duce the glandular enlargements when applied locally; and routine study of the blood may make it possible to anticipate and forestall their recurrence. In this condition it is often possible to treat the local manifestations of the disease very successfully, that is, to reduce the glandular tumors, while the general condition of the patient remains almost unchanged. Radiation must be applied not only to the enlarged lymph glands, but to the splenic tumor as well, to obtain the maximum degree of benefit.

HODGKIN'S DISEASE

Hodgkin's disease may be successfully treated by radiation, for a time. Here again treatment probably does not significantly prolong life, but it does relieve the symptoms referable to pressure from enlarged lymph glands. It is now recognized that Hodgkin's is a systemic disturbance, and thorough treatment should include all accessible lymph gland structures in the body-the enlarged nodes first and after they are reduced in size, the apparently normal ones. The initial course of treatment is usually very effective, and many a patient deludes himself in the belief that a complete cure has been accomplished in spite of his physician's assurance to the contrary. The disease inevitably recurs after a period varying from a few weeks to a few months, and radiation is then less effective. Eventually, as in the leukemias, its effect is lost completely.

The blood picture is not a guide for treatment in this condition because there are no characteristic changes. Prolonged radiation will usually reduce the leucocyte count quite markedly, and when this occurs it would seem to indicate that radiotherapy has reached the limit of its usefulness. Such cases, when radiated still further, usually do badly. The guide for treatment in this disease is a general onethe size of the enlarged glands when these are accessible to examination, and the general condition of the patient.

POLYCYTHEMIA

Polycythemia, erythremia or Vaquez's disease, as it is variously called, is not very responsive to radiation. It is rather uncommon in occurrence, which makes a consideration of it at present less important than the conditions already mentioned. Red blood cells are among the most resistent to radiotherapy, while white cells are among the most susceptible, and it is usually difficult to bring about any reduction in the red cell count without also causing marked destruction of the circulating leucocytes. It is sometimes possible, however, to reduce the number of red cells, with accompanying relief of symptoms, either by radiation alone, or combined with benzol given by mouth. Treatment is given over the spleen

and long bones. Cases with splenomegaly respond better than those without, perhaps because the enlarged spleen offers a better target for the therapeutic rays. Since the primary object of treatment is to reduce the number of circulating red cells without markedly damaging the leucocytes, radiation must be very carefully controlled by routine study of the blood. A rapid fall in the white cell count is an indication for stopping treatment. This is an extraordinarily chronic disease, with frequent fluctuations in severity, and the results of treatment are difficult to evaluate.

TYPES OF RADIATION

For therapeutic purposes with reference to diseases of the blood, there are two principal types of radiation-X-ray and radium. The ultimate results from these two are closely comparable. Radium furnishes more penetrating rays, and the effect of treatment is more quickly seen; but with a somewhat longer time X-ray will produce the same results. The limit of helpful treatment in either case is far short of controlling the progress of the disease. Occasionally a case which no longer responds to X-ray, may respond to radium for a time, but never for long. The practical use of improved X-ray apparatus, designed to give a ray much like the harder radium rays in penetrability, is now in the process of being worked out. Too much must not be expected of this apparatus, however, for its best results probably cannot surpass the already known results of radium itself.

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VI. THE ANNUAL OVERHAULING-..

PHYSICAL EXAMINATION

JOHN SUNDWALL, Ph. D., M. D. Professor of Hygiene and Director of the Department of Hygiene and Public Health. University of Michigan, Ann Arbor, Mich.

Genuine achievement in our "health promotion" or "physical efficiency" program will come only when people will begin to look at their bodies as machines which are in constant need of intelligent care. We must develop this "machine attitude" toward the body on the part of the public. Now that the automobile is the machine of fashion and interest in it is almost universal, let us adopt this slogan in "putting over" the "physical efficiency" interests and activities of public health: "In order to run smoothly and efficiently, your body demands the same care as does your automobile," or "Treat your body as you do your automobile."

To maintain an automobile at its maximum of value and efficiency and to be reasonably assured that it will function well for a long time it is indispensable that the operator thereof be familiar with its internal workings. Furthermore, he must know the actual needs of the machine along the lines of lubrication. Again, the minimum amount of gasoline or fuel essential to procure the most power or energy and the proper mixture of air and gasoline must be ascertained and applied. The skillful and intelligent operator knows that bolts must be tightened frequently, that defects must be remedied and that the machine is in constant need of periodical overhauling. Constant vigilance and care assures to the automobile a long life of efficiency.

Now, if each individual would take the same rational attitude toward and interest in his body machine, then the goal of physical efficiency would soon be within our vision. Can we develop on the part of the public this rational and sound "machine attitude" toward the physical body?

In our endeavors "to put over" a far reaching and effectual "personal fitness" program, appeals must be made more and more to the other vital interests of life rather than to the health phases. The term "health" has been overworked in a large measure. One may better resort to those fundamental impulses and interests which are normally present in most people. For example, the average individual wants to be successful. He has an impelling desire to win. He dreams of leadership and power. He longs to prove himself of genuine value to society. It is, therefore, to these impulses that the "physical efficiency" objective should appeal. It is not difficult to convince people that man's ability to do physical or mental work depends upon his ability to generate force; that is, to convert food, water, air into organic faculty, then into

effective energy and that whenever man rises to prominence in any of the walks of life it is because of his generating powers. As society becomes more complicated and as competition becomes more keen, the energy generating abilities of one's body machine becomes paramount.

In our future attempts to inspire the boy and girl to achieve those "heights that great men reached and kept" let us remember that the boy and girl must be ineradicably impregnated with this fact that in our day and age physical efficiency is the first and foremost requisite to success in life. As Sargent has said, "There is a dynamic relationship between good digestion, circulation and respiration and the ability to make a life's labor of mercantile, professional or highly intellectual pursuits." In the strenuous battle of life a time comes in the experience of everyone when a sound body is the last great issue. It is the crisis. If one has not the strength to "put himself across," then someone else who has not neglected his body will forge ahead and "grab" that success.

Intelligent and effective care of the body machine with a view of getting out of it a long life of high degree generating power includes several factors. First, the individual must know something about the structure-anatomy, and something about the functions of the various organs-physiology. However, caution must be exercised, in advancing the physical efficiency program, not to lay too much stress on structure and function. This may prove to be too laborious and disinteresting to those to whom the physical efficiency program is being applied and, therefore, result in defeat of the genuine objectives in mind. The important thing is to make the individual feel that he is dealing with a machine of infinite value. Compare his food or fuel intake with gasoline. Practically everyone knows that the measure of automobile efficiency is the number of miles one can get out of a gallon of gasoline. In other words, it is the maximum of power derived from the minimum of fuel that determines in a large measure the value of a machine. At least people are interested in it. Now then, the same principle should be applied to food with a view of avoiding overingestion and the evils thereof, such as the degenerative diseases, etc. The avoidance of unnecessary wear, tear, and of exposure whereby the scrap heap is soon reached, applies equally to both machines. Prevention and correction of defects; in the case of the automobile by tightening bolts, avoiding rust, proper lubrication, and "seeing to it" that the gasoline and air essential to combustion and power are free from foreign substances and in the case of the human machine by applying the principles and practices that have already been considered in the previous discussions; contribute much to the life and efficiency of the two types of machine. It must be remembered, however, that in the human machine, a new part cannot be substituted for an old worn out one.

Thus the similitudes of the two machines can be carried on almost indefinitely.

Not only from the physical standpoint should this

"machine attitude" towards our bodies be cultivated, but it is of equal importance from the mental point of view. The efficient operator of the automobile takes a sane, rational attitude toward his car. He is not disturbed with worries, anxieties, apprehensions or fears. A similar mental attitude must be developed toward the human machine. We must by all means avoid inculcations of introspections and other forms of neurosis and psychosis which, in the past, have contributed so much to invalidism and subnormalcy.

XI. Physical Examinations. I have purposely delayed the discussion of physical examinations; perhaps the most important of all the interests and activities concerned with health promotion-physical efficiency-the attaining and maintaining of a sound, active, vigorous and harmoniously developed body and which is to be the chief concern of the new public health; until attention had been called to the other important factors essential to the promotion of health.

For the purpose of concreteness or visualization, it may be well to put our ideas regarding physical efficiency and its various approaches or supports (already discussed) into some form of art. Let this be a fresco or a mosaic or a bas-relief. Perhaps to chisel it in marble would be more appropriate. Some such figure of ideal physical perfection as Venus of Milo which is the very embodiment of beauty, strength and serenity, or Fraxitile's Hermes, may well represent our ideals of physical efficiency or personal fitness. The figure would be supported by a number of Ionic columns aesthetically and harmoniously arranged, and each would symbolize those interests and activities or supports by which physical efficiency is maintained. One column would represent food or nutrition; another, air; a third activity and so on until all the approaches to or supports of physical efficiency are represented such as sex hygiene, mental hygiene, avoidance of bodily poisons and the prevention of defects. The base support for these columns would be the solid rock of physical examinations. In other words the very foundation of our physical efficiency program is the physical examination. Without this basic solid structure our efforts directed along the lines of health promotion will be of little or avail. The statue will crumble.

no

Again let us return once more to the desired "machine attitude" toward our bodies. Every efficient operator knows that his automobile is in need of periodic overhauling. This, in spite of the fact that every care is manifested in its operation. He realizes that from time to time his machine must be "gone over" by the expert.

Likewise, the human machine is in need of periodic overhauling. Let us say that this overhauling should take place at least once each year from the cradle to the grave. The annual physical examination, is after all, the most important activity in all health promotion programs. We shall learn later on that it is likewise the predominating factor in that other interest of public health-the control of communicable diseases.

No effectual public health activities either along the lines of health promotion or disease prevention can be maintained unless ample provisions are made for physical examinations.

They are of inestimable value in all applied hygiene activities. In infant welfare, the periodic physical examination will do much to prevent heart disease and other on-coming defects. It offers unusual opportunities for that personal or human touch which is so essential in all efficient public health work. Here the mother can be taught the hazards of babyhood and the fundamentals of health promotion and disease prevention as applied

to infant welfare. In fact, no more timely occasion is conceivable for intensive education along the lines of health than is that presented by the physical examination.

Already we have learned that from seventy-five to eighty per cent of our school children have defects which are potentially or actually detrimental to health. These defects, in the very largest measure, can only be discovered by scientific physical examinations. Schoolmen are now beginning to appreciate the fact that physical efficiency in school children must be made a twin companion of intellectual progress and, therefore, they are interesting themselves more and more in the establishment and maintenance of all facilities whereby personal fitness in pupils may be acquired and sustained. Furthermore, schoolmen are realizing that the annual physical examination of each pupil is the most effectual procedure by which this can be brought about.

Assuredly, if universal annual physical examinations and overhauling were the vogue with children then our problems concerned with physical subnormalcy would be largely solved. Physical defects would tend to disappear as if by magic. Another nation-wide health census such as the recent draft examination would not reveal the appalling fact that one-third of our young men are so subnormal that they cannot answer the nation's call for defense.

The annual physical overhauling is of inestimable value in adult life. It is in the early adult period that the degenerative diseases are prone to begin and which contribute so much to our national morbidity and mortality. As a rule these retrogressive changes begin and progress and reach irreparable stages before the individual is cognizant of their presence. And right here we may well emphasize the supreme importance of the annual physical examination, it picks up the defects that the individual himself cannot and in a measure should not discover for himself and, therefore, corrective measures can be applied before the irremediable stages are reached.

To illustrate, let us insert here the results of physical examinations conducted by the Life Extension Institute of New York City.*

"First: Insurance policyholders, to whom the privilege of free medical examination at certain intervals has been extended by the life insurance companies having contracts with the institute to perform this service.

"Second: Employes of commercial houses, banks, trust companies, etc., to whom this privilege has been extended by their employers who contracted with the institute for this service.

Results of the Examination of Life Insurance Policyholders by the Life Extension Institute. Per Cent

The above statement shows the percentages that the various impairments are of the whole number of employes examined. Many employes, of course, show several combined impairments. Average age 30.

"The first group is composed of individuals who apply voluntarily for this service. It has been assumed that many of these people had at least a subconsciousness of impairment. Nevertheless, 93 per cent of those found impaired were, according to their statements, unaware of any impairment.

"Although the second group were not compulsorily examined, a practically unanimous consent to the examination removed any element of self-selection and the group may be regarded as fairly representative of the average condition obtaining among the employes of such business institutions in large cities.

"In studying these figures, it should be borne in mind that the particular purpose back of this system of examining is to secure a complete picture of the individual, and thus all impairments or imperfections found have been carefully recorded without

regard to the present state of knowledge as to their significance. Examination for life insurance, for tuberculosis, for eligibility for employment, for ascertaining the influence of particular occupations or hazards, etc., and other physical examination for special purposes might produce a different record. In the institute's work, however, information is sought for the sole purpose of assisting the individual to raise himself to a higher standard of health, and efficiency; hence, any departure from the normal is recorded, and particular attention is given to harmful living habits carrying potential impairment.

"The noteworthy features of the record are as follows:

1. The high percentage of impairments or imperfections.

2. The high percentage of disturbances or impairments of the heart, blood vessels and kidneys. 3. The large percentage of individuals in both groups who were not aware of impairment-93 per cent among insurance policyholders and 96 per cent among commercial groups.

"Among the insurance policyholders 65 per cent, and among the commercial groups 59 per cent, were sufficiently impaired to be referred to physicians for treatment with full report of the conditions found. In appropriate cases instruction in personal hygiene was also given.

"Those in the commercial group were examined by trained examiners of the home office staff, all of whom followed uniform methods and standards. All laboratory work was done at the home office, thus eliminating possible errors from differing standards of examination or technique. Those in the life insurance group were scattered throughout the country, but were examined by physicians specially selected and instructed regarding the standards and methods to be observed.

"Probably the most striking and important fact revealed by these examinations is the large percentage of young men showing arteriosclerosis, or thickening arteries. This condition is one of slow growth, and it is not, after all, surprising, in view of the high and increasing death rate from cardiovascular troubles in middle life, that we should find the beginnings of these chronic changes in early life.

"The lesson from these figures is that we must often start in at 25 or earlier to prevent a death from apoplexy at 45.

"The checking of the degenerative maladies is not such a spectacular matter as the stamping out of typhoid, yellow fever or tuberculosis, but the possibilities for effective work through personal hy giene and guidance in correct living habits are quite as great. All along the line we find magnificent opportunities for improvement, teeth, eyes, nose, throat, ears, circulation, living habits, etc.

"Those who accept the average man as a fairly able-bodied citizen seldom realize how far below his attainable condition of physical soundness and efficiency he is.

"To some, this may seem like a study in pessimism. It may smack of pathological detective work which seeks to uncover human frailties and conjure up a Cassandra-like vision of "Woe, woe, to the human race." This is a superficial and pitifully inadequate view of activities fraught with tremendous possibilities for racial advancement.

"What about the harmful effect of mental suggestion? For some years we have had a surfeit of "mental suggestion." Everything from stone-inthe-kidney to bow-legs has been ascribed to mental suggestion, or to something buried in the psyche, and there has been a tendency to encourage a tim