195THE CERTIFICATION OF BLINDNESS.

THE LANCET.

LONDON: SATURDAY, JANUARY 23, 1932.

THE CERTIFICATION OF BLINDNESS.1

A COMMITTEE was appointed in November, 1930,by the Union of Counties Associations for theBlind to report on the problems of the preventionof blindness. The committee, which was givenpower to coopt persons to its body, availed them-selves freely of the permission, and the result is aunanimous report of extensive utility. For theeconomic importance of blindness from the nationalpoint of view has been pressing since 1919, whengrants in aid of the welfare of the blind were firstmade by the Ministry of Health. Pensions werethen granted to all persons over 50 years of agewho were " so blind as to be unable to performany work for which eyesight is essential," while in 1920 the Blind Persons Act was passed which put these grants and pensions on a permanentbasis. Grants through local authorities are nowmade at rates varying from 15s. to 27s. 6d. a week,and pensions to the blind who are over 50 years ofage are provided by the State at the rate of 10.?.a week. But unfortunately, even now, no uniformsystem of registration and certification of theblind is in force in England. The Ministry of Healthhave been endeavouring for a long period to

persuade the local authorities to adopt a registra-tion clause providing for the certification of theblind by a medical practitioner with specialexperience in ophthalmology, but in the summerof 1931 only 52 per cent. of the counties andcounty boroughs of this country had either

formally or informally adopted this proposal.Further, many of these local authorities only fellin with the process of registration in respect ofcases which were considered doubtful, and that isa matter where, except in cases where both eyeshave been excised, it is unwise to leave decisionsto the judgment of any but a skilled ophthal-mologist. The committee’s first recommendation, ’,therefore, is that the employment of an ophthalmicsurgeon should be made compulsory in every casebefore a blind person is put on the register as such.With regard to the grant of Old Age Pensions theprocedure is somewhat different, but even herethere exists no guarantee that the local pensionofficer may not decide the claim of an applicantwithout ever having had the opinion of a skilledophthalmologist.At present it is possible for a person to be put

on the blind register by the local authority andto be refused a pension by the pension authority

1 Report on the Certification of Blindness and the Ascertain-ment of the Causes of Blindness. Copies from the Secretary,Prevention of Blindness Committee, 68, Victoria-street, S.W.Price 1s.

.vhen he attains the age of 50, and vice versa.

The second recommendation of the committee is,therefore, that the procedure for certifying blind-ness, both for the purpose of entry in the blindregister and for the granting of blind OldAge Pensions, should be unified. It must be

emphasised that the actual certification of blindnessmay be a matter of considerable difficulty, and uptill now there has certainly been a lack of uniformityin the standard required by various authorities ininterpreting the phrase " so blind as to be unableto perform work for which eyesight is essential."A circular issued by the Ministry of Health, notas a rigid instruction, but as a guide to the certifyingsurgeon, puts a visual acuity of 3/60 as a limitunder which a person may usually be consideredblind, while those with vision 6/60 or bettercannot be considered blind unless there are othervisual disabilities, and more especially a greatlycontracted field of vision. Concerning those withvision between 3/60 and 6/60 the circular isindefinite, and it is evidently intended that in

deciding on these difficult borderland cases a gooddeal should be left to the discretion of the certifyingsurgeon. In making their recommendations as tofuture procedure the committee have taken as amodel the system recently introduced into Scotland,after having been for a few years in actual workin Glasgow. This system provides for the examina-tion of every case by two experts, so that personalidiosyncrasy may be checked. For this purposea limited number of clinics have been organisedin the chief centres, while for outlying districtsspecial arrangements have to be made. Theclinic system is being used in Scotland to secure,in addition to the certificate, a statement of thecause of blindness, and with this purpose in view aform has been drawn up on which the results ofthe examination have to be stated in considerabledetail. The committee recommend that thissystem should be adopted. Stress is laid upon the

necessity or stating not only tne condition or tne

eyes which involves blindness, but also its cause.Certain detailed recommendations are made withregard to the definition of blindness, with specialreference to the borderland cases in which thevisual acuity lies between 3/60 and 6/60 ; guidanceas to what degree of defect of the field should beconsidered as a factor is given, while the age of thepatient at the time, and not when the onset of" blindness " occurs must also be taken into ac-count. Such directions should give much neededhelp in his difficult task to the certifying surgeon,while leaving him with a good deal of personalresponsibility. The Scottish plan of requiringevery certificate to be signed by two ophthalmicsurgeons when possible is therefore specially to becommended.

. Besides the form of certificate of blindness

applicable to adults, suggested in the report,forms are framed of two certificates for childrenunder 16. Here, for purposes of the EducationAct, the definition of blindness now in use is " tooblind to be able to read the ordinary school-booksused by children," and these forms of certificate areframed for two purposes. First, their employment

196

would enable the education authorities to dis-criminate between children so blind that theycan only be appropriately taught in a specialschool or class for totally blind children, from thosewho can appropriately be taught in a school orclass for the partially blind. Secondly, thesecertificates would distinguish between thosechildren who, when they attain the age of 16,are likely to be so blind as to come within the

provisions of the Blind Persons Act, and those ofwhom this cannot be said. There is also a formof certificate meant to apply to those cases of

partial blindness of a progressive character notyet blind enough to fall within the provisions ofthe Act but likely to become so at a later period.It is obvious that the information which these exa-minations and certificates are meant to elicit wouldbe of value also in determining whether childrenwith defective sight are more suitably educated inan ordinary school, a blind school, or a specialschool or class for the partially blind. It is alsoobvious that to obtain reliable information on allthese points cases must be examined with care,knowledge, and skill. We therefore heartilycommend this important report to the considerationof the authorities concerned.

MODERN HOSPITAL CONSTRUCTION.THIS is not a time to contemplate with

equanimity the demands of a community for anew hospital. In this country hospital beds areadmittedly wanted, and badly wanted in manyplaces, but, as far as possible, we must mostlyrely upon modifications, annexes, and partialrebuildings and adaptations, even though the policyof providing a whole new hospital would be thebest course. Indeed, it might be in the long runthe more economical direction of effort, but thegeneral financial position does not allow of the

expenditure of large sums to-day in order thatstill larger sums may be saved later. To many,therefore, it may seem inopportune just now tocall attention to the modern principles of hospitalconstruction, but there are reasons for the otherview. First, we can contemplate the ideal andlearn lessons for the future without the temptationto spend ; and, secondly, we can from scrutinyof the latest manners in hospital constructionderive valuable lessons for procedures of renovation.The last issue of Nosokomeion, published in

October, 1931, contained a series of articles onmodern hospital construction by leading specialistsin England, America, France, Germany, and Italy.These show in a most suggestive fashion thatfundamental changes in hospital planning havebeen taking place recently upon American models.And though the details of structure vary with thearchitectural tendencies of each country certaincommon principles have been evolving. The

pavilion system which long remained the standardtype is no longer followed in an invariable way.The ward units are more often placed verticallyone above the other, rather than side by side asformerly. The sanitary tower is also disappearingthough it had many architectural advantages.

Taller buildings, smaller wards, larger windowspace, and a more ample provision of balconiesare among the more obvious changes noticeable inmodern hospitals. They have been broughtabout by a desire for efficiency and economyexpressed by a more compact plan and a moreconcentrated arrangement of the engineeringservices, and they take note, inter alia, of suchdifferent things as modern views on cross-infection,the desire for greater privacy and comfort for thepatients, and safety as evidenced in new methodsof fireproof construction. In all these things nodoubt the influence of American hospital planninghas been a powerful factor in bringing aboutchanges in European countries. For example,the Columbia-Presbyterian Medical Centre inNew York City, an illustrated account of which waspublished in a special supplement to THE LANCET,1is echoed in France by the designs for the Hospitalat Clichy. But in this building the balcony pro-jection on the cantilever principles has been made astrong feature of the design, particularly on thetenth and eleventh storeys where it is continuous.These two top storeys not only form an effectivehorizontal line to the top of the building butprovide open-air lying-space for tuberculous

patients. The balcony principle has been carrieda step further in another French example, the

hospital at Colmar, where the terrace type of

balcony has been employed in an ingenious way.The storeys are set back one behind the otheron the south side to provide balconies for the

patients, but the building has only six storeysmaking no attempt to

"

sky-scrape " ; to employusefully the width of the lower floors, a series ofoverhangs have been built. This was made

possible by using reinforced concrete and showsthat in times to come the architects of hospitalsmust take this form of building into consideration.Many of the points mentioned appear in graphicillustrations and ground plans which are reproducedin this journal, but the chapter in Nosokomeionon German hospitals is not illustrated. Thisis unlucky for some of the most interesting ofmodern hospitals have been erected in that country.But as Herr v. A. LOMMEL, the writer of the chapterpoints out, the present economic crisis may resultin a central corridor type of plan. But it is to be

hoped that the small ward, facing south and openingoff a north corridor, will continue in favour. Manyof the changes in hospital construction to whichattention has been drawn are well illustrated in the

designs for the new Freemasons’ Hospital, atRavenscourt Park, of which an excellent sketchplan appeared in the Times on Wednesday last.

In England among the most interesting develop-ments noted in the hospitals selected for noticeis the increased use of the type of ward in whichthe beds are placed parallel with the walls, withglazed metal screens separating the heads of thepatients. Mr. C. E. ELCOCK, who is responsiblefor the chapter on the present position of hospitalconstruction in this country, describes and illus-trates the variation of this type which he names the

1 THE LANCET, Jan. 5th, 1929.