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Ministry of education circular 146
PUBLIC
POLICY
HEALTH,
April, 1948
IN D E A L I N G W I T H B L I N D A N D SIGHTED PERSONS
135
PARTIALLY
. A discussion on the above s u b j e c t was held by t h e Section of O p h t h a l m o l o g y , Royal Society of Medicine, on N o v e m b e r 13th, 1947. In response to a n invitation f r o m Mr. A. S e y m o u r Philps, H o n o r a r y Secretary of t h e Section, Dr. A. A. E. N e w t h was selected to represent t h e views of the School $-Iealth Service Group o[ the Society. Dr. D. D . S t e n h o u s e S t e w a r t , in his o p e n i n g paper, said t h a t it was very i m p o r t a n t t h a t a n y efforts to alleviate t h e m i s f o r t u n e s . o f blindness or defective vision should be so acceptable as to m a k e those concerned c o n t e n t e d m e m b e r s of society. It was t h e c o n s t a n t a i m of those working for t h e b l i n d a n d of b l i n d persons themselves to break the historic barriers w h i c h segregated t h e m f r o m comm u n a l life. T h o s e concerned for the welfare of t h e blind were dissatisfied with t h e definition " so b l i n d as to be u n a b l e to do a n y work for w h i c h eyesight was essential," b u t no better alternative b a d as yet been b r o u g h t forward. Such a n arbitrary decision, m a d e often after a single e x a m i n a t i o n , m i g h t be exceedingly diffic u l t in borderline cases. T h e medical m e n u n d e r t a k i n g this work were unlikely to h a v e a n extensive knowledge of the various types of e m p l o y m e n t , a n d t h e y were instructed to interpret disability on v i s u a l g r o u n d s alone, d i s r e g a r d i n g all other factors a s age, physique, t e m p e r a m e n t , opportunity, intellect, t r a i n i n g a n d aptitude. T h e Disabled Persons ( E m p l o y m e n t ) A c t now m a d e it possible to give practical recognition to g r a d u a t i o n of visual h a n d i c a p . T h e a i m s of education a n d e m p l o y m e n t of t h e visually h a n d i c a p p e d m u s t go b e y o n d t h a t of compulsory instruction and subsidised u n e c o n o m i c occupation. W i t h regard to children, he considered t h a t it was useless to t e a c h Braille to those whose eyes were more c o m p e t e n t t h a n their fingers. A s for partially s i g h t e d children, as soon as progress was retarded b y visual defect a n d interest d i m i n i s h e d by frustration, the c h i l d should be t r a n s p l a n t e d without delay to a special school for the partially sighted. It was unlikely t h a t t h e o p h t h a l m i c needs of every c h i l d would be properly m e t until t h e y were dealt with by fully qualified o p h t h a l m i c surgeons a n d be decried t h e e m p l o y m e n t of persons with i n a d e q u a t e post-graduate t r a i n i n g in s u c h work. It was now agreed t h a t n o r m a l use of t h e eyes did n o t cause irrevocable d a m a g e a n d t h a t restriction of u s e h a d a more h a r m f u l effect on m e n t a l development t h a n a beneficial one, i f any, u p o n the incidence a n d progress of m y o p i a ; t h a t deliberate under-correction of m y o p i a in children was misguided, in t h a t it did not prevent f u r t h e r s p o n t a n e o u s increase a n d left t h e children in u n n e c e s s a r y residual difficulty; a n d t h a t t h e h e a l t h of t h e eye required bodily health, n o t to be attained by s t r i n g e n t limitation of physical exercise, F o r m e r t e a c h i n g in this respect h a d been u n d u l y cautious. Eye doctors were considerably to b l a m e for n a r r o w i n g their specialty b y losing contact with their professional colleagues a n d b y expressing their views in special publications f rom w h i c h digested material was seldom adequately presented elsewhere
Dr. A. A . E. N e w t h drew attention to t h e stress t h a t t h e E d u c a t i o n Act, 1944, a n d t h e H a n d i c a p p e d Pupils Regulations, 1945, laid on t h e a s c e r t a i n m e n t a n d e d u c a t i o n of blind a n d partially s i g h t e d children, t h e definitions involving b o t h educational a n d medical considerations. W i t h r e g a r d to the blind, it h a d been f o u n d t h a t no child could be t a u g h t Braille until h e was so b l i n d t h a t h e could n o t see print. Consequently, t h e words in t h e definition " whose s i g h t is likeJ.y to become so defective " could be practically rifled out of consideration. L.E.A.s t h r o u g h o u t the c o u n t r y were considering m e a n s for the provision of schools for t h e blind. He h a d a s s u m e d ~hat t h e official e s t i m a t e of 0"2 to 9.3 per t h o u s a n d school population was n o t likely to increase unless some unforeseen epidemic were to occur involving serious i n j u r y to t h e eyesight of y o u n g children, a n d there seemed no reason to fear this. He drew attention to t h e v a r y i n g s t a n d a r d s of b l i n d n e s s for children a n d adults a n d appealed to o p h t h a l m i c surgeons to rectify this. As for t h e partially sighted, h a v i n g dealt with those whose vision was so defective t h a t special education was essential (and it was r e m a r k a b l e how well some children m a y get on in ordinary schools with quite seriously defective vision), it was i m p o r t a n t for school medical officers to know w h e t h e r the eyesight of children could be injured b y t h e ordinary c u r r i c u l u m . Up to the last few years fears h a d b e r n e n t e r t a i n e d t h a t m y o p i a m i g h t be caused or increased by the use of t h e e y e s for r e a d i n g or other near work, b u t lately o p h t h a l n m l o g i c a l opinion seemed to have veered r o u n d to t h e view t h a t m y o p i a was not due to reading and t h a t t h e r e was little d a n g e r in e n c o u r a g i n g myopes to use their ~ves as m u c h as possible. "ff this opinion was generally m a i n t a i n e d t h e n there was no object in restricting myopes with regard to their education. In fact, in view of t h e obvious i m p o r t a n c e of e n c o u r a g i n g children to lead as n o r m a l a life as possible, t h e n u m b e r of children requir-
i n g special educational t r e a t m e n t on a c c o u n t of partial s i g h t would be greatly diminished. T h i s h a d indeed occurred in his own area where t h e n u m b e r s h a d fallen m i l c h below t h e official estimate of one per t h o u s a n d , h a l f of w h o m were supposed to be suitable for special schools while t h e other h a l f could be r e t a i n e d in ordinary schools. It also followed t h a t children with defective vision retained ]n o r d i n a r y schools need n o t be subjected to restrictions a n d special f u r n i t u r e a n d e q u i p m e n t would n o t be necessary, w h i c h was f o r t u n a t e as t h e y were difficult to provide. H e t h o u g h t t h a t visual aids m i g h t be useful in special schools, b u t h e d o u b t e d if t h e y were feasible in ordinary schools. E a r l y a s c e r t a i n m e n t of serious visual defects was of obvious i m p o r t a n c e a n d he asked w h e t h e r o p h t h a l m i c surgeons considered t h a t t h e p o s t p o n e m e n t of routine testing of children's eyesight until t h e y could read the Snellen's T e s t T y p e s was a serious drawback. Personally he t h o u g h t not, as doctors, nurses, teachers a n d educational psychologists could a n d did refer y o u n g children for retinoscopy by t h e o p h t h a l m i c s u r g e o n if a n y defect of vision was suspected. H e concluded b y s a y i n g t h a t school m e d i c a l officers were m o s t a n x i o u s to do all t h e y could for t h e h a n d i c a p p e d c h i l d a n d t h e y relied u p o n t h e o p h t h a l m i c specialists to advise t h e m on these a n d m a n y other points w h i c h involved h i g h l y technical considerations. M r . M o f f a t t of the L.C.C. described the L o n d o n s c h e m e for d e a l i n g with t h e partially sighted. T h e y did n o t take into a c c o u n t so m u c h t h e degree of m y o p i a as s u c h features as rapidity of c h a n g e in myopia, f a m i l y history, crescents, f a i l i n g visual acuity ' a n d early vitreous opacities, as g r o u n d s on w h i c h to determine w h e t h e r t h e children's sight m i g h t be d a m a g e d by ordinary educational effort. It h a d been f o u n d t h a t children in t h e partially s i g h t e d schools did not a d v a n c e educationally as well as t h e y s h o u l d do. R e a d i n g aids were in t h e e x p e r i m e n t a l stage. It was h e l d in L o n d o n t h a t myopes s h o u l d be controlled in t h e use of their eyes, a l t h o u g h not so rigidly as in t h e past. Dr. M. L. H i n e t h o u g h t t h a t it m i g h t be an a d v a n t a g e to teach Braille to children while still r e t a i n i n g useful vision. Dr. N. Pines suggested h e a r i n g aids in schools for partially s i g h t e d where accurate h e a r i n g was important. Dr. A r t h u r Lister t h o u g h t t h a t r e a d i n g tended to increase m y o p i m Dr. F. A. Juler said t h a t there was no sure evidence t h a t increase in m y o p i a occurred as a result of u s i n g t h e eyes, a n d if so children s h o u l d have as n o r m a l an e d u c a t i o n as possible a n d s h o u l d be e n c o u r a g e d in ,physical activity. He supported t h e theory t h a t m y o p i a was not increased by t h e use of t h e eyes. Sir Steward Duke-Elder said t h a t no one was in a position t0 say d o g m a t i c a l l y or scientifically w h e t h e r the use of t h e eyes tended to increase myopia. He drew attention to newer m e t h o d s ef m e a s u r i n g myopia. Mr. Frederick Ridley agreed with m u c h t h a t Sir Stewart D u k e . Elder h a d said. T h e r e was n o t h i n g to be gained by educational restrictions. T h e myopic crescent was congenital, it occurred ia hyper.metropic families a n d could be ruled o u t as a factor in myopia. Mr. J. P. F. Lloyd pleaded for the m a n b l i n d e d after his 40th b i r t h d a y . A t present t h e law did n o t allow for t h e t r a i n i n g cr r e h a b i l i t a t i o n of s u c h a person. T h e President (Mr. H. Levy) associated h i m s e l f with Mr. Juler in w h a t h e h a d said a b o u t t h e uselessness of a n y a t t e m p t to l h n i t t h e child on t h e g r o u n d t h a t he m i g h t become more myopic. Some of t h e m r e m e m b e r e d their struggles with o p h t h a h n i c surgeons in years gone b y when s u c h surgeons refused to myopic children t h e benefit of scholarships a n d so on, with no justification. H e was glad to know t h a t t h a t sort of practice was ended, a n d he h o p e d t h a t m e a s u r e s would be t a k e n to help these u n f o r t u n a t e children. T h e child even with poor vision could see his school work perfectly well; w h e t h e r t h e print was large or small did not m a k e a n y difference. (This report h a s been prepared f r o m notes k i n d l y supplied b y the Editor of t h e Proceedings of t h e Royal Society of Medicine.)
CORRESPONDENCE MINISTRY OF EDUCATION CIRCULAR 146 To the Editor of PUBLIC HEALTIt SIR,--The British Psychological Society seek a m e n d m e n t to Circular 146 on t h e g r o u n d s t h a t it forbids t h e medical officer to include t h e report of t h e educational psychologist, a n d t h e y contest t h e point t h a t t h e medical officer s h o u l d do t h e testing all over again. On page 70 of your J a n u a r y issue it is stated t h a t " T h e Council agreed t h a t t h e present w o r d i n g of t h e Circular should s t a n d b u t t h e medical officer s i g n i n g t h e report would normally record t h e findings of other officers."
PUBLIC
136 It appears to me t h a t to insist in every case on an approved m e d i c a l officer b e i n g always required to carry out t h e final intelligence tests before deciding to take action u n d e r Section 57 would in some cases be a waste of the medical officer's time. 1 refer, in particular, to cases to be dealt with u n d e r Section 57(5). M a n y of these cases are in t h e special schools for a n u m b e r of years a n d have t h u s been regularly e x a m i n e d by a n approved medical nflicer~ in order to satisfy h i m s e l f t h a t t h e child is still educationally s u b - n o r m a l . In f o r m i n g s u c h opinion he h a s not only been guided by t h e result of his own findings h u t also b y t h e reports of the child's teachers as to his educational a t t a i n m e n t s , abilities, aptitudes a n d social a n d emotional characteristics. T h e medical officers t h e r e b y g a i n s u c h a t h o r o u g h knowledge of these children t h a t t h e y have no hesitation in deciding t h a t certain of t h e m s h o u l d be notified, irrespective of a n y m i n o r c h a n g e s in their I.Q.s as d e t e r m i n e d w i t h i n t h e child's last six m o n t h s at school. I a m of t h e opinion, therefore, t h a t the regulations s h o u l d be so a m e n d e d as to p e r m i t approved medical officers to use their discretion as to w h e t h e r or not t h e y s h o u l d also carry o u t intelligence tests w h i c h have been carried out h y a psychologist within t h e sixth m o n t h l y period. t a m , Sir, Liverpool. Yours, etc., March 24th, 1948. R. GAMLIN. [The opinion o~ t h e Council was t h a t Circular I46 does not forbid t h e inclusion of a report of a n e d u c a t i o n a l psychologist, b u t requires t h a t the approved medical officer should h i m s e l f carry out an intelligence test. Most school medical officers would no doubt agree t h a t the opinion of a n approved medical officer of experience as tO action to be t a k e n u n d e r Section 57 is of greater value t h a n an I.Q., b u t probably few would care to omit t h e latter from t h e records. It is d o u b t f u l w h e t h e r a court of law would accept the report of a medical ofi]cer who relied entirely u p o n the opinion of a n educational psychologist for an estimate of t h e I.Q. in such a d o c u m e n t as F o r m 2 H.P.--Editor, PUBLIC HEALTH.]
OBITUARY JOSEPH JOHN CLARKE~ L.R.C.P,I., L.M.S.S.A., D.P.H. Dr. J. J. Clarke, Justice of t h e Peace for Essex a n d late Medical Officer of H e a l t h , W a l t h a m s t o w , died at his h o m e in Hove on T u e s d a y , F e b r u a r y 24th, in h i s 87th year. He Was previously in private practice in W a l t h a m s t o w in p a r t n e r s h i p with his brother. W e are indebted to Dr. A. T. W. Powell, t h e present M.O.H. of W a l t h a m s t o w , for t h e following n o t e : Dr. Clarke obtained his ~nedical education at Q u e e n ' s College, Cork, a n d the Middlesex Hospital, o b t a i n i n g t h e D i p l o m a in Public H e a l t h with h o n o u r s in 1898. He was appointed p a r t - t i m e Medical Officer of H e a l t h to the W a l t h a m s t o w U.D.C. in J a n u a r y , 1898, a n d whole-time M e d i c a l Officer of H e a l t h on J u l y 1st, 1906, retiring on pension on Marc.h 31st, 1930. D u r i n g this period, Dr. Clarke built up a h e a l t h service in W a l t h a m s t o w w h i c h compared more t h a n f a v o u r a b l y With t h a t in a n y comparfible area. In p a r t i c u l a r , h e was largely responsible for t h e erection of a very fine Infectious Disease Hospital, i n c l u d i n g t h e first cubicle block ever erected in this country. T h e idea followed from a visit to Paris, a n d t h e plan of t h i s cubicle block was for m a n y years a feature in the public h e a l t h textbooks. T h e block is still actively f u n c t i o n i n g a n d h a s been in every way satisfactory for more t h a n 40 years. Dr. Clarke also sponsored the erection of an up-to-date W e l f a r e Centre in M a r k h o u s e Road a n d concentrated on t h e provision of specialist facilities in connection with school h e a l t h services. He will be r e m e m b e r e d by his colleagues a n d friends for his c h a r m i n g Irish personality a n d his readiness to help in all cases of m i s f o r t u n e . H i s latter retirement, has, u n f o r t u n a t e l y , been m a r r e d b y ill-health. A retired colleague writes: " One gratefully r e m e m b e r s h i m as a b r o t h e r official, easily accessible, with a smile for a l l - - h i g h or low h u m o r o u s , generous a n d appreciated everywhere. I r e m e m b e r the time when, as part-time M.O.H. h e would drive up in his open l a n d a u , c o a c h m a n ' u p ' in e m e r a l d green three-quarter, coat, long whip, h a n d - m e - d o w n top h a t with cockade a n d a well groomed nag. H i m s e l f in i m m a c u l a t e silk h a t a n d p a y i n g a visit to our tiny office in the old town hall. T h e sanitary inspector a n d l were t h e sole staff in a truly rural W a l t h a m s t o w in I899." Dr. Clarke was for m a n y years a Fellow of" t h e Society of M.O.H.
Council Re#ort, PUBLIC HEALTH, March, #. 112.--There should be included a f u r t h e r reference to Min. 9 of t h e General Purposes Committee. It was reported t h a t t h e Medical Society for S t u d y of V.D. would n o t support t h e proposed conference a n d t h e Council Concurred in view of t h e recent m e e t i n g at t h e M i n i s t r y of H e a l t h a t t e n d e d b y Port a n d V . D . M . O . s f r o m m a n y areas.
SOCIETY
OF
MEDICAL
HEALTH,
OFFICERS
OF
April, 1948
HEALTH
EASTERN BRANCH President: D r . T . R u d d o c k - V ) e s t ( C . M . O . H . , Norfolk). Hon. Secretary: Dr. A. J. Rae ( D e p u t y C . M . O . H . , W e s t Suffolk). A m e e t i n g of the B r a n c h was held at t h e G r a n g e G u e s t H o u s e , Brome, n e a r Diss, on S a t u r d a y , F e b r u a r y 14th, 1948, at 3 p . m . T h e P r e s i d e n t w a s in t h e chair, a n d 35 m e m b e r s a n d visitors were present. T h e P r e s i d e n t w e l c o m e d the supervisors of m i d w i v e s a n d s u p e r i n t e n d e n t h e a l t h visitors w h o h a d been invited to a t t e n d the m e e t i n g .
Care of Premature Babies Dr. M a y o n W h i t e , of t h e D e p a r t m e n t of E x p e r i m e n t a l Medicine, U n i v e r s i t y of C a m b r i d g e , gave a talk on t h e care of p r e m a t u r e babies. H e d e m o n s t r a t e d the n e e d to reduce their mortality a n d outlined their particular r e q u i r e m e n t s , e m p h a s i s i n g t h e i m p o r t a n c e of w a r m t h a n d t h e avoidance of cross infection. H e dealt w i t h their care in t h e large m a t e r n i t y u n i t , in t h e small cottage hospital a n d in t h e cottage. T h e respective m e r i t s of incubators, electric blankets ( r u n off car batteries d u r i n g electricity cuts) and~ hot water bottles were discussed, together with the p r e m a t u r e b a b y ' s ability to digest h u m a n a n d cow's milk and t h e stages at w h i c h v i t a m i n s s h o u l d be a d d e d to t h e diet. W i t h regard to t h e n u r s e , D r . M a y o n W h i t e stressed t h e i m p o r t ance of the h u m a n factor, t h e presence of a w o m a n w h o was good at the job b e i n g of greater assistance t h a n t h e possession of streamlined chromium-plated equipment. The m e e t i n g was interested to hear a b o u t t h e work w h i c h is being done in o t h e r parts of Britain, s u c h as B i r m i n g h a m , a n d in A m e r i c a . It was h e a r t e n i n g to find that t h e speaker was u n i m p r e s s e d by his experience of v a p o u r barriers a n d exotic diets. A vigorous d i s c u s s i o n followed, a n d m a n y p e r t i n e n t q u e s t i o n s were fired at Dr. M a y o n W h i t e in rapid succession. T h e a d v a n t ages a n d d i s a d v a n t a g e s of t h e n u r s e w h o speeialised in n u r s i n g p r e m a t u r e babies c o m p a r e d w i t h t h e m i d w i f e w h o u n d e r t o o k the care of her o w n cases, aided by advice a n d e q u i p m e n t available t h r o u g h t h e local M a t e r n i t y a n d C h i l d W e l f a r e A u t h o r i t y , were discussed a s was also t h e q u e s t i o n of w h e n a n d h o w to transport a baby f r o m a cottage to a h o s p i t a l unit. T h e m e e t i n g was pleased to learn that survival rates on the d i s t r i c t were as h i g h as t h o s e of the large m a t e r n i t y units,, b u t there was no feeling of c o m p l a c e n c y about the m e e t i n g . M e m b e r s a n d visitors w e n t away with their interest q u i c k e n e d a n d filled with the conviction t h a t t h e survival rates in their areas could and w o u l d be i m p r o v e d . A hearty vote of t h a n k s was accorded to t h e speaker , a n d M i s s L i n d s a y of East Suffolk, on behalf of the supervisors a n d s u p e r i n tendents, t h a n k e d t h e B r a n c h for inviting t h e m to be p r e s e n t at this meeting.
HOME COUNTIES BRANCH President: Dr. G. L. Brocklehurst (M.O.H., M a r g a t e M.B.). Hon. Secretary: Dr. J. M a d d i s o n (M.O.H., T w i c k e n h a m M.B.). T h e N o v e m b e r m e e t i n g of t h e B r a n c h took t h e f o r m of a visit to t h e Central Middlesex C o u n t y Hospital, Park Royal¢ L o n d o n , N.W.10.
The Relationship of a Large Hospital to the District Local Health Services Dr. Horace Joules, Medical Director of t h e Hospital, a n d Dr. F. A v e r y Jones, D e p u t y Medical Director, gave an exceptionally interesting talk on t h e aboVe subject. Dr. Joules b e g a n b y s a y i n g t h a t t h e district hospital should be i n t i m a t e l y related t o t h e district w h i c h it served, a n d t h a t there should be inter-related services. W e should Consider how t h e district hospital could be related to active general practice a n d the h e a l t h centres. It was h o p e d t h a t it would soon be possible to b r i n g students into t h e centres. He strongly advocated relating the t e a c h i n g hospitM to t h e district in w h i c h it was situated and in the best interests of medicine he advocated t h a t some health centres should he m a d e available. R e g a r d i n g t h e relationship of t h e district hospital to t h e local h e a l t h authorities a n d t h e general set-up, Dr. Joules t h o u g h t it o u g h t to be possible in theory to relate local h e a l t h a u t h o r i t y areas m t h e local hospital areas, a n d t h a t there o u g h t to be m o r b i d i t y statistics for e a c h area. W h a t did we know of t h e true position of, say, p n e u m o n i a in a n area ? T h i s seemed to be a case for t h e hospital a n d t h e tocat medical officer to work together. W h a t s h o u l d be t h e relationship of t h e a l m o n e r ' s d e p a r t m e n t to t h e h e a l t h workers ? In t h e past t h e a l m o n e r h a d s p e n t h e r time j u g g l i n g finances. T h e r e was greater need for more knowledge o!
POLICY
HEALTH,
April, 1948
IN D E A L I N G W I T H B L I N D A N D SIGHTED PERSONS
135
PARTIALLY
. A discussion on the above s u b j e c t was held by t h e Section of O p h t h a l m o l o g y , Royal Society of Medicine, on N o v e m b e r 13th, 1947. In response to a n invitation f r o m Mr. A. S e y m o u r Philps, H o n o r a r y Secretary of t h e Section, Dr. A. A. E. N e w t h was selected to represent t h e views of the School $-Iealth Service Group o[ the Society. Dr. D. D . S t e n h o u s e S t e w a r t , in his o p e n i n g paper, said t h a t it was very i m p o r t a n t t h a t a n y efforts to alleviate t h e m i s f o r t u n e s . o f blindness or defective vision should be so acceptable as to m a k e those concerned c o n t e n t e d m e m b e r s of society. It was t h e c o n s t a n t a i m of those working for t h e b l i n d a n d of b l i n d persons themselves to break the historic barriers w h i c h segregated t h e m f r o m comm u n a l life. T h o s e concerned for the welfare of t h e blind were dissatisfied with t h e definition " so b l i n d as to be u n a b l e to do a n y work for w h i c h eyesight was essential," b u t no better alternative b a d as yet been b r o u g h t forward. Such a n arbitrary decision, m a d e often after a single e x a m i n a t i o n , m i g h t be exceedingly diffic u l t in borderline cases. T h e medical m e n u n d e r t a k i n g this work were unlikely to h a v e a n extensive knowledge of the various types of e m p l o y m e n t , a n d t h e y were instructed to interpret disability on v i s u a l g r o u n d s alone, d i s r e g a r d i n g all other factors a s age, physique, t e m p e r a m e n t , opportunity, intellect, t r a i n i n g a n d aptitude. T h e Disabled Persons ( E m p l o y m e n t ) A c t now m a d e it possible to give practical recognition to g r a d u a t i o n of visual h a n d i c a p . T h e a i m s of education a n d e m p l o y m e n t of t h e visually h a n d i c a p p e d m u s t go b e y o n d t h a t of compulsory instruction and subsidised u n e c o n o m i c occupation. W i t h regard to children, he considered t h a t it was useless to t e a c h Braille to those whose eyes were more c o m p e t e n t t h a n their fingers. A s for partially s i g h t e d children, as soon as progress was retarded b y visual defect a n d interest d i m i n i s h e d by frustration, the c h i l d should be t r a n s p l a n t e d without delay to a special school for the partially sighted. It was unlikely t h a t t h e o p h t h a l m i c needs of every c h i l d would be properly m e t until t h e y were dealt with by fully qualified o p h t h a l m i c surgeons a n d be decried t h e e m p l o y m e n t of persons with i n a d e q u a t e post-graduate t r a i n i n g in s u c h work. It was now agreed t h a t n o r m a l use of t h e eyes did n o t cause irrevocable d a m a g e a n d t h a t restriction of u s e h a d a more h a r m f u l effect on m e n t a l development t h a n a beneficial one, i f any, u p o n the incidence a n d progress of m y o p i a ; t h a t deliberate under-correction of m y o p i a in children was misguided, in t h a t it did not prevent f u r t h e r s p o n t a n e o u s increase a n d left t h e children in u n n e c e s s a r y residual difficulty; a n d t h a t t h e h e a l t h of t h e eye required bodily health, n o t to be attained by s t r i n g e n t limitation of physical exercise, F o r m e r t e a c h i n g in this respect h a d been u n d u l y cautious. Eye doctors were considerably to b l a m e for n a r r o w i n g their specialty b y losing contact with their professional colleagues a n d b y expressing their views in special publications f rom w h i c h digested material was seldom adequately presented elsewhere
Dr. A. A . E. N e w t h drew attention to t h e stress t h a t t h e E d u c a t i o n Act, 1944, a n d t h e H a n d i c a p p e d Pupils Regulations, 1945, laid on t h e a s c e r t a i n m e n t a n d e d u c a t i o n of blind a n d partially s i g h t e d children, t h e definitions involving b o t h educational a n d medical considerations. W i t h r e g a r d to the blind, it h a d been f o u n d t h a t no child could be t a u g h t Braille until h e was so b l i n d t h a t h e could n o t see print. Consequently, t h e words in t h e definition " whose s i g h t is likeJ.y to become so defective " could be practically rifled out of consideration. L.E.A.s t h r o u g h o u t the c o u n t r y were considering m e a n s for the provision of schools for t h e blind. He h a d a s s u m e d ~hat t h e official e s t i m a t e of 0"2 to 9.3 per t h o u s a n d school population was n o t likely to increase unless some unforeseen epidemic were to occur involving serious i n j u r y to t h e eyesight of y o u n g children, a n d there seemed no reason to fear this. He drew attention to t h e v a r y i n g s t a n d a r d s of b l i n d n e s s for children a n d adults a n d appealed to o p h t h a l m i c surgeons to rectify this. As for t h e partially sighted, h a v i n g dealt with those whose vision was so defective t h a t special education was essential (and it was r e m a r k a b l e how well some children m a y get on in ordinary schools with quite seriously defective vision), it was i m p o r t a n t for school medical officers to know w h e t h e r the eyesight of children could be injured b y t h e ordinary c u r r i c u l u m . Up to the last few years fears h a d b e r n e n t e r t a i n e d t h a t m y o p i a m i g h t be caused or increased by the use of t h e e y e s for r e a d i n g or other near work, b u t lately o p h t h a l n m l o g i c a l opinion seemed to have veered r o u n d to t h e view t h a t m y o p i a was not due to reading and t h a t t h e r e was little d a n g e r in e n c o u r a g i n g myopes to use their ~ves as m u c h as possible. "ff this opinion was generally m a i n t a i n e d t h e n there was no object in restricting myopes with regard to their education. In fact, in view of t h e obvious i m p o r t a n c e of e n c o u r a g i n g children to lead as n o r m a l a life as possible, t h e n u m b e r of children requir-
i n g special educational t r e a t m e n t on a c c o u n t of partial s i g h t would be greatly diminished. T h i s h a d indeed occurred in his own area where t h e n u m b e r s h a d fallen m i l c h below t h e official estimate of one per t h o u s a n d , h a l f of w h o m were supposed to be suitable for special schools while t h e other h a l f could be r e t a i n e d in ordinary schools. It also followed t h a t children with defective vision retained ]n o r d i n a r y schools need n o t be subjected to restrictions a n d special f u r n i t u r e a n d e q u i p m e n t would n o t be necessary, w h i c h was f o r t u n a t e as t h e y were difficult to provide. H e t h o u g h t t h a t visual aids m i g h t be useful in special schools, b u t h e d o u b t e d if t h e y were feasible in ordinary schools. E a r l y a s c e r t a i n m e n t of serious visual defects was of obvious i m p o r t a n c e a n d he asked w h e t h e r o p h t h a l m i c surgeons considered t h a t t h e p o s t p o n e m e n t of routine testing of children's eyesight until t h e y could read the Snellen's T e s t T y p e s was a serious drawback. Personally he t h o u g h t not, as doctors, nurses, teachers a n d educational psychologists could a n d did refer y o u n g children for retinoscopy by t h e o p h t h a l m i c s u r g e o n if a n y defect of vision was suspected. H e concluded b y s a y i n g t h a t school m e d i c a l officers were m o s t a n x i o u s to do all t h e y could for t h e h a n d i c a p p e d c h i l d a n d t h e y relied u p o n t h e o p h t h a l m i c specialists to advise t h e m on these a n d m a n y other points w h i c h involved h i g h l y technical considerations. M r . M o f f a t t of the L.C.C. described the L o n d o n s c h e m e for d e a l i n g with t h e partially sighted. T h e y did n o t take into a c c o u n t so m u c h t h e degree of m y o p i a as s u c h features as rapidity of c h a n g e in myopia, f a m i l y history, crescents, f a i l i n g visual acuity ' a n d early vitreous opacities, as g r o u n d s on w h i c h to determine w h e t h e r t h e children's sight m i g h t be d a m a g e d by ordinary educational effort. It h a d been f o u n d t h a t children in t h e partially s i g h t e d schools did not a d v a n c e educationally as well as t h e y s h o u l d do. R e a d i n g aids were in t h e e x p e r i m e n t a l stage. It was h e l d in L o n d o n t h a t myopes s h o u l d be controlled in t h e use of their eyes, a l t h o u g h not so rigidly as in t h e past. Dr. M. L. H i n e t h o u g h t t h a t it m i g h t be an a d v a n t a g e to teach Braille to children while still r e t a i n i n g useful vision. Dr. N. Pines suggested h e a r i n g aids in schools for partially s i g h t e d where accurate h e a r i n g was important. Dr. A r t h u r Lister t h o u g h t t h a t r e a d i n g tended to increase m y o p i m Dr. F. A. Juler said t h a t there was no sure evidence t h a t increase in m y o p i a occurred as a result of u s i n g t h e eyes, a n d if so children s h o u l d have as n o r m a l an e d u c a t i o n as possible a n d s h o u l d be e n c o u r a g e d in ,physical activity. He supported t h e theory t h a t m y o p i a was not increased by t h e use of t h e eyes. Sir Steward Duke-Elder said t h a t no one was in a position t0 say d o g m a t i c a l l y or scientifically w h e t h e r the use of t h e eyes tended to increase myopia. He drew attention to newer m e t h o d s ef m e a s u r i n g myopia. Mr. Frederick Ridley agreed with m u c h t h a t Sir Stewart D u k e . Elder h a d said. T h e r e was n o t h i n g to be gained by educational restrictions. T h e myopic crescent was congenital, it occurred ia hyper.metropic families a n d could be ruled o u t as a factor in myopia. Mr. J. P. F. Lloyd pleaded for the m a n b l i n d e d after his 40th b i r t h d a y . A t present t h e law did n o t allow for t h e t r a i n i n g cr r e h a b i l i t a t i o n of s u c h a person. T h e President (Mr. H. Levy) associated h i m s e l f with Mr. Juler in w h a t h e h a d said a b o u t t h e uselessness of a n y a t t e m p t to l h n i t t h e child on t h e g r o u n d t h a t he m i g h t become more myopic. Some of t h e m r e m e m b e r e d their struggles with o p h t h a h n i c surgeons in years gone b y when s u c h surgeons refused to myopic children t h e benefit of scholarships a n d so on, with no justification. H e was glad to know t h a t t h a t sort of practice was ended, a n d he h o p e d t h a t m e a s u r e s would be t a k e n to help these u n f o r t u n a t e children. T h e child even with poor vision could see his school work perfectly well; w h e t h e r t h e print was large or small did not m a k e a n y difference. (This report h a s been prepared f r o m notes k i n d l y supplied b y the Editor of t h e Proceedings of t h e Royal Society of Medicine.)
CORRESPONDENCE MINISTRY OF EDUCATION CIRCULAR 146 To the Editor of PUBLIC HEALTIt SIR,--The British Psychological Society seek a m e n d m e n t to Circular 146 on t h e g r o u n d s t h a t it forbids t h e medical officer to include t h e report of t h e educational psychologist, a n d t h e y contest t h e point t h a t t h e medical officer s h o u l d do t h e testing all over again. On page 70 of your J a n u a r y issue it is stated t h a t " T h e Council agreed t h a t t h e present w o r d i n g of t h e Circular should s t a n d b u t t h e medical officer s i g n i n g t h e report would normally record t h e findings of other officers."
PUBLIC
136 It appears to me t h a t to insist in every case on an approved m e d i c a l officer b e i n g always required to carry out t h e final intelligence tests before deciding to take action u n d e r Section 57 would in some cases be a waste of the medical officer's time. 1 refer, in particular, to cases to be dealt with u n d e r Section 57(5). M a n y of these cases are in t h e special schools for a n u m b e r of years a n d have t h u s been regularly e x a m i n e d by a n approved medical nflicer~ in order to satisfy h i m s e l f t h a t t h e child is still educationally s u b - n o r m a l . In f o r m i n g s u c h opinion he h a s not only been guided by t h e result of his own findings h u t also b y t h e reports of the child's teachers as to his educational a t t a i n m e n t s , abilities, aptitudes a n d social a n d emotional characteristics. T h e medical officers t h e r e b y g a i n s u c h a t h o r o u g h knowledge of these children t h a t t h e y have no hesitation in deciding t h a t certain of t h e m s h o u l d be notified, irrespective of a n y m i n o r c h a n g e s in their I.Q.s as d e t e r m i n e d w i t h i n t h e child's last six m o n t h s at school. I a m of t h e opinion, therefore, t h a t the regulations s h o u l d be so a m e n d e d as to p e r m i t approved medical officers to use their discretion as to w h e t h e r or not t h e y s h o u l d also carry o u t intelligence tests w h i c h have been carried out h y a psychologist within t h e sixth m o n t h l y period. t a m , Sir, Liverpool. Yours, etc., March 24th, 1948. R. GAMLIN. [The opinion o~ t h e Council was t h a t Circular I46 does not forbid t h e inclusion of a report of a n e d u c a t i o n a l psychologist, b u t requires t h a t the approved medical officer should h i m s e l f carry out an intelligence test. Most school medical officers would no doubt agree t h a t the opinion of a n approved medical officer of experience as tO action to be t a k e n u n d e r Section 57 is of greater value t h a n an I.Q., b u t probably few would care to omit t h e latter from t h e records. It is d o u b t f u l w h e t h e r a court of law would accept the report of a medical ofi]cer who relied entirely u p o n the opinion of a n educational psychologist for an estimate of t h e I.Q. in such a d o c u m e n t as F o r m 2 H.P.--Editor, PUBLIC HEALTH.]
OBITUARY JOSEPH JOHN CLARKE~ L.R.C.P,I., L.M.S.S.A., D.P.H. Dr. J. J. Clarke, Justice of t h e Peace for Essex a n d late Medical Officer of H e a l t h , W a l t h a m s t o w , died at his h o m e in Hove on T u e s d a y , F e b r u a r y 24th, in h i s 87th year. He Was previously in private practice in W a l t h a m s t o w in p a r t n e r s h i p with his brother. W e are indebted to Dr. A. T. W. Powell, t h e present M.O.H. of W a l t h a m s t o w , for t h e following n o t e : Dr. Clarke obtained his ~nedical education at Q u e e n ' s College, Cork, a n d the Middlesex Hospital, o b t a i n i n g t h e D i p l o m a in Public H e a l t h with h o n o u r s in 1898. He was appointed p a r t - t i m e Medical Officer of H e a l t h to the W a l t h a m s t o w U.D.C. in J a n u a r y , 1898, a n d whole-time M e d i c a l Officer of H e a l t h on J u l y 1st, 1906, retiring on pension on Marc.h 31st, 1930. D u r i n g this period, Dr. Clarke built up a h e a l t h service in W a l t h a m s t o w w h i c h compared more t h a n f a v o u r a b l y With t h a t in a n y comparfible area. In p a r t i c u l a r , h e was largely responsible for t h e erection of a very fine Infectious Disease Hospital, i n c l u d i n g t h e first cubicle block ever erected in this country. T h e idea followed from a visit to Paris, a n d t h e plan of t h i s cubicle block was for m a n y years a feature in the public h e a l t h textbooks. T h e block is still actively f u n c t i o n i n g a n d h a s been in every way satisfactory for more t h a n 40 years. Dr. Clarke also sponsored the erection of an up-to-date W e l f a r e Centre in M a r k h o u s e Road a n d concentrated on t h e provision of specialist facilities in connection with school h e a l t h services. He will be r e m e m b e r e d by his colleagues a n d friends for his c h a r m i n g Irish personality a n d his readiness to help in all cases of m i s f o r t u n e . H i s latter retirement, has, u n f o r t u n a t e l y , been m a r r e d b y ill-health. A retired colleague writes: " One gratefully r e m e m b e r s h i m as a b r o t h e r official, easily accessible, with a smile for a l l - - h i g h or low h u m o r o u s , generous a n d appreciated everywhere. I r e m e m b e r the time when, as part-time M.O.H. h e would drive up in his open l a n d a u , c o a c h m a n ' u p ' in e m e r a l d green three-quarter, coat, long whip, h a n d - m e - d o w n top h a t with cockade a n d a well groomed nag. H i m s e l f in i m m a c u l a t e silk h a t a n d p a y i n g a visit to our tiny office in the old town hall. T h e sanitary inspector a n d l were t h e sole staff in a truly rural W a l t h a m s t o w in I899." Dr. Clarke was for m a n y years a Fellow of" t h e Society of M.O.H.
Council Re#ort, PUBLIC HEALTH, March, #. 112.--There should be included a f u r t h e r reference to Min. 9 of t h e General Purposes Committee. It was reported t h a t t h e Medical Society for S t u d y of V.D. would n o t support t h e proposed conference a n d t h e Council Concurred in view of t h e recent m e e t i n g at t h e M i n i s t r y of H e a l t h a t t e n d e d b y Port a n d V . D . M . O . s f r o m m a n y areas.
SOCIETY
OF
MEDICAL
HEALTH,
OFFICERS
OF
April, 1948
HEALTH
EASTERN BRANCH President: D r . T . R u d d o c k - V ) e s t ( C . M . O . H . , Norfolk). Hon. Secretary: Dr. A. J. Rae ( D e p u t y C . M . O . H . , W e s t Suffolk). A m e e t i n g of the B r a n c h was held at t h e G r a n g e G u e s t H o u s e , Brome, n e a r Diss, on S a t u r d a y , F e b r u a r y 14th, 1948, at 3 p . m . T h e P r e s i d e n t w a s in t h e chair, a n d 35 m e m b e r s a n d visitors were present. T h e P r e s i d e n t w e l c o m e d the supervisors of m i d w i v e s a n d s u p e r i n t e n d e n t h e a l t h visitors w h o h a d been invited to a t t e n d the m e e t i n g .
Care of Premature Babies Dr. M a y o n W h i t e , of t h e D e p a r t m e n t of E x p e r i m e n t a l Medicine, U n i v e r s i t y of C a m b r i d g e , gave a talk on t h e care of p r e m a t u r e babies. H e d e m o n s t r a t e d the n e e d to reduce their mortality a n d outlined their particular r e q u i r e m e n t s , e m p h a s i s i n g t h e i m p o r t a n c e of w a r m t h a n d t h e avoidance of cross infection. H e dealt w i t h their care in t h e large m a t e r n i t y u n i t , in t h e small cottage hospital a n d in t h e cottage. T h e respective m e r i t s of incubators, electric blankets ( r u n off car batteries d u r i n g electricity cuts) and~ hot water bottles were discussed, together with the p r e m a t u r e b a b y ' s ability to digest h u m a n a n d cow's milk and t h e stages at w h i c h v i t a m i n s s h o u l d be a d d e d to t h e diet. W i t h regard to t h e n u r s e , D r . M a y o n W h i t e stressed t h e i m p o r t ance of the h u m a n factor, t h e presence of a w o m a n w h o was good at the job b e i n g of greater assistance t h a n t h e possession of streamlined chromium-plated equipment. The m e e t i n g was interested to hear a b o u t t h e work w h i c h is being done in o t h e r parts of Britain, s u c h as B i r m i n g h a m , a n d in A m e r i c a . It was h e a r t e n i n g to find that t h e speaker was u n i m p r e s s e d by his experience of v a p o u r barriers a n d exotic diets. A vigorous d i s c u s s i o n followed, a n d m a n y p e r t i n e n t q u e s t i o n s were fired at Dr. M a y o n W h i t e in rapid succession. T h e a d v a n t ages a n d d i s a d v a n t a g e s of t h e n u r s e w h o speeialised in n u r s i n g p r e m a t u r e babies c o m p a r e d w i t h t h e m i d w i f e w h o u n d e r t o o k the care of her o w n cases, aided by advice a n d e q u i p m e n t available t h r o u g h t h e local M a t e r n i t y a n d C h i l d W e l f a r e A u t h o r i t y , were discussed a s was also t h e q u e s t i o n of w h e n a n d h o w to transport a baby f r o m a cottage to a h o s p i t a l unit. T h e m e e t i n g was pleased to learn that survival rates on the d i s t r i c t were as h i g h as t h o s e of the large m a t e r n i t y units,, b u t there was no feeling of c o m p l a c e n c y about the m e e t i n g . M e m b e r s a n d visitors w e n t away with their interest q u i c k e n e d a n d filled with the conviction t h a t t h e survival rates in their areas could and w o u l d be i m p r o v e d . A hearty vote of t h a n k s was accorded to t h e speaker , a n d M i s s L i n d s a y of East Suffolk, on behalf of the supervisors a n d s u p e r i n tendents, t h a n k e d t h e B r a n c h for inviting t h e m to be p r e s e n t at this meeting.
HOME COUNTIES BRANCH President: Dr. G. L. Brocklehurst (M.O.H., M a r g a t e M.B.). Hon. Secretary: Dr. J. M a d d i s o n (M.O.H., T w i c k e n h a m M.B.). T h e N o v e m b e r m e e t i n g of t h e B r a n c h took t h e f o r m of a visit to t h e Central Middlesex C o u n t y Hospital, Park Royal¢ L o n d o n , N.W.10.
The Relationship of a Large Hospital to the District Local Health Services Dr. Horace Joules, Medical Director of t h e Hospital, a n d Dr. F. A v e r y Jones, D e p u t y Medical Director, gave an exceptionally interesting talk on t h e aboVe subject. Dr. Joules b e g a n b y s a y i n g t h a t t h e district hospital should be i n t i m a t e l y related t o t h e district w h i c h it served, a n d t h a t there should be inter-related services. W e should Consider how t h e district hospital could be related to active general practice a n d the h e a l t h centres. It was h o p e d t h a t it would soon be possible to b r i n g students into t h e centres. He strongly advocated relating the t e a c h i n g hospitM to t h e district in w h i c h it was situated and in the best interests of medicine he advocated t h a t some health centres should he m a d e available. R e g a r d i n g t h e relationship of t h e district hospital to t h e local h e a l t h authorities a n d t h e general set-up, Dr. Joules t h o u g h t it o u g h t to be possible in theory to relate local h e a l t h a u t h o r i t y areas m t h e local hospital areas, a n d t h a t there o u g h t to be m o r b i d i t y statistics for e a c h area. W h a t did we know of t h e true position of, say, p n e u m o n i a in a n area ? T h i s seemed to be a case for t h e hospital a n d t h e tocat medical officer to work together. W h a t s h o u l d be t h e relationship of t h e a l m o n e r ' s d e p a r t m e n t to t h e h e a l t h workers ? In t h e past t h e a l m o n e r h a d s p e n t h e r time j u g g l i n g finances. T h e r e was greater need for more knowledge o!