Capacity for Work.-101 cases have been referred purely on capacity for work, but the distinction between a "capacity for work" and a "state of health" reference would appear to be in many ways an artificial one.

It is important to realise that physical fitness is a relative individual term, and the assessment of "incapacity or otherwise must be determined by a careful scrutiny of the subjective symptoms, an accurate observation of the physical signs, as definite a diagnosis as possible of the disease present and the stage it has reached, aided by that personal clinical knowledge which constitutes in the mind of every practitioner a working rule. However individual and empirical such a rule may be, it is the only equation available. Definite borderline cases are, of course, referred to and not cases of pure malingering.

It has been found, almost universally, that in definite borderline cases doctors prefer to ask Societies to have the patient referred. It can then be done without prejudicing the practitioner in any way. Whether it is necessary for the source of reference to be divulged to the patient is, probably, a matter for consideration.

As proof of the "borderline" type of the referred cases under review, it may be mentioned that in approximately 60 per cent. the patients were found incapable of work.

refer

It is also interesting to note that the "incapacity ences by practitioners have steadily decreased, and that references requesting an opinion on state of health " have markedly increased.

The proportion of Cases in which further help was required. -No further help was required in the 101 capacity for work references.

In the 399 "state of health references it was found that hospital treatment was required either for further observation or treatment in 150 instances; laboratory facilities in 20; X-ray examination in 14; special treatment, e.g. massage, in 17; dental treatment, where the condition of the teeth seemed to be the direct cause of the disease, in 19; and a specialist in nine. In four cases certification and removal to an asylum were required.

In 202 cases with the help of the practitioner a satisfactory diagnosis and line of treatment could be arrived at.

It is obvious from the above that, while the question of any extended benefit must include the consideration of hospital facilities, the district medical officer can, in consultation with the practitioner, fill a useful position, more especially if X-ray and laboratory facilities are available.

The Type of Cases Referred; "State of Health" and

Incapacity" arranged in Systemic Diseases.

Diseases of the Nervous System.-This forms the largest class of case referred, the total number being 139. The specific diseases and numbers were as follows :

:

Mental Diseases.-Subdivision of the 55 cases of mental

In no case occurring in private practice is there so much difficulty met with as in one of mental disease. It was noticeable that several were referred following upon the decision in the Harnet case. The question of asylum control in three at least was an urgent one.

Two cases of anxiety hysteria were of great interest. The attack occurred in twins who were so alike in personal appearance as to be almost indistinguishable. They both left the country and became domestic servants in Glasgow, working in different families. They both simultaneously broke down with similar mental symptoms and required control for a short period. When examined they were on the way to improvement, and were urged to look out for employment in surroundings which had not the inducements for excitement of a large city. Of these they had taken full advantage.

One case of hysterical paraplegia is also of great interest. A man who had been an asylum attendant had been for two years off work with hysterical paraplegia of his right arm below the elbow. He had been seen on more than one occasion, and the possibility of obtaining psycho-analytic treatment had been discussed with the doctor. Pending arrangements for this, while he was walking along the street he suddenly saw a cat

going in front of a motor; unconsciously he put out his right arm to grasp the cat, and realised when he had it in his arms that the power had returned. He promptly reported to his

doctor and is now at work.

The frequency of mental disease, its varying severity, the difficulties of diagnosis, the complete inadequacy of any provision for treatment, short of the stigma of certification, point to the provision of facilities for research and treatment.

A similar want is felt in dealing with cases of neurasthenia, of which there were 36 cases. All grades of severity were met with, the greater proportion perhaps being types of the wellknown neurasthenic condition associated with the menopause.

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Fatigue could be elicited as a cause of incapacity in several instances, and is a potent factor under present industrial conditions. The fatigue point" is undoubtedly in the sensorium, at the synapsis. If the synaptic resistances be overcome by long continued strain or monotony, then the impulses may run along any of the association fibres; hence arise multifarious. manifestations.

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One case may be mentioned in which the condition was of such severity as to constitute a true anorexia nervosa." This was a woman of thirty, in whom loss of flesh had reached the point of emaciation, her weight having fallen from 9 stone 7 lbs. to 5 stone 7 lbs. No definite cause could be found to account for the condition, although everything possible was thought of. Under proper feeding and nursing, improvement slowly set in, and her doctor a few days ago reported that she was now working and weighed 10 stone. The main difficulty in her case was to counteract the "vegetarian convictions" regarding diet and the Christian Science leanings of her relatives, which were only abandoned when the perilous state of health of the patient was brought home to them.

There were seven cases of encephalitis lethargica. In three the symptoms were acute and unequivocal, and the patients made good recoveries, although one shewed for many months the altered mentality which is always present during convalescence and which is not sufficiently recognised.

In three cases there was well marked affection of the basal ganglia; one with marked tremor and one with marked rigidity and masklike facies. The latter case had had two slight unrecognised attacks, and it was only when the rigidity signs developed that the real cause of the condition was diagnosed and the nature of the previous attacks determined.

One case shewed the "cerebellar" type of the disease. The signs and symptoms were mainly cerebellar in type with severe attacks of vertigo, and for some time cerebellar tumour was suspected. The condition, however, eventually proved to be a case of encephalitis. On the other hand, of the two cases of cerebral tumour in the series, one, affecting the temporo sphenoidal lobe, was at first looked upon as a case of encephalitis.

Diseases of the Circulatory System.-There were 92 cases of diseases of the circulatory system, subdivided as follows:→→

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...

...

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1

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1

5

Infective Endocarditis

Disordered Action of the Heart

Myocardial Debility (following Influenza)

The case of infective endocarditis, which was fatal a few days after being visited, well illustrates the tragedy that may occur in a heart affection. A strongly built man of thirty, with history of rheumatic fever, mitral stenosis and suffering from severe dental sepsis, suddenly developed acute symptoms, and death occurred in a few weeks.

In 37 cases arterio-sclerosis and its effects were the condition. present. In no class of illness does the capacity for work depend more on the careful elucidation of the state of health. The whole question depends on the extent of the lesion, and whether or not vital organs shew signs of suffering from diminished blood supply. Some had well-marked focal signs and symptoms; in others the signs and symptoms were more general than focal, and they could reasonably be expected, after care and treatment, to return to work of some kind.

Observation of the cases of varix and varicose ulcer shewed that sufficient care is not taken in treating the varicose veins accompanying pregnancy, and that on account of their ambulant treatment and perfunctory dressing varicose ulcers lead to a period of incapacity far in excess of what it should be. They constitute one of the minor problems of incapacity which would well repay investigation.

Respiratory Diseases.-There were 48 diseases of the respiratory system, divided as follows:

Five of the cases of pneumonia were acute, and were referred on the question of diagnosis; in four resolution was delayed, and

the question whether or not the condition was a tubercular one was the cause of the reference. The case of pneumothorax was a very acute one, due to rupture of a small phthisical cavity, and the condition of mediastinitis illustrates the necessity of the most careful examination where the symptoms are mainly subjective and the condition chiefly neurasthenic. It was only after two careful X-ray photographs had been taken and a definite and most unusual mediastinitis demonstrated by an expert radiologist that the patient's undoubted incapacity could be unequivocably recognised.

Abdominal Diseases.-The 48 diseases in this category were divided as follows:

In no class of case is the necessity of hospital facilities more apparent than in the diseases of the abdomen; abdominal diagnosis is now by the use of modern methods coming into line with surgical treatment, and diseases which a few years ago could only be suspected, are now being diagnosed at an early stage with great accuracy. In fact it can be confidently stated that in the great majority of cases where definite abdominal symptoms have been present for any length of time, hospital observation is required. Insistence on this point will be followed on the one hand by a gratifying increase in the number of successful permanent recoveries after abdominal operations, and may on the other give medical treatment by its early institution a greater chance of success.

One other point might be mentioned. The question is sometimes asked whether a person suffering from chronic appendicitis should be considered capable of work pending operation, which, with the congested hospital waiting lists, may be unfortunately