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of their " mentions " ; and a conference will then bearranged of the people and bodies who contributed thenames. It may turn out that many " mentions " do notnecessarily mean a problem family, and this is one ofthe things the survey sets out to test. Some of thefamilies on the consolidated list will probably be excludedas outside the range of the inquiry, and a shorter list ofpossible problem families will be compiled and assessedat first hand by a health worker. As a result of her visitsto the home the list will doubtless be still further reduced.For each of the remaining, authentic, problem familiesa card will be filled in and sent to the committee’s head-

quarters where the results will be examined and analysed.The six areas to be surveyed are Bristol, Warwickshire,Luton, Rotherham, West Riding, and Kensington—a reasonable cross-section of England, since they includea port, a metropolitan borough, two administrativecounties in the Midlands, a county borough, and anactively growing industrial town. (Two of the areasinclude rural districts.) These surveys should widen our

knowledge considerably and clear the way for the nextstep-treatment.

’

SCHOOL FEEDING

Mr. F. Le Gros Clark sees school meals as more than auseful safeguard of the nutrition of children. In a newbooklet on the history of their development he com-ments on two important educational aspects of theservice : it must establish, over the course of a generation,a flexible and wholesome set of food habits, and it mustinitiate the child into good social habits at the same time." We cannot," he says, " make the child, tolerant, self-reliant and easy-mannered in the abstract ; we have tochoose some medium through which these qualities canbe imparted to him. For such a purpose the meal tableis ideal."

School feeding, like so many other social services,was begun by voluntary bodies. In the late ’80s of thelast century schemes for providing free school mealswere numerous and increasing ; and in 1889, on theinitiative of the London School Board, a School DinnersAssociation was formed. By 1906-when the first Actpermitting the provision of these meals by local authori-ties was passed by Parliament-Manchester, Birmingham,Bradford, Glasgow, and several other boroughs werealready supporting private funds of some size. The firstProvision of Meals Act, which gave local authorities thepower to supply meals to necessitous children from theproceeds of a id. rate, had plenty of opposition. Tax-

payers, it was said, were already overburdened, and thefamilies of children who were freely fed would be pau-perised. The Board of Education, however, was quietlydetermined that the provision of meals should be amedical and educational measure ; and this was achieved,though, as result of opposition from the Lords, Scotlandwas excluded from the Act. Nevertheless, the businessof deciding which children were necessitous enough to befed was still claiming more attention than was the typeof food to be provided or the manner in which it was tobe served. When the School Medical Service was founded,a year or two later, the task of selecting children wasplaced in the hands of the school doctor ; but there wereadministrative difficulties about this. Moreover, thenecessitous child was fed only on school days and wenthungry during holidays. Nevertheless the numbers ofchildren being fed rose gradually if not spectacularly-inLondon from 29,000 weekly in 1906 to 41,000 weekly in1911 ; but as might be expected charitable donationstowards school meals declined, falling from £17,000 in1908 to S950 in 1914 when the next Act was passed.Under this Act, the powers of the local authorities to

1. Social History of the School Meals Service. Published for theLondon Council of Social Service by the National Council ofSocial Service, 26, Bedford Square, London, W.C.1. Pp. 28.2s.

provide meals were still permissive, but they were nolonger expected to do it on the yield of a d. rate. Abad time followed : the Act was passed on the daywar broke out, and Government policy at that timewas the reverse of that in the recent war. During thefirst year of war 420,000 children received meals, but bythe last year only 43,000 were getting them, and thisdecline was encouraged by the Minister of Food. In the

postwar depression the Geddes axe aimed another

dangerous blow at the scheme : in 1922 the board’s

grant was restricted, and authorities were instructedto show economies. During the whole period of the

peace the proportion of children receiving meals rarelyrose above 3,5%, and sometimes fell to 2%. Towardsthe close of the ’20s the custom of providing milk inschools became more general, and a growing number ofauthorities accepted this partial measure as a solutionof their difficulties.

In the ’30s a change came ; the boroughs were begin-ning to concentrate on the provision of free meals forpoorly nourished children, while the counties, thoughproviding meals on payment in a few rural schools, were *making little attempt to provide free meals. The parents,too, still hung back, seeing free school meals as a form ofcharity. The 1939-45 war had the effect of reversing thisprejudice, we may hope for good. The Government’spolicy of feeding the children led to a wide developmentof the school meals service, at first in the reception areasand later throughout the country. It was an extraordi-nary achievement, raising the percentage of elementary-school children receiving meals from 11-4 in 1942 to33-8 in 1945. Even so, the parents had to be persuadedto accept the scheme by a completely fresh approach.The figure is still far below the 75% proposed as a targetby the Government, but it represents an advance in oursense of social responsibility which it would have beenhard to imagine a hundred, or even fifty, years ago.

TREATMENT OF THYROTOXICOSIS

WHEN the Medical Society of London discussed thyro-toxicosis eighteen months ago,l most speakers preferredsurgical methods to treatment by thiouracil. Dealingwith the same topic last month, members of the LiverpoolMedical Institution took a rather more kindly view ofthis drug. Neither method, as Mr. Philip Hawe pointedout, is ideal ; and each is used best only by carefulselection of cases. He suggested that all well-definednodular goitres and most goitres in elderly patients,especially when associated with cardiac complications,should be considered for operation, while the youngpatient with a diffuse goitre should have a trial of

thiouracil; for the many intermediate cases there canbe no hard-and-fast rule. He has had gratifying resultsin preoperative treatment with thiouracil followed by acourse of iodine. Since the war, he observed, post-operative crises seem almost to have disappeared,possibly because of improved preoperative care. Ivlr.A. M. Abrahams mentioned his impression that thedisease itself’has become less severe.Some of the essential factors in causation are still

unknown ; and Prof. Henry Cohen remarked that theclinical picture of thyroid affections shows that thyro-toxicosis and hyperthyroidism are not synonymous,though the former includes the latter. Moreover, thediverse patterns of thyrotoxicosis suggest that it may bethe expression of more than one ætiological factor, andthat the susceptibility of different tissues to thyroxine,and their capacity to use -it, may modify the clinicalpicture. Thiouracil and radioactive iodine do not attackextrathyroid causative factors ; but despite toxic hazards,the risk of mechanical difficulties from swelling of -thegoitre, and the possibility of overlooking malignant

1. See Lancet, 1947, i, 376.

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disease, thiouracil, in Professor Cohen’s view, has a

place in treatment. It will be remembered that in ourissue of Oct. 30 Sir Carrick Robertson, comparing sur-gical and medical results in a series of 350 cases, recom-mended thiouracil for young people with Graves’sdisease, for elderly people who are serious surgical risks,for cases with predominance of nervous symptoms otherthan depression, for cases of thyrotoxicosis recurring afteroperation, and as a means of preoperative preparation.

STANDARDISATION OF TRANSFUSION EQUIPMENTAT a meeting in Oslo last month representatives of

Norway, Sweden, and Denmark decided to adopt a commonstandard for equipment used in blood-transfusion.The equipment chosen is similar to the British, and

any part can be used with a British set. The benefitof this arrangement is that standard bottles filled in

any one of these countries can be readily used fortransfusion in either of the others. In the Inter-NordicStandards Association the Scandinavian countries havean effective body for the arrangement of agreed standards.The obvious advantages of standard equipment maypersuade the countries of the Western Union to followScandinavia’s example.

THE HYPERTENSIVE’S LIFE-SPAN

DESPITE the prevalence of essential hypertension,doctors are still unable to estimate with any confidenceits effect on the expectation of life. A report publishedlately in the United States suggests that this effect isfar less than is usually supposed. From his privatecase-records, dating back to 1914, Burgess chose thefirst hundred patients with essential hypertension whowere found to have a blood-pressure of 180/100 mm. Hgor more and who were alive eight or more years after-wards (aiming in this way to exclude any cases of

malignant hypertension). Of these hundred patients-ninety were found to have had- hypertension before1932, while the remainder were first observed between1934 and 1936. In 1947 forty-seven were still alive,while fifty-three had died. Of those alive, the averageduration of life since the hypertension was discoveredwas 16-9 years, compared with an average expectationof life of 21-6 years. The comparable figures for thosewho had died was 14-2 and 17-8 years. Taking all

patients together, the figures were 15-7 years for theactual duration and 19-8 years for the expectation.Every patient who was 65 years or older when the

hypertension was first noted attained the life expec-tation.

Of greater interest is the analysis of the thirty-twopatients in whom the hypertension was discovered ator before the age of 50. Of these, twelve had died,having lived an average of 15 years, compared with anexpectation of 26 years. The twenty survivors had livedan average of 18 years since the hypertension was firstnoted, compared with an average expectation of 29-4years ; all but three of these patients are leading normallives without symptoms. Of the twenty-seven patientswith a systolic pressure of 250 mm. Hg or more at sometime or other while under observation, the duration oflife for the nine still alive had been 19-1 years (comparedwith an average expectation of 22-9 years), while theeighteen who had died had an average duration of16 years (compared with an expectation of 18-5 years).The significance of these observations is enhanced bythe fact that the five patients in whom a reading of300 mm. Hg or more was recorded on one or moreoccasions, had an average duration of life slightly inexcess of the normal. In striking contrast is theposition of those with severe diastolic hypertension.Of fifty patients with a diastolic pressure of 120 mm. Hg

1. Burgess, A. M. New Engl. J. Med. 1948, 239, 75.

or over, twenty were still alive, with an average durationof life of 17-8 years (compared with an expectation of24 years). For the thirty who had died the compar-able figures were 14’6 and 21-7 years. Of those withdiastolic pressures under 120 mm. Hg, twenty-sevenwere alive with an average duration of life of 16-2 years(compared with an average expectation of 20 years),and twenty-three had died having lived an averageof 14-7 years since the hypertension was first noted

(compared with an average expectation of 16-6 years).Taking the group as a whole, the shortest duration oflife after the discovery of hypertension was 9 years andthe longest was 25 years. In other words, the patientwith the type of hypertension dealt with in this reportusually lives to within 3-4 years of his normal expectationof life. The younger the age at which hypertensiondevelops, the less likely is the individual to live out hisfull life-span ; yet the average expectation of life forthose developing hypertension under the age of 50 isover 15 years.

This study suggests that, irrespective of age, sex, orwhether or not the diastolic pressure is below 120 mm. Hg,these patients will probably live for 14-19 years. Thoughbased on a small series the analysis raises the question,which Burgess himself asks, whether any patient withnon-progressive benign hypertension should be subjectedto such a serious operation as sympathectomy. AsDr. Horace Evans remarked last month to the Devonand Exeter Medico-Chirurgical Society, surgical treat-ment for the relief of high blood-pressure is nowaday’too lightly undertaken.

SICKNESS IN THE POST OFFICE

Too often the reporting of morbidity statistics becomesfirst a formal routine and then a meaningless ritual ;but there is nothing mechanical about the report on thehealth of Post Office workers by their chief medicalofficer, Dr. Cecil Roberts’!As Roberts says, sickness-rates cannot be intelligently

interpreted except against a background of the policiesof personnel management and the selection and invalidingstandards of the medical advisers. Thus, in the longhistory of sickness recording in the Post Office since1891, the annual sickness-rate is clearly associated withthe invaliding policy effective at the time ; an invaliding-rate raised by the discharge on medical grounds of thechronic-sick absentee was associated with a low sick-absence rate, and vice versa. Purely statistical factorsalso enter the picture. Studies by the GovernmentActuary’s department have reaffirmed the prime impor-tance of age and sex composition in determining a popula-tion’s sickness experience. As in the country as a whole,the Post Office has been facing the problems of an ageingworking population. Some, if not all, of the increase insickness absence in recent years derives from the increasein the average age of Post Office workers, and the rise insick-absence rates between the wars need not have beenattributed to failure in morale. Had age-sex standardisa-tion of the rates been carried out, much of the apparentincrease would no doubt have been eliminated.

Unfortunately the lack of the basic data for such acorrection also impedes the comparisons made betweenthe sickness experience of different occupational groupswithin the Post Office, but some interesting distinctionshave nevertheless been drawn. " The hard core of malesick-absence problems is to be found among the bigbattalions of the postmen "-and the reason is not farto seek. During the war postmen were not on thereserved schedule ; young fit men were called up and

replaced by women and elderly men who were unequalto the consistent monotonous grind of the postman’sday. Sickness among engineering workmen, on the other

1. Mon. Bull. Min. Hlth P.H.L.S. September, 1948, p. 184.