Guiding principles in the medical examination of applicants for motor vehicles driving permits: revision 2

~V 0 R L D H E A L T H O~:GANIZATION ORGANISATION MONDIALE DE LA SANTE WHQ/Accid.Prev./1 Rev.2 Corr.2 22 May 1956 ORIGINAL: ENGLISH GUIDlliJG PRINCIPLES IN THE MEDICAL EXAHINATION OF APPLICANTS FOR MorOR VEHICLE DRIVING PEfu~ITS CORR IGENDUM Pages 36, 37, 38, 39 and 40: column 3 of table, first line, replace 11A.B. PERMIT (LIGHT VEHICLES)" by "A.B.F. PERMIT {LIGHI' VEHICLES) 11 Page 36: column 3 of table, at the end of the second paragraph, after parenthesis, insert 11 (Applicable to Permits B and F) 11 column 3 of table, after the words 11 intact thumb11 at the end of the third paragraph, insert 11 (Applicable to Permit A) 11 Page 37: column 3 of table, after 11 Inf:irmity of both lower extremities", insert "(Applicable to Permits B and F)" column 3 of table, after the word 11 factors 11 at the end of the last paragraph, insert "{Applicable to Permit A) 11 Page 38: column 3 of table, after "Infirmity in one lower extremitY:", insert 11 (Applicable to Permits B and F)" column 3 of table, after paragraphs 3 and 4 beginning "Amputation of one leg anywhere , • •" and nnisarticulation of one hip is •• •" respectively, insert 11 (Applicable to Permit A) 11

WORLD HEALTH ORGANIZATION '· ORGANISATION MONDIALE DE LA SANTE f WHO/Acoid.Prev./1 Rev.2 Corr.l 6 Hay 1956 ORIGINAL: ENGLISH GUIDING PRINCIPLES m THE MEDICAL EXAMINATION OF APPL!CANTS FDR MOTOR VEEICLE DRIVING PEIDUTS Page 2: line 8 from the bottom of the pag,e, replace "(1951)" by "(1941)" 11 2: line 9 from the bottom of the page, replace "(1950)" by 11 {1940) 11 tt 7: lines 5 and 7, replace 11 ophthalmologica1U by 11 eye-sight 11 tt 8: lines 5 and 6, delete 11 depthtt n 14: line 5 from the bottom of the page, delete 11 in11 11 22: line 14, insert 11 severe 11 before 11 polioreyelitis 11 11 28: line 6 from the bottom of the page, in parenthesis insert 11 but 11 before 11 see11 " 30: line 5, delete 11well11 lt 31: line 7, insert 11 at least 11 between 11 examined11 and "every" tl 33: line 14, insert 11 driving11 between 11 his 11 and 11 permit 11 tt 35: line 8, replace 11 Herschensoh11 by "Herschensohn11 2:i333

UNITED NATIONS WORLD HEALTH ORGANIZATION NATIONS UNIES ORGANISATION MONDIALE DE LA SANTE WHO/ Accid.Prev ./1 Rev .2 \-· 24 Februar,y 1956 ORIGINAL: ENGLISH GUIDING PRINCIPLES IN THE MEDICAL EXAMINATION OF APPLICANTS FOR MOTOR VEHICLE DRIVING PERMITS The question of the mental and physical fitness of drivers was taken up by the Committee of Experts on the Licensing of Motor Vehicle Drivers, convened in 1952 by the United Nations for the purpose of considering the establishment of minimum uniform regulations for the licensing of drivers of the various categories of motor vehicles.1 The Committee recommended, inter ~ia, the preparation by WHO of a handbook containing rules for the guidance of I!Edical practitioners when making examinations of health, vision and hearing. This document contains guiding principles in the I!Edical examination of applicants for motor vehicle driving permits which have been drawn up by the Consultant Group on Medical Requirements for the Licensing of Motor Vehicle Drivers, convened in Geneva from 29 August to 2 September 1955 by WHO with the participation of UN, ILO and the International Federation of Ophthalmology • . . . INTRODUCTION 1. In view of the large and increasing number of vehicles at present on the roads it is essential, in the interests of safety, to ensure that as far as possible a good standard of physical and mental fitness is maintained in those who drive. Little evidence is available to show the con~exion between accidents and physical or mental defects of drivers, but it mqy be safely assumed that, as most accidents are due to personal failures, a reasonable degree of physical health and mental alertness is desirable among those who have charge of a motor vehicle. Health and physical fitness play a major part in maintaining the skill ' of drivers. When the driver has the added responsibility of the safety of some 1 The recommended uniform regulations have been published in document E/CN .2/1.3.3 Rev .1; lfReport submitted by the Conunittee of Experts on Licensing of Motor Vehicle Drivers to the sixth session of the Transport and Communications Commission" WHO/Accid.Prev./1 Rev.2 page 2 60-70 passengers, the assessment of fitness for driving must be of paramount importance. Similar considerations also app~ to drivers of heavy goods vehicles. Where re dical examinations are required under the regulations of licensing authorities before the issue of a driving permit there is therefore need for great care, both in carrying out the examinations themselves and in reporting on an applicant's fitness to drive, in the interests of the safety of the travelling public. The examination should be undertaken only by qualified nedical practitioners. While the medical standards prescribed for motor vehicle drivers vary considerably between different countries, it is hoped that the general information given in the ensuing paragraphs will be of use to all. This do cumant contains guiding principles for examining physicians who will, of course, need to meet the requirem:mts of the licensing autho~ities in each country but, within the administrative boundaries prescribed by these authorities, the recommendations given herein 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. Although drivers of private cars, motor-cycles, and similar small vehicles are not alw~s medically examined at the request of the authority which issues permits, nevertheless these drivers usual~ come under the care of a general medical practitioner sooner or later. This document therefore provides a useful guide to general practitioners of medicine in advising those of their patients who are drivers on the road, whatever type of vehicle they may drive. A general consideration of the medical stand~rds of fitness for driving is given by Dunlop (1945), Herschensohn (1950), Kerr (1953), Ministere des Travaux Publics, des Transports et du Tourisme, Paris (19J3 and 1954) and Selling (1951). 2. Transport undertakings soretimes request physicians to examine drivers in connexion with their efficiency, for example, to determine whether 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-employment and periodical medical examination of drivers in order to determine their fitness for employment: its purpose is on~ to establish criteria for cases where medical conditions render driving unsafe, and therefon3 oblige the licensing authorities to refuse WHO/Accid.Prev./1 Rev.2 page 3 the granting or renewal of a d::r:..ving permit, with a view to maintaini.,.;:; safety on the roads. 3. In this document, drivers of motor vehicles are generally considered in tt.::~ categories: (a) drivers of light motor vehicles; (b) drivers of heavy motor vehicles. Light motor vehicles include motor vehicles mentioned in the categories A and B ~iven in Annexes 9 and 10 of the Conve~tion on Road Traffic concluded at Geneva, 19 September 1909 which are as follm\'s ~ A. Motor-cycles with or without a side~car, invalid cRr~iages and three- wheeled motor vehicles with an unladen weight not e:Gceeding L:.oo k": (900 ?,b.). 1 B. t-1otor vehicles used for the transport of ;_Jas;:;engers and com~:-.:'ising, in addition to the driver's seat, nt most eight seats, or those used for the transport of goods and having a permissible maximu~ weight not exceeding 3500 kg (7700 lb.). Vehlcles in this category may be coupled with a light trailer. Heavy motor vehicles include those motor vehicles indicated in the categories C, D and E in Annexes 9 and 10 of the Convention on Road Traffic referred to above which are as fo:J.lows; C. Motor vehicles used for the transport of goods and of wnich the permissible ma.xinv..m weight exceeds )5CO kg (7700 lb.). Vehicles in this category may be coupled with a light trailer. D. Motor vehicles used for the transport of pe.ssengers and comprising, in addition to the driver'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 with ot~er tl:e>.n a light trailer. 1 Motor scooter drivers should .• from a ;JhysiologicPj_ poir:t of vic'fl$ be considered as drivers of lig.."lt motor vehicles and therefore bo J.ico;:ceci in the sam<) w-:-·.:r. WHO/Accid.Prev./1 Rev.2 page 4 In general, too madical requirements for heavy motor vehicle dr1 vera, particularly those responsible for passenger transport, should be more strict than those for light motor vehicle drivers, in view of their responsibility for passengers and the fact that the fornBr are usual.:cy on the road for many hours each day. The length or their eJq>osure to accidents is greater than that or light motor vehicle drivers, although the experience and skill of heavy motor . vehicle drivers are usually greater and their accidents therefore less. METH<D OF EXAMrNATION 4. It is important that the JErson to be examined should be completely undressed, 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 t"ests, ophthalmos copic examination (where in4icated) 1 urine tests for sugar and albumen, auriscope examination, and masurement of blood pressure. Special examinations which are occasionally required include the electrocardiogram, chest or other radiograph, blood sugar estimation and electro- encephalogram. 5. Examiners who undertake considerable numbers of these examinations gener~ find it usefUl to carr,y out the examination procedures according to a routine. For example, the eyesight and hearing might be examined first, followed by the cheat, upper limbs, lower limbs, abdomen, blood pressure and urine tests in that order. A fUll account of a suggested routine nethod of ex.amination is given in paragraph 5B. 6. As a general rule, applicants for motor vehicle driving permits should be assessed medicallY according to the following criteria: ( i) Is the applicant physically and mmta.lly able to manipulate the controls and maintain such Wdrk for long periods? (!li) Has the applicant a safe standard of vision and hearing? (id.i) Is there any risk of sudden loss of consciousness while driv:ing? (tv) Is there a likelihood of severe fatigue towards the end of the ~, with eoneequent inorea8ed danger of aooidentt WHO/Accid.Prev./1 Rev.2 page 5 If the answer to these four questions is sa-l:.isfa.Gtory tho applicant may safely be permitted to drive but if the:ro is any d:tsease or dis3.biH.ty p":"esent which may become chronic or progressive b.e s~1o-..::.ld be kept under regular observation or he may be given a permit of which tm va2.idity is especially lirnited. EYESIGHr TESTING .AND STANDARDS 7. The importance of good eyesighJv for d!'ivlilg motor vehicles needs no emphasis • .Although there is no accurate inform3.tion or statistics whieh ral.ate visual acuity to the occurrence of accidents, some information has been coller.ted by the Road Safety Information Centre of the World 'rou:dng and Aut-omobile Assodation, London. Evidence on this question collected in California in 1936 and 1938 revealed that more than half of the motor vehicle dri ve:rs who had been a:rres'!::.ed for 11 cutting in" had one eye with subnormal ac-ait.y. Th9 Californjan enquiry also sho-~Jed that motor vehiC'J.e drivers with accident-free :cec')rcls had better "Vi::::mal acuity than those with bad driving recorcs; in a n~oer of cases jn w~i~h the driver jnvolved had defective v2sion in one eyo, he had collided with a vcl1icle or pedestrian approachjng on the side of his weak eye, T:1ese drivers were UIJ.e,ware that they had any defect of eyesight. .m i...'1vestigatio:'1 of 103 fatal accidents occu:::-ring at road :intersections showed that 71 had involvAd mo•: or vehicle drivers with defective vision in one eye; in 61 of these cases the driver had collided with a vehicle approach:ing on the side of the Heak eye. A useful summary of these f:indings, with discussion of the problems involved, is given by Fletche:r (19~~8). It was also found in an enq"..liry in Michiga:.1 t.h.'lt ac("ident-f:ee motor vehicle drivers were significantly superior to a.ndden+.-repeate:r.s with rogard to ·IJ"isual acuity (Eno Foundation, l94F' , In all cases where the visual acuity is below norrr~ the eyes should be examined for the presence of any oc"..l..lar disease whh:h may have affected the acuity. An insidious deterioration of visio:1. may occu'r.' du:t'ing the progr8ssive evolution of a cataract or another ocular disease, and the drive:r c.once!';.1ed may be unaware that his eyesight is becoming worae; sonBtires also he may porsis·t in driv:ing although he knows that his vision is poo:t•. For t:1e se reasons, 7.est.s of visual functions should be required for all categories of dri ve!'S. WHO/ Aocid.Prev ./1 Rev .2 page 6 Periodic~~y of Efesight Examinations 8. In the interests of safety it is desirable that drivers of heavy motor vehicles should have their eyesight tested at least every six years up to the age ot 65 and then annuaJ..ly for the renewal of their permits. 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 permit, 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 Req'!liremmts of { i) Heavy Motor Vehicle Dri~ 9. Visual acuity The visual acuity of heavy motor vehicle drivers should alw~s be tested by a physician and any cases in which there is doubt as to whether a permit 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: Right eye: 1.0 Right eye: 0.7 left; eye: left; eye: 0.7 l 0.9 etc. 1 For comparative purposes the equivalent standards on different notations are as follows: Decimal American English German Notation Notation Notation Notation 0.1 20/200 6/60 5/50 6/36 (0.17) 5/40 (0.125) 5/30 (0.17) 0.2 20/100 6/30 5/25 20/80 (0.25) 6/24 (0.25) 5/20 ·(0.25} 20/70 (0.28) 0.3 20/60 (0.33) 6/18 (0.33) 5/15 (0.33) 0.4 20/50 0.5 20/40 6/12 5/10 0.6 20/30 (0.66) 6/9 (0.66) 5/?.5 (0.66) 0.7 0.8 20/25 0.9 1.0 20/20 6/6 5/5 - WHO/Accid.Prev./1 Rev.2 1=age ? If the total visual acuity without glasses is less than these requirements it is essential that the driver should always wear glasses when he is driv.ing, and this should be recorded on the driverts permit. In this ease also a spare pair must be carried. In order to detect the development of a cataract, or other disease affecting visual acuity, all persons should te given an ophthalmological examination on first application for a hea~ motor vehicle driving permit; subsequently ophthalmological examination should be carried out if the visual acuity, corrected b,y glasses, is 0.5 or less in either eye. should not be permitted to drive a heav,y motor vehicle. 10. Visual fields One-eyed persons Good lateral vision on both sides is an obvious necessity for safe driving. Occasional oases of severely restricted visual fields occur (tubular vision) and these severe cases should not be permitted to drive any form of motor vehicle. M accurate lll:3asurement 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 therefore not practicable as a routine test by general medical practitioners or for the examination 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 ts eyes in turn and requesting the examinee to look at the examiner t s nose with the open eye. A movement of the fingers at the peripheral edge of the visual field should then be equally detected by both the examiner and the examinee, provided the examiner knows that his own visual fields are normal. Any 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. 11. Colour vision Experience has shown that accurate colour discrimination is UZlilecessary for motor vehicle drivers. No colour vision tests are therefore recommended. WHO/Accid.Prev,/1 Rev.2 page 8 12. St:ra~isiiiUs and diplopia If there is a definite diplopia a drive!'ls permit should not be granted, Applicants with strabismus should be referred to an ophthalmologist for examination. 13. Stereos co:e.:!-.~ ~th percepti.2_n, ocular IIIUS cle balance and night vision Tests of binocular vision, stereoscopic depth perception, ocular muscle balance.and night vision are not essential for the standard eyesight examination of heavy motor vehicle drivers, but these tests may be undertaken by an ophthalmologist in p~rticular cases where doubt has arisen as to visual etticiena,y. 14. All applicant.s should have their visual acuity tested by the non-mdical examiJ.J.er using the Snellen or similar chart method. A total visual aouity of at least 0.8 for both eyes together should be required and with glasses if necessar,y. Those who fail the test should be referred to an ophthalmologist for examination. All one-eyed applic~Dts and those in whom the vision in one eye is less than 0.1 with glasses should be referred to an ophthalmologist for examination and a vision of 0.8 reTI~red in the good eye. EAR CONDITIONS For practical purposes, the hearing of applicants for a motor vehicle driverts permit may be tested by the following method: the examiner stands behind the ap-plicant and co'\.rers each ear jn turn" 'l'he applicant is requested to repeat a se:cies of numbers chosen at rc:rndom which are spoken and then whispered by the ex<un5.ner. In this way the rl"istance at which conversational voice (C. V.) and whispered voice (W.V.) :1-c: l!eard may be recorded for each ear separately. It is sometimes said that this test loses its value because examiners var,y considerablY in the loudness of their vo:1.ce pr·oduction, but this is not quite correct; each ~xam..i.ner develops, with experience of testing large numbers of cases, an acute WHO/Accid.Prev./1 Rev.2 page 9 appreciation of any variation in an applicant 1 s hearing. A similar practical test may be given using the ticki.."'lg of a we.tch as the auditory signal, but in both the watch test and the whispered voice test it is maL~ly the higher frequencies which are under examination. Tests by ruans of an audiometer are not usually carried out as a routine and the:r.·e is no raason for undertaking audiometry tests except in cases with more ti.:.an moderate loss of hearing. There may be considerable variation from dqy to d~ in an individual's degree of deafness and for this reason also a practical test is to be preferred to the more refined audiometry. There are no generally accepted standards of hearing for mo-tor vehicle. drivers and the!'e is a surprising lar.k of infonn:1tion in regard to the safety or otherwise of deaf drivers. Enquiries m3.de of i.Ylsu.~3.Ilce compa:1ies in Great Britain ( 11 Rex" 19 5.3) reYeale d that some companio s do not accept in sur ances .:'rom deaf drivers, but t.he majority adopt the 1·. -~~~co'r.n!:,:-, ~ll:!ne of indicating that each case depends on i ~s :}ndi v::du.al ITEr its. The s a..w paper refers to a scientific study in which the conclusion was roach:Jd thaJc. there was little difference between the acQident-proneness of a deaf person and that of a person with normal hearing; in fact, the inves-tigation showed et elight balance in favour of the deaf. It was concluded that the reason for this is that deaf persons are particularly conscious of their handicap and that they therefore exercise extra care. An interesting discussion on the importance of hearL~g to automobile drivers is given by Macfarlan (19.37) who considers that the deaf are general~ safe drivers; they are cautious and on the alert because they know the risk they are taking. While good hearing is a.~ undoubted assat to a d:'iver, it is by no reans essential. Hearing in some cases may well be mo:.~o acute in the noise of traffic than in a quiet room; it is doubtful whet'.:.,Jr dri"ring safety is materially enhanced by the possession of high degrees of auditory perception such as are required to hear a whispered voice in a still ro~m at a considerable distance. In order to hear overtaking vehicles it is sometimes thought that hearing in the left ear is more important in countries where vehicles are dri".ra:1 on the right side of the road, but the importance of this should not be exaggerated, for whichever side the defect, tmilateral deafDess r0sults in some di.ffi~ulty in the WHO/Accid.Prev./1 Rev.2 page 10 location of sound. It is unlikely that moderate impairment of hearing in a competent and experienced driver will constitute a danger or detract serious~ from his driving ability. Persons who app~ for the first time for a permit to drive heavy motor vehicles should undoubtedly not be permitted to undertake this work i.f 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 the work, or results in an increased frequenqy of accidents. Marked reduction of hearing should be a barrier to driving any motor vehicle. No benefit is to be expected from the use of hearing aids in driving, because of extraneous noises, variability and rne chanical defects which may develop in thu instruments, and the diffioulty in locating the position of a sound. Therefore hearing aids should not be permitted. Where a driver is required to drive at high altitudes it is desirable to ensure that the Eustachean tubes are patent. 16. Vertigo and labyrinthine conditions In eases where there are sudden attacks of vertigo, for example in Meniere ts SyndrmJE with tinnitus, deafness and vertigo, persons should not be permitted to drj ve a motor vehicle. In cases of chronic suppurative otitis mdia where aural vertigo develops suCh persons should not be permitted to drive any motor vehicle. Where a suppurative ear condition develops in a trained and experienced driver, the condition should be kept under observation and the driver removed from driving duties as soon as aural vertigo develops. Cases of idiopathic labyrinthitis occur which necessitate a temporary cessation of driving duties,· but usual~ after some weeks of recovery from this condition, driving may be resumad. In doubt.f'ul cases, where tm p:resence of aural vertigo or labyrinthitis is suspected the pa·.::ient may usefully be referred to an otologist for his opinion. GENERAL PHYSIQUE 17. Applicants for permits as drivers of heavy motor vehicles should be of good general physique. The physical requirements depend to a large extent on the nature of the vehicle concerned; most modern types of vehicle do not require much WHO/Accid.Prev./1 Rev.2 page 11 actual physical strength to manipulate the controls, but the changing of a wheel, the changing of a tyre, turning the ha."ld starter, loading and unloading which may be required in some cases, may suddenly call for a considerable physical effort. lS. ~r limbs The shoulders, elbows, wrists and finger joint movenents should be examined and any muscular wasting observed. Fixation of a shoulder 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 instance. Where this disability develops in a trained and experienced driver he may sometimes be permitted to drive, provided that the ~n~le of fixation is suitable, i.e. around 135° and midway between pronation and supination. New applicants for driving should have full pronation and supination movements and a good range of flexion and extension of the wrist joints. ,i,~-~.cylosis 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 tne ability to secure adequate handling of the controls of a motor vehicle. ~1Scular wasting, if not progressive, need not bar a person from taking up driving, provided there is sufficient strength for manipulation of the controls. In the caoe 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 Qts~bilities in the arll13 should be assessed in relation to the physical requirements of driving a small motor vehicle. If there 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 disability. In some countries there are arrangemnts for giving special driving tests to disabled drivers. 19. Lor.Ner l:Lmbs Applicants to drive heavy motor vehicles should have free and painless movements of the hips, knees and ankles without seVE:re 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 Yehicle. l1edical p::-aditioners should WHO/Accid.Prev./1 Rev.2 page 12 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. 20. S.E,inal colurrm 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 active. When spinal diseases 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 tasks. Persons suffering from prolapsed intervertebral disc are usually able to drive a heav.y 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 previously. In this connexion, the design of the driverls seat is important; the back rest should be low down so as to accommodate comfortably the normal lumbar curvature of the spine. 21. In the above paragraphs on general physique, the disabilities which are likely to be net 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 assessment of physical disability should rather be based on mechanical considerations, that is, whether the disability or deformity is likelY to interfere with the efficient and r~pid manoeu~ring and handling of controls under all driving conditions, including emergency action, for prolonged periods. 22. Disabled drivers WHO/Accid.Prev./1 Rev,2 page 13 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 vehicles. Where there is a definite disability of this kind, trained and experienced drivers may be required to discontinue professional driving, and a careful assessment of the disability in relation to the requirelll'3nts of driving should therefore be made. In France, for example, specific provisions are made in this regard (see Appendix). In sone 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 licensing authority is sometimes able to arrange for a practical test of a personts driving abilities to be tmdertaken before he is permitted to drive on the road. It should be emphasized that these special arrangements apply only to light motor vehicle drivers and that driving of heav,y motor vehicles should not be permitted if the applicants suffer from such disabilities, Light motor vehicle drivers who are disabled should be required to obtain an arumal permit 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 responsibilit.y 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. CARDIOVASCULAR CONDITIONS 23. Method of examination In examining the cardiovascular system it is useful to proceed in the following order: venous congestion, cardiac enlarge100nt, cardiac valves, rhythm, pre.sence of active infection, condition of blood vessels and prognosis. The only indication of the presence of certain conditions suCh as coronary heart disease may, in soroo cases, be the 100dical history. In a few cases where special examination is required and there is doubt as to the presence or absence of WHO/Accid.Prev./1 Rev.2 page 14 organic heart disease, an electrocardiogram or orthodiagrophic radiograph may be taken and the case referred to a cardiologist. The blood pressure should be neasured with a mercury sphygmomanometer which should be overhauled from time to time, 24. Venous congestion Where there are signs of early congestive cardiac failure, such as dyspnoea, congestion of the lung bases, oedema, or rise in venous blood level above the manubriosternal angle when the patient is lying dow.n, driving or heav.y motor vehicles should not be permitted in view of the risk of rapid collapse. With minor degrees of early congestive cardiac failure, persons may be allowed to drive light motor vehicles, but if driving is to be continued, the condition should be kept under regular medical observation from the point of view o£ safety as well as of the treatnent of the person himself. 25. f?diac enlargenent Persons should not be permitted to drive heav,y motor vehicles if there is significant enlargenent of the heart. Dependent on the cause and degree of the enlargemnt, 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 driving, as well as for treatment of the condition itself. :tsafe driving11 in this connexion implies that there is unlikely to be any sudden loss of consciousness, faintness or weakness which would render the driver incapable of remaining in control of his vehicle. 26. Valvular disease Although in many cases the presence of valvular heart disease is compatible with a normal duration of life, or nearly so, applicants with significant valvular heart disease who have an increased liability to attacks of sudden loss of consciousness, such as in cases of aortic valvular disease, should not be permitted to drive C!IlY motor vehicle. Those whose valvular condition (other than aortic val wlar disease) is well compensated and otherwise medically fit should be permitted to drive any type of motor vehicle provided that they are kept under medical observation at intervals depending on the severity of the lesion. WHO/Accid.Prev./1 Rev,2 page 15 Persons suffG.ring f:rom orga.'1ic disturbances of rhythm, such as auricular fibrillation aJ.d flutta1~, should not be permitted to drive heavy motor vehicles; this applies also to persons who experience definite attacks of paroxysmal tachycardia. Ftmctional disturbance of rhythm, such as sinus arrhythmia, and extra-systoles if unaccompanied by other evidence of disease, need not be a barrier to dr~ving any type of motor vehicle. Persons who are drivers of light motor vehicles and who are suffering from auricular fibrillation or other serious disturbance of :.~bythm should be kept under regular observation from the point of view of safety in drivir.g, in addition to that of medical treatment, and should be advised not to drive if congestive cardiac failure or embolism occurs. The presenc0 of partial or complete heart block or pathological bradycardia renders a person unfit, to dri ,.G any root.or vehicle. 28. Infection Pe:r·sons suffering from active bacterial infection of the cardiac valves should be under trea-t.ment and should not drive motor vehicles, at least temporarily. When the ~1fection has subcided, dri,~g mqy be permitted in the absence of any condition whj_ch is likely to causa a sudden loss of consciousness or of control of the vehicle; val vula.z· disease usually persists after the infection and should be assessed in re~l_ation to driving in accordance with the recommendations given in paragraph 26 above. Persons suffering from definite malignant hypertension should not be permitted to drive motor vehicles. Where there is severe essential hypertension, with a systolic press'U.'r'e persjstently over 200 mm mrcury, or a diastolic pressure persistently above lOO mm mercu~·, driving of a heavy motor vehicle should not be permitted. Wit:-1 lesser degrees of hypertension, periodic examination at regular intervals of six or twelve months should be required, according to the severity of the case. C~~e should be ta~en at these examinations to avoid inducing a neurosis; they have ~:.he adv-mtage in many cases of giving the heavy moto:r vehicle driver WHO/Accid.Prev./1 Rev.2 page 16 ample time in which to seek alternative employment. 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 100 plus the applicant's age in years, or the diastolic pressure is over 100 mm mercur.y; these figures having been found to persist at repeated examinations and taking into accOlmt the general clinical picture.1 The effect of hypotensive drugs should be carefully assessed; some persons develop symptoms of vertigo or transient faintness when the hypertension is lowered by neans 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. 30. Lowered blood pressure Persons suffering from hypotension are liable to sudden attacks of giddiness, faintness or loss of consciousness. Persons who have shown these 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 lOO mm mercury 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 100 mm mercury; drivers of these types of vehicles should not be permitted to continue driving. Drivers of light motor vehicles should be advised to discontinue 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. However, the arbitrary standard of 100 mm mercury should 1 It was found in a survey of 22 000 officers of the United States Army that transient hypertension or transient tachycardia or overweight, each by itself, increased the probability of the later developmmt of sustained hypertension and of retirement 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. (Hillman et al., 1944-4?) WHO/Accid.Prev./1 Rev.2 page 17 be interpreted with care as there are some small individuals, usual~ weighing less than 50 kg (110 lb.), mose blood pressure at repeated tests is below this level without apparently producing any adverse effects. :n. Coro~_!rtery disease, including angina pectoris Persons with a history of coronary thrombosis, coronary insufficienoy, or angina pectoris should not be permitted to drive heavy motor vehicles. A.f'ter 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 mqy develop without adequate warning, Drivers of light motor vehicles should be advised, if there 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 regular 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. 32. Other cardiovascular conditions Cases of other organic heart diseases should be judged accordiPg to the possibility of a sudden collapse occurring without sufficie~t warning to apply the brakes and steer the motor vehicle to a safe stop. Particularly in drivers of heavy motor vehicles, the possibility of increased fatigue - such as occurs in mitral imcompetence - 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 heav,y 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 permit provided they submit to a periodic medical examination. Where a symptomless congenital defect which is fUlly compensated is found in a driver who is alreaqy employed he may be permitted to continue driving subject to periodic examination. Driving of heavy motor vehicles should not be permitted in cases of aneurysm of the aorta. Drivers WHO/Accid.Prev./1 Rev.2 page 18 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. 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 necessa:ry 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 eangrene has occurred, it may no longer be possible for 2 driver to continue the safe operation of a motor vehicle. Cases of vaso-vagal fainting attacks should be considered on their Ill3rits; they are unlikely to_ occur in the sitting position and there may be sufficient warning to allow the. driver who experienc-es sucn an ~att~·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 physician should advise on the side of safety; this may necessitate advising drivers of light motor vehicles to discontinue driving if the attacks parsist. 33. Varicose veins Even if severe, varicose veins and associated varicose conditions, such as varicose 6(;Zema or ulceration, are not likely to cause danger in driving, although they may affect a professional driver Is efficiency and his regular attendance at work. Haemorrhoids are soJmtimes considered to occur more frequently in drivers and this may possibly arise from the sedentary nature of their occupation and a t::mdency to constipation which may result from irregular hours of duty and hA. bite. It is not usually necessary to exclude such a pers-on from driving any type of motor vehicle unless there is pain or there has been sufficient haemorrhage to cause a severe degree of anaemia, 34. Prognosis --.. The prognosis of many organic heart lesions varies .acoording-.to.-th~ir _otio~ogy 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 WHO/Accid.Prev./1 Rev.2 page 19 been present will also have an important bearing in assessing fitness to continue driving and the need for periodic medical examination at stated intervals. DISORDERS OF THE ENDOCRINE SYSTEM 3 5. Thyroid gland If there is any evidence of thyrotoxicosis or a toxic adenoma of the thyroid gland 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 be maintained in mild cases and if the signs of tremor, tachycardia ar 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 marked tachycardia or irregular rhythm, tremor, exophthalmos ar visual disturbances, emotional or mental changes, the driver may be permitted to continue at work sub,ject to observation at frequent intervals of, sqy, 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 tim, 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 slowing of the reactions or other symptoms liable to interfere with the safe conduct of a motor vehicle. 36. Diabetes The urine should be tested for sugar in the case of all persons applying for permits to drive heavy motor vehicles, and at all subsequent medical examinations for renewal of permits. In order to avoid substitution, the WHO/Accid.Prev./1 Rev.2 page 20 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 person completely undressed. Persons suffering from diabetes, whether treated with insulin or controlled by diet alone, should not be permitted to drive heav.y 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 g~cosuria has been detected for the first time. Where the blood sugar curve is normal and the condition appears to be due to renal glycosuria, the driving of any type of motor vehicle rna;y be permitted. If the diabetic is in receipt of insulin injections there is a risk of hypogzycaemic 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 oocupati~ns 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 ~lderly 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 p3nnitted. 37. Addison's disease In typical cases with a low systolic blood pressure (see paragraph 30) applicants should not be permitted to drive a motor vehicle~ 38. 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 pituitar,y enlargement mqy ~-JHO/\·:dc:, P .co~l ./l hev. 2 page 21 produce hcml<1.'1opia c.::tusucl. by p.c:: >.Ju.;:-e on th:o. optic chia::;rn3. or sirrj_l;:J.l~ restriction of the visual fie ld:'l . :ersons suffering f..:·om dia..butes insip-Ldus should no-': be permitted to d.~'ii,-o a mosor v'.::hi('.l::;. 39. /1'1 'lpplican·t wi·::.h ,1 l1istory of ·1ny for:n of 0pilepsy sho"-".1d net be permitted to d:::--:..v ~ a ;10 to'!:' ve~1icle. I:::-1 ca~es of senii3 de;nGn"iji'L whsre the condition :-..o sufficientJy evident to be diagJOSGd -vr.ith certain~:r, the applicant should not be perrnitted to drive a motor YGhicle ,, Where de:n3~t5_o. paralytic"'. (gr:;nora.l paralysis of ·l~1e insaae) is diagnosed, the dri0~ng of nea~>~r :i-;.oto• veUcb.s sl-":::Juld ::1ot ha perm,..:t~Gcl; t!:le drlv~1:g of light motoi' veJliclc:-c sh.o:1~.d o:::1.ly be 3l:!.oc·rc~ if t1.erc; l3 a::.1 apparcmt2y good response to and :10 o·0i1-:::,' ::-t:]1'3 u:f o:~gc-mic J.::.sG::.~J:J az·e p:':'esent., c;··1c!:"l a pecson msy be advised that it io s:1::o to CCJ.l~in,_,_'J d.d .... ~£1,~ l::..t:;:lt r:Ji:.or ve!:l::_;;.h:.3 but, h3 shculd :csmnin If tr..s:r·e iR evicla:·lcs of th:: soq-u.el~e o::: cmcepnaJ.itis, such a3 rigidity of the arms o:c l11gs) or loss c J' em0tio·.13l contr-ol) of su.ffident degree for the diagnosis to be m3.de with c,c:rta~i:c,ty, the applicant s"wuJ/ not be permitted to drive a motor vehicle, 'Ihe opera":..ic~.1 of p:-a---.::·2orrt:tl 0.2 '!:.r'"'..:nc.o:.·::,itql le,_:cuts::ny or lob0tomy or topectomy (frontal1obect•nzy) G.oe3 ::1ot us·Jally of itsslf rel'td'?.I' a person unsafe to drive a motor vehicle, b::·~ E sl-::.8u1d be ro;mrr..:Jered that, raLrwr more than 10 per cent. of WHO/Accid.Prev./1 Rev.2 page 22 these persons have epileptic fits atter the operation. The underlying condition for which any of tbese operations was performed and the effect of the operation upon it should be assessed in relation to the responsibility C#f drivmg. In general, persons should not be permitted to drive heav.y motor vehicles if they have been subjected to any of these operations and it will usually be found advisable to remove experienced drivers who have had such operations from driving this type of motor vehicle. 41. Diseases of the ep::inal cord Persons who have suffered a traumatic lesion with damage to the spinal cord and resulting paraplegia may sometimes drive a light motor vehicle which is fitted with 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 sufferfug from any degree of certain organic diseases of the spmal cord, such as disseminated sclerosis, syrmgomyelia, amyotrophic lateral sclerosis, poliornlfelitis sequalae and tabes dorsalis' should not be permitted to drive m the first inst~mce or continue driving heavy motor vehicles. In some cases trained 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 m the interests of safety to remove the driver from his duties of driving heavy motor vehicles. Certain of the signs present in these diseases may be of particular danger in connexion with driving, such as anaesthesia of the feet, and loss of proprioceptive position sense in tabes dorsalis; the occurrence of ataxia or spasticity of the leg muscles in disseminated sclerosis may be highly dangerous to a driver. Where definite signs of these diseases are present, especially when there is loss of :muscular co-ordination or definite diminution of :muscular power, the driving of any motor vehicle should not be permitted. 42. Other organic nervous diseases Where conditions such as progressive muscular atrophy and congenital rnlfOtonic disorders are sufficiently severe as to be diagnosed with certainty, such persons should not be permitted to drive in the first instance or rontinue driving heavy motor vehicles. Light motor vehicle drivers should be advised against driving if WHO/.Accid.Prev./1 Rev.2 page 2.3 the condition is sufficiently severe as to interfere with the muscular co-ordination necessary for the safe handling of the motor vehicle. :tvligraine is not a barrier to driving any type of motor vehicle. Trigeminal neuralgia and various forms of tics do not ~ormally prevent a person from driving any type of motor vehicle. Persons suffering from mlfasthenia 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 :roodication may som;timcs drive if they avoid doing so for long distances and a.re kept under regular and frequent observation. Affections of the peripheral nervous system, such as neuritis or palsy of individual nerves should be judged in relation to driving motor vehicles on the degree of impairm:mt of function caused by the lesion. If there is any possibility of progression of the condition a person 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. 4.3 • Psychos is Where there is a definite diagnosis of psychosis by a psychiatrist, vlhether 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 a person has ever received tn-patient treatment at a m:mtal hospital, he should not be permitted to drive heavy motor vehicles. In such cases it is necessary to bear in mind the modern tendena,y towards voluntary admission to a mental hospital for treatment of psychoneurotic disorders where the S,Ymptoms 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 WHO/Accid.~rev./1 Rev.2 page 24 a definite diagnosis of psychosis has been made a driving permit should only be issued upon certification of fitness qy a psychiatrist. Mental detectives 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 employnent history may give a usefUl indication of the applicantls 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 impaired concentration over long periods and a lack of responsibility. Where, therefore, I!Ental defect is recognized, even if of minor degree, permission to drive heavy motor vehicles is not recommended. Low-grade mental defectives should not be permitted to drive any motor vehicle. Illiterates who cannot read but who are not :rrentally defective should not be disqualified from dri v:1ng. 44. PsychoAeurosis· This is one of the most difficult fields in which the medical examiner ~ be called upon to express his opinion. Minor degrees of emotional disturbances are probab~ frequently associated with accidents; they also frequently occur in 11 normal11 people. Where there is a hist6r;v 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 recover,y mqy 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 sufftpring from these conditions sometimes complain of quite irrelevant symptoms such as pain in a lmee or foot anC. 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 usual~ 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, 2 page 25 PSYCHOLOGY OF DRIVING AND PSYCHO-PHYSICAL APTITUDE TESTS IN THE SELECTION OF DRIVERS 45. Host 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) concentration 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 re chanisms; and (c) resistance to distraction. No really satisfactory tests of these processes have yet been devised and applied on a large scale. 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 46. 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 permit to drive a motor vehicle should not be granted. However, even minor degrees of anaemia are characterized by 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 permit is suffering from anaemia, a blood haemoglobin estimation should be carried out and the applicant should be temporarily 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 1mless the haemoglob:in falls to less than about 60-70 per cent.; investigation and treatmmt often result in a rapid improvement and return to duty. Where the condition is likely to recur, regular periodic medical examinations should be advised. \:!EO /Accic":.. ?rev. /1 R£v o 2 pagG 26 Leukaemia and other blood d;r:::c:casias should be judged on their indi 'V::.dual merits as ree;ards the person's fit;:"Jess to drive_, bec.ring in mind t~e tendency to fatigue a::-~d associated anaomia 3 fntie:;ue in th8 latter par't of: the day 1 s work be:\.:·.13 a potentially danger0us ha',3ard i:r. the occu:Jation of C:r~_v:i.Yl~.o A:n.plioants sufft:ring frcm bl·Jod <iisorC.ers of this type should not ;·),:; pet'mi t ~ed to d:>:>~ va hee..vy m0tc'r vehicl;:;s in tho first insta:.Jce. 'l'hose who are already d.:.:<!. v:1..ng lJl'·JfeG;;;j_onally n:ay be pcrmi tted to continue d.r::. v:!.ng if the condi tio:1 is not o-:: severe degree and fatigue and otl:.er de,ng91'' s~nptoms and sigas are absent. Lf ·tlJere is a history CJ' evic":.ence of haemophilia tbe applicant should not be pe;rmitte<i to d.rive heavy mJtor v::::h::.cles. 47., Mos-t. skin d~.seA.ses arc n ~t, lib:;ly to ~.nterfere wi.th the safe ha.nd.:'.i!"lg of a motor vehicle~ but in cort:t.in casc3 ''lherc the skJ.:1 is inelastic, U··.ictoned o:.." scarred, movcmei1ts of the li;nbs n1<1.y be rcr, c:.."ict(,J ,. ':!.'here is a close d0veJ.cpmcntal connc:xion bctw~~en the skin and t~e central nervot.:·.s syste!TI and c;:;rta::.n sl':i:1 diseases tend. to t,e a.ssociate:J. W:.L th ne,woses ?nd p.:;:ychopa·::.nie: pe-:-s•Jnnli tics of various forms. ·The exis.- tence of a sk:.n di.sease .• sucb as so::1o r::ases of sevc:re roe::lfn·rbooj c dermatitis may m1ggest the prGseDce o!: a r;eJrotic co:1ditior.. :Lf so, this condition should be explored in t:1e lig..~t of ::::>ara.gra:;:;r~s 4 3 and 44. l t is r:ot g<=ne:':'r..J.ly necessary to <Lclvise the removG.l of a drivel" from cl.:"iv:ng duties on acco•·nt o"!: thece skin coc1ditions alont::. 48. Inu.ut5.ve pulmon<=-.ry tubcrcu~.osis does not wuJ:c a pc::c::o ':YJ , ).:1fi t fo.e sr~.fc driving b~.tt a r.::areful ass·ass:nent of such a po:':'son 1 s cord: t:i.on i . .s :oec·az.sar:~ :•.n rolation to t:i.1e par- c>.cti ve t"J.berculosis of thn lungs and those who h2.ve roc-::::::1tly r: c1I.'f. e:>2C. from tuberculosis of th8 lungs s:. ould be permitted to ch"iVG hsavy n"o·co:.:' v::.·h:i.cles in the first instanc9. 'Ir2atme:1t by moans of a smt'l.ll pl."l':!lJmo~thorax is not, in it£:clfJ a bc:.:-orier to ~lT·Lv<:)r C:)lli"~.J3ing at tl1e wl1cel is negllgible in most cases, hu.t. :'2:t-.~.f_;ue to,,c>.rds tJv-~ WHO/Accid.Prev./1 Rev.2 page 27 mentioned. In such cases the driver should be required to attend for medical examina- tion at regular intervals of three to six months at first. Whenever possible a chest X-ray should be made. Applicants 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 49. Peptic ulceration and other digestive disturbances1 Applicants 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 some- times unavoidable in this occupation. A person who has had a partial gastrectomy operation for duodenal ulcer may, however, be permitted to drive 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 regular hours of duty. A history of duodenal ulcer or of some types of functional dyspepsia may be assoc- iated 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 a person temporarily unfit to drive, other chronic conditions should 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 6). 50. Hernia In driving the heavier types of motor vehicles, particularly the older types, in which the handling of controls, repairs or manoeuvres~ calls for increased physical 1 It is commonly supposed that motor vehicle drivers and other transport workers suffer from peptic ulcers with greater 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 failed to show with certainty any difference in the sickness experience of transport workers as regards gastric conditions (Hill, A. B •• 1937). A recent investi- gation showed that drivers and other transport workers did not suffer any more or less from peptic ulceration than other types of workers (Doll, R. & Avery Jones. 19~1). WHO/Accid.Prev./1 Rev.2 page 28 effort, a sudden rise of intra-abdominal tension occurs during these moments. Even though this rise of tension is small and unlikely to cause the production of an abdominal hernia, it may lead to some increase in size of an already existing one. For this reason, applicants for a driving permit should be encouraged to have operative treatment for any hernia which is present; in cases 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 51. Persons suffering from most acute infectious diseases are generally unfit for work temporarily and their own condition prevents them from driving a motor vehicle; they should not be issued with a driving permit until they have recovered. VENEREAL DISEASES 52. 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 continue to drive when suffering from these conditions but they should be kept under observation in order to ensure 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 reg~lar observation. A definite diagnosis of tabes dorsalis or dementia paralytica should exclude a sufferer from driving a heavy motor vehicle (see paragraphs 40 and 41). DISEASES OF THE GENITO-URINARY SYSTEM 53. 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 considered. Vesical calculi, ~THO/Accid.Prev./1 Rev .. 2 page 29 enlarged prostate, or urinary infections may result in frequency of ~icturition with consequent interference with the efficient and safe driving of a heavy motor vehicle, and applicants suffering 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 (soc pare.fTaph 36) and albumen whenever an applicant for driving heavy motor vehicles is medically exa~ined and at all subsequent examinations for renewal of por~its. If albumen is present at repeated examinations, the applicant should be referred to hospital for investigation of the cause. Care should be taken to exclude orthostatic albu~inuria qy the examination of an early morning specimen or a specimon passed after lying down for two or three hours. Such specL~ens are free from alb~~cn in cases of orthostatic alb~~inuria, which is of no significance and is ~ore co~~on in younger ~en. ALCOHOL A~ID DRUGS 54. Medical practitionGrs are sometimes asked to complete medical certificates showing whether an applicant for a ~otor driving permit exhibits any evidence of addiction to alcohol or drugs. The fncies, gross tremor, watery eye, furred tongue, cramps, :nyalgia and drea~s 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 document, but it is quite clear that any effect wrach alcohol may have on driving is to decrease efficiency and enhance the risk of accidents. Professional drivers should be instructed not to cons~~e 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 early cases, enquiry as to nny modica~onts consumed by the applicant for a driving permit may reveal that regular doses of phenobarbitone or other drugs are being taken and this WHO/Accid.Prev./1 Rev.2 page 30 again may suggest further enquiry in regard to the history of epileptic conditions. Persons who take coffee in excess and who regularly take certain st~leting drugs should not be permitted to drive ~otor vehicles. Persons who take regular or frequent doses of sedative drugs for any purpose in other than minimal quantities should not bo per~tted to drive heavy ~otor vehicles and should bo well advised not to drive lirht :notor vehicles. The effect of the antihistalninic drugs is to cauE~ drowsiness in some people and occasional~ a sense of euphoria which may lead to irresponsibility in a driver. This should be well appreciated qy the medical practitioner, particularly in advising patients who are professional drivers and who may be issued with considerablo quantities of these drugs for the treatment of such eonditions as h~ fever and allergic rhinitis. 55. It is advisable for medical practitioners to be always on the alert in prescribing sedative or hypnotic drugs, antihista~inic or other medicines which may affect the ~esponsible control of a ~otor vehicle for those of their patients who are drivers. PERMISSIBLE HOURS OF DRIVING 56. If a physician is called upon to advise upon maxi.~u.~ hours of driving, reference may be ~ade to the agreed suggestions adopted for guidance by the Inland Transport Co~~ittee of the International Labour Organisation. According to these, the driver of a heavy ~otor 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 poriod of 24 hours. Every driver should, as a rule, have an average rest period of not less than 11 hours, which mqr, in certain cases, be reduced to eight hours. 1 P .RIODICAL !<1EDICAL EX1~1INATIONS 57. In so~e countries the renewal of a pormit to drive a passenger transport vehicle is required at intervals prescribed qy the transport authorities, 1 Me~orandmn No. 51 concerning conditions of employment in road transport in International Labour Office, Official Bulletin Vol. XXXVII, No. 2, page 33. WHO/Accid.Prav./1 Rev.2 page 31 Drivers of heavy :notor vehicles should be medically examined at intervals of three years after the age of 40 and annually after the age of 60. These exa~inations may also be required, for e~~ple, on resumption of duty after illness lasting more than three or four weeks, or after accidents which prevent the driver working for three days or moro, or in any case where the supervisor considers that the driver should be medically exa.'llined in the interests of safety. The eyesight of drivers of heavy motor vehicle3 should be examined every six years and annually· after the age of 65 (see paragraph B). It is also necessary to examine drivers who suffer from or who have been certified as suffering .from, vertigo, fainting, epilep$1, ar heart diseasa, or indeed any condition which is like~ to affect the driver's appreciation of danger, to cloud his judgement or to render him suddenly uncon!cious, 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 SCf{E}fE FOR ROUTINE MEDICAL AND EYESIGHT EX!JUNATION OF DRIVERS 58, Most medical practitioners who examine largo n~~bers of applicants for motor vehicle drivine permits or who conduct other ex~~ations of drivers find it convenient to c~-rry out the various procedures required according to a routine. In this way the in· ~vert3nt omission of any important part of the medical examination is prevented. The tL~e required to complete the exa~ination varies great~~ but on an average approx~~tely 15 to 20 minutes may be allowed for each examination. In order to ensure that an adequate exa~ination may be carried out, the exa~inee should be fully ur~Tessed. The following procedure is sugrested: (a) It is important to take an adequate medical history. The applicant should complete a form containing as a minL~um the following questions: Have you ever suffered from the following? (1) Fainting attacks; epileptic fits, "blackouts" or "nerves" (2) Heart disease or disorder ~ ' . WHO/Accid.Prav./1 Il.cv.2 page 32 (3) Tuberculosis (4) Ast~~a or chronic bronchitis (5) Nervous or mental disorders (6) Skin diseases (7) Rupture. If "Yes11 , do you wear a support? (8) Digestive disorders (9) Dj_abetes (10) Rheu...11atis:n or joint trouble {11) Any other illrtess (12) Anlf accident or injury Have you ever been hosp!talized or undergone an operation? If so, give particulars and date Have you ever been rejected or invalidod fr~11 t~e Arm~d Forcts or aqy public service? The answers to these questions provide a guide to a detailed medical history which will be taken if any of the answers are unsatisfactory. Evidence of drug takin? or other addictions may be obtained from the history, and the medical exa~ination shotud include observation for any clinical evidence of these conditions. The medical history is alw9fs confidential, and the written replies to the above questions and the notes of the medical exa~ination itself should ~e retained by the medical practitioner. For the sa11o rcasGn applicants should ~ exa11inod privately and not as a group together. The followinf routine is suggested for the medical examination itself: (b) E,yesight examination, including pupil reaction to light (paragraphs 7-14). (c) Note any abnormality of the mouth, throat, nose and neck. (d) Standing bohind the applicant, test the hearing of each ear separately with conversational and whispered voice; exa11ine the external auditory meatus and dru...11 vrith aural speculu.~ (paragraphs 15 and 16), (e) Exa."lline articulations and muscular condition of upper limbs (paragraph 18). ltiHO/Accid~Prev./1 Rev.2 pafe JJ (f) Exa11ine the chest, front and back.i inspect~ on and auscultation of heart and lungs, -vrith ::-ray and other special exam~_nations as indicated (paragraph 23 et seq). (g) Heasure and record the systolic and C:'iastolic blood pressure (paragraphs 29 and JO). (h) Exa:r1ine the abdomen; exa:nine for hernia (paragraph 50). (i) Test knee and ankle re=lexes (paraeraph 39 et seq). (j) Exa"'lline articulations and muscular condition of spine and lot-rGr li:"11bs, particularly for varicose conditions (paragrap~·,sl9, 20 and JJ) .• (k) Ro~bcrg testo (1) Test urine for the presen~e of sugar and albu:nen (paragraphs 36 and 53). The result of these examinations and tests will suggest any further more detailed exa:l1ina·cions 1·rhich nsecl to be carria::l. ou·:,. It is reco:n.·nended that ·LhG blood group of the applicant bs tested and should a permit be granted the blood group of the holder should be recorded in his permit in order that rapid aid may be obtained in case of an accident~ CONCLUSION 59. In the preceding paragraphs an account has been given of the various procedures required in the exa:nination of appJ ica.."lts for :no tor vehicle driving permits. The essential requirements from the medical point of view for safe driving have been discussed in detail in relation to particular medical conditions, If these requirements are satisfied, an applicant for a motor vehicle driving permit may safely be per;nittod to drive, so far as medical coLsiderations are concerned. Very large n~11bers of accidents are now occurring on the roads in every count~;, and constant vigilance by medical practitioners will help t~ reduce the nlli'11ber of accidents if medically unfit drivers and those whose vision is seriously defective are prevented from driving heavy motor vehicles and adv~sed not to drive light motor vehicles. i,,fHO/Accid.Prev./1 Rev.2 page 34 The drivers of heavy motor vehicles need to maintain a high standard of physical and mental fitness of which they are justly proud, and the knowledge of this, in turn, pro~otes the confidence of the travelling public. The maintenance of si..-nilar high standards by drivers of all types of motor vehicles is desirable and should be encouraged b.1 medical practitioners in their d~-to-da,y work with those of their patients who are drivers~ REFERENCES ~mo/Accid.Prev./1 Rev.2 page .35 Doll, R. & Avery Jones, F. (1951) Occupational factors in the aetiology of gastric and duodenal ulcers, Spec, ~~P· 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) Pe_!'.§.2~~J..sh!'!!'acteristics of traffic ~ccident rep~~· p. 51. Connecticut Fletcher, E. D. (1948) Visual problems in ~otor vehicle administration. Oklahoma Hersoh~nsoh, H. L. (19l!,Q) Physical examination of drivers, Hygiea (Stockh.) 18, 988 Hill, A, B. (1937) An investigation into the sickness experience of London ~ransport workers, with special reference to digestive disturbances. Medical Tiesearch Council I.H.R.B. Report No. 79. 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 22,741 Officers of the United States Army, J. Amer. med. Ass. 1:2.• 699; 126, 829; 1.?.~· 1059; 129, 585; ill• 951; 112 .. 77 Kerr, D. J. A. (1953) The health, physical standards and training of motor drivers in relation to road accidents, f,dinb. me~~· (Transactions of the Medico- Chirurgical Society of Edinburgh), ~~. 31 Macfarlan, D. (1937) Hearing of automobile drivers, J. med. Soc. N.J. ~. 182 Ministere des Travaux Publics, des Transp~3et du Tourisme, Paris. Liste indicative des Incapacites physiques pour lesquelles le certificat medical d'aptitude a conduire les voitures automobiles a~fectees aux transports en commun des personnes et les voitures automobiles pesant en charge plus deJDOO Kgs ne pourra etre delivre. (Arrete mintst6r~-~J du 23 Janvier 1933). Journal Official ~e la Republique Fran9aise, 29 Janvier 1933, p. 1001 Ministere des Travaux Publics, des Transports et du Tourisme, Paris. Affections incompatibles avec ·la delivrance du permis de conduire les vehicules automobiles (Arrete ministeriel du 21 Juillet 1954). Journal Officiel de la Republigue Franyaise, 22 Juillet 1954, pp. 6918-6920 Ministry of Labour (1939) The health of London Central busmen. H.M. Stationery Office, London "Rex" (1953) Insurance of deaf motorists. The Policy Insurance Weekly. London, 21 May 1953 Selling, L. S. (1941) Some problems confronting the physician in the examination of automobile drivers. An!!:_ inteEE_, Med. 15_. 265 WHO/Accid.Prevo/1 Rev.2 page 36 APPENDIX1 Extract from 11 Hru1dicaps which are incompatible with the issue of driving 'ermits11 2 CoD.E. PEFU1IT (HEAVY VEHICLES) "nnar 11 .... ~ amputation, even urd l_~t.Ar."l.l, \ t ""'.!:"'•·'"" .cu.v r xtremities except of fingers, and these latter on l condition that there is normal gripping, . power bet1v-een the thumb and the first, : 1 'second or third finger on one hand, and! j that the other hand is anatomically and J functionally intact, it being under-· I ; stood that the latter will be used to j hold the steering-wheel, while gear ' 1 changes will be made with the former. Normal gripping power between the thlli~b and the first, second or third finger m~ be considered as co~atible with mutilations of the thumb and all , ten fingers, if three conditions are I fulfilled: 1 (1) that the thumb has not been 1 amputated beyond the distal phalanx, j and that the stlli~p iF non·-painful; I j (2) that one of the fingers (first, 1 second or third) still has its 1 proxL~al and middle phalanges intact, with non-painful sturr:p, even if the other fingers have been amputated by metacarpo-phal~~geal disarticulation; (3) that the grip between the thu.'11b and each of the three fingers which still have proximal and middle See paragraph 22-" page 13 A.B. PERHIT (LIGHT VEHICLES) Anlf infirmity or mutilation which prevents the driver from being able at all ·times to effectively cont~ol the steering- wheel either 1-1ith the normal hand or with a prosthetic hand, is to be considered ~s a~ eliminating factor. Cont.::.~ol of the steering wheel by means of a prosthetic hand shall not be permitted unless the elbow joint is intact. One upper extremity must be intact, except that partial amputation of fingers may be considered as compatible on condition that an effective grip can be achieved between the hand and the stum? of the thumb and the fingers or finger stu.'11ps (mf:mt.ion3 nprosthesisn if nece:::s2.ry). One of the upper extremities raJ .:::t be corr;;~l · "':-ely j ntact. Neverthel63S; amputations or infirmities of the fingers may b8 considered as compatible on condition that an effective grip can be achieved with the aid of a functionally intact thumb, 2 Journal O.fJicield::_1f.~7~::-.fY.·)1j_gc.f ___ F_:r_~nc:;a?-se_, Jeu.di 22 Juillet J.954, pp 6918-6920 3 "mention11 means that the p3rmit is only valid if the driver 1vears a prosthesis, aye-glass or other visual corrective, or drives a spGc:~.ally adapted vehicle as is indicated in the permi.t. ., ! I l I Lower extre.:nitieE I f C.D.3. PEill'!IT (HEAVY VEHICLES) VfclO/Accid.Prev./laN.2 page 37 Appendix A.B. p·~Rl'1IT (LIGHT VEHICLES) The articul.:ction of the elbow phalant;es is as strong as that between of the mutilated member must be the sa.'Tle finger and thumb of the other intact. (Uention "prosthesis" hand which is of normal strength. if mcessary.) Any permanent lesion of nerves, bones, joints, tendons or muscles, causing dL~inution of strength or mobility of a member comparable 1.;ith the lesions mentioned above, is to be considered as an eliminating factor. Any amputation, even unilateral, except of toes or forefoot, is to be considered as an eliminating factor. The toe functions may be dispensed with in both feet on condition that the tibio-tarsal joint is fully l mobile and of normal strength. I fo~~s~s~~ ~~; ~~et~~u~~~e~~~~li~st~~t I to be considered as an eli:ninating i factor (T).l I l Any permanent lesion of nerves, bones, joints, tendons or muscles causing a diminution of strength or mobility in a limb or part of a limb is to be considered as an eliminating factor, and no compensatory prosthesis m~ be authorized. Any lesion in a. lL'Tlb which makes driving uncertain shall be considered as an eliminating factor. Infirmity of both lm-rer extremities A'Tlputation of both thighs, dis- a~ticulation of one hip may be considered compatible on condition that the vehicle is appropriate or specially arranged so that the driver, sitting in a normal positior•: can effect the manoeuvres normally done by the feet without being at Emy moment obliged to remove control : from the steering-wheel. In the case of below-knee a.'Tlputations, prosthetic appliances may be used to perform the functions of the missing limb, under the same conditions. Disarticulation of both hips, thigh a~putations and knee dis- articulations are to be considered as elL'Tlinating factors. 1 The letter (T) means that a permit can only be issued for a limited period to be determined by the exa~ner and that this must be mentioned on the permit. WHO/Accid.Prev./1 Rev.2 page .38 Appendix 'T J C. D. E. PERMIT (HEAVY VEHICLES) 1~. D. P~FlEIT (LIGHT VEHICLE.S) Candidates who have had both lo~s a.'ll.putated below the knee but who have still the two knee joints intact so that they can use prostheses may be considered as eligible for driving a specially arranged motor cycle. (Mention in this case 1 11 Specially arranged vehicle and prosthesis".) Infir:nity in one lower extre:nity Candidates who have undergone disarticulation of one hip, a.."Tlputation of ono thir:h, disart:i- culation of one knee :nay be considered as eligible on cond:~-L -;_rn that they can sit normally. (Mention: "Specialzy arran£c,c~ vehicle".) J.:nputation of one leg anywho:ro below ths knee is to be considnred as co:nnatiblo. (Hontion: "Specially arranged vehicle and prosthesis".) Disarticulation of ono hip is to be considered as an oli:ninating factor. il..'Tlpu tat ion of one thir h, onn knoo, one log anywhere bolou the knee is to be considered as co:npatible on condition that a prosthetic appliance is worn ensuring adeauate bilateral functioning. (~1ention: "ProsthesiS' .:, I I C.D.E. PERMIT (HEA~I VEHICLES) I Club feet Unilat~ral or bilateral club feet. Restriction Any restriction of ~obility or of mobility ankylosis of the knee. or ankylo- l sis of the knee ! I ! I Restrictionll 1U11 restriction of mobility or of mobility ankylosis of the hip. or ankylosis of the hip. WHO/Accid.Prev./1 Rev.2 page 39 Appendix A.B. PEm1IT (LIGHT VEHICLES) Arry lesion which hinders the functioning of one or of both '! lower extremities and malws driving uncertain is to be considered as l an eliminating factor. B1lateral club feet, or uni- lateral club foot on ~~e Qide of tho accelerator pedal, arc to be considered as eliminating factors unless the tibio-tarsal articula- tion r~~ains intact. If such articulation is intact, the handicaps in question are not to be considered as elL~inating factors, and there should be mention of 11 Specially arranged vehicle". A club foot on the opposite side from the accelerator pedal is not to be considered as an eliminating factor. Restriction of mobility or ankylosis of a knee is to be con- sidered as compatible on condition that the driver 1 s seat is placed farther back or raised. ( 11 Specially arranged vohicle 11 ). Restriction of mobility ia a hip is to be considered as an elL~inating factor unless the driver can sit. In this case, the driving seat :nust be specially 1 arranged and the lovers lengthened. j (Mention: :!Specially nrranged 1 vehicle" • ) j WHO/Accid.Prev./1 Rev.2 page 40 Appendix C,D. E. PW!IT (HE/~VY VEHICLES) ~Short.ening •11 Arty shortening of a lower f a lower b"J :nore than 4 cm. xtre:nity 1 I ! ~lpper and ~over · rxtre:nities ! I i ' I I I I ! extremity 1 A. B. PER!1IT (LIGHT V:~HICLES Shortening of a lowor extro;n.i ty m~ be compensated by raisL~g of pedals or by the wearing of prosthetic boots. (HGntion: "Specially arranged vehicle or prosthesis".) Total loss of use of one upper and one lower extremity, whether both on the same side or on oppo- site sides, is not to be con- sidered as an eliminating factor. LIST OF MEMBERS Dr P. Behague Rapporteur permanent de la Commission des Incapacites Physiques au Ministere des Travaux Publics Paris __ , __ France Dr Seward E. Miller Medical Director-Chief Division of Special Health Services Department of Health, Educa.tion and Welfare US Public Health Service }!~shin~~· D.C. U3A Dr J. da Costa Moreira L. scto:~ do Servi~o Medica do D.F.S.P. Cabinete do Chefe de Policia Pio de Janeiro Erazil Dr L. G. Norman Chief Medical Officer London Transport Executive Londo'1. -----United Kingdom Dr I. Sayo Director Remedios Clinic Manila Philippines S~ther participants International Council of Ophthalmology - Dr J. 5lum Secretariat WHO/Accid.Prev./1 Rev.~ page 41 Appendix (Chairman} (:Rapporteur) United Nations - Mr H. G. Ha.l'bertsma, Transport and Communications Division, New York International Labour Office - Mr A. A. Evans, Assistant Chief of the Industrial Committees Division World Health Organization - Dr J. S. Peterson., Director, Organization of Public Health Services Dr A. L. Bravo, Chief, Social and Occupational Health Section Dr T. S. Sze, Social and Occupational Health Section (Secretary)