribers. I had read aloud to Sophy four or five of the most
entertaining cases when I was startled by the heading, "Tampering
with a registrar's book. Strange case." I read the report under this
heading rapidly to myself, and Sophy, observing that something had
startled me, sat in silence and did not speak a word. The case was
not concluded in the paper I was reading from. The last line ran:
"Adjourned till to-morrow for the production of an important witness
from London." I looked at the date of the newspaper--it was the day

before yesterday. The other paper which I had not yet taken up was
of yesterday's date, and I found in it the conclusion of the case. The
first day's report, with its pregnant heading, startled me, as I have
said. The second day's report startled me still more. By the merest
accident my fingers were on the pulse of the torture of Emilia's life. I
ran down to the bar; the landlord stood behind it, wiping some
glasses.
"Is the village of Glasserton at a great distance from here?" I
asked.
"Oh, no," replied the landlord, "about eleven miles. You can
shorten it by two miles if you cut through Deering Woods."
I glanced at the clock--half-past four. "It's a melancholy walk
through the woods," remarked the landlord, "but to be sure the
moon will rise at ten."
"Can anyone show me the short cut?" I asked. "I wish particularly
to go to Glasserton to-night."
"My daughter will put you in the way of it."
"Thank you. Ask her to get ready. I will give her half-a-crown for
her trouble."
I called to Sophy, and asked her if she was ready fur a long walk.
"I am ready for anything," she said, "along o' you."
"Ten miles there, and ten miles back, Sophy," I said, for it was my
intention to return to the inn that night.
"I'll walk all night if yer want me to."
"Come along, then, my girl."

I settled my account with the landlord before I left, and then,
accompanied by his daughter, a girl of fourteen, we walked to
Deering Woods.
"There!" said she, "keep on this track and it will take you right
through the woods till you reach the road for Glasserton. When you
come to two tracks keep to the left."
The directions she gave were clear, and I made her happy with
the promised half-a-crown.
"How far do the woods extend?" I asked.
"You'll have to walk six or seven miles," she replied, "before you
get out of 'em--and mind you take care of the cliffs. They're
dangerous."
"We shall see them, I suppose, before we come on them?"
"Oh, you'll see 'em right enough, but nobody goes nearer to 'em
than they can help."
She stood looking after us till thick clusters of trees hid us from
her sight.
"Step out, Sophy," I said, "we've got a long walk before us."
An explanation of the motive for my sudden visit to Glasserton will
be found in the following extracts from the Fleetdyke Herald:
THE FIRST EXTRACT.
"Tampering with a Register Book. Strange Case.--M. Bordier and
his son, Julian Bordier, of Swiss extraction, were charged with
erasing a name, and writing another over it, from a marriage entry

in the register book of marriages in the parish of Glasserton. Mr.
Hare, the registrar, stated that the accused visited him yesterday
afternoon, for the purpose, as they said, of verifying a copy of a
marriage certificate which they brought with them. The marriage in
question was solemnized over nineteen years ago, and, according to
the entry as it now stands, was between Gerald Paget and Emilia
Braham, The elder of the accused made the examination, and
professed himself satisfied. He then requested the registrar to step
out of the office with him, saying that he wished to make some
private inquiries of him. The registrar consented, and the two went
outside for a few minutes, the questions which M. Bordier asked
relating to the witnesses to the marriage, Julian Bordier meanwhile
remaining alone in the office with, the register book. Mr. Hare, who
has been registrar for nine or ten months only, answered the
questions to the best of his ability, and then M. Bordier summoned
his son from the office, and the accused departed. In the evening
Mr. Hare had occasion to consult the register book, and as a matter
of curiosity he referred to the entry which his visitors in the
afternoon had called to verify. To his astonishment he discovered
that the name of the bridegroom had been erased, and the name of
Gerald Paget written over the erasure. His suspicions fell
immediately upon M. Bordier and Julian Bordier, and learning that
they had left the village, he obtained a warrant for their arrest, and,
with a policeman, started in pursuit. The accused were greatly
agitated when told to consider themselves under arrest, and the
elder of the two commenced an explanation, to which, however, Mr.
Hare and the constable refused to listen. He then begged to be
permitted to write and telegraph to London for legal and professional
assistance which, he said, would establish their innocence, and his
request being granted, he wrote and despatched both letters and
telegrams. The registrar having finished his evidence, the magistrate
said the case was quite clear, and asked the accused what they had
to say in their defence. M. Bordier, who assumed the office of
spokesman, his son preserving a somewhat scornful silence, handed
the magistrate two telegrams he had received from London in reply
to those he had despatched. M. Bordier said that he refrained from

putting any questions to the registrar, giving as a reason that he was
ignorant of the procedure in English Courts of Justice. The
magistrate, having read the telegrams, remarked that the names
attached to them were those of eminent and renowned gentlemen
whose time must be very valuable. As they promised to attend the
court on the following morning and were anxious to return on the
same day the accused were therefore remanded till to-morrow for
the production of these important witnesses from London."
THE SECOND EXTRACT.
Tampering with a Register Book. Strange and Important
Evidence.--Result.--M. Bordier and his son, Julian Bordier, were
brought up on remand on the charge of altering a signature in a
marriage entry in the register book of the parish of Glasserton. Upon
the case being called Mr. Lawson, of the well-known firm of Lawson
& Lawson, St. Helen's, London, who said he appeared for the
defence, asked that Mr. Shepherd, the eminent expert in caligraphy,
should be allowed to examine the register book, and the application
was granted. The clerk read the evidence given yesterday by Mr.
Hare, the registrar, who stated, in reply to a question from the
magistrate, that he had nothing to add to it. Mr. Lawson then
proceeded to cross-examine the witness:
"'You state that the register book was examined in your
presence?'--'Yes.'
"'Was there any possibility of the signature being tampered with
while you were by?'--'It could not possibly have been done in my
presence.'
"'Was M. Bordier left alone in the office with the book?'--'No.'

"'In point of fact, you did not lose sight of him during the whole of
the visit?'--'I did not.'
"'Not even for a moment?'--'Not for one moment.'
"'Then he could not have made the erasure or have written the
name over it?'--'He could not.'
"'You do not accuse him?'--'Of actually committing the offence,
no. Of being an accessory, yes. He called me out of the office to give
his accomplice time to do what he wished.'
"'We shall see. Only M. Julian Bordier could possibly have altered
the entry?'--'Only him.'
"Mr. Lawson (to the Magistrate): 'This proves that M. Bordier
could not have made the erasure.'--Magistrate: 'Exactly.'
"Cross-examination resumed: 'It is not important to the case, but
are you familiar with the record of the marriage of Emilia Braham
and Gerald Paget, or between her and any other person?'--'No, I
never had occasion to refer to this particular entry.'
"'Were M. Bordier and his son the only visitors you received on
that day who wished to verify an entry in the register book?'--'The
only visitors.'
"'After they left you did you leave your office?'--'For an hour in the
evening.'
"'Before you discovered that the entry had been tampered with?'--
'Yes, before that.'
"'Who was in charge of the premises while you were away?'--'The
servant, Jane Seebold.'

"'When you made the discovery of the erasure, did you ask Jane
Seebold if anyone had called in your absence?'--'I did not.'
"'Did you at any time inform her that the book had been
tampered with?'--'I did not.'
"'You jumped at the conclusion that the gentlemen you accuse
must be guilty?'--'There is no other conclusion.'
"'That will do. Call Mr. Shepherd.'
"Mr. Shepherd stepped into the witness-box.
"Mr. Lawson: 'You are an expert in handwriting?'--'Witness: I am;
it is my profession.'
"'You have given evidence in many celebrated cases?'--'I have.'
"The Magistrate: 'Mr. Shepherd's name and reputation are well
known.'
"'Have you examined the entry of the marriage between Emilia
Braham and Gerald Paget?'--'I have.'
"'There is an undoubted erasure of the signature of the
bridegroom?'--'There is.'
"'The name, Gerald Paget, as it now appears, has been recently
written?'--'Quite recently, within the past week. The state of the ink
in which the name is freshly written proves it.'
"'You put a marked emphasis upon the words "freshly written."
Have you a reason for doing so?'--'I have. Upon a careful
examination of the entry I am of the firm opinion that the name
erased is the same as the name written above the erasure. The
letters have been very cleverly traced.'
"The Magistrate: 'That sounds very strange.'

"Mr. Lawson: 'It does; but it is a puzzle that may be solved. Say
that there is here a question of property which would fall to the
Emilia Braham who is married according to this entry. To become
possessed of this property, she must prove her marriage with Gerald
Paget. Some one interested on the other side gets hold of the
register book, and erases the name of Gerald Paget. What name
shall be substituted in its place? What but that of Gerald Paget? This
opens up the suggestion that a friend of Emilia Braham (speaking of
her in her maiden name) has also paid a visit to the register, book,
has erased the bridegroom's name, and written in its place that of
Paget, to prove the said Emilia's marriage with him. A formidable
suspicion is thrown upon her, and the very entry upon which she
relies is weighty evidence against her.'
"The Magistrate: 'It is an ingenious theory, but I cannot see that it
has any bearing upon the present case.'
"Mr. Lawson: 'It has an indirect bearing. I have here a copy of the
marriage certificate, which I must ask you to compare with the entry
in the register book. You will see in the copy that the name is Gerald
Paget, and you cannot doubt that the copy is genuine."
"The Magistrate: 'There can be little doubt of that. The state of
the paper is a proof.'
"Mr. Lawson: 'If the copy had been lost, it would have greatly
strengthened those whose interests are opposed to Mrs. Paget's. I
have nothing further to ask you, Mr. Shepherd. Call Jane Seebold.'
"Jane Seebold was shown into the witness-box.
"'Your name is Jane Seebold?'--'Yes.'
"'You are in the service of Mr. Hare?'--'Yes.'
"'Do you remember the day before yesterday?'--'Yes.'

"'In the evening Mr. Hare went out for an hour?'--'Yes.'
"'Was the office in which the official books are kept open?'--'Yes,
it was, and I was sweeping it out.'
"'Did anybody call while you were so employed?'--'Yes, a
gentleman.'
"'Did he inquire for any one?'--'Yes, my master.'
"'Well?'--'I told him he was out.'
"'What did he say to that?'--'He said he would wait for him.'
"'You allowed him to wait?'--'Yes.'
"'In the office?'--'Yes.'
"'What did you do while he waited?'--'I had work in other parts of
the house, and I went and did it.'
"'For how long was the gentleman left alone in the office?'--'Half
an hour, perhaps.'
"'Then you went in to him?'--'Yes, and he said he was going, and
he went.'
"'Did you tell your master of the gentleman's visit when he
returned?'--'No, I didn't.'
"'Why didn't you?' The witness hesitated. 'Why didn't you?
Remember that you are on your oath, and that if you prevaricate or
speak falsely you may get yourself into serious trouble. Why did you
not tell your master of the gentleman's visit?'--'Well, he gave me five
shillings, and told me to say nothing about it. I don't see that I've
done any harm.'
"'You can step down.'

"The Magistrate: 'Stop a moment. Where were the official books
while the gentleman was in the office?'--'In their proper place--the
desk.'
"Mr. Lawson: 'Was the desk locked?'--'The lock's been broke all
the time I've been in the place.'
"'So that all a person had to do to get hold of the books was to lift
the lid?'--'Yes.'
"The Magistrate: 'Your conduct was very reprehensible.'
"The witness then left the box.
"Mr. Lawson: 'We have brought the inquiry now to this point.
Supposing the erasure to have been made on the day in question,
the commission of the offence lies between M. Julian Bordier and the
person who visited the registrar's office in his absence.'
"The Magistrate: 'Quite so. I think the registrar should keep these
important public books in a more secure place--in an iron safe.'
"The Registrar: 'I am not supplied with one, your Worship, and I
cannot afford to buy one. My servant's evidence comes upon me as
a surprise.'
"The Magistrate: 'I repeat what I said. These official records
should be kept in safer custody. The authorities should provide
proper receptacles for them.'
"Mr. Lawson: 'I shall proceed now to prove that it is an utter
impossibility that M. Julian Bordier can be guilty of the offence with
which he and his father are charged. Call Mr. Wordsworth.'
"This gentleman, whose name and fame are world-renowned,
then gave his evidence, which was short, conclusive, and surprising.

"'You are an oculist?'--'I am.'
"'You are attending M. Julian Bordier?'--'Yes.'
"'Is that the gentleman?'--'That is the gentleman.'
"'What are you attending him for?'--'For his sight.'
"'Could he the day before yesterday have erased a name from the
register book and written another name above it?'--'It is utterly
impossible.'
"'Why?'--'Because he was blind. He is blind now; His eyes are
open, but he cannot see. It is against my express wish that he left
London. If he does not return immediately and abide by my
instructions, I shall despair of restoring his sight.'
"M. Bordier: 'May I say a word?'
"The Magistrate: 'Certainly.'
"M. Bordier: 'I came to Glasserton to compare the copy of a
marriage certificate with the original entry. My son's happiness hung
upon this proof, and he insisted upon accompanying me. He would
not be dissuaded, and although I feared there was a risk, I yielded
to his wish. When we were arrested I endeavored to explain matters
to the registrar and the officer, but they would not listen to me.
Ignorant of the methods of English courts of justice, I thought it
wisest to obtain counsel and assistance from London. That is all I
have to say.'
"Mr. Lawson: 'Is it necessary, your worship, for me to address
you?'
"The Magistrate: 'No. The gentlemen are discharged, and I regret
that they have had to submit to this trial. I trust, Mr. Wordsworth,
that you will be able to cure M. Julian Bordier.'

"Mr. Wordsworth: 'If he will be guided by me, I hope to restore
his sight.'
"The parties then left the court."
CHAPTER LVI.
NIGHT IN DEERING WOODS.
I had a twofold object in going to Glasserton. In the first place I
wished to see for myself the original record of the marriage in the
register book; in the second place I wished to obtain from the
registrar's servant, Jane Seebold, a description of the visitor she
allowed to remain in the office while her master was absent from the
house. It was evident that she had no knowledge of the purpose of
the visit which M. Bordier and his son Julian paid to the registrar in
the morning; and it was equally evident that the man who bribed
her to silence was the man who erased the signature. I had no
doubt that it was either M. Felix or Dr. Peterssen, who by this artful
trick hoped to pave the way to a doubt of the genuineness of
Emilia's marriage with Gerald Paget. The scoundrels had no idea that
the copy of the marriage certificate had been found, or that M.
Bordier and his son were in the village on the same day as
themselves. All that they wished to do was to make some provision
for a possible contingency in the future. If, as was very likely, they
read the case in the newspaper, they must have been confounded by
the conviction that they were hoist with their own petard. Another
thing, I was now satisfied that when I left Bob I had started on a

true trail, despite the knavish devices of Dr. Peterssen's tool,
Crawley.
The walk through Deering Woods was a dreary one, but it would
have been much more dreary had it not been for Sophy, who was
always entertaining and original, and never more so than on the
present occasion. I let her partly into my confidence, and she was
delighted to know that she had been the direct means of throwing
light on a cruel injustice. We trudged along side by side, the most
amicable and agreeable of companions.
"It'll wake aunty tip when she 'ears everything," said Sophy.
"She'll think me good for something now."
"You are the best and brightest little girl in my acquaintance,
Sophy," I said.
"I didn't take you in, did I?" she asked.
"No, indeed," I replied. "It was a lucky day for me when I first
met you."
"Not so lucky for you as for me," she said. "I've got a silver
watch."
"It will turn into a gold one by the time you're a woman."
"Will it?" she exclaimed. "Shan't I be proud!"
About half way through the woods I saw the cliffs of which the
landlord's daughter had warned me. In the dark they would have
been dangerous indeed to one unfamiliar with them. At some time
or other there had been a great landslip, which had opened up a
chasm of great depth; in parts slight fences had been put up, but
there were spaces entirely unprotected, and I was thankful we had
been warned of the danger. It was half-past seven by my watch
when we reached Glasserton, and I had no difficulty in finding the

registrar's house. He was at home when I called, and did not receive
me too cordially. He had been upset by the trial, and it was with the
greatest difficulty I succeeded in obtaining a glance of the original
entry of the marriage. It was only by bribery and threats that I
effected my purpose, and I had to use extreme persuasion to induce
him to grant me an interview with Jane Seebold. I elicited very little
from her in consequence of the state of confusion she was in, but I
was satisfied in my own mind that it was M. Felix who had tampered
with the book. From her imperfect description of the man I judged
that he must in some way have disguised himself for the purpose of
the visit, and I was assisted to this conclusion partly by the height of
her visitor, who she said was not a tall man. Dr. Peterssen was not
less than six feet, and having to decide between him and M. Felix I
decided unhesitatingly in favor of the latter. The registrar had been
in Glasserton but three or four years, whereas Jane Seebold had
been in it all her life, and I learned from her that two of the three
witnesses to the marriage, the doctor and the old wagoner, had long
been dead. At nine o'clock my inquiries were ended, and Sophy and
I started back for the inn.
"Tired, Sophy?" I asked.
"Not a bit," she answered, cheerfully, "I could walk all night."
Still we did not get along so fast as in the early part of the
evening; it would have been cruel to take unfair advantage of
Sophy's indomitable spirit; the girl would have walked till she
dropped, and I had some consideration for her. Therefore it was that
we did not reach the middle of Deering Woods till past ten, by which
time the moon had risen. When I was not talking to Sophy my mind
was occupied by the task upon which I had been engaged. Since my
first introduction to the Mystery of M. Felix a great deal had been
accomplished. The mystery has been practically solved, although the
public were not yet in possession of the facts. Emilia's agony was
over, as I believed, for my wildest dreams would not have
compassed what was to occur during the next few weeks; she had

been fortunate in gaining a champion so noble and generous as M.
Bordier, and her daughter's happiness was assured. I could
understand now her anxiety as to M. Bordier's silence since his
discovery of the copy of the marriage certificate, and I divined his
reason for it. With a horror of publicity, and out of regard for her, he
did not wish her to become acquainted with his and his son's arrest
until he himself informed her of it, and he entertained a hope that
the report of the case would not get into the London papers. I also
now understood her anxious references to M. Julian's state of
health; they bore upon his failing sight, to restore which he and his
father had come to London. The young man had been imprudent,
but I trusted to Mr. Wordsworth's assurances that he could make a
cure of him if Julian would abide by his instructions. I had no doubt,
now that Emilia's good name was established, that Julian would
submit to the guidance of this eminent oculist, whose heart was as
kind as his skill was great.
So far, all was well, but I was not satisfied; I could not consider
my task accomplished till I had brought Dr. Peterssen and M. Felix to
the bar of justice and restored to Emilia's arms the husband she
believed she had lost in Switzerland.
Sophy broke in upon my musings.
"Is there a man in the moon?" she asked.
"They say so," I answered, lightly.
"I see 'is face," said Sophy, "as plain as plain can be."
We were near the fallen cliffs as these words passed between us,
and before I had time to utter another my attention was arrested by
the sound of a shot.
"What's that?" cried Sophy.
"A gun or pistol fired," I replied, "and not far off."

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