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thing but the most moderate degree of exertion, and the remaining man was a chronic invalid.

Exception has been taken to these inferences on the ground that these grading results are not a true reflection of the health of the nation for two reasons:

First, that the grading was inaccurate. In reply to this criticism it is to be observed that men dissatisfied with their grading had the right to appeal to an independent tribunal against their grading, and that the number of men whose grading was altered on appeal was less than 0-4 % of the total number of examinations, in other words an independent tribunal only altered the finding of the board in between 3 and 4 cases out of every 1,000. Further, though we do not know to what extent grading was found by actual experience in the army (the only real criterion) to represent truly the degree of physi- cal fitness, it is certain that any conclusions we may reach from the grading results will, if anything, lead us to overrate the physical fitness of our manhood, since every factor in the situation contributed toward grading men too high rather than too low.

Secondly, that the men examined were the dregs of a population exhausted by 3 years of war. This criticism, though natural and self-evident at first sight, is inadmissible principally for the reason that it is made in ignorance of the extent to which fit men of military age were employed in such industries and occupations as agriculture, mining, shipbuilding, and munition works, and protected from recruitment by law during the earlier years of the war, remaining in civil life until in the fourth year of the war these industries had to be " combed-out " in response to the increasing strain upon the diminishing reserve of man-power. Analysis shows that the men examined during the year under review belonged to one of the five following groups:

(1) Men in the protected industries, which in the nature of things employed a high proportion of the physically fit, and this group was numerically much the largest.

(2) Men who were now refused further exemption by tribunals owing to the urgent demand for men caused by the military situation.

(3) Lads who attained the age of 18 years during this year; in number 261,137.

(4) Men who had been previously rejected when the need for soldiers was less urgent.

(5) Men between 41 and 51 who became liable for military service under the Military Service No. 2 Act of April 1918.

Inasmuch as group (i), the largest, comprised an abnormally high proportion of the physically fit, group (4) an abnormally low, and group (2) an average proportion, while groups (3) and (5) were a " virgin soil," we can hardly escape the inference that in the aggre- gate the men examined during the year under review represented the manhood of military age from the standpoint of health and physique, and that therefore the observations made at their medical examina- tions form a trustworthy criterion of the national health.

With this general picture before us, we may well and rightly ask what are the causes of this great mass of physical inef- ficiency which low grading means and to what extent is it preventable. After all, the large majority of babies are born healthy, and the conditions and environment subsequent to birth are created by mankind and are capable of a large range of modification. It will be readily understood that such a mass of records and observations require full and detailed analysis before complete conclusions as to the lessons obtained can be reached. While a complete analysis was not yet available in 1921, the matter had been sufficiently explored to reveal several striking results.

First, as to the causes for which such a large proportion of men were placed in Grades III. and IV., viz., 1,007,139 or 41-5% of the total number of .examinations. Men placed in these grades, it must be remembered, presented such marked physical disabilities or such evidence of past disease that they were only considered fit to undergo the most moderate degree of exertion, and some were so incapacitated as to be totally and permanently unfit for any form of military service. The reasons for 2 out of every 5 men of military age being so physically unfit clearly requires explanation. The largest group of men in these two grades which has been analysed is 160,545 men, examined in the London region during the period Jan. to Oct. 1918; of these 82,645 were placed in Grades I. and II., the balance of 77,900 (48-5%) falling to Grades III. and IV., namely 60,031 (37-4%) in Grade III. and 17,869 (11-1%) in Grade IV. In the case of the Grade III. and Grade IV. men in this large group the accom- panying table shows the disease or disability on account of which they were so graded.

Broadly speaking, this table shows that of this large group of men of military age half were found to be suffering from organic

Disease or disability

i. Valvular disease of heart. 2. Deformities, congenital and

12,562

7-9

1-6

6-3

acquired (including flat-foot,

hammer toe, kyphosis, etc.) 3. Diseases of circulatory system

8,605

5-3

o

4-3

(other than V. D. H.) includ-

ing varicose veins. 4. Diseases of lungs and bronchi

6,275

3-9

6

3-3

(other than tuberculosis) and

of respiratory system

6, 1 88

3-8

6

3'2

5. Pulmonary tuberculosis.

4,327

2-6

2-O

6

6. Functional diseases of heart

3.385

2-1

I

2-O,

7. Wounds, injuries, etc., including

traumatic deformities, ampu-

tations, etc

3.335

2-O

3

7

8. Diseases of ears ....

I -9

3

6

9. Diseases of nervous system

(other than insanity and

epilepsy)

? 066

9

C

4

8

2

6

II. Defective vision.

2,620

6

2

4

5

I

4.

13. Hernia

2 >!79

3

2

T^ I

14. Diseases of digestive system.

2,170

3

2.

I

15. Diseases of eyes

,886

.1

5

6

708

o

2

8

26s

.7

2

1 8. Haemorrhoids ....

^"O

,140

i 7

05

65

19. Skin diseases ....

053

6

15

45

20. Diseases of generative organs

T^

and of genito-urinary system

(other than venereal disease,

albuminuria and glycosuria)

983

6

75

525

21. Albuminuria ....

951

5

3

2

22. Tuberculosis (other than pul-

monary)

911

5

3

2

23. Insanity

656

4

3

I

24. Syphilis

556

3

I

2

25. Glycosuria

214

I

i

26. Venereal disease (other than

syphilis)

162

I

02

08

1-9

375

I-525

77,900

48-5

U-I

37-4

ii-i

48-5

disease of one kind or another of a severity sufficient at least to render them incapable of a normally active life. It will be observed that diseases of the heart were the most frequent disability. Valvular disease 12,562 (7-9%) and functional dis- ease 3,385 (2-1%) made up 15,947 cases of heart disease in all, or 10-0% of the number examined. There had been no pre- vious opportunity of gauging the frequency of heart disease among the population, but it can be safely stated that such an incidence as one in ten among men in the prime of life would never have been expected. It indicates the importance that should be attached to insuring that adequate treatment is given Jto all cases, and to the infections such as rheumatism in which it frequently originates especially in the earlier years of life.

Another figure which naturally attracts attention is that for tuberculosis; 4,327 had pulmonary tuberculosis, 911 had tuber- culosis of other organs, 5,238 in all, or 3-1% of the number examined. Of these 3,874 (2-3% of the number examined) were cases sufficiently advanced or sufficiently active to warrant the boards in relegating the men to Grade IV., i.e. totally and perma- nently unfit for any form of military service. Great doubt and difficulty have always attended aU. attempts to estimate the frequency of tuberculosis; a disease of many manifestations, it is often impossible to prove its existence in a given case and frequently impossible to exclude it. It is rather striking to find that 2-3% of this large group of men presented sufficiently