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unduly delayed. When an appendix has been diagnosed as diseased, no work of any kind should be attempted until the operation has been successfully completed, as abdominal diagnosis has not yet reached the stage of being able to state the actual pathological condition of the organ.

Locomotory System.-There were 58 cases, divided as follows:

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There seems to be a tendency unduly to extend incapacity in cases of fibrositis. While extremely common, except where really acute, it should not be looked upon as incapacitating, unless, as frequently happens, a definite focus of infection be present, removal of which will be usually followed by excellent results. With regard to arthritis, unless it be of the degenerative variety, the position is somewhat similar. Foci of infection should be dealt with, but extra-articular thickening should not be a cause of incapacity, if the joint condition is no longer subacute. An X-ray examination is very necessary in such cases.

A case of tubercle of the scapula was interesting, as the patient, who lived in a remote area, was operated upon with a most successful result by his own panel practitioner. A recent examination shewed the patient to be quite recovered and able for ordinary work.

Two of the fracture cases illustrate a difficulty which is sometimes met with. They were both compensation cases and both had been examined on behalf of the Insurance Company and passed fit. In both cases the panel doctor disagreed with the finding and referred them for independent opinion. In both the opinion of the panel practitioner was upheld.

Diseases of the Skin.-The 10 diseases of the skin were as follows:

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Urinary Diseases.-The 12 cases of urinary diseases were :

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None of the above diseases call for comment.

Diseases of Blood and Ductless Glands.-The 38 cases in this

category were divided as follows:

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Most of the diabetes cases were referred regarding arrangements for insulin treatment. Two were of special interest; one the case of a man aged 68 with advancing emaciation and threatened coma. Insulin was cautiously administered, and he was seen on several occasions with his panel practitioner. The result was satisfactory, in that he voluntarily presented himself at the office a short time ago and reported himself as very much improved. The other case was one of diabetic gangrene and was referred regarding the advisability of operative treatment. This was carried out, but unfortunately was unsuccessful.

Most of the anæmia cases were referred on the ground of the possibility of the anæmia being due to some infection, possibly a tubercular one.

Diseases of the Special Senses.-The 12 cases of diseases of the special senses were as follows:

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The case of iridocyclitis was a particularly severe one, occurring in a remote part, and was referred for details of treatment. Gynecological.-There were 19 gynæcological cases, subdivided as follows:

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Three of the pregnancy cases were referred to elucidate the question of pregnancy as a cause of incapacity under the National Health Insurance Acts. The remaining case was an urgent acute one of pregnancy pyelitis of great severity.

Infectious Diseases.-The five cases in this category were :

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Other Diseases.-There were 19 cases in this category. They

were as follows:

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None of the above cases call for special notice.

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From the variety of the cases referred it is apparent that the district medical officer can be of the greatest service in discussing difficult cases with the insurance practitioner, and cooperating with him in determining desirable lines of treatment. It is undoubtedly in the rural areas where he can be of greatest value. Only those with experience of country practice can fully testify to the "medical loneliness" which is from time to time experienced, especially when cases are troublesome, when no improvement is observed and friends are apprehensive. visit of an independent medical comrade, examining the cases and talking over the difficulties, has a salutary effect on all concerned. To accomplish this part of the work satisfactorily, sufficient time is necessary. The examination must be made as soon as possible and it must be thorough and detailed. It has been noticed that a letter afterwards, with a full account of the condition present and suggestions for treatment, is usually expected. The procedure in fact must follow exactly that of the employment of a consultant for a private patient.

During the past two years Approved Societies have been

almost invariably notified that their member has been examined and the result of the examination has been given. This has many advantages it is, as a rule, desired by the doctor; it gives the Society information about their member, who may not be in the area of a sickness visitor; it may save the Society from referring the case, and in the case of the local Societies more especially this variety of service would appear to be appreciated. To the district medical officer the experience is invaluable.

Further Notes on the Problem of Mitral Disease following
Rheumatic Fever.

In last year's Report a study of heart disease as a cause of incapacity for work was given. The subject is developed in the following notes on the problem of mitral disease following rheumatic fever.

Interest in the problem of rheumatism in all its forms has materially quickened in recent years. In both the lay and the medical Press the serious economic waste involved has been brought prominently before the public, and steps are being taken to have the whole problem intensively studied with a view to early treatment and possible prevention.

The etiological relationship in which the various types of the disease, grouped under the generic name "Rheumatism," stand to one another, is still undecided. The actual cause is absolutely unknown, as is also its method of entrance into the body.

There is a strong argument in favour of directing special attention to the study and treatment of rheumatic fever, its cardiac complications and sequelæ. It is universally admitted that the heart disease as seen in early adult life can usually be traced to one or more attacks of rheumatic fever, either in form of an acute attack or of one of the frequently unrecognised larval forms of the disease. At the moment no treatment can be said to be curative, nor is there any definite knowledge when the disease is arrested or cured.

Analysis of 1,300 cases examined during the past year revealed the presence of heart disease in the form of mitral stenosis in 29 instances. There were 13 females and 16 males with an average length of incapacity for work prior to reference of 63 weeks. The average age was 27.

In a paper published by the Heart Committee of the New York Tuberculosis and Heart Association, an analysis of 1,001 cases of organic heart disease among adults shewed that onefourth presented rheumatic heart disease, two-fifths arteriosclerosis, one-tenth syphilitic disease, and one-tenth heart disease of unknown origin. Other factors such as scarlet fever, hyperthyroidism, nephritis, &c., together comprised less than one-tenth of the total number. It was also found that of the cases classified as of "unknown" ætiology, 63.9 per cent. presented lesions typical of rheumatic heart disease, 6-7 per cent. presented lesions typical of syphilitic heart disease, and the remaining 29.4

per cent. presented lesions not typical of any definite group. The presumption of a rheumatic aetiology in many of the latter is strongly suggested by the fact that between 75 and 90 per cent. of the cases occurred before the age of 50.

An analysis of the 39 cases examined in the Northern District during the year 1926 gave the following history :-rheumatic fever in 19 cases; chorea in one case; sore throat in one case; severe growing pains in three cases; and no history of rheumatic fever or rheumatic manifestations in five cases. All the five cases, although no history of rheumatic fever could be elicited, presented lesions typical of rheumatic heart disease.

Presence of demonstrable focus of infection.-The importance of a secondary infection, as a predisposing cause towards a relapse or as aggravating an endocarditis already present, is as yet undetermined. That such an infection may precipitate the tragedy of an ulcerative endocarditis is undoubted, and that there may be an improvement in a cardiac condition following treatment of the septic focus is certain.

Careful examination of the cases shewed the presence of severe dental sepsis and pyorrhoea in seven instances, chronic otitis media in one; markedly unhealthy tonsils and nasopharynx in one; and tonsillar abscess in one instance. The last was a case of great interest, a joiner, aged 35, who had been 52 weeks on benefit. There was a history of two attacks of rheumatic fever, and his cardiac condition on examination shewed severe mitral stenosis with tachycardia and easily-induced dyspnoea. The left tonsil was seen to be slightly enlarged, and shewed at the upper pole a small head of pus. A probe passed into a small abscess cavity. Removal of the tonsil was followed by definite improvement in the cardiac condition, and in the course of a comparatively short time he was able to resume work.

The following deductions may be made :—

1. The treatment of rheumatic fever, though largely empirical, should be long-continued, and careful observation should be made regarding the possibility of an inflamed mitral valve, under prolonged rest, returning more or less to normal.

2. While the rôle of focal infection is as yet undetermined, its thorough treatment should, on analogy at least, be followed by favourable results.

3. While it is not definitely known whether or not there is a hereditary predisposition to the disease, there seems to be no doubt that the disease may shew its various manifestations in different members of the same family.

4. There would seem to be the strongest possible indication for the establishment of cardiac clinics, which should have full facilities for accessory examination and treatment under the charge of a skilled heart specialist. The value of such clinics would be immensely enhanced by provision for convalescent treatment and home visitation.

5. Whether the best results would accrue if the disease were

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