683THE EXAMINATION OF RECRUITS FOR AFFECTIONS OF THE HEART.

THE LANCET.

LONDON: SATURDAY, OCTOBER 14, 1916.

The Examination of Recruits forAffections of the Heart.

ONE of the most difficult problems in connexionwith the examination of recruits is the exact

estimation of the condition of the heart. If theheart is of the normal size. the sounds clear, andthe rhythm regular, a satisfactory conclusion can bearrived at promptly; but if a murmur is heard, orthere is irregularity of the beat, then skill and

experience are required in order to distinguishbetween functional and organic conditions. Themain point is to estimate, if possible, the amountof cardiac reserve power; but this is not the onlymatter for consideration, and, quite rightly, casesin which doubt arises are now referred to expertsfor opinion.

Since last February, by the direction of theMedical Department of the War Office, recruits inthe London district whose rejection was contem-plated on account of the state of their heart havebeen sent to the National Hospital for Diseases ofthe Heart for examination and report. As up to

now over 4000 cases have been dealt with, it willbe of interest to explain the general idea under-lying the scheme. All recruits are seen in the firstinstance by a recruiting Medical Board, and thosewhose hearts are manifestly defective, as shown bythe ordinary methods of clinical examination, arerejected or placed in the categories for which theyare suitable, while those with obviously healthyhearts are passed. It is only when real doubtarises as to whether a recruit’s heart is defective,or how far an observed defect is likely to impairefficiency for military purposes, that the man is sentto the Heart Hospital and subjected to a searchingexamination with the aid of instrumental appli-ances, which could not possibly be available for

employment by the recruiting boards without theassistance of some such institution. After con-

sideration of the various points and consultationwith recognised authorities, a scheme of examina-tion was decided upon at the Heart Hospitalwhich experience has shown to be very efficientin elucidating the problems which present them-selves. Every recruit is asked to state what, if

anything, he complains of, and a record is madeof this, together with a detailed history of his

previous diseases and habits. Any subjectivesymptoms which may be present are inquiredinto in detail and recorded. He is then given a

standard piece of work to do, the pulse, respira-tion, and blood pressure being recorded before,immediately after, and three minutes after. Theurine is analysed, and an electrocardiogram istaken. In a very large proportion of the cases the

heart and chest are also examined by the X raysFurnished with these data, the physicians proceedto make a thorough clinical investigation underthe usual heads of inspection, palpation, percussion,and auscultation. A diagnosis is arrived at, aftertaking into consideration all the evidence, and anopinion is expressed as to which category of militaryservice, so far as his heart is concerned, the recruitis to be placed under. Here the most practicalpoint for consideration is that, although a man

with a slight cardiac lesion may support well thestrains of civil life, when he can stop workat will, he may not be found suitable for mili-

tary service, in which he must " carry on" or

become a casualty. A copy of the paper contain-

ing all the data, as well as the diagnosis andopinion, is transmitted to the Medical Board sendingthe recruit, with whom, of course, the final decisionrests.

That the practised medical examiners whoconstitute the recruiting boards of London shouldhave felt the desirability of having as many as

between 4000 and 5000 cases examined in thisdetailed manner before arriving at a decision is

perhaps one of the most striking pieces of evi-dence that could be adduced of the progress thatthis department of medicine has made during thelast few years, and of the importance attached tothe modern instrumental aids to diagnosis. Of1000 cases examined 447 have been classified as fitfor full military service either at home or abroad,291 as fit for garrison duty or labour purposes, and262 as fit only for clerical work or totally rejected.These figures are of high significance; they tendto show that many men who at the first examina-tion did not seem fitted for military service, onfurther investigation were passed for some form ofmilitary work, the proportion that were classifiedas fit for full service being high.

.

A Campaign against AdultMortality.

Dr. CHARLES F. BOLDUAN, Director of the Bureauof Public Health Education in New York, hasrecently stated that most of the health work oflate years has been directed to the saving of

infant and child lives, while practically nothinghas been done to prolong adult life. He illustratesthis statement by a comparison of the New Yorklife-tables of the two triennia 1879-81 and 1909-11.The comparison shows that whereas in New Yorkthe expectation of life at birth is now about ten

years greater than it was a quarter of a centuryago, the adult of 40 years or over has actually ashorter expectation than formerly, the decrease

amounting to a year or more, according to the exactage-period. Dr. BOLDUAN finds that this con-

dition is not confined to New York City, butapplies also to the whole of the United States

registration area. The death-rate per 1000 at

the age-period 45 to 54 has increased by nearly2 per cent. during the last ten years, and

1 Monthly Bulletin of the Department of Health of the City of NewYork, vol. vi., No. 4.

684 A CAMPAIGN AGAINST ADULT MORTALITY.

at the next older decennium by nearly 7 percent. He regards the solution of the problem asa matter of the greatest importance, middle agebeing the period at which the addition of years oflife would be of most value to the race. Similarconsiderations have evidently weighed in the

appointment by the Department of Trade andCustoms of the Commonwealth of Australia of a

committee appointed to inquire into the causes ofdeath and invalidity in the Commonwealth andhave resulted in a special report, which has justappeared on the risks of middle age and on thechances which cut off thousands of people in theirfull maturity.The causes of the risks of middle age are care-

fully discussed by the Australian Committee, andin a single paragraph they give without hesitationan answer to the question as to their origin.Everything, they say, which involves overstrain,everything which favours chronic poisoning of theblood with alimentary toxins or with productsof tissue change, everything which encouragesinfection of the blood from bowel or throatmust count among the causes of excessive blood

tension. And in high blood tension they see

the principal risk of middle age. Put shortly,accumulating wastes and unreasonable strainare the determining factors. The report drawsa picture of the man who has had an activeschool career, with devotion to athletics, followedby a hard struggle for success in some handicraft orprofession, who still taxes to the utmost his nerveand muscle, who still pursues, it may be, somevigorous athletic sport, and who takes food

rapidly and in large quantity, with soup and meatforming a substantial part of his diet. The pictureis one not unfamiliar in the mother country.The report goes on to call attention to the

high rate of death from apoplexy as well as

from pneumonia and pericarditis, which are in ’Australia very deadly for patients with high tension.The dangers of the period of failing tension are dweltupon, when the persistent strain has much triedthe heart, and when, if the patient is not carried offby apoplexy or some intercurrent inflammation orinfection, signs of heart failure become dominant. Inhospital practice in Australia at least two-thirds ofthe deaths attributed to organic heart disease areconsidered a sequel of raised tension. Due credit is

given in the report to the effects of alcohol, syphilis,and gout as adjuvant causes of the risks of middleage, but stress and diet are allotted their place asthe primary agents. Dr. BOLDUAN, out of a widefamiliarity with the conditions in the United States,deals with the same etiological factors. The rush ofmodern city life has been credited, especially inAmerica, with the increased death-rate from cardiacand arterial disease, but he finds that the ruraldistricts show precisely the same tendency. Ex-

posure, strain, and occupational injury are factorswhich are common to all classes and countries, andwhile alcohol, syphilis, and other chronic poisoningsmust take their share of the blame, stress and

2 Printed and published for the Government of the Commonwealthof Australia by Albert J. Mullett, Government printer for the Stateof Victoria. No. 296. F 6226.

over-eating, especially over-eating of protein, are

I those on which in America, as in Australia, sus-i picion rests most heavily.!

To combat this high adult mortality, Dr. BOLDUAN, suggests an organised campaign, and he gives ani outline of a plan of education for the control of. diseases of the heart, kidneys, and arteries. At theI outset he thinks nothing would be more effectivethan a large exhibition of adult hygiene on the linesof an exhibition held at Dresden a few years ago.He would keep public opinion aroused by constantlyreiterating the statement in the press and else-where that persons over 40 do not live as long asthey did 30 years ago-an assumption on whichvital statistics should have some critical thingsto say. He would organise boards of sanitarycontrol to watch over the health of employees,putting the responsibility for the sanitary con-

ditions of any industry upon the industry itself.He points to the good example of the NewYork Department of Health, which has placed theservices of a highly trained medical examiner atthe call of all its employees. A complete medicalexamination can be obtained by them free of charge,and the information turned to good purpose indetecting the onset of degenerative disease at theearliest stage, when treatment is still hopeful ofresult. In the next rank of importance he placesan extension of work directed against the vene-

real diseases. The Australian Committee beginsfurther back with its proposals, and suggests anextension of the medical inspection of schools, andan increase of school instruction in personalhygiene. This is to be followed by an inquiry intothe undue prevalence of high tension in certainoccupations and by the provision of facilities forthe early diagnosis and treatment of high tension.The Australian Committee proposes concretely thatprovision be made for industrial workers not toreturn to arduous work after serious illness untiltime has been allowed for proper convalescence;and that some system of oversight of thehealth of industrial workers should be insti-

tuted, correlated with the provision, when neces-sary, of temporary relief by some scheme ofinsurance. These proposals are in a line withthose recently made by Professor W. J. ASHLEYin an introductory address at BirminghamUniversity.The evils alluded to in both the reports are very

wide, and the remedies suggested, though compre-hensive, seem somewhat vague. But the idea of a

campaign against avoidable adult mortality is onewhich has much to commend itself to thoughtfulpeople; and it need not become an opportunity forthe exhibition of rampant faddiness, though risklies in this direction. The further development ofthe schemes will be watched in this country withkeen interest by our medical men, sanitarians, andstatisticians.

FATAL CASE OF ANTHRAX.—At an inquest held atMossley, Yorkshire, on Oct. 4th, on a Congregational ministerof that town it was stated that deceased had purchased ashaving brush while on a holiday at Blackpool and themedical evidence showed that anthrax was due to the useof this brush.

685A CURVE OF WORKING EFFICIENCY.

Annotations.

A CURVE OF WORKING EFFICIENCY.

"Ne quid nimis."

MOST of us are aware that we do not begin ourwork in the morning at full efficiency, and that sometime may elapse after the commencement of the

working day before the maximum speed of outputis reached. At the end of the working period acorresponding tailing off may be less readilyobserved. Exact observations on this interestingsubject have been made by Dr. H. M. Vernon inregard to the output at munition works, and pub-lished as an appendix to Memorandum No. 5 by theHealth of Munition Workers Committee. In workswhere the motive power is electric, and the amountsupplied to each section is registered by a separatewatt-meter, the rate of starting and stopping workcan readily be ascertained by means of these powerrecords. Dr. Vernon found that in a large shell shopwhich turned out 30,000 3-inch shrapnel shells perweek, the power supplied began to mount up twominutes after starting time, and reached half its fullvalue in four minutes; while the power suppliedto a section of 200 women turning fuze bodies didnot begin to rise till five minutes after startingtime, and did not attain half its maximum valueuntil six minutes later. In other words, thewomen operatives wasted about seven minutesmore in starting than did the operatives in theshell shop, most of whom were men. On the otherhand, the fuze-turners finished more strongly thanthe shell shop operatives, and it was found thatboth sets of operatives lost, on an average, about thesame aggregate of time in starting and finishingduring the course of the whole day-viz., 34 minutes.There was no inherent reason why work shouldhave been started promptly in one shop and notin the other. Dr. Vernon considers there can be nonecessity for the waste even of this amount oftime in starting and finishing work, and that 10 or15 minutes should be an ample allowance. The20 minutes thereby saved could then be deductedfrom working hours without any reduction of out-put. The matter is of practical importancebecause, although stern necessity may compellong hours of labour on the part of many muni-tion workers, it is evident that the shorter thetimes for which they are shut up in the factoriesthe better their chances of health and happiness.At one large block of works the manager makes apoint of going into the various shops at startingtime and seeing that the operatives begin workpromptly. In this way he found that a considerableamount of time was saved. Concentration at workhas for a corollary longer hours at play, and isclearly shown by the memorandum to be a factormaking for health.

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SICKNESS BENEFIT AND VENEREAL DISEASES.

ONE serious obstacle in the way of early re-

cognition of venereal disease and of its efficientdiagnosis and treatment is now likely to beremoved. At the present time venereal diseasecomes under the clause in the Insurance Actunder which benefit is not given when illnessis caused by wilful misconduct. The NationalConference of Friendly Societies recently held inLiverpool was addressed by Dr. Otto May on behalf

of the National Council for Combating VenerealDiseases, who put the case very forcibly for thegranting of sickness benefit by Friendly Societies,trades unions, and others to their members whowere known to be suffering from venereal disease ;to place, in fact, venereal disease in the sameposition as other infectious diseases as regardstheir treatment. Dr. May’s address was wellreceived, and a resolution was carried :-That this executive committee of the National Conference

of Friendly Societies, having seriously considered the reportof the Royal Commission on Venereal Diseases and theseveral recommendations made therein, is of opinion thatsuch vital national and domestic interests are involved thatit is desirable, with a view to the effective treatment andpossible ultimate extermination of such diseases, thatsocieties should consider the advisability of revising theirrules in such a manner that members shall not be deprivedof sickness benefits by reason of their suffering from anysuch disease.

Besides this academic resolution, which mightor might not carry force among the constituentFriendly Societies, a definite rule was suggested foradoption by Approved Societies pending the pro-posed amendment of the National Insurance Act.The rule is as follows :-An insured member shall not be entitled to sickness or

disablement benefit in respect of an illness or accidentcaused by his or her serious or wilful misconduct, providedthat a member shall not be deprived of sickness or disable-ment benefit if incapable of work through venereal disease.

This action of the Friendly Societies is anotherwelcome indication of the change of attitude amongthe public at large towards the treatment ofvenereal diseases, and increases the hope of a

really efficient campaign in the future. This hopeis fortified by the fact that the London CountyCouncil propose to carry into immediate effect therecommendations of the Royal Commission.

THE BRITISH JOURNAL OF OPHTHALMOLOGY.

IN 1857 a journal of ophthalmology was startedby the staff of the Moorfields Eye Hospital underthe title " The Royal London Ophthalmic HospitalReports." The title was at that time somewhatmisleading, for although the contributors consistedentirely of Moorfields surgeons and students, theperiodical contained abstracts of the ophthalmicliterature of foreign countries and other matterof cognate interest. This periscope of abstractswas discontinued after 1864, and perhaps partlyowing to the lack of any such convenient source ofinformation, the Ophthalmic Review was inaugu-rated in 1882. It differed from the Reports in beingopen to all comers for original communications,whilst specialising in short reviews of currentliterature. These two were the only British journalsdevoted to ophthalmology, and apart from theTransactions of the Ophthalmological Society,started in 1881, were the only medium for the con-tribution of articles specifically to ophthalmicsurgeons until 1903, when Mr. Sydney Stephensoncommenced the publication of the Ophthalmoscope.Thenceforth, until the present time, all three

journals have continued to appear. At the out-break of the European war in 1914 it was felt bymany that British ophthalmologists should drawtogether and unite in issuing a single journalwhich would be more thoroughly representa-tive of British ophthalmology. Indications werenot wanting that such a scheme wouldmeet with the approval and support of theircolleagues in neutral and allied countries, and,indeed, one of the strongest supporters and eveninitiators of the idea was the late Professor Straub,