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of warmth this makes all the difference between a climatewhich is tolerable and one which is too warm for comfort

(Ellis 1952). Adequate methods for controlling theclimate within warships are available today , but the

necessary modifications in design must be compatiblewith the other requirements of a fighting ship, andacceptable in other climates.

SUMMARY

Naval officers and ratings serving afloat and on shorein the tropics answered a questionnaire about the effectof climate on their efficiency and health.The great majority of those serving in the ships

thought that they were less efficient in the tropics thanwhen serving afloat in more temperate waters, andtwo-thirds of those living on shore thought that theywere less efficient than when serving on shore in England.Climatic factors were regarded as the main cause of thisloss of efficiency by over 80% of 157 men who thoughtthey were less efficient, and only 4 men (2-5%) considereddomestic, economic, or related factors to be more impor-tant than climate. The views expressed by officers andmen were in close agreement.Whereas over 70% of those in the ships thought that

they were less healthy in the tropics, nearly two-thirdsof those living on Singapore Island thought that theywere equally healthy or more healthy in the tropicsthan in a temperate climate.When healthy men serve for a long time in an unduly

warm climate, some of them will suffer from hot-climatefatigue, typified by lethargy, mental retardation, reducedpowers of concentration and sense of responsibility,irritability, and mild changes in personality and forget-fulness, which are associated often with excessive

sweating, unsatisfactory sleep, skin diseases, loss of

weight, loss of appetite, and ill-defined digestive disorders.This syndrome develops when men live and work atlevels of warmth which result in the presence of unevapor-ated sweat on the skin and in the clothing or bedding.The majority of men exposed to these conditions willsuffer in one way or another after a time, but in a healthycommunity serious breakdown will not be encounteredvery often, and there will be little reference to thecondition in routine sickness returns. Most of theseeffects can be surmounted temporarily when it is

necessary to make a special effort, and are relieved byresumption of life in a cooler climate.The evidence available suggests that hot-climate

fatigue does not raise many serious problems among themale naval community in Singapore Island but becomesincreasingly prominent with long service afloat in a

tropical climate.This account is published by permission of the Admiralty

and the Medical Research Council’s Royal Naval PersonnelResearch Committee. I am indebted to the Commander-in-Chief, Far East Station, and the Flag Officer, Malayan Area,for permission to circulate the questionnaire ; to SurgeonCommander T. Barlow, R.N., who arranged for its distributionand collection in the cruiser ; to the officers and men who

provided the answers ; and to Sir Frederic Bartlett, Dr. R. K.Macpherson, Dr. J. O. Irwin, and Dr. K. Cameron for helpfuladvice.

REFERENCES

Bedford, T. (1946) Environmental Warmth and its Measurement.Medical Research Council War Memorandum no. 17. H.M.Stationery Office.

(ameron, K. (1945) Rep. 45/252 M.R.C. Royal Naval PersonnelResearch Committee.

Critchley, M. (1945) Brit. med. J. ii, 208.Ellis, F. P. (1945) Rep. 45,202 M.R.C. Royal Naval Personnel

Research Committee.— (1948) Brit. med. J. i, 587.— (1952) J. Hyg., Camb. (in the press).

Fraser Roberts, J. A. (1948) Brit. J. soc. Med. 2, 55.Mackworth, N. H. (1951) Spec. Rep. Ser. med. Res. Coun., Lond.

no. 268.Macpherson, R. K. (1949) Univ. Queensland Papers (Physiol.) 1, 1.Pepler, R. D. (1951) Unpublished rep., M.R.C. Royal Naval Personnel

Research Committee.Rogerson, J. P. G. (1945) Appendix v, rep. 45 202 M.R.C. Royal

Naval Personnel Research Committee.

THE HEALTH OF THE ARMY

IN the complexities, stresses, and strains of modernwarfare, health has become increasingly important tothe fighting Services ; and the switch of emphasis fromthe prevention of disease to the attainment and mainten-ance of health is shown by the change of title of theDirectorate of Hygiene to that of Army Health. Thistendency can also be seen in the recently publishedReport on the Health of the Army in the years 1946-48,which covers the period of demobilisation and run-downfrom the war-time peak. *

HEALTH EDUCATION

An accurate definition of ’’ health " and a satisfactorymethod of assessing it are essential; and the chapter onrecruiting and medical classification is important. Theintroduction in 1948 of the PULHEEMS system ofmedical classification into the three Services improvedthe assessment of physical and mental health ; and theInterdepartmental Standing Committee on MedicalClassification, set up in the same year, was given theresponsibility, among others, of keeping the PULHEEMSsystem up to date. The lead given by the Services inmedical classification and in personnel selection mightwith advantage be followed in civilian life to a greaterextent than at present.During these post-war years physical training was

modified in accordance with the Arzuy’s changing require-ments. Cooperation between physical-training staffs andthe medical services became closer ; and medical super-vision of the recruit and the trained man in their basicand battle training, and tests, was intensified. Theremedial aspect of physical training for the sick andwounded and for the substandard recruit was also devel-

oped, especially at the three physical-developmentcentres, where the physique of substandard recruits wasbuilt up. In 1946 these three centres were amalgamatedin one centre at Chester, accommodating 1800 recruits.In 1948 man-power shortage led, unfortunately, to itsclosure. Presumably mobilisation plans provide for thesecentres to be reopened. But it might be worth consideringwhether these substandard recruits should not bedetected long before call-up, and given physical-develop-ment courses under civilian auspices before they leaveschool.The Army tackled health education vigorously. All

cadets and recruits, and all officers, N.C.O.S, and trainedmen received essential instruction, planned according totheir needs, from medical officers, and instructors trainedat the Army School of Health. At the school and in centresabroad, courses were held for unit sanitary and water-duty personnel. Instruction on service in the tropics andsubtropics was given on all troopships proceeding to theMiddle and Far East. All possible use was made of films,filmstrips, models, pamphlets, books, and the like. The

difficulty was to ensure that, in the welter of training andinstruction which the soldier received, sufficient timewas set aside for education in health. In this the supportof the military training authorities was invaluable.

ENVIRONMENTAL RESEARCH

During the late war personnel research was carriedout under the ægis of the Military Personnel ResearchCommittee, which lapsed in 1945. In 1948, in view of theincreasing complexity of modern equipment and of thewide range of environments in which the soldier of todayhas to serve, a new committee was formed, under thechairmanship of Sir Charles Lovatt-Evans, F.R.S., to

consider applied physiological and psychological research.The members include civilian physiologists and psycho-logists as well as representatives of the three Servicesand of the Ministry of Supply. Four subcommittees deal’ Thi& report is not on &aJe, but copies have been gent to learned

societies.

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with special aspects of the work, such as clothing andequipment, fighting vehicles, and steel helmets and bodyarmour. Some progress has been made, but the personneland resources for the large amount of applied researchrequired seem inadequate. Fundamental researchremains the responsibility of the Medical Research Councilthrough its Interservices Personnel Research Committee-.

Of recent years soldiers have been increasingly exposedto industrial hazards owing to the formation of largeworkshops, light-aid detachments, and similar units. Itbecame clear that to combat these hazards the Armyneeded outside help ; and a committee was set up,under the chairmanship of Dr. E. R. A. Merewether, H.M.senior medical inspector of factories, which included

representatives of the three Services and of the Ministriesof Health, Supply, Labour, and National Service.

PREVENTION OF DISEASE

No striking advances in prevention were made in theperiod under review, but research was continuously inprogress.

In 1948 proguanil was substituted for mepacrine in prophy-laxis against malaria. Proguanil causes no skin discoloration,and a shorter period of build-up is required.A sharp increase in diphtheria among troops in Germany at

the end of 1945 led to an inquiry into the immunisation stateof recruits ; and in 1946 instructions were issued for the

Schick-testing, and immunisation when necessary, of allrecruits. This measure is now normal practice ; and inGermany, along with other more local measures, it resulted ina drop in diphtheria incidence from 306 per 1000 in 1946to 0-95 in 1948.

In Germany and Austria acute ulcerative gingivitis alsocaused much anxiety. Here the only certain method of

prevention was a high standard of oral hygiene and, in

treatment, penicillin.Native food-handlers in kitchens and messes were con-

sidered to be responsible for small localised outbreaks of theenteric group in the Middle East. It was difficult to tracethe carriers owing to the intermittency of the condition.A contributory factor was the relatively low standard ofaccommodation and sanitation in many parts of the MiddleEast. Together with fly infestation, this was also responsiblefor much of the dysentery in the Middle East. In fact, in theyears under review the incidence increased from 24-05 per1000 in 1946 to 33-01 in 1948. The dysentery-rates forthe Middle East were higher than those for the Far East.The failure to improve this situation, despite adverse factors,should be investigated further.

In 1947 there was not a single case of cholera in Britishtroops or their families, though in Egypt they were living inthe closest proximity to the outbreak in the Canal area ; allthose concerned deserve the highest credit. Reliance was

placed mainly on general measures, and on the cooperationof the Forces in these measures. It was at a late stage in theoutbreak, when the battle was already almost won, that

popular anxiety at home led to inoculation of the troops withcholera vaccine.

Venereal disease in Germanv and in the Far East causedconcern in 1946. Since then there has been a steady improve-ment in the Far East and a dramatic drop in Germany.In the Middle East the rates were comparatively low, and inthe United Kingdom low.The introduction of chloramphenicol in 1948 completely

changed the outlook for scrub-typhus.Skin diseases remain, as in the past. an important cause of

sickness and ineflioienry. Apart from scabies, which runsparallel with venereal disease. the type of case varied with theCommand. In the Far East fungus infections caused the mosttrouble, in the Middle East septic conditions. In 1948 a teamvisited the Far East to study improved methods of preventionof skin diseases. An investigation at Aldershot in the sameyear showed that in a random sarnple of 1016 newly joinedNational Servicemen 3-6700 had tinea pedis. Communalshowers and swimming-pools were thought to be more

important causes than hyperhidrosis.The average incidence of tuberculosis in overseas theatres

was less than 1 per 1000 per annum. In the United Kingdomit was about 3 per 1000 owing to the inclusion of recruits foundby mass miniature radiography to be infected on entry. Massminiature radiography was carried out mainly by 10 mobile

Army teams, but the Ministry of Labour and National Servicehas now agreed to this work being done at the initial medicdboard. Owing to shortages of staff, apparatus, and accommo-dation, the take-over by the Ministry is gradual, and it willbe some time before the transfer is complete.The war-time emergency vaccine laboratory at Ever-

leigh has been transformed into an independent unit.with the title of Army Vaccine Laboratory. It has amixed military and civilian staff divided into a bacterio-logical department for the preparation of immunisingvaccines and diagnostic sera and suspensions, and a

transfusion department for the preparation of crystal-loids and the servicing of transfusion-sets. In 1948,960 litres of T.A.B. vaccine were produced, and 198 litresof other kinds of vaccine.

PROBLEMS OF INTAKE

Psychiatric disorders accounted for 9 discharges per1000 of the strength each year-far in excess of anyother cause. Every effort was therefore made to screenthoroughly the recruits at intake centres. Personnelselection officers interview each recruit and refer to amilitary psychiatrist all who are so dull as to be unlikelyto absorb military training or who appear to be ofdoubtful stability for a Service life. The rise in the

percentage of intake referred from 10% in 1946 to 17%in 1948 was due rather to an increasing awareness of thevalue of the psychiatric screen than to deterioration inquality of the intake.The problem of the employment of men of low intelli.

gence remained as difficult as ever, as also the specialproblems of the s.G.5 group-i.e, the lowest group interms of ability to learn-into which approximately 13%of the Army’s recruit intake fell. About 5% of the

Army’s recruits were unable to assimilate normal trainingand had to be allocated to the Royal Pioneer Corps forsimple labouring duties.

HOSPITAL PROBLEMS

On the surgical side in 1946-48 there was a steadydecline from a first-class and fully staffed specialistservice in the Royal Army Medical Corps to an over-stretched service of doctors with minimum specialistcover. Furthermore, there was the general difficulty ofrecruiting doctors for the R.A.M.C., on account of

unsatisfactory pay and conditions of service. At thesame time overseas responsibilities increased greatly;for in certain commands British civilian members of theControl Commission became entitled to treatment; andthe number of military families increased greatly. Ahigh standard of surgery was, however, maintained, anda policy adopted of evacuating early from overseas long-term cases and those needing highly specialised forms oftreatment.The hospital admission-rates per annum among British

troops in the four large commands over the three yearswere as follows (per 1000 strength) :

1946 1947 1943U.K. ..... 432 360 311Germany ..... 499 586 4tiMiddle East .... 479 390 473Far East...... 685 571 551

CONCLUSION

The progressive attitude of the Army medical authori-ties shown in this report can reassure us all that the soldieris in excellent hands. The National Serviceman shouldreturn to civilian life physically and mentally improvedand the cumulative effect of this on the nation as a wholemust be considerable. Inter-Service cooperation andliaison with the civilian medical world, which was such aprofitable feature of the war years, has continued andindeed increased. Moreover, the opportunities forresearch in the controlled community of the Army areclearly not being lost.