A draft handbook for the guidance of medical practitioners in examining applicants for motor vehicles driving licences: revision 1

\ ~1 0 P. L D H ~ A LT H O:<.GANIZATION :rrlo/;~.ccid.Prev./1 Hev.v 8 September l955 RESTRICTED H.JmBOO~C FOR THE GUIDANCE OF :ZDICLY~ PRACTITIONERE:- IN EXiuiiNING AP.2LICANTS FOR i•lOTOR VEhiCLE DRIVING LICE.l~CES The question of the mental and physical fitness of drivers was taken up by t.he Committee of Experts on the Licensing of ~:otor Vehicle Drivers, convened in 1952 by the United Nations for the pur-pose of considering the establishment of . minimum uniform regulations for the licer ... sing of drive:.s of the various categories of motor vehicles. The Committee re~omrnended, inter alia, the preparation by ·~-mo of a handbook containing rules for the guidance of medical practitioner-s when making examin2.tj_ons of hea~t.h, vis~ on ar..o. !1ec:.ring. Th: .. s handbojk for the guidance of physicians h.::s been prepared by the Consultant Group on Hedic.fll R2quire1rents for the Licensing of 1-1otor Vehic:e Drivers, convened in Geneva from 29 August to 2 September 1955 by ··,mo with the participation of U1~, ILO and the International Federation of Ophthalmological Societi8~~ INTRODUCTION lo In view of the large and increasing number of vehicles at present on the roads it is essential, in the ir.tere.sts of safety, to ensure that as far as possible a good standard of physical and mental fitnc.:;s is 'naintained in those who drive. In the interests vf the safe+.y of ·t:.he travelling public, a high st911dard of fitness should be requir.:::d of t.:1c~>~ 1-1ho are r·::-sponsible for driving passenger transport vehicles. Lit,tle eYidence is availab.:"..e to show the connexion between accidents and physical or :mental defec·t:.s of drivers, but it may be safely assumed that, as most accidents are due to personal failures, a reasonable degree of physical hea1-t.:.1 and mental alertness:!t¥;€-"~_J:rable am-:mg those who have charge ,./ \ .... _ l"' j 1. ,,..., of a motor vehicle.. Health and phY.:;ical fitness play a major part in maintaining I - ' the skill of passenger transport <1+-~t-v;.r~r ~hicb. ~ turn p·:-om.ctes the confidence of ,\ I. 'J V L ' ' . ' I ~ ·' .. ~"',J t./ ~"-· ' 4~ < ... .,; WHO/Accid~Prevo/1 Rev.l page 2 tre 'c.ravelling public. In this case the driver has the added responsibility of the safety of some 60-70 passengers and the assessment of fitness for driving must always hold this consideration to be of paramount importance. Similar considerations also apply to drivers of heavy goods vehicles. Where medical examinations are required under the regulations of licensing authorities before the issue of a driving licence th~re is therefore need for great care, both in carrying out the examinations themselves and in reporting on an applicant 1s fitness to drive, in the interests of the safety of the travelling publico The administrative requirements for motor vehicle drivers and the medical standards prescribed va~ considerably between different countries, but the general information given in the ensuing paragraph will, it is hoped, be of use to all. This handbook contains guidance on principles for medical examiners: examining physicians will of course neGd to m"et the :~equirL.ments of the licensing authorities in each country but within the administrative boundaries prescribed by these authorities the recommendations given in the handbook will, it is hoped, be of assistance to physicians who are called upon to examine people as to their medical fitness to drive. In doing so, the examining physicians must necessarily form their own judgement in each individual case; these notes are intended to serve as a guide to the examining physician and the examination should be undertaken only by qualified medical practitioners. i\lthough drivers of private cars, motor-cycles, and similar small vehicles are not always medi.cally examined at the request of the authority which issues licences, nevertheless these drivers usually come under the care of a general medical practitioner sooner or laterA This handbook therefore provides a useful guide to practitiorers of medicine in advising those of t.heir patients who are drivers on the road, whatever type of vehicle they may drive. A general consideration of the medical standards of fitness .for driving is given by Dunlop (1945), Selling (1951), Herschensohn (1950) and Kerr (1953)~ 2~ In some countries, applicants for motor vehicle drivj~g licences are given a practical test of their ability to drive before being issued with a licence; the d:rivin.g examiner is then in a position to ensure that the applicant 1 s eyesight is sufficient for practical purpuses} and the:.:. his limbs ap_f>t.ar to function adequately for t.he control of the vehicle., WHO/Accid.Prev./1 Rav.l page 3 3. Transport undertakings sometimes request physicians to examine drivers in oonnexion with their efficiency, for examp1o; to determ:L11e ~rhether a driver is liable to excessive absence on account of sickness. It is not the purpose of this handbook to establish criteria for the pre-employme:nt and periodical medical examination of drivers in order to determine their fitness for employment: its purpose is only to establish criteria for cases where medical ~ond~tions render driving unsafe, and therefore oblige the licensing authorities to refuse the granting or renewal of a driving licence, with a view to maintaining safety on the roads. 4. It is recommended that the blood group of each driver be recorded in his licence. 5o In this handbook, drivers of motor vehicles are generally considered in two categories: (a) drivers of light motor vehicles (b) drivers of heavy motor vehicles Light motor vehicles consist of the m~tor vehicles mentioned in the categories A and B given in Annex 9 of the Convention on R~ad Traffic concluded at Geneva, 19 September 1949 whiCh are as follows: A. Motor-cycles with or without a side-carJ invalid carriages and three- wheeled motor vehicles with an unladen weight not exceeding 400 kg (900 lb).* B. Motor vehicles used for the transport of passengers and comprising, in addition to the driver's seat, at most eight seats, or those used for the transport of goods and having a permissible maximum weight not exceeding 3,500 kg (7,700 lb). Voh~_cles in th:i_s category may be coupled with a light trailer. Heavy motor vehicles consist of those motor vehicles indicated in the categories C, D and E in Annex 9 of the Convention on Road Traffic referred to above which are as follows: * Motor scooter drivers should, from a physiological point of view, be considered as drivers of light motor vehicles and therefore be licensed in the same way. WHO/ .AccidiPrev ./1 Rev .1 page 4 C. Motor vehicles used for the transport of goods and of which the permissible max:ilnum weight exceeds 3, 500 kg ( 7, 700 lb) • Vehicles in this category may be coupled with a light trailer. D. Motor vehicles used for the transport of passengers and comprising, in addition to tre driver 1 s seat, more than eight seats. Vehicles in this category may be coupled with a light trailer. E. Motor vehicles of categories B, C and D, for which the driver is licensed, with other than a light trailer. In gpneral, the medical requirements for heavy motor vehicle drivers, particularly those responsible for passenger transport 1 should be more strict than those for light motor vehicle drivers, in view of their r~cponsibility for passengers and the fact that the former are usually on the road for many hours each day. The length of their exposure to accidents is greater than that of light motor vehicle drivers, although the experience and skill of heavy motor vehicle drivers are usually greater and their accidents therefore less. METHOD OF EXAI'illl':•TION 6~ It is important that the person to be examined should be completely un!Rressed, as it is possible to overlook important physical defects unless this is done. The examination should be undertaken in a good light and facilities should be provided at least for eyesight tests, ophthalmoscopic examination (where indicated), urine tests for sugar and albumen, auriscope examination, and measurement of blood pressure. Special examinations which are occasionally req;1ired include the electrocardiogram, chest or other radiograph, blood sugar estimation and electro-encephalogram. 7. Examiners who undertake considerable numbers of these exa.mi,nations generally find it useful to carry out the examination procedures according to a routine. For example, the eyesight and hearing might be examined first, followed by the chest, upper limbs, lower limbs, abdomEI} blood pressure and urine tests in that order. A full account of a suggested routine method of examination is given in paragraph 60. WHO/Accid.Prev./1 Rev.l page 5 8. As a general rule 1 applica!lts for motor v::·hicle driving licences should be assessed medically according to the follow:L1g criteria: (i) Is the applicant physically and ~e~tally able to manipulate the controls and maintain such work fo:r J.o:1g periods? (ii) Has the applicant a safe standard of vision and hearing? (iii) Is there any risk of sudden loss of consciousness while driving? (iv) Is there a likelihood of severe fatigue towards the end of the day, with consequent increased danger of accident? If the answer to these four questions is satisfactory the applicant may safely be permitted to dri vc but if there is any disease or disability present which may become. chronic or progressive he should be kept under regular observation or he may be given a permit of which the validity is especially limited~ EYESIGHT TESTDJG JIND STANDARDS 9. The importance of good eyesig.1.t for driving motor vehicles needs no emphasis. Although there is no accurate information or statistics which relate visual acuity to the occurrence of accidents, some information has been collected by the Road Safety Information Centre of tre World Touring and Automobile il.ssociation, London. Evidence on this question collected in Cal1.fornia in 1936 and 1938 revealed that more than half of the motor vehicle drivers who had beea arrested for "cutting in 11 had one eye with subnormal acuity. The California enquiry also showed that motor vehicle drivers with accident-free records had better visual acuity than those with bad driving records; in a number of cases in which the driver involved had defective vision in one eye, he had collided with a vehicle or pedestrian approaching on the side of his weak eye. These drivers were unaware that they had any defect of eye- sight. An investigation of 103 fatal accidents occurring at read intersections showed that 71 had involved motor vehicle drivers with defective vision in one eye; in 61 of these cases the driver had collided with a vehicle approaching on the side of the weak eye. A useful summary of these f:i.ndings.9 vJith discussion of the problems involved, is given by Fletcher (1948)s It was also found in an enquiry in Michigan that accident- free motor vehicle drivers wore significantly su.LJGrior to accident.-.repeaters with regard to visual acuity (Eno Foundation, 19·18). WHO/li.ccid.Prev./1 Rev.l page 6 In all cases where the visual acuity is below normal the eyes should be examined for the presence of any ocular disease which may have.affected the acuity. An insidious deterioration of vision may occur due to tho development of a cataract or other ocular disease, and the driver concerned may be unaware that his eyesight is becoming worse, or he may persist in driving although he knows that his vision is poor. For these reasons, visual tests and standards of eyosight should be required for the two categories of drivers (i) the heavy motor vehicle drivers and (ii) the light motor vehicle drivers. PERIODICITY OF EYESIGHT EXAIIflNAT IONS 10. In the intorests of safety it is desirable thnt heavy motor vehicle drivers should have their eyesight tested at least every five years and annually if the,y continue to be employed on this work after the age of 65. Periodical medical checks of the vision of drivers of light motor vehicles cannot usually be arranged on account of the large number of drivers concerned. Where eyesight tests are required by the licensing authority before granting a licence, the medical examiner should be empowered to require periodic tests to be carried out at more frequent intervals in cases in which, in his opinion, such additional examinations should be undertaken. VISUAL REQUIREMENTS OF (i) HEAVY MOTOR VEHICLE DRIVERS 11. Visual acuity The visual acuity of heavy motor vehicle drivers should always be tested by a physician and any cases in which there is doubt as to whether a licence should be granted should be referred to an ophthalmologist. The total visual acuity should be at least sixteen to seventeen tenths (16-17/10) for both eyes together with glasses, for example: ri@t eye: 1.0 right eye: 0.6 left eye: left eye: 0.7 * 1.0 etc. ·~ ' For comparative purposos the equivalent standards on different notations are as follows: Decimal American Notation Notation 0.1 20/200 0.2 20/100 20/80 (0.25) 20/70 (0 .. 28) 0.3 20/60 (0~33) Oo4 20/50 ·----- --- 0.5 20/40 0.6 20/30 (0.66) - I 0.7 0.8 20/25 - - 0.9 1.0 20/20 - WHO/AccidcPrev./1 Rov.l page 7 ' _.._ ___ Engli.sh German Notation Notation 6/60 5/50 6/36 (0.17) 5/40 (0.125) 5/30 (0.17) 6/30 5/25 6/24 ( 0.25) 5/20 (0.25) - 6/18 (0.33) 5/15 (0.33) 6/~2 5/10 ----- - 6/9 (0. 66) 5/7.5 (0. 66) - 6/6 5/5 If the visual acuity without glasses is loss than these requirements it is essential that tho driver should always wear glasses when he is driving, and this should be recorded on the driver's licence. Hhere the visual requiremants are satisfied only with glasses a spare pair must be carried. In order to detect the development of a cataract, or other ocular disease affecting visual acuity, all persons should be given an ophthalmological examination on first application for a heavy motor vehicle driving licence; subsequently ophthalmological examination should be carried out if the visual acuity, corrected by glasses, is 0 .. 5 or less in either eye. One-eyed persons should not be permitted to drive a h8a·vy motor vehiclG, WHO/Accid.Prev./1 Rev.l page 8 12. Visual fields Good lateral vision on both sides is an obvious necessity for safe driving. Occasional cases of severely restricted visual fields occur (tubular vision) and these severe cases should not be p~rmitted to drive any form of motor vehicle. An accurate me<:>.surel'IJ3nt of the visual fields may be undertaken by means of one of the several types of perimeter which are available on the market, but this test requires 20 to 30 minutes to perform. It is thorofore not practicable as a routine test by general medical practitioners or for the ex~minntion of large numbers of applicants. A practical and convenient test is the 11 confrontation test" in which the medical examiner faces the examinee, covering each of the examinee's eyes in turn and requesting the examinee to look at the examiner's nose with the open e;ye. A movement of the fingers at the peripheral edge of the visual field should thon be equally detected by both the examiner and the examinee, provided the examiner knm-Ts that his own visual fields are normal. Jmy definite restriction of the visual field detected by the "confrontation test" should cause the case to be referred to an ophthalmologist for a further opinion. 13. Colour vision Experience has shown that accurate colour discrimination is unnecessary far motor vehicle drivers. No colour vision tests are therefore recommended. 14. Strabismus e.nd diplopia If there is a definite diplopia a driver's licence should not be granted. Applicants with strabismus should be referred to an ophthalmologist for examination. 15. Stereoscop_ic depth percep_tion, ocular muscle balance and night vision Tests of binocular vision, stereoscopic depth perception, ocular muscle balance and night vision arc not essential for the standard eyesight examination of heavy motor vehicle drivers, but these tests may be undertaken by an ophthalmologist in particular casos where doubt has arisen as to visual efficiency. VISUAL REQUIREr-1E:NTS OF (ii) LIGill' HOTOR VEHICLE DR:rVERS WHO/Ac~idoPrev./1 Revol page 9 16. All applicants should have their visual acuity tested by th'3 non--medical exam:!.ner using the Snellen or similar chart method. 1--.. tot,al visual acuity of at let1.st 0 .. 8 for both eyes together should be required and with glasses if necessary. Those who fa:l the test should be referred to an ophthalmologj.st for examination. All one-eyed applicants and those in whom the vision in on'3 eye is less than 0.1 with glasses should be referred to an ophthalmologist for examination and a vision of 0.8 required in tl1e good eye. Ei.R CONDITIONS For practical purposes, tbe hearj_ng oi appl:.cant s for a motor vehicle driver's licence may be tested by the following mathod; the examiner stands behind the applicant and coyers each oar in tu:rn. The applican:, is requested to repeat a series of numbers chosen at random which are spoken and then whispered by the examiner. In :,his vray the distance at which conversational voice (C.V.) and whispered voice (W.V.) is hoard may be recorded for each ear separately G It is sometimes said that th!R test loses its value because examiners vary considerably ir.. tl1e l0udness of th8ir voice production, but this is not quite correct; each examiner develo~.s, with experience of test:ing large numbers of cases, an acute appreciation of any variation in an applicant's hea~ing. A similar practical test may be given using the ticking of a watch as the auditory signal, but in both the watch test and the whispered voice test it is mainly the hi@ler frequencies which are under examination. Tests by means of an audiometer are not usually carried out as a routinG a."'ld there iR no reason for undertaking audiometr tests except in cases with more than moderate loss of hearing. There may be considerable variation from day to day in an individual's degree of deafness and for this reason also a practical test is to be preferred to the more refined audiometryo There are no generally accepted utandards of hearing for motor vehicle drivers and there is a surprising lack of information i:'"l rog"l.rd to the saf6ty or otherwise of deaf drivers" Enquiries made of in.su:::-ance companies :i .. :':l. c.-:..~eat Britain ( 11 Rex'1 1953) WHO/Accid.Preva/l Rov.l page 10 revealed that s omo com:pa.nies do not accept insurances from deaf drivers, but the majority adopt the noncornmit~al line of indicating that each case depends on its individual meritso The saiiD paper refers to a scientific study in which the con- elusion was reached that there was little difference between the accident-proneness of a deaf person and that of a person with normal hearing; in fact, the investigation showed a slight balance in favour of the deaf. It wa.s concluded that the reason for this is that deaf persons are particularly conscious of their handicap and that they therefore exercise extra care. An inter0sting discussion on the importance of hearing to automobile drivers is given by Macfarlan (1937) who considers that the deaf are generally safe drivers; they are cautious and on the alert bocauBe they know the risk they are taking. Hhile good hearing is an undoubted asset to a driver, it is by no means es::;cnt.ic..L I·baring in ::;or:l.:; cas0s may well be more acute in the noise of traffic than in a quiet room; it is doubtful whether driving safety is materially enhanced by the possession of high degr8es of ~uditory perception such as are required to hear a whispered voice in a still room at a considerable distance. In order to hear overtaking vehicles it is sometim0s thought that hearing in the left ear is more important in countries where vehicles .:1!'8 driven on the right side of the road, but the :i.Inpor~ance of this ffiould not be exaggerated, for whichever side the defect, unilateral deafness results in some difficulty in the location of sound. It is unlikely that moderate impairment of hearing in a competent and experienced driver 1vill con3titute a danger or deuract seriously from his driving ability. Burger (1937) considers that good hearing is required for passenger transport drivers. Persons who apply for th"' first time for a licence to drive heavy motor vehicles should undoubtedly not be permitted to undertake this work if they suffer from more than a minor degree of deafness, Trained experienced drivers who develop deafness may, however, be permitted to drive unless the degree of deafness is so severe as to interfere with the performance of tho work} or results in an increased frequency of accidents. Marked reduction of hearing should be a barrier to driving any motor vehicle.. No benc~.:.t. :L:; J.:.0 lkl ~Af!OC~ecl fJ.:'vd th~ ·..:;se of hearing aids in driving, because of extl~aneous noises, variability and mechanical defects which may develop in the instruments, and the difficulty in locating the position of a sound. Therefore hearing <rids shouJd not be permittedo WHO/Accid.Prev./1 Rev.l page 11 \"f.1ere a driver is required to drive a·::. high altitudes it is desirable to ensure that the Eustachea.n tubcG are patent o In cases where there are sudden attacks of vertigo .9 for example in Meniere 1 s Syndrome with tinnitus, deafness and vertigo, persons sln.ouJ..d not be permitted to drive a motor vohicleo In cases of chronic suppurative otitis media where aural vertigo develops parsons Ehould not be permitted to drive any motor vehicle. vJhere a suppurative car condition developJ in a trained and expe:ienced driver, the con- dition shrmld be k:::;?t under observation and the driver removed from driving duties as soon as aural vert.igo develops. Cases of idiopathic lab~inthitis occur which necessitate a temporary cessation of driving chties, but usually after some weeks of recove::r-y from this cond:i..tion;~ dr:i.ving may be resumed. In doubtful cases, where the presence of aural vertigo or labyr:L':lthi~;-J..s is suspected the patient may usefully be refc:::-red to an otologi.s·c, i'ol~ his op:l.niono GENERAL PHYSIQUE 19. Persons selected for cmployrr.ent as drivers of heavy motor vehicles should be of good general physique. The requirements depend to a large extent on the nature of the vehicle concerned and most modern types of vehicle do not require much actual physical strength to :':'lan:.pt:1ate the conJ.:,rols, The shoulders, elbows 1 wri.st.o and finger joint move:::1ents. should be examined and any muscular 1-vasting observed... Fj.xation of a shou2.der joint, if painless, need not be any handicap in driving. Ankylosis of an elbow joint may,. however, be a considerable handicap, and persons with this disability should not be permitted to drive heavy motor vehicles in the first in~tance~ Where this disability develops in a trained and experienced driver he may sometimes be permitted to drive, provided that the angle of fixation is suitable, i.e. around 135° and midway betw8on pronation and supination., New applicant-s for driving ehould have full pronation and supination movements and a good range of flexj_on and extor.sion of the wrist joints. Ankylosis 111]HO/ Accid.Prev .. /1 Rev .1 page 12 of finger joints is usually no barrier to driving, but where one or more fingers are amputated the degree of grip obtainable should be measured in relation to the ability to secure adequate handling of the controls of a motor vehicle. Muscular wasting, if not progressive, need not bar a person from taking up driving, provided there is sufficient strength for manipulation of tho controls. In the case of light motor vehicle drivers, who will usually be examined as patients of the medical practitioner rather than at the request of a vehicle licensing authority, any physical disabilities in the arms should be assessed in relation to the physical requirements of driving a small motor vehicle. If toore is any severe disability, the possibility of using a specially adapted vehicle should be considered, and the driver would be well advised to inform the authorities of his disabilityo In some countries there are arrangements for giving special driving tests to disabled c1rivers .. 21.. Lower limbs Applicants to drive heavy motor vehicles should have free and painless movements of the hips, knees and ankles without severe muscle wasting and with good muscular power in each limb., Persons with a knee joint ankylosed should not be permitted to drive a heavy motor vehicle- Medical examiners should advise drivers of light motor vehicles to declare to the traffic authorities any disability affecting the lower limbs. The degree of disability, where a joint is ankylosed, varies with the position in which the joint is fixed, and it may be possible for the driver to continue driving his car with safety.. The alternative of using a car with specially adapted controls should, however, be considered. For example, cars can be obtained which are fitted with a main braking system which is operated by means of a hand control on the steering column instead of by a foot pedal. 22. Spinal col~ In cases where there is active spinal disease, such as tuberculosis or ankylosing spondylitis, applicants should not be permitted to drive heavy motor vehicles so long as the condition remains activeo When spinal Qiseases of this type become quiescent and provided there is no serious physical disability or deformity, driving of both heavy and light motor vehicles may be permitted with safety. In this connexion it should be remembered that driving is an occupation whiCh requires less physical effort than many manual taskso WHO/Accid.Prev./1 Rov.l page 13 Persons suffering from prolapsed intervertebral disc are usually able to drive a heavy or light motor vehicle, even though they may be encased in a plaster of Paris jacket or fitted with a spinal brace. Such persons, once they have been fitted with the plaster jacket or corset, usually feel more comfortable when driving than they have done for some time previously. In this connexion, the design of the driver's seat is important; the back rest should be low down so as to accommodate comfortably the normal lumbar curvature of the spine, 23. In the above paragraphs on general physique, the disabilities which are likely to be met with are not usually such as to cause a sudden loss of consciousness of the individual concerned while he is driving a motor vehicle. The assessmer/':. of physical disability should rather be based on mechanic~l considerations, that is, whether the disability or deformity is likely to interfere with the efficient and rapid manoeuvring and handling of controls under all driving conditions, including emergency action, for prolonged periods. 24. Disabled drivers Persons with marked physical disabilities, such as amputation of a foot or more than three fingers should not be permitted in the first instance to drive heavy motor ~t;!hicles. 1tJhere there is a definite disability of this kind, trained and experienced drivers may be required to discontinue professional driving, but a careful assessment of the disability in relation to the requirements of driving should be made. For example in France the following provisions are made: Upper extremities - Eliminating factors for candidates for driving licences in the "heavy" category ( 11 C. D. E. 11 licence) are to be as set out hereunder: Any amputation, even unilateral, except of fingers, and these latter on condition tl1at there is normal gripping power between the thumb and the first, second or third finger on one hand, and that the other hand is anatomically and functionally intact, it being understood that the latter will be used to hold the steering-wheel, while gear changes will be made with the former. WHO/Accid.Prev./1 Rev.l page 14· Normal gripping power between the thumb and the first, second or third finger may bo considered as compatible with nrutilations of the thumb and all ten fingers, if three conditions are fulfilled: (1) that the thumb has not been amputated beyond the terminal phalanx, and that the stump is non-painful; (2) that one of the fingers (first, second or third) still has its phalanx and phalnngine intact, with non-painful stump, even if the other fingers have been amputated by metacarpalphalangeal disarticulation; (3) that the grip between the thumb and the finger which still has its phalanx and phalangine is as strong as that between the same finger and thumb of the other hand which is of normal strength. Any permanent lesion of nerves, bones, joints, tendons or muscles, causing diminution of strength or mobility of a member comparable with the lesions mentioned above, is to be considered as an eliminating factor. Upper extr_cmities - Eliminating factors for candidates for driving licences in the 11 light11 category ("A. B. F~ 11 licence) are to be as set out hereunder: Any infirmity or mutilation which prevents the driver from b~ing able at all times to effectively control the steering-wheel either with the normal hand or With a prosthetic hand, is to be c'onsidered as an eliminating factor. Control of the steering-wheel by means of a prosthetic hand shall not be permitted unless the elbow joint is intact. One upper extremity which is intact except for partial amputation of fingers may be considered as compatible on condition that an effective grip can be ·achieved between the hand and the stump of the thumb and the fingers or finger stum.ps (mention "prosthesis" if necessary) • One of the upper extremities must be completely intact. Nevertheless, amputations or infirmities of the fi~gers may be considered as compatible on condition that an effective grip can be achieved with the_aid of a functionally intact thumb .. IVHO/Accid.Prev./1 Rev.l page 15 The articulation of the elbow of the mutilated member must be intact. (Mention "E.rosthe.~s" if necessary.) Arry lesion in a limb which makes driving uncertain shall be considered as an eliminating factoro Lower extremities - Eliminating factors for candidates for driving licences in the 11heavy11 category ( 11 C. D_. Eo 11 licence) are to be as set out hereunder: Arry amputation, even unilateral, except of toes or forefoot, is to be considered as an elim:i.nating factor. The toa functions may be dispensed with in both foot on condition that the tibio-tarsal joint is fully mobile and of normal strength. Loss of use of the forefoot in the foot used for the clutch Eedal is not ~e considered as an eliminating factor, (T). Any permanent lesion of nerves, bones, joints, tendons or muscles causing a diminution of strGngth or mobility in a limb or part of a limb is to be considered as an eliminating factor, and no compensatory prosthesis may be authorized. The following arc to be eliminating factors: Unilateral or bilateral club feet. Any s~iffness or ankylosis of the knee. Arry stiffness or ankylosis of the hip. Arry shortening of a lower extremity by more than 4 cm. Lower extrcmit~ - Eliminating factors for candidates for driving licences in the "light vehicle" category ( 11 A. B. F." liconce) are to be as set out hereunder. ~mitl of both lower extremities Amputation of both thighs, disarticulation of one hip may be considered compatible on condition that the vehicle is appropriate or specially arranged so that the driver, sit~~-~n a normal_Eosition, can effect the manoeuvres normally done by the feet without being at arry moment obliged to remove control from the steering-wheel~ WHO/Accid.Prev~/1 Rev~l page 16 In the case of foreleg amputa:::.ions, prosthetic appliances may be used to perform the functions of the missing limb, under the same conditions. Disarticulation of both hips·' thigh amputations and knee disarticulations are to be considered as eliminating factors. Candidates who have had both forelegs amputated but who have still the two knee joints intact so that they can use ~e~ may be considered as eligible for driving a specially arranged motor cycleo (Mention in this case: ~~-~~J..aD.;z_§:_!2'a"nged vehicle and prosthesis".) Candidates who hc:vo undergone d:!.sarticulation of one hip, amputation of one thigh, disarticulation cf one knee may be considered as eligible on condition that they can sit normallyo Amputation of ono foreleg (and lower) is to be considered as compatible. (Mentio::: 11 ~'?_p.£l_2,i.al~;z:_-~~anged veh~clc and prosthesis".) Dis.:trticulation of one hip is to be considered as an eliminating factoro Amputation of one thigh, one knee, one foreleg and lower is to be considered as compatible on condition that a prosthetic appliance is worn ensuring adequate bilateral functioning. Any lesion which h:L1ders the functioning of one or of both lower extremities and makes driving uncerGain is to be considered as an eliminating factor. Bilateral club feet and unilateral club foot on the side of the accelerator pedal are to be considered as eliminating factors unless the tibio-tarsal articulation remains intact If such a~ticula-:.ion is intact, the handicaps in question are not to be considered as eliminating fa~tors, <md there should be mention of 11.§1?.~2-_a~ ~~~~Y.~~-i_c}.;~n. WHO/Accid.Prev./1 Rev.l page 17 A club foot on the opposite side from the accelerator pedal is not to be considered as an eliminating factor. Stiffness or ankylosis of a knee is to be considered as compatible on condition that the driver's seat is placed farther back or raised ~'Specially arranged vehicle"). Stiffness of a hip is to be considered as an eliminating factor unless the driver can sit. In this case, the driving seat must be specially arranged and the levers strengthened, (Mention: "Specially arranged vehicle".) Shortening of a lower extremity may be compensated by raising of pedals o~ by the wearing of prosthetic boots~ (Mention: "Specially arranged vehicle and prosthesis".) Total loss of use of one upper and one lower extremity, wl;L~ther ~otl;L o"n the same side or on opposite sides, is to be consiPe~ed as an eliminating factor. In some countries light motor vehicles are available which can be specially adapted to suit the requirements of a disabled driver. For example, a car operated entirely by hand controls is suitable for paraplegic drivers. In cases of doubt the vehicle licensing authority is somctim?s able to arrange for a practical test of a person's driving abilities to be undertaken before he is permitted to drive on the road. It should be emphasized that these special arrangements apply only to "iight motor vehicle drivers and that driving of heavy motor vehicles should not be permitted if the drivers suffer from such disabilities. Light motor vehicle drivers who are disabled should be required to obtain an annual licence to drive, in order that their case may be kept· under observation by the licensing authority. Before the first driving licence is issued to any person, he should be required to give particulars of any physical defect from which he is suffering. The responsibility for these arrangements rests mainly with the licensing authority concerned, but the medical practitioner is sometimes asked to advise in individual cases of difficulty and doubt as to whether a person is physically fit to drive. WHO/Accid.Prev./1 Rev.l page 18 CARDIOVASCULl'.R CONDITIONS 25. Method of examination An adequate and careful clinical examination is neccssa~ as a routine in assessing the fitness of parsons for driving different types of motor vehicles. In examining the cardiovascular system it is useful to proceed in the following order: etiology and prognosis, venous congestion, cardiac enlargement, cardiac valves, rhythm, presence of active infection and condition of blood vessels. The only indication of the presence of certain conditions such as coronary heart disease may, in some cases, be the medical history. In a few cases where special examination is required and there is doubt as to the pr3sence or absence of organic heart disease, an electro- cardiogram or orthodiagraphic radiograph may be taken and the case referred~acardiuw~. The blood pressuroShould be measured with a mere~ sphygmomanometer which should be overhauled from time to time. 26. Etiology and prognosis The prognosis of many organic heart lesions varies according to their etiology and an assessment of fitness for driving should include consideration of this factor. The age of the patient and the duration for which the cardiac lesion has been present will also have an important bearing in assessing fitness to c ontinuc driving and the need for periodic medical examination at stated intervals. 27. Venous congestion Where there are signs of early congestive c2rdiac failure, such as ~spnoea, congestion of the lung bases, oedema, or rise in venous blood level above the manubrio- sternal angle when the patient is lying down, driving of heavy motor vehicles should not be permitted in view of the risk of rapid collapse. With minor degrees of early congestive cardiac failure, patients may be allowed to drive private· cars, but if driving is to be continued, the condition should be kept under·regular medical observation from the point of view of safety as well as of the treatment of the patient himself. 28. Cardiac enlargement WHO/Accid.Prev./1 Rev.l page 19 Persons should not be permitted to drive heavy motor vehicles if there is significant enlargement of the heart. Dependent on the cause and degree of the enlargementJ those who are already employed may continue to drive under periodic observation, provided the general condition is otherwise satisfactory. Drivers of light motor vehicles who have significant cardiac enlargement should be kept under regular observation from the point of view of safety in drivingJ as well as !or treatment of the condition itself. 11Safe driving" in this connexion implies that there is unlikely to be any sudden loss of consciousness, faintness or weak- ness which would render the driver incapable of remaining in control of his vehicle. 29. Valvular disease Although in many cases the presence of valvular heart disease is compatible with a normal duration o£ life, or nearly so, applicants with significant valvular heart disease should not be permitted to drive any motor vehicle unless certified as physically fit to do so by a physician. Particularly is this the case where there are no arrangements for periodic medical examinations 1 and the development of such conditions as auricular fibrillation with the risk of sudden embolism, may be unnoticed. In cases of aortic valvular disease there is an increased liability to attacks of loss of consciousness, and persons with this condition should not be permitted to drive a heavy motor vehicle. Drivers of light motor vehicles should be advised that they are fit t.o continue driving, provided that the valvular condition is well compensated and that they are otherwisG medically fit. Such patients should be kept under occasional observation at intervals dapending on the severity of the lesion. 30. Rhythm Persons suffering .t'rom organic disturbances of rhythm, such as auricular fibrillation and flutter, should not be permitted to drive heavy motor vehicles; this applies also to patients who experience definite attacks of paroxysmal tachycardia. Functional disturbance o£ rhythm, such as sinus arrhythmia, and extra-systoles if WHO/Accid.Prev./1. Rev.l page 20 unaccompanied b,y other evidence of disease, need not be a barrier to driving any type of motor vehicle. Patients who are drivers of light motor vehicles and who are suffering from auricular fibrillation or othe~ serious disturbance of rhythm should be kept under regular observation from the point of view of safety in driving, in addition to that of medical treatment, and should be advised not to drive if congestive cardiac failure or embolism occurs. The presence of partial or complete heart block or bradycardia below 40 per minute renders a person unfit to drive any motor vehicle. 31. Infection A patient suffering from active bacterial infection of the cardiac valves should ' be under treatment and should not drive motor vehicles, at least temporarily. When the infection has subsided, driving may be permitted in the absence of any condition which is likely to cause a sudden loss of consciousness or of control of the vehicle; valvular disease usually persists after the infection and should be assessed in relation to driving in accordance with the recommendations given in paragraph 29 above. 3~.. Raised blood pressure Persons suffering from definite malignant hypertension should not be permitted to drive motor vehicles. vlliere there is severe essential hypertension, with a systolic pressure persistently over 200 mm mercury, or a diastolic pressure per- sistently above lOO mm mercury, driving of a heavy motor vehicle should not be permitted. With lessor degrees of hypertension, periodic examination at regular intervals of six or twelve months should be required, according to the severity of the case. Care should be taken at these examinations to avoid inducing a neurosis; they have the advantage in many cases of giving the professional driver ample time in which to seek alternative employnEnt. Driving of heavY motor vehicles is also not recommended in the first instance for· those whose systolic pressure in mm of mercury is much more than lOO plus the applicant's age in years, or the diastolic pressure is over lOO mm mercury; these figures having been found to persist at repeated examinations. It was found in a survey of 22,000 officers of the United WHO/Accid.Prev./1 Rev.l page 21 States Army that transient hypertension or transient tachycardia or overweight 1 each by itself, increased the probability o! the later development of sustained hyper- tension and of retireJWnt or death with cardiovascular-renal disease. The presence of two of these conditions was of greater importance in these respects than of any one alone. The presence of all three was a circumstance of major prognostic importance. (Hillm.an et al., 1944-4?) The effect of hypotensive drugs should be carefully assessed; some patients develop symptoms of vertigo or transient faintness when the hypertension is lowered by means of drugs of this group. Drivers of heavy motor vehicles should not be permitted to drive when they are receiving these drugs and drivers of light motor vehicles should be advised to discontinue driving when there is considered to be any danger from the lowering of arterial tension due to hypotensive drugs. Applicants known to take these drugs habitually should not be permitted to drive any motor vehicle. 33. wwered blood pressure Persons suffering from hy'Iot·ension arc liable to sudden attacks of giddiness 1 faintness or loss of consciousness. Persons who have shown the se symptoms should not be permitted to drive a motor. vehicle. An individual of 30 years of age or over who has a systolic pressure persistently less than 110 mm marcury should not be permitted to drive a heavy motor vehicle in the first instance. In cases where hypotensive symptoms have developed or the systolic pressure is persistently less than lOO mm mercury, drivers of these types of vehicles should not be permitted to continue driving. DrivGrs of light motor vehicles should be advised to disc~ntinue driving where the systolic pressure is persistently less than 100 mm mercury or symptoms develop and there appears to be a definite risk of attacks of faintness. The arbitrary standard of lOO mm mercury should be interpreted with care as there are some small individuals, usually weighing less than 50 kg (110 lb) whose blood pressure at repeated tests, is bPlow this level without apparently producing any adverse effects. 'vJHO/ Accid.Prev ./1 Rev .1 page 22 · 34. Coronary artery disease, including angina pectoris Persons with a history of coronary thrombosis, coronary insufficiency, or angina pectoris should not be permitted to drive heavy motor vehicles. After one definite attack of coronary thrombosis it is probably wiser for drivers of these types of vehicles to discontinue driving owing to the liability of further attacks which may develop without adequate warning. Drivers of light motor vehicles should be advised, if ther~ is apparent complete recovery with no persistent signs such as lowered blood pressure, that they may continue driving, but such persons should be kept under rcgul~r observation. Drivers of light motor vehicles suffering from angina pectoris should be advised not to drive when the attacks are severe or frequent, and particularly when they are brought on by emotion. Where the anginal attacks are caused through exertion only it is usually safe for a driver of a light motor vehicle to continue driving until the attacks become frequent or disabling; he should be kept under regular observation. 35. Other cardiovascular conditions Cases of other organic heart diseases should be judged according to the possibility of a sudden collapse occurring without sufficient warning to apply the brakes and steer the motor ve~icle to a saf~ stop. Particularly in professional drivers, the possibility of increased fatigue - such as occurs in mitral incompetence - resulting in an increased risk of accident should be borne in mind. Where any organic heart disease, congenital or acquired, is present, a person should not be permitted to drive a heavy motor vehicle in the first instance. However, those suffering from congenital stenosis of the aorta and who have been successfully operated upon may be granted a driving licence provided they submit to a periodic medical examination. Where a symptomless congenital defect which is fully compensated is found in a driver who is already employed he may be permitted to continue driving subject to periodic examination. rriving of heavy motor vehicles should not be permitted in cases of aneurysm of the aorta4 Drivers of light motor vehicles may be advised to continue driving unless the aneurysm.is a large one or complications are present which increase the risk of collapse. WHO/Accid.Prev./1 Rev.l page 23 Cases of intermittent claudication are not likely to be so severe as to cause attacks to occur when driving even in a long application of the brakes, and it is not usually necessary to take drivers off their normal duties in the early stages of this disease, but regular observation should be undertaken and in severe cases, or where gangrene has occurred, it may no longer be possible for a driver to continue the safe operation of a motor vehicle. Cases of vaso-vagal fainting attacks should be considered on their merits; th~ are unlikely to occur in the sitting position and there may be sufficient warning to allow the driver mo experiences such an attack to take action. Nevertheless, if attacks occur frequently or without warning or are severe, a driver should not be permitted to continue driving heavy motor vehicles. In all cases, the examining practitioner should advise his patient on the side of safety, and this may necessitate advising drivers of light motor vehicles to discontinue driving if the attacks persist. 36. Varicose veins Even if severe, varicose veins are not likely to cause danger in driving, although they may affect a professional driver's efficiency and his regular attendance at work. Haemorrhoids are sometimes considered to occur more frequently in drivers and this may possibly arise from the sedentary nature of their occupation and a tendency to constipation which may result from irregular hours of duty and habits. It is not usually necessary to exclude such a person from driving any type of motor vehicle unless there is pain or there has been sufficient haemmorrhage to cause a severe degree of anaemia. DISORDERS OF THE ENDOCRINE SYSTEM 37. ThYEoid gland If there is any evidence of thyrotoxicosis or a toxic adenoma of the.~hyroid is present, a person should not be permitted to drive a heavy motor vehicle. So far as men already engaged on this work are concerned, regular observation should WHO/AccidePrev./1 Rev.l page 24 be maintained in mild cases and if the signs of tremor, tachycardia or exophthalmos become well marked they should not be permitted to continue driving this type of motor vehicle. Emotional disturbances commonly occur in this disease, and in view of the association of anxiety, or even psychotic symptoms, it is usually advisable to prohibit the driving of heavy motor vehicles in cases where more than minimal signs of hyperthyroidism are present. Under modern treatment the symptoms are frequently controlled, and provided there is no :mm~ed tachycardia or irregular rhythm, tremor, exophthalmos or visual disturbances, emotional or mental changes, the driver may be permitted to continue at work subject to observation at frequent intervals of, say, one to two months. Similar advice should be given to drivers of light motor vehicles, erring on the side of safety, but except in severe cases it will usually be found that sufficient medical or surgical control of this condition can be obtained to enable such persons to continue driving with safety. In severe cases of myxoedema where there is an obvious slowness of reaction time, applicants should not be permitted to drive any motor vehicle. Where this condition is adequately controlled by medication, such a person may continue to drive a light motor vehicle provided he is kept under regular observation and there is no gross slow~<g of the reactions or other symptoms liable to interfere with the safe conduct of a motor vehicle. 38. Diabetes The urine should be tested for sugar in the case of all applicants for work as drivers of heavy motor vehicles, and at all subs0quent medical examinations·while they are employed on this work. In order to avoid substitution, the specimen to be tested should be passed in the presence of the examiner. In the case of persons suffering from diabetes the marks of insulin injections may be seen on the skin and observation for this sign again emphasizes the importance of examining the patient completely undressed. Persons suffering from diabetes, whether treated with insulin or controlled by diet alone, should not be permitted to drive heavy motor vehicles in the first instance. If, on examination, the urine is found.to contain sugar, the examinee should be·referred for a blood sugar estimation if the glycosuria WHO/Accid.Prev./1 Rev.l page 25 has been detected for the first time. vfuere the blood sugar curve is normal and the condition appears to be due to renal glycosuria, the driving of any type of motor vehicle may be permitted. If the diabetic is in receipt of insulin injections there is a risk of hypoglycaemic attacks which may occur without warning; even where small quantities of slow-acting insulin are being administered it is advisable for this reason to remove a driver from the operation of heavy motor vehicles. These occupations involve irregular meals and variable hours of duty and there may be unexpected exertion if the driver is required to change a wheel of the motor vehicle or unload it. Diabetics who are not receiving insulin, such as elder~ diabetics who are treated by means of a special diet only, may continue to drive ' all types of motor vehicles but should be kept under regular medical supervision every six to twelve months. A few individuals suffer from attacks of spontaneous hypoglycaemia which may be associated with other disorders of the endocrine system. Where these attacks produce faintness or actual loss of consciousness, driving should not be permitted. 39. Addison's disease In t,ypical cases with a low systolic blood pressure (see paragraph 33) applicants should not. be permitted to drive a motor vehicle. 40. Other endocrine diseases Cases of pituitary or parathyroid disease must be judged on their individual merits as to whether there is any disturbance of the central co-ordinating and locomotor functions which is liable to interfere· with the safe driving of a motor vehicle. It should be remembered also that cases of pituitary enlargement may produce hemianopia caused by pressure on the optic chiasma or similar restriction of the visual fields~ Cases of diabetes insipidus should not be permitted to drive a motor vehicle. WHO/Accid.Prev./1 Rev.l page 26 CENTRAL NERVOUS SYSTEM 41. Epilepsy A person with a history of any form of epilepsy should not be permitted to drive a motor vehicle. 42. Diseases of the brain In cases of senile dementia, where the condition is sufficiently evident to be diagnosed with certainty, the applicant should not be permitted to drive a motor vehicle. Where dementia paralytica (general paralysis of the insane) is diagnosed, the driving of heavy motor vehicles should not be permitted; the driving of light motor vehicles should only be allowed if there is an apparently good response to treatment witl1 absence of mental or locomotor signs, and the patient should be kept under regular observation. Cases where cerebral thrombosis has occurred may present difficulty, but if there has been a complete recovery with little or no remaining signs of disability and no other signs of organic disease are present, such a person may be advised that 1 t is safe to continue driving light motor vehicles but he should remain under periodic observation. Driving of heavy motor vehicles should not be permitted if there has been a cerebral thrombosis or cerebral haemorrhage, including sub-arachnoid haemorrhage. If there is evidence of the sequelae of encephalitis, such as rigidity of the arms or legs, or loss of emotional control, of sufficient degree for the diagnosis to be made with certainty, the applicant should not be permitted to drive a motor vehicle. The operation of pre-frontal or transorbital leucotomy (or lobotomy) does not usually of itself render a person unsafe to drive a motor vehicle, but it should be remembered that rather more than 10 per cent. of these patients have epileptic fits after operation. The underlying condition for which the leucotomy was performed, WI10/Accid.Prev./l Rcv.l page 2.? and the effect of the operation upon it should bG assessed in relation to the responsibility of driving.. In general, persons should not be permitted to drive heavy motor vehicles if they have been subjected to this operatlon and it will usually be found advisable to remove experienced c~ivers who have had leucotomy (or lobotomy) operations from drhr:ing this type of motor vehicle~ 43o Diseases of the s~nal ~£rq Persons who have suffered a traumatic lesion with damage to the cord and resulting paraplegia may sometimes drive a light motor vehicle which is fitted vdth specially adapted controls so that driving is undertaken by the use of the hands alone. Driving of heavy motor vehicles should not be permitted. Persons suffering from any degree of certain organic diseases of the spi.nal cord, such as disseminated sclerosis, syringe myelia, amyotrophic lateral sclerosis and tabes dorsalis, should not be permitted to drive in the first instance or continue driving heavy motor vehicles. In some cases trainGd and experienced drivers may continue to drive in the earliest minimal stages of these diseases, but usually, if the condition is severe enough to be definitely diagnosed, it is best in the interests of safety to remove the driver from his duties of driv:l.ng hGavy motor vehicles. Certain of the signs present in theso diseases may be of particular danger in connexion with dri~~ng, such as the an~osthesia of the feet, and loss of proprioceptive position sense in tabes dorsalis; the occurrence of ataxia or apasticity of the leg muscles in disseminated sclerosis may be highly dangerous to a driver. Where definite signs of these diseases are present, especially with loss of muscular co-ordination, the driving of any motor vehicle should not be permitted. Where conditiona such as progressive muscular atrop\y and congenital myotonic disorders are sufficiently severe as to be diagnosed with certainty, such persons should not be permitted to d~ive in the fi~st instance or continue driving heavy motor vehicles~ Light motor vehicle drivers should be advised against driving if the condition is suf.ficien tly severe as to interfere with the muscular co-ordination necessary fo~ thB safe handling of the motor vehicle. WHO/Accid.Prev./1 Rev.l page 28 Migraine is not a barrier to driving any type of motor vehicle. Trigeminal neuralgia and various forms of tics do not normally prevent a person from driving any type of motor vehicle. Persons suffering from myasthenia gravis should not drive heavy motor vehicles; except in mild cases it is advisable for sufferers from this condition not to drive light motor vehicles, but cases which respond well to medication may sometimes drive if they avoid doine so for long distances and are kept under regular and frequent observationA Affections of the peripheral nervous system, such as neuritis if palsy of individual nerves should be judged in relation to driving motor vehicles on the degree of impairment of function caused by the lesion. If there is any possibility of progression of the condition the patient should be kept under frequent observation. Minor degrees of these conditions should not prevent a trained and experienced driver from continuing to operate heavy motor vehicles. Applicants suffering from significant peripheral nerve lesions should not be permitted to drive heavy motor vehicles in the first instance. Where there is traumatic severance of individual nerves, the degree of resulting disability should be assessed in relation to the ability to manipulate the controls of a motor vehicle for long periods. 45. Psychosis Where there is a definite diagnosis of psychosis by a psychiatrist, whether schizophrenia, manic-depressive, paranoia, involutional melancholia, or mixed types, such persons should not drive any motor vehicle. If there is a history of any one of these conditions, or if the applicant has ever received in-patient at a mental hospital, he should not be permitted to drive heavy motor vehicles. In such cases it is necessary to b0ar in mind the modern tendency towards voluntary admission to a mental hospital for treatment of psycho-neurotic disorders where the symptoms are not of such severe or lasting degree as to prevent the sufferer permanently from driving a motor vehicle, even in a professional capacity. When a definite diagnosis of psychosis has been made a driving licence should only be issued upon certification of fitness by a psychiatrist. WHO/Accid.Prev./1 Rev.l page 29 Mental defectives are not usually able to concentrate their attention for long periods and are therefore unsuitable for driving motor vehicles. It may be difficult to recognize the high-grade mental defective, but the previous employment history may give a useful indication of the applicant's capacities. It is sometimes stated that persons suffering from a degree of mental deficiency which is not too severe are likely to make good drivers, but this ignores the fact that such persons usually suffer from impai~ed concentration over long periods and a lack of responsibility. Wbere 1 therefore, mental defect is recognized, even if of minor degree, permission to drive heavy motor vehicles is not recommended. Low-grade mental defectivesshould not be permitted to drive any motor vehicle. Illiterates llbo cannot read but who are not mentally defective should not be disqualified from driving. 46. Psycho-ne'¥'~ This is one of the most difficult fields in whiCh the medical examiner may be called upon to express his opinionA Minor degrees of emotional disturbances are probably frequently associated with accidents; they also frequently occur in "normal" people. Where there is a history of anxiety state or other definite emotional breakdown occurring, for example, during military service, it is probably wiser not to permit the applicant to drive heavy motor vehicles, even though a complete recovery may appear to have taken place. A loss of confidence in driving is a not infrequent occurrence among men who have been driving motor vehicles for many years, and it is important in the prevention of accidents that there should be no hesitation in removing such drivers temporarily or permanently from their driving duties. Drivers suffering from these conditions sore times complain of quite irrelevant symptoms .such as pain in a knee or foot and when no signs are found on examination it becomes clear that such a person is really suffering from a loss of confidence. The usual symptoms of insomnia, inability to concentrate, depression and unreasoned fears tend usually to be present in varying degrees also, and such cases usually benefit from being placed for a period of six or twelve months on work which does not involve driving a motor vehicle. Persons who have suffered at any time from conversion hysteria should not be permitted to drive heavy motor vehicles. WHO/Accid.Prev./1 Rev.l page 30 PSYCHOLOGY OF DRIVING AND PSYCHO-PHYSICAL APTITUDE TESTS IN THE SELECTION OF DRIVERS 474 Most accidents are believed to be due to human faults, that is to say, care- lessness, inattention and wandering concentration. The mental aspects of the task of driving - and upon the skill of the driver rests many lives • involve (a) concentratior of the visual (and to a lesser extent auditory) processes, it may be for many hours at a time; (b) concentration of the mental processes so as to maintain a close link with visual and auditory perceptive mechanisms; and (c) resistance to distraction. No really satisfactory tests of these processes have yet been devised and applied on a large scaleA There may also be a difference in the driving skill of different personality types, but no investigation has yet been undertaken of the relationship between personality type and accident rate. The value of psycho-physical aptitude tests in the selection of drivers has not yet been proved and no such tests are recommended for routine use. DISEASES OF THE BLOOD 48. Blood diseases are generally not considered likely to interfere with the safe performance of driving duties unless there is present a severe degree of anaemia which may induce faintness. In cases of severe anaemia a licence to drive a motor vehicle should not be granted. Howev~r, even minor degrees of anaemia are characterized b.Y increased fatigue which is an important factor in driving and may lead to slow reactions of the driver towards the end of his working day. If, therefore, the symptoms and signs suggest that an applicant for a driving licence is suffering from anaemia, a blood haemoglobin estimation should be carried out and the applicant should be rejected, pending the result of investigation and treatment. In the case of trained and experienced drivers of heavy motor vehicles it is not usually necessary to advise exclusion from work unless the haemoglobin falls to less than about 60-70 per cent.; investigation and treatment often results in a rapid improvement and return to duty. Where the condition is likely to recur, regular periodic medical examinations should be advised, WHO/Accid."Prev./1 Rev.l page 31 Leukaemia and other blood dyscrasias should be judged on their individual merits as regards the person's fitness to drive, bearing in mind the tendency to fatigue and associated anaemia, fatigue in the latter part of the day's work being a potentially dangerous hazard in the occupation of driving. Persons suffering from blood disorders of this type should not be engaged for driving heavy motor vehicles in the first instance. Those who are already driving professionally may be permitted to continue driving if the condition is not or· severe degree and fatigue and other danger symptoms .and signs are absent. If there is a history or. evidence of haemophilia the applica~t should not be permitted to drive heavy motor vehicles. DISEASES OF THE SKIN 49. Most skin diseases are not likely to interfere with the safe handling of a motor vehicle, but in certain cases where the skin is inelastic, thickened or scarred, movetoonts of the limbs may be restricted. There is a close development~l connexion between the skin and th·e central nervous system and certain skin diseases tend to be associated with neuroses and psychopathic personalities of various forms. Th8 existence of a skin disease,· such as some cases of severe seborrhoeic dermatitis may suggest the presence of a neuroti~ condition which renders an applicant unfit for engagement as a heavy motor vehicle driver in the first instance. It is not generally necessary to advise the removal of a driver from driving duties on account of these conditions. vJhere a person 1 s skin is sensitized to oil and grease, or there is a history of industrial dermatitis due to these materials, he should not be employed as a heavy motor vehicle driver if the nature of his duties involves contact with these substances; thus, in some unde:t'takings the driver may have mechanical duties to perform whereas in ot~ers he would rarely, if ever, come into contact with oil and grease. DISEASES OF THE RESPIRATORY SYSTEM 50. Inactive pulmonary tuberculosis does not make a person unfit for safe driving but a careful assessment of such a person's condition is n~cessary in relation to WHO/Accid.Prev./1 Rev.l page 32 the particular duties of his work as a driver. Driving is a sedentary occupation in which there are few contacts with other people for a large part of the day, and the work is therefore theoretically suitable for many cases of tuberculosis, as the risk of spreading infection is less than in many occupations. But generally it is not recommended that those who have active tuberculosis of the lungs and those who have recently suffered from tuberculosis of the lungs should be permitted to drive heavy motor vehicles in the first instance. Treatment by means of a small pneumo-thorax is not 1 in itself, a barrier to driving a light motor vehicle nor is a thoracoplasty operation. The risk of the driver collapsing at the wheel is negligible in most cases, but fatigue towards the end of the day is common and may result in an increased risk of accident. Where a trained and experienced driver wishes to return to work after an absence due to pulmonary tuberculosis, his case should be carefully reviewed from all the aspects mentioned. In such cases the driver should be required to attend for medical examination at regular intervals of three to six months at first. Whenever possible a chest X-ray should be made. Persons who have signs of severe chronic bronchitis should not be permitted to drive heavy motor vehicles in the first instance. DISEASES OF THE GASTRO-INTESTINAL SYSTEM 51. It is commonly supposed that motor vehicle drivers and other transport workers suffer from peptic ulcers with gr~ater frequency and severity than workers in most other occupations. This suggestion was made, for example, at an enquiry into the health of London Central Busmen in 1937 (Ministry of Labour, 1939). An investigation into the sickness experience of London Transport workers with special reference to digestive disturbances was carried out by Bradford Hill (1937), but this enquiry was not able to show with certainty whether there was any difference in the sickness experience of transport workers as regards gastric conditions. Although the evidence was therefore inconclusive, the opinion has persisted that transport workers suffer from an excess of gastric sickness. A recent investigation by the Medical WHO/Accid.Prev./1 Rev.l page 33. Research Council, however, (Doll & Avery Jones, 1951) showed that drivers and other transport workers do not, in fact, suffer fram any excess of peptic ulceration; care was taken in this investigation to include an adequate nUDber of transport workers and it w~s found that their incidence of peptic uloer~t~tn was the same as the average for all types of workers - that is, transport workers had no excess of ulceration nor did they suffer any less frequently from this condition. Persons who have a history of peptic ulceration, ulcer-type pain, or any severe dyspepsia should not be permitted in the first instance to drive heavy motor vehicles, on account of the shift work, long hours and irregular meals which are sometimes · unavoidable in this occupation. A person Who has had a partial gastrectomy operation for duodenal ulcer may, however, be engaged for this work if he has been free from symptoms for a year or more. Those who are already trained and experienced drivers are sometimes able to continue at work if care is paid to diet and medication, but . the driver's own condition, rather than considerations of safety, often necessitate his transfer to alternative employment with r~gular hours of duty. A history of duodenal ulcer or of some types of functional dyspepsia may be associated with a tense anxious personality, and these two conditions together may render an applicant unsuitable to drive heavy motor vehicles. While acute gastro- intestinal conditions may render the patient temporarily unfit to drive, other chronic conditions sho~ld be judged in relation to driving, according to the criteria of ability to handle the controls, liability to collapse, and the possibility of the disease resulting in increased fatigue (see paragraph 8). 52. Hernia In driving the heavier types of motor vehicles, particularly the older types, the eontrols of which require more physical effort for their manipulation, a rise of intra-abdominal tension occurs whenever force is exerted. This rise of tension is small and unlikely to contribute to the production of an abdominal hernia, but where a hernia already exists, it is theoretically possible that some increase in size may occur in this way. For this reason, applicants for a driving lic~nce should be encouraged to have operative treatment for any hernia which is present; in cases \.J'HO/Accid.Prev./1 Rev.l page 34 in which operation is contra-indicated, or refused, a satisfactory truss should be obtained. This appliance should be inspected to ensure that the hernia is adequately controlled. A large or irreducible hernia is a contra-indication to the issue of a permit to drive heavy motor vehicles. ACUTE INFECTIOUS DISEASES 53. Sufferers from most acute infectious diseases are generally unfit for work temporarily and the~r own condition prevents them from driving a motor vehicle; they should not be issued with a driving licence until they have recovered. VENEREAL DISEASES 54. When an applicant is found to suffer from an acute attack of one of the venereal diseases it is advisable to recommend temporary deferment until he has been placed under satisfactory treatment~ There is generally no reason, from the safety point of view, why drivers of heavy motor vehicles should not aontinue to drive when suffering from these conditions but they should be kept under observation in order to cmsure that adequate treatment haS been carried out. These conditions will generally be viewed from the angle of treatment of the patient and the possibility of infecting others, but late sequelae, such as tabo-paresis, may be dangerous conditions in a driver, and any case where such a condition may develop should be kept under regular observation. A definite diagnosis of tabes dorsalis or dementia paralytica should exclude any sufferer from driving a motor vehicle (see paragraphs 42 and 43). DISEASES OF THE GENITO-URINARY SYSTEN 55. Diseases of the urinary tract are not commonly associated with any lack of safety in driving a motor vehicle, but the possibility of chronic infection, resulting in undue fatigue, or of uraemia, should be conside~.ed, Vesical calculi, enlarged prostate, or urinary infections may result in frequency of micturition with consequent interference with the efficient ~~d safe driving of a heavy motor WHO/Accid.Prev./1 Rcv.l page 35 vehicle, and sufferers from these conditions should not be permitted to drive these types of motor vehicles in the first instance. Those who are already employed as drivers should be kept under observation at regular intervals if any of these conditions develop. The urine should be tested for sugar (see paragraph 38) and albumen whenever an applicant for driving heavy motor vehicles is medically examined and at all subseqoont exal'llinntions of employed drivers. If albumen is present at repeated examinations, the applicant should be referred to hospital for ~vestiga,tion of the cause; but care should be taken to exclude orthostatic albuminuria, which is of no significance and is more common in younger men, by the examination of an early morning specimen or a specimen passed after lying down for two or three hours. Such speCimens are free from albumen in cases· of orthostatis albuminuria. ALCOHOL AND DRUGS 56. Medical practitioners are sometimes asked to complete medical certificates showing whether an. applicant for a motor driving licence exhibits any evidence of addiction to alcohol or drugs. The faeces, gross tremor, water eye, furred tongue, cramps, myalgia and dreams of falling, with a history of morning vomiting or dislike of breakfast of the chronic alcoholic may give sufficient indication that such a person should not be permitted to drive motor vehicles. The effect of alcohol on driving is not considered in this .handbook, but it is quite clear that any effect which alcohol may have on driving is to decreas~ efficiency and enhance the risk of accidents. Professional drivers should be instructed not to consume any alcohol during working hours, and such an instruction will usually be found to be a condition of their employment. Drug addicts should clearly not be allowed to drive heavy motor vehicles, but evidence of the existence of this condition may be difficult to detect in ear~ cases; enquiry as t~ any medica.nents consumed by the applicant for a driving licence may reveal that regular doses of phenobarbitone or other drugs are being taken and this again may suggest further enquiry in regard to the histor.y of epileptic conditions. WHO/Acdid.Prev./1 Rev.l page 36 Persons who take coffee in excess and who regularly take certain stimulat:ing drugs should not be permitted to drive motor vehicles. Persons who take regular or frequent doses of sedative drugs for any purpose in other than minimal quantities are well advised not to drive, and should not be permitted to dFive heavy motor vehicles. The effect of the antihistaminic drugs is to cause drowsiness in some people and occasionally a sense of euphoria which may lead to irresponsibility in a driver. This should be well appreciated by the medical practitioner, particularly in advising patients 'Who are professional drivers and who may be issued with considerable quantities of these drugs for the treatment of such conditions as hay fever and allergic rhinitis. 57. It is advisable for medical practitioners to be always on the alert in prescribing sedative or hypnotic drugs, antihistaminics or other medicines which may affect the responsible control of a motor vehicle for those of their patients who are drivers. 58. Permissible hours of driving If a physician is called upon to advise upon maximum hours of driving, reference . may be made to the agreed suggestions adopted for guidance by the Inland Transport Committee of the International Labour Organisation. According to these, the driver of a heavy motor vehicle should have a break of at least half an hour between the fourth and the sixth hour of driving. The total driving hours should not exceed ten in every period of 24 hours. Every driver should, as a rule, have an average rest period of not less than 11 hours, which may, in certain cases, be reduced to eight hours •1 PERIODICAL MEDICAL EXAMINATIONS 5~. In some countries the renewal of a licence to drive a passenger transport vehicle is required at intervals prescribed by the transport authorities. 1 Memorandum No. 51 concerning conditions of employm:mt in road transport in International Labour Office, Official Bulletin Vol. XXXVII, No. 2, page 33 WHO/Accid.Prev./1 Rav.l page 37 Drivers of heavy motor vehicles should be medically examined at intervals of three years after the age of 40 and annually after the age of 6o. These examinations may be required, for example, on rasumption of duty after illness lasting more than three or four weeks, or after accidents which prevent the driver working for three days or more, or in any case where the supervisor considers that the driver should be medically examined in the interests of safety. The eyesight of professional drivers should be examined every five years. It is also necessary to examine drivers who suffer from or who have been certified as suffering from, vertigo, fainting, epilepsy, or heart disease, or indeed any condition which is likely to affect the driver's appreciation of danger, to cloud his judgment or to render him suddenly unconscious; examinations in these cases should be undertaken whether the driver has been absent from work or not. Following an important illness or a serious accident a medical examination should be required before a driver is permitted to return to work. OUTLINE SCHEME FOR ROUTINE MEDICAL AND EYESIGHT EXAMINATION OF DRIVERS 60~ Most medical practitioners 'Who examine large numbers of applicants for motor vehicle driving licences or who conduct other examinations of drivers find it con- venient to carry out the various procedures required according to a routine. In this way the inadvertent omission of any important part of the medical examination is prevented. The time required to romplete the examination varies greatly, but on an average approximately 15 to 20 minutes may be allowed for each examination. In order to ensure that an adequate examination may be carried out, the examinee should be fully undressed. The following procedure is suggested: (a) It is important to take an adequate medical history. The applicant should complete a form containing as a minimum the following questions: Have you ever suff£red from the following? (1) Fainting attacks; epileptic fits, 11blackouts 11 or 11nerves11 (2) Heart disease or disorder WHO/Accid.Prev./1 Rev.l page 38 (3) Tuberculosis (4) Asthma or chronic bronchitis (5) Nervous or mental disorders (6) Skin diseases (7) Rupture. If 11 Yes 11 , do you wear a support? (8) Digestive disorders ( 9) Diabetes (10) Rheumatism or joint trouble (11) Any other illness (12) Any accident or injury Have you ever been hospitalized or undergone an operation? particulars and date If so, give Have you ever been rejected or invalided from the Armed Forces or any public service? The answers to these questions provide a guide to a detailed medical history which will be taken if any of ~he answers are unsatisfactory. Evidence of drug taking or other addictions may be obtained from the history, and the medical examination should include observation for any clinical evidence of these conditions. The medical history is always confidential, and the written replies to the above questions and the notes of the medical examination itself should be retained by the medical practitioner. For the same reason applicants should be examined privately and not as a group together. The following routine is suggested for the medical examination itself: (b) Eyesight examination, including pupil reaction to light (paragraphs 9-16). (c) Note any abnormality of the mouth, throat, nose and neck. (d) Standing behind the applicant, test the hearing of each ear separately with conversational and whispered voice; examine the external auditory meatus and drum with aural speculum (paragraphs 17 and 18). WHO/Accid.Prev./l Rev.l page 39 (e) Examine articulations and muscular conditions of upper limbs (paragraph 20), (f) Examine the chest, .front and back; inspection and auscultation of heart and lungs, with X-ray and other special examinations as indicated (paragraph 25 et seq). (g) Measure and record the systolic and diastolic blood pressure (paragraphs 32 and 33). (h) Examine the abdomen; examine for hernia. (i) Test knee and anklo reflexes (paragraph 41 et seq). (j) Examine articulations and muscular conditions of spine and lower limbs, particularly for varicose conditions (paragraph 21 and 22). (k) Romberg test. (1) Test urine for the presence of albumen and sugar (paragraphs JS and 55). The result of these examinations and tests will suggest any further more detailed examinations which need to be carried out. CONCLUSION In the preceding paragraphs an account has been given of the various procedures required in the examination of applicants for motor vehicle driving licences. The essential requirements from the medical point of view for safe driving have been discussed in detail in relation to particular medical conditions. I£ these require- ments are satisfied, an applicant for a motor vehicle driving licence may safely be permitted to drive, so far as medical considerations are concerned. Very large . numbers of accidents are now occurring on the roads in every country, and constant vigilance by medical practitioners will help to reduce the number of accidents if medically unfit drivers and those whose vision is seriously defective are preventod from driving professionally and advised not to drive light motor vehicles. WHO/Accid.Prev./1 Rev.l page 40 The drivers of passenger transport vehicles need to maintain a hi@P standard of physical and mental fitness of which they are justly proud, and the knowledge of this, in turn, promotes the confidence of the travelling public. The maintenance of similar high standards qy drivers of all types of motor vehicles is desirable and should be encouraged by medical practitioners in their day-to-day work with those of their patients who are also drivers. REFERENCES Burger, H. (1937) Ned. T. Geneesk. ~' 4295 WHO/Accid.Prev./1 Rev.l page 41 Doll, R. & Avery Jones, F. (1951) Occupational factors in the aetiology of gastric and duodenal ulcers, Spec. Rep. Ser. med. Res. Coun. (Lond.), No. 276. H.M. Stationery Office, 1951 Dunlop, H. A. (1945) Medical standards of fitness for driving, Practitioner, 154, 201 - Eno Foundation for Highway Traffic Control (1948) Personal characteristics of traffic accident repeaters, p. 51. Cc:'.\.'leC~5.c''lt Fletcher, E. D. (1948) Visual problems in motor vehicle administration. Oklahoma Herschensoh, H. L. (1940) Physical examination of drivers, Hygeia1 ~~ 988 Hill, A. B. (1937) An investigation into the sickness experience of London transport workers, with special reference to digestive disturbances. Medical Research Council I.H.R.B. Report No. 791 H.M. Stationery Office, London Hillman et al. (1944-1947) Studies of blood pressure in Army Officers based on an analysis of the medical records of 22 1 741 Officers of the United States Ar.my, J. Amer. med. Ass., 125, 699; 126, 829j 128, 1059; 129, 585; 131, 951; 135, 77 - - - - - - Kerr, D. J. A. (1953) The health, physical standards and training of motor drivers in relation to road accidents, Edinb. med. J. (Transactions of the Medico- Chirurgica1 Society of Edinburgh) h), 31 Macfarlan, D. (1937) Hearing of automobile drivers, J. med. Soc. N. J. 34, 182 Ministry of Labour. (1939) The health of London Central busmen. H.M. Stationery Office, London 11Rex" (1953) Insurance of deaf motorists. !he Policy Insurance Weeklz. London, 21 May 1953 Selling L. S. (1941) Some problems confronting the physician in the examination of automobile drivers, Ann. intern. Med. 15, 265