(1) One of the important and integral
duties of every practitioner who takes service under
the National Health Insurance Act is to assess Physical
Capacity or Capacity for work.
(2) That, while work is not defined by the
Act, and while there is not perfect agreement as to
what constitutes incapacity, and how far, or to what
extent, each disease modifies the ability to follow
remunerative employment, it eventually must be a
medical question, and the panel practitioner is alone
competent to decide whether a physical ailment con-
stitutes incapacity or not.
(3) Estimation of capacity must be gauged
by careful consideration of the symptoms, by an
accurate observation of the physical signs, by à
,general knowledge of the disease present and the stage
reached and by, as far as possible, the individual
consideration of each case, and the class of work to
be followed.
(4) The value of the National Health
Insurance Act, as a preventive measure, as a means of
testing the efficacy of preventive measures in so far
as it increases the working capacity on the part of
each civic unit, and as one guide as to the age at
which working capacity should cease is touched upon.
(5) The area from which the 1200 cases of
incapacity has been drawn is shortly described, and a
map pointing out the boundaries of the area is
appended/
(5) The cases are classified according
to the classification agreed upon by the International
Commission, Paris, Oct. 14th 1920.
The sex, age in tens, length of time
on benefit in weeks, occupation, whether fit or unfit
is given in each case, and any interesting clinical
findings are added;
(6) Each table is considered seriatim,
and clinical signs and symptoms that have been of
assistance in estimating capacity are noted, as well
points of interest in diagnosis and treatment.
(a) Epidemic Endemic and Infectious
Diseases -
Phthisis has been fully considered; the
capacity for work depends on the presence of activity
of the disease. The danger of diagnosing phthisis
is when there is merely a fibroid condition of the
right apex. The difficulty for finding suitable
work for cases that have come out of a Sanatorium,
the co- operation of a masseur trained in remedial
exercises attached to each County Authority, are
dwelt upon.
Influenza. The importance of the necessity
for care in the treatment, and during the convalescent
period, the fact that though the initial infection
be slight, the sequelae may be serious, and the
danger of the disease in cases of arterio- sclerosis,
and in those suffering from previous cardiac disease
is insisted on. Analysis of the cases during
19227
1922 who gave an attack of influenza as a cause of
their incapacity is attempted. The following
conclusions are arrived at:-
(1) That the disease, mild as well as severe,
be most circumspectly treated.
(2) That a too early return to work is not
advisable.
(3) That the last epidemic appeared to hive
circulatory sequelae.
(4) That if any system showed the presence
of disease, aggravation of the disease, sometimes
serious, was apt to supervene.
(5) That the disease in those past middle
life must be looked on as a serious one.
(b) General diseases not included in Table 1 :-
Arthritis. -
A common cause of incapacity and the
cause of the great loss of productive work. While
many cases are infective in origin, probably some
are degenerative in nature, and frequently accompanied
by other signs of degenerative change.
If the disease be acute, progressive,
with a demonstrable infective focus, work is out of
the question. If the condition be mainly extra -
articular, if the condition be quiescent, and the
stiffness due to adhesions from the previous
inflammation, then vigorous movement should be
instituted, and work attempted as speedily as possible.
Fibrositis forms many of the cases diagnosed
as arthritis and neuritis. Many are accompanied by
a general neurasthenic state, an infective focus is
frequently found. Most are capable of work.
Anaemia is far too loosely diagnosed. In
no instance ought a full examination of the chest be
neglected and so a tubercular infection missed.
Exophthalmic Goitre - working capacity
depends on the cardiac state, and evidence of cardiac
exhaustion.
(c) Diseases of the nervous System -
Several cases of mental disorder included.
Working capacity depends on the presence or absence
of acute or subacute symptoms, whether mental
enfeeblement is present as an accompaniment or a
result and on general physical condition. Cases of
Hysteria, Freudian in type, are cited. The prominence
of mental symptoms after Encephalitis Lethargica is
pointed out. Epilepsy,as presenting great difficulty
in estimating capacity, is specially dwelt upon.
As contraindications to work I would postulate: -
(I) Signs of mental enfeeblement,
(2) Frequent and regular seizures,.
(3) Seizures severe with mental sequelae,
(4) Seizures result of organic disease.
Insular Sclerosis found to be the commonest
cause of incapacity in X ervta : D:iaQages.
(d) Diseases of Circulatory System -
Mitral Stenosis is the most common
cardiac lesion. It is frequently missed. Working
capacity frequently is broken in upon by failure of
compensation. Nine cases were accompanied by
auricular fibrillation.
Myocarditis - in 19 cases was
degenerative in nature, probably from focal arteriosclerosis.
Arterio -Sclerosis - 70 cases, generally
aged between 60 and 70. The disease is insidious in
onset, frequently accompanied by muscular pains
(intermittent classification). Examination of Brachials
generally reveals arterial change. Estimation of
working capacity in circulatory cases depends on the
condition of the heart muscle and the presence of
compensation.
Varicose Veins - a common cause of
incapacity. The possibility of malignant degeneration
in a varicose ulcer mast be borne in mind.
(e) Diseases of the Respiratory System -
Bronchitis and Asthma the commonest disease causing
incapacity. Work is very intermittent, is subject to
climatic conditions. Incapacity is permanent when
secondary change is marked. The question of tubercle'
ought always to be raised.
(f) Diseases of the Digestive System -
Gastric and Duodenal Ulcer and appen dititis the
commonest diseases. .Average length of time on
benefit of the former 76 weeks. Seven cases after
gastro -enterostomy still incapacitated. The
disease in the early stage not treated medically by
sufficiently drastic measures. After operation the
after treatment is not directed to the frequent
hyperchlorhydria and gastric dilatation.
Appendicitis - Incapacity found to average
24 weeks, Operation in acute cases still too long delayed,
after treatment of the occasional accompanying
hyperchlorhydria and gastric dilatation is neglected.
(g) Diseases non -venereal of the Genito
Urinary System and Annexa - a small class calling for
no special comment. Albuminuria after an attack of
acate nephritis no bar to work, bat care should be
taken to eliminate an acate attack superimposed
upon a chronic condition.
(h) Fregnanc,y and Puerperal State -
Pregnancy per se is not a disease, no distinction is
to be made, however, between incapacity due to
pregnancy and due to any other cause. In my opinion
work during the last two months of pregnancy ought
not to be done, the difference between work in terms
of recreation and in terms of remuneration being
clearly understood. The puerperium is supposed to
last one month. Post puerperal debility is too
commonly certified as a cause of incapacity.
(i) Diseases of Skin - Few in number.
Rarely/
Rarely per se incapacitating, bat taken in conjunction
with kind of work not unfrequently so.
(j) Diseases of Bone and Locomotory
System - Small Class. Flat foot commonest disability.
Failure to treat thoroughly in early acute stage,
and correct deformity by proper modification of
boots, results in an avoidably protracted incap 'city.
(k) Diseases due to External Causes -
Majority due to War injuries. Training does not
in itself entitle to benefit. Incapacity must also
be present. During training such improvement must
take place as to render a man capable.
(1) Neurasthenia - A large number of
cases - is not a disease of the idle and leisured
only, fatigue, monotony and strain all definite
causes. Endocrine disturbance at the menopause a
potent factor. Fatigue is a general condition,in
rare cases a local one; probably the synopses
constitute the fatigue points in the brain. No
cases are more difficult to assess; borderland cases
are common. The "forget your ailment and return to
work "school misunderstands the condition. Success
in persuading the patient to return to work depends
frequently on the manner the advice is tendered.
(m) Light work - the necessity for the
qualification, whether or not it constitutes an
injus tice to the insured person, and the kind of cases
to which the qualification should be applied are touched
upon.
