AC 4411 (1) BARK 79 Question and Answer In which Medical officer of Health reports on the Health of the Children of Barking for the year 1947 Borough of Barking telephone no Public Health Dept., rippleway 3880 Barking, Essex With the Compliments of the Medical Officer of Health BARK 79 Question: What is this book about ? Answer: This book tells something of the health of some of the people of Barking, and these "some" are very important. They are the young people, and in this book is set forth what is being done to promote health and to maintain health among them. Public Health Department, Barking, Essex. July, 1948. To the Chairman and Members of the Barking Committee for Education. The dry bones of statistics are dead; the task of your Medical Officer in his Annual Report is to make them live. I am deeply conscious of the fact that this is a difficult task and am therefore constrained to ask your kindly indulgence. Once again I must ask you to read this report with imagination so that the dry bones are knit together and clothed with flesh and skin and stand—a living witness to the intense story of human endeavour which lies behind the factual statement I am privileged to submit to you. This report follows broadly the same design as my previous reports on this subject, but I have had the temerity to set it forth in a series of questions and answers which I believe may have some merit in novelty, and which will, I believe, make it handier as a book of reference, particularly to members of the public. I am, Your obedient servant, C. LEONARD WILLIAMS, Medical Officer of Health. 5 EDUCATION. Question:—Why are Medical Officers of Health so interested in Education ? Answer:—Medical Officers of Health are vitally interested in Education because they believe, so far as the past is concerned, that all great advances in Public Health have waited on great advances in Education, and because they believe that, both at the present time and in the future, a well educated public is the only real foundation of co-operation between Medical Officers and the people they strive to serve. SERVICES PROVIDED FOR SCHOOL CHILDREN. Question:—What Medical Services are provided for School Children ? Anszcer:—In the year 1947, so we are told, there were officially 12,119 school children in Barking, and of these no less than 8,970 were seen by your Medical Officers during the course of Periodic Medical Inspection. This Periodic Medical Inspection is the most important of all the services provided. The results of the findings of such enable you to assess the health of the children as a whole and enable you to detect defects which require attention. When the defects are detected they are dealt with by Assistant Medical Officers where possible and, if necessary, these children are referred to the various Specialist Consultant Sen-ices. Of course not all the defects which come to our notice do so by reason of Periodic Medical Inspection. In many cases the parents themselves bring their children to us at the Clinics and in some cases children are referred to us by their teachers. SCHOOL HYGIENE. Question:—What is meant by the term "School Hygiene" ? Answer:—"Hygeia" was the Goddess of Health, and "Hygiene "—named after her—is the science of such health. Strictly speaking the application of this knowledge should be named "sanitation" but, loosely speaking, the word ''Hygiene" is used not only to cover the scientific side of this matter but sometimes in its practical application. Specialist Consultant Services Ear, Nose and Throat. Orthopaedic. Ophthalmic. Paediatric. Skin. 6 School Hygiene, of course, is the study of the principles of promoting the health of children whilst at school. The first of all commandments is "Let there be Light" and the first principle in school hygiene is that the classroom shall be light, not only light enough to see by, but full of that light which is health giving. We do not want this light filtered through glass, even good glass, so that whenever practicable all the windows should be open. The possibility of using special glass which does not filter off the health giving rays should be entertained, but it must be remembered that a thin film of dirt on this glass makes it just so opaque as ordinary glass. Moreover, it has been found that where a place is not well lit it is rarely kept scrupulously clean, so that a well lit classroom is not only beneficial directly, but indirectly. The next general principle is that the classroom must be well ventilated and the air must be moving within the classroom; stagnant air has been spoken of as "dead" air. The ancients, in their days, recognised that it was essential to have air moving and chose one and the same word for life and moving air. To maintain movement of air naturally it may be found necessary to introduce more air than is strictly necessary for the purpose of ventilation and, of course, this air may be too cold to be comfortable; under these circumstances, and provided a sufficient volume of air is introduced in any period of time, the necessary movement can be artificially produced by adequate fans, electrically driven. In this country, particularly in the winter, in addition to light and fresh air we must of course provide warmth. It is impossible to say what is the ideal temperature at which a classroom should be maintained because there are several factors to be considered—to wit—the movement of the air—the degree of moisture in the air—and we have to recognise that most of the children, for most of the time in the classroom, will be sitting down. Subject to the reservations I have mentioned above as to the movement and humidity of the air, temperatures of something about 60° will be found to be desirable. How to maintain this temperature is a question fraught with great difficulty; we have had all sorts of ideas, from floor heating to ceiling heating; I thoroughly endorse that we must have some form of general heating, but I still believe that nothing will take the place of focal point heating, and that every classroom should have a fireplace which, of course, is one of the best forms of ventilation. The antiquated idea of putting school lavatories in some obscure corner of the playground is to my mind quite out of date; the idea that, of necessity, they must be smelly is wrong; nor is there any need to try to kill one smell with another; a reasonable standard of cleanliness will be assured if a lavatory is properly designed and there is no reason therefore why children should, in winter time, have to go across rainswept playgrounds to frozen lavatories. I look forward to the time when no water closet will be looked upon as suitable unless there is a hand basin within, and I see no reason why the flush should not be foot operated. These remarks about school hygiene are illustrative of the principles which must be entertained in making our schools health giving centres of education. 7 FOLLOWING UP. Question:—I know that my children are examined at school. I send them to the Clinic from time to time to be treated, but plainly I ask, what do I know about it all ? I cannot get either to the school or the Clinic. Answer:—The whole of the town is divided into areas, and each area is sufficiently small for the Health Visitor to know the people who live there individually. It is true that we have not enough of these Health Visitors at the present time; that is something which is common all over the country, but there is a Health Visitor for your area. I feel sure you know her and it is only for you to speak to her and you will find possibly she knows all the answers to your questions or that she can soon find out these answers. It is the Health Visitor who is a link between the services provided at the school and at the Clinic on the one hand, and the home on the other. If you have not seen the Health Visitor for a few days visiting somewhere in your street, you can no doubt find time at least to call into the nearest Clinic and leave a message, when the Health Visitor will be pleased to call on you. Last year over 2,000 such visits were paid and we hope the time is not far distant when this large number will be considerably extended. MEDICAL INSPECTION. Question:—It is eighteen months to two years ago since my little boy was examined by a School Doctor. How often should he be seen ? Answer:—Our aim in Barking is to see every child at school, every year. This was, of course, impossible during the war, and it is only now that we are beginning to hope the time has come when this standard will be practicable. Last year we did not do badly, and as will be seen from the table opposite, there were nearly 9,000 examinations carried out which, having regard to the fact the school population was 12,119, means that 75% of the children were seen during the year. Whilst in 1947 it was not possible to see every child at school, we are reasonably confident that our "Special" examinations covered most, if not indeed all, the scholars who required such an examination on medical grounds. Medical Inspection Group Entrants 1,786 Second Age-groups 2,047 Third Age-groups 1,700 TOTAL 5,533 Other Inspections 3,437 GRAND TOTAL 8,970 8 Question:—My child is quite healthy. As a matter of fact I have got two, a boy and a girl, and they are both healthy. They have both been examined medically very thoroughly recently for quite another matter, which convinces me more than ever they are quite healthy, so what is the use of School Medical Inspection to me ? Answer:—To you, personally, the only value of a school medical inspection is to make quite sure everything is all right, and there can be no harm in another examination. It is, however, very important you should have your children examined and the doctor's assessment placed on record, because the primary object of these examinations is to discover what favourable or unfavourable effects the system of education may have upon the physical health and well being of children as a whole. From this standpoint it is highly desirable that the children who are fit should be classified and recorded, otherwise the Committee and the Ministry would not be in a position to assess the physical progress of children attending school. I can assure you these figures make most interesting reading to students, who of course make comparisons between certain age groups and so forth, now and years ago. Supposing we take one illustration. No less than 8,970 children were examined during the year 1947. It was found that of these 2,974 were first-class nutrition, 5,971 normal and 25 slightly sub-normal. Incidentally I may mention that the heights and weights are all recorded and we believe positively that children generally are inches taller and pounds heavier than they were a generation ago. What is more, Committees and Officers are able to compare the physical development of one area of the country with another. Herein I may mention I have reason to believe that Barking does not suffer by any such comparison. ARRANGEMENTS FOR TREATMENT. Question:—What arrangements are made for treatment of children other than Specialist Consultant Clinics ? Answer:—There are three Health Centres in the Borough—Central Health Centre, Vicarage Drive, Ripple Road, Barking; Porters Avenue Health Centre, Porters Avenue, Dagenham; and Woodward Health Centre, Woodward Road, Dagenham. At each of these Health Centres a Minor Ailment Clinic is conducted each morning (Sunday excepted) where a Medical Officer is always in attendance. 9 A Minor Ailment Clinic is, in fact, a well organised surgery where many major defects are first discovered; here the Medical Officers deal with cuts, bruises and apparent trivial complaints which unless treated at the onset may develop into a serious illness. During the year 1947, there were 27,156 attendances at these Clinics. Clinic No. of days Clinic was open No. of attendances Daily average attendance No. of cases dealt with Total No. of attendances Total No. of cases dealt with Central 3°7 9,036 29.4 2,221 27,156 7,036 Woodward 3º7 10,589 34.5 2,580 Porters Avenue 3°5 7,531 24.7 2,235 TREATMENT OF DEFECTIVE VISION AND SQUINT. Question :—Why is it so many children have defective vision ? Answer :—We have become accustomed to adults wearing glasses and we do not take much notice of it but somehow or other we do take note of a child wearing glasses, and so it comes about we tend to get a wrong impression of the number of children who have to wear glasses. As a matter of fact it is because it is not usual for children to wear glasses that the wearing of glasses by children is so obvious ; also, by reason of the fact that their features are not so well formed as in later life, glasses tend not to fit so well. This makes them more obvious and of course we cannot expect children to take the same care of their glasses, with the result that the joints become loose, the fit becomes even less satisfactory, and the glasses become still more obvious. There were, as a matter of fact, during the year 1947, only 119 children for whom glasses were prescribed for the first time. TREATMENT OF DEFECTIVE VISION AND SQUINT (Excluding Minor Eye Defects Treated as Minor Ailments.) No. of defects dealt with Errors of Refraction (including squint) 749 Other defect or disease of the eyes — Total 749 No. of pupils for whom spectacles were:— (a) Prescribed 414 (b) Obtained 5°3 10 We are today using our eyes under conditions which are quite different from the circumstances under which the eye was developed. When Euclid (or whoever it was before him) introduced geometry with straight lines and right angles, he introduced a difficulty our eyes were never designed to meet. One man no doubt sees an oak leaf one shape and another man sees it a different shape and it does not matter at all, but straight lines and right angles are altogether a different proposition and any minor disability in the apparatus of the eye is noticeable; in a word, therefore, because straight lines and right angles are the order of the day it is necessary to correct relatively minor errors. There is another disability from which we are suffering today, and that is a very large number of us now for long periods of the day are living under conditions where the eye has not its necessary periods of rest. The eye can never be at rest unless it is focussed on something about 20 feet away or over. In the ordinary classroom, therefore, unless the child is looking out of the window instead of doing his work, the eye of the normal child is rarely completely at rest. This disability is increased considerably where for long periods the child is engaged on desk work. The Victorians with their mirrors (which unfortunately have gone out of fashion) had this advantage over us, that at least these mirrors did double the distance of the object at which they were looking. In many cases this accommodation is relatively easy in children although more difficult in adults, but it still does have some effect on the eyes of children. As a matter of fact the eye is not a precision instrument as a piece of optical apparatus. It is the brain beyond the eye which, by trial and error, learns to see clearly what is, after all, only imperfectly focussed on the back of the eye. I am not suggesting that children should be encouraged to look out of windows instead of doing their work, but I do suggest they should be definitely taught when not actively engaged on some task, to rest their eyes by looking at something in the distance. ORTHOPTIC CLINIC. Question:—What treatment is given for squint, and is it successful ? Answer:—Training the eyes cannot be undertaken until the child is able to look at pictures and it has been found by experience that it is an intelligent child who can do this before the age of four or five. Unfortunately, training in the muscles of the eye does not do much good after the child is eleven or twelve years old. It is therefore necessary to concentrate between these years. What is done is as follows:— 11 There is a machine which has a long name (and has not got a short one)—it is called a Synoptophore. This consists of two periscopes; the child looks through one periscope with one eye and the other periscope with the other eye. Looking down one periscope the child sees an illuminated picture of—let us say—a butterfly; looking down the other periscope the child sees an illuminated picture of a net, and the game is to juggle with these two periscopes in such a way that the child can get the butterfly into the net. In order to avoid boredom there are several other pairs of pictures—such as getting a sentry into the box—but the game is always the same, getting the two objects into a certain position. Not much progress can be made at any one sitting. It must be very tiresome for a child to attend again and again to get this treatment, but having regard to the fact that benefits can only be achieved between certain ages it is necessary to attend continuously; any sessions lost are, as it were, gone for ever. Wearing glasses, even against the wishes of the child, may be equally necessary— so also is the necessity, when advised, of wearing a disc in front of one eye in order to constrain the other eye to its proper amount of work. Orthoptic Clinic Number of children attended 81 Number of new cases 55 Number of old cases 26 Number of attendances 416 Number discharged cured — Number discontinued 1 Number of sessions 76 TREATMENT OF DEFECTS OF EAR, NOSE AND THROAT. Question:—What is done, so far as the ear, nose and throat are concerned, besides hacking children's tonsils out ? Answer:—This question, like so many others to which I have addressed myself, is one which has actually been put to me by a member of the public. It is a curious thing that once you have "given a dog a bad name you may as well hang him" and, of course, it is true that forty and fifty years ago an operation for tonsils and adenoids was looked upon as a very minor operation, properly undertaken by a very junior surgeon, but this is not true today. Indeed, an operation for tonsils for anybody getting on in life must be regarded (and is regarded) as an operation of a major nature, 12 It cannot be too often emphasised that tonsils are not taken out merely because they are enlarged. Tonsils have to be taken out when they are diseased or when they are obstructive. Personally I have found a third circumstance—to wit—when by reason of their size and shape they act as though they were a foreign body at the back of the throat, making the child feel a little sick. It is, I believe, the relief of this symptom which leads to an increase in appetite noted by so many mothers after the child has been operated on for tonsils. The Ear, Nose and Throat Surgeon is, however, interested in a much wider field than tonsils and adenoids, and from the standpoint of preventive medicine I am most interested—in his interest—in what are termed sinuses, that is, cavities in the bones of the face that are filled with air which is in direct communication with the nose: such cavities are to be found behind the eyebrows and behind each cheek bone. When these cavities become infected it is very difficult to clear up this infection, and they tend to become a recurring source of infection throughout the whole of the air passages leading right down to the lungs. It is useless beginning to think of clearing up certain chest conditions before you have dealt with the sinuses. Your surgeons do have a lot to do with making quite sure that no child is prevented from deriving proper benefit from education at school by reason of lack of acuity of hearing. This lack of acuity may be due to disease in the ear, as such, or disease in the nerve which is the bond between the ear and the brain. It is an expert job both to come to a decision in this matter and to provide any necessary treatment. My own opinion is that the Ear, Nose and Throat Surgeon has an even more important part to play in the future than he has in the past. The table inset shows the number of children who received operative and other forms of treatment at Clinics and Hospitals throughout the year. TREATMENT OF DEFECTS OF NOSE AND THROAT Total Number Treated Received operative treatment: (a) for adenoids and chronic tonsilitis 223 (b) for other nose and throat conditions - Received other forms of treatment 308 Total 531 13 DENTAL SERVICE. Question:—What does Mr. Tran, your Senior Dental Surgeon, say about " your service " ? Answer :—Mr. Tran writes as follows :— "Your dental service for the year has shown a marked improvement on recent years and there is every hope that such improvement will not only be maintained but surpassed, provided the necessary dental staff is available. The shortage in the dental profession is a national bogey and gives grave concern to all who visualise a complete National Dental Service; there are only about one thousand more dentists in the country today than there were twenty years ago, and it is common knowledge that in the clinics alone the requirements have increased manifold. The public today are more dental minded than ever they were, nowhere is this fact more apparent than in Barking, undoubtedly due to your policy of extending dental facilities to other than school children. The object of the School Dental Service is to render the child dentally fit upon leaving school and at the same time educating him or her to be so dentally minded as to seek periodical inspection and advice of his or her own free will throughout adult life. Hitherto, a considerable amount of the school dentist's work has been wasted in that after leaving school the periodical visit to the dentist has been allowed to lapse on account of the parent, or the adult patient, having to foot the bill and in an age when there are so many calls on the pocket it is hardly to be wondered that dental treatment has been looked upon rather as an unpleasant, expensive luxury, until such time as an offending molar drives the sufferer to have an old and faithful servant removed at whatever the price. The advent of the new Health Act will enable all who wish to avail themselves of the opportunity to have satisfactory dental treatment free of charge, and this may well prove to be one of the Act's greatest boons as undoubtedly dental hygiene plays a great part in good health. To achieve the aim of rendering the child fit upon leaving school, periodical inspection is essential and conservative treatment, wherever possible and practicable, should be carried out. The extent to which such conservative treatment should be carried out in respect of the deciduous or temporary teeth is a matter of considerable controversy within the dental profession itself. Your dental officers, on the advice of your Senior Dental Officer, adopt a middle-line course, with due regard to the child's age and temperament, the general condition of the teeth and their relationship to the jaws and also the psychological attitude of the parent; hence there can be no hard and fast rule with regard to the filling of the temporary teeth, each case has to be weighed up and treated on its own individuality, with the conservation of the permanent teeth always in mind. It must also be borne in mind that indiscriminate extraction of the temporary teeth leads to irregularities of the permanent teeth, often necessitating orthodontic treatment at a later date. 14 The conservation of the first permanent molars presents another difficulty when dealing with the majority of parents; these teeth erupt at the approximate age of six years behind the temporary teeth, and because the child has not lost any of the temporary teeth, the parent frequently refuses to believe that these teeth are indeed second teeth; consequently these very important members of the dentition are frequently permitted to decay even to an advanced stage, when the teeth could in fact be saved by early conservative treatment for many years, or at least until the second permanent molar erupts at the age of twelve years." Table of statistics for the past three years Year 1945 Year 1946 Year 1947 (i) Number of Children inspected by Dental Officers:— (a) Periodic Age-groups :— Age 5 (and 4) 279 441 555 6 136 196 426 7 153 211 380 8 146 223 459 9 98 140 391 10 95 160 509 11 239 372 815 12 200 399 779 13 266 428 718 14 (and 15) 104 242 406 1,716 2,812 5,438 (6) Specials 1,783 1,002 746 (c) Total (Routine and Specials) 3,499 3,814 6,184 (2) Number found to require Treatment 1,099 1,946 3,366 (3) Number actually treated 602 1,002 2,548 (4) Attendances made by pupils for Treatment 5,444 6,326 10,511 (5) Half-days devoted to:- Inspection 12 21 33 Treatment 548 682 966 Totals 560 703 999 (6) Fillings—Permanent Teeth 2,139 2,166 3,715 Temporary Teeth 365 916 1,282 Totals 2,504 3,082 4,997 (7) Extractions—Permanent Teeth 1,305 871 1,669 Temporary Teeth 3,352 2,564 5,100 Totals 4,657 3,435 6,769 (8) Administrations of general anaesthetics for extractions 2,385 1,696 3,089 (9) Other operations 1,126 1,880 2,873 15 ORTHODONTICS. Question:—What is "Orthodontics" and why do you use such an awkward word ? Answer:—"Orthodontics" is the art and science that has to do with keeping the teeth regularly arranged. It is a modern art; it has been properly called Orthodontic because Orthodontic means straight teeth or properly aligned teeth, and up to the present the public have not found any ordinary name for it. Elsewhere in this report, I have asked the Senior Dental Officer to deal with some matters with regard to the question as a whole, but what I want to say is this—that it is most important the teeth, particularly the permanent teeth, should be regular. Unfortunately English people on the whole tend to have jaws which are a little too small for the full number of teeth. John Bull, in many a Continental cartoon, is figured as having his front top teeth sticking out—a very common form of lack of alignment. These badly arranged teeth are difficult to keep clean and teeth which are not kept clean are apt to decay; as a matter of fact whilst cleaning teeth with an artificial brush and artificial aids is commendable where necessary, if only teeth were properly aligned and we were to eat the right food, there would be no need to clean the teeth at all. It is necessary to understand how important it is to have teeth properly arranged because the task of putting them right when once they are wrong is difficult and tedious, and only those who recognise how important this work is are likely to persevere through the months, and sometimes years, of treatment which are necessary in order to regulate the teeth. ORTHOPAEDIC CLINIC. Question:—In your last Annual Report I read about an Orthopaedic Clinic. What is an Orthopaedic Clinic ? Answer:—Orthopaedic is a compound of two Greek words which together may be interpreted to mean the art, or science of bringing up children straight. An Orthopaedic Surgeon, therefore, is a man who tries to bring your child up correctly; he puts right this and that deformity. Orthodontics Extractions 324 Impressions taken for Record Models and Plates 214 Plates fitted 51 Attendances for adjustment 366 Orthopaedic Clinic Attendances Primary examination by Surgeon 56 Re-examination by Surgeon 154 For treatment 5,360 Total 5,570 Treatments 908 Number for treatment Number of treatments 6,681 Admitted to hospital 3 16 Believe it or not, when I was a grown man this work was undertaken by general surgeons who had a special bent towards this sort of work, but who were not full time specialists. "Orthopaedics" therefore may be said to be of recent growth and the general public have not yet found an ordinary name for this sort of work. Until the public of England find an ordinary English name for it I must perforce to continue to use the scientific name, but this I shall be glad to discontinue at the earliest possible moment. Mr. A. M. A. Moore, F.R.C.S., Consultant Surgeon in Orthopaedics, holds a clinic at the Manor School, sometimes once a month and, because the work is increasing in Barking, sometimes visits indeed more frequently than this. He has trained staff working with him and this staff carries out his instructions between visits. Where hospital treatment is recommended we do our very best to see this is provided but, as the public are no doubt well aware, hospital beds are scarce and difficult to come by. Actually the Consultant Surgeon visited us on 15 occasions during the year under review, whilst the physiotherapists held 962 sessions. SPEECH THERAPY. Question:—Can stammering be cured ? Answer:—The straight answer is no. People who stammer suffer definitely from some particular stress or strain which is an hereditary quality and is not likely to be altered any more than the colour of the eyes and the shape of the nose, but this does not mean to say that nothing can be done for stammerers to help them, and there are literally hundreds of people who have stammered very badly but who, nevertheless, address large audiences. The essence of all the various forms of treatment is relaxation. This, together with help in speaking various sounds and, of course, confidence which comes from improvement, all combine to work what appear to be miracles, but the unfortunate stammerer must always be thinking of the advice which has been given, even though it is no longer necessary actually to take lessons. This, however, is not a hardship really as, after all, early in life you are taught to clean your teeth, but you have to go on cleaning your teeth all your life and, in the same way, a person who is a stammerer must go on and on and on practising relaxation and carrying out the every advice which he has learnt from the specialist who has helped him to help himself. Insofar as conversation is the very basis of social relationship, I look upon speech training as one of our most important functions. Difficulty in speech is likely to alter a person's whole outlook on life and all life means. Speech training, of course, whilst it has a lot to do with stammering, takes in other defects also, and during the year 1947 a total of 658 treatments were received by children at the Speech Therapy Clinic. 17 CHIROPODY. Question:—Why does my child develop corns and why do some children have plantar warts ? Answer:—Plantar warts definitely are an infection. Fortunately we do not get a large number of these; fortunately, also, they can be dealt with quite simply. What is definitely indicated is that your child has walked somewhere in bare feet where someone who has plantar warts has already walked; alternatively, he or she has worn a pair of socks worn by a child with plantar warts. What we can do to prevent the spread of plantar warts is to detect them immediately and to treat them immediately, also—of course—to obviate the necessity of children wearing one another's shoes, etc. With regard to corns they are an equally simple matter. A corn develops in response to intermittent pressure. A corn becomes painful when it begins to press upon something, and children's feet are so soft in structure that pain by pressure usually only occurs after the corn has developed to a relatively considerable size. From this standpoint it is wrong of necessity to blame the pair of shoes the child is presently wearing. Of course the present shoes the child is wearing may be the cause of the corn, particularly if they were bought a little bit too small with the idea they would be comfortable after they were broken in. Equally, it may be true that the corn was started entirely by a previous pair of shoes and, indeed, the child may be wearing sandals at the time the corn becomes an active nuisance. Although I am writing this report for the year 1947, and the remarks I wish to make have particular regard to 1948, I would like to take time by the forelock and say how disappointed I am that all children's shoes have now become free from coupons. I do wish it could have been possible for approved shoes only to have been made coupon free. PAEDIATRIC SERVICE. Question:—What is a paediatrician ? Answer:—A paediatrician is a man who, from a medical standpoint, tries to help people in bringing their children up healthy. He may be said to be a children's specialist but we do not want this to be true if it means that the paediatrician of the future is going to be linked to the children's specialist of the past, because the children's specialist of the past was far more interested in st udying the diseases of children and curing them than in helping to train parents to bring their children up healthy. Chiropody (a) Number of Patients 404 (b) Number of Treatments 1.525 18 There is a definite field for this specialisation; firstly—because children cannot help the doctor to make a diagnosis in the way that adults can, and therefore require an altogether different technique of examination from that of adults, and secondly— many diseases which are common both to children and adults run a different course in children than in adults. To give one simple little illustration of this I mention that where it would be quite usual for an adult to have a shivering attack at the commencement of a chill a child does not commonly so shiver but alternatively suffers from what is known as a fit. Thirdly, of course, there are certain diseases which although not uncommon among the adult population may be said to be children's diseases. What happens in Barking is that the Assistant Medical Officers send cases to the particular clinic where there attends a Consultant Paediatrician. We very carefully see that this Clinic is held at the Barking Hospital so that the services of this specialist may be available for the very young babies in the hospital so well as those who are older. At this Clinic, whenever possible, an Assistant Medical Officer attends, not only to facilitate the work at the Clinic but to be a link between the Specialist Services and the general work which is carried out at your clinics and your schools. This Assistant Medical Officer is changed from time to time but we find it advantageous to have one particular Medical Officer in attendance for several weeks. Your Consultant Paediatrician saw 115 children during the year 1947. INFECTIOUS DISEASE. Question:—To what extent, if any, is infectious disease spread by children being at school ? Answer:—In the sense that being born may facetiously be spoken of as the first stage in contracting infectious disease, so also does school life, no doubt, add in some ways to the danger of catching an infectious disease, but this is not merely because the child goes to school but because the child is getting to an age when—quite normally—he or she would be running about more with other children. Some years ago a very learned man wrote a paper and from the figures he produced proved, to his own satisfaction, that a child in an Infectious Disease Hospital was less likely to catch an infectious disease than a child outside. I was Infectious Diseases Scarlet Fever 71 Whooping Cough 85 Measles 264 Diphtheria 4 Pneumonia 12 Poliomyelitis (both nonparalytic) 2 19 not quite convinced about his figures but recognised there was a lot to be said for his submission and, in the same way, in our modern schools if—on the one hand— a child has an added chance of infection by reason of meeting other children—so, also, can it be said to have a less chance by reason of the fact that the children are meeting together under very good hygienic conditions, adequate ventilation and so forth. As a matter of fact I would not like to answer this question categorically one way or the other—it is like a ledger in which there are both credits and debits. Classes at school or whole schools can be closed if the Medical Officer so advises, but by long experience it has been found that this is only advisable occasionally because whether we like it or not children will mix with one another, particularly in towns, and as a matter of fact keeping the children at school (where they can remain under expert observation if necessary) has much to commend it. Infectious disease among school children showed a decline during the war and we are still in this fortunate condition. Scarlet Fever showed a decrease during the year, 71 cases being notified as against 101 in 1946. Whooping Cough is one of the diseases which must, of necessity, be spread in school because, of course, it is spread everywhere, in buses, cinemas, churches, at parties—where children may be together. It is unfortunate that with regard to Whooping Cough we have not yet any reliable lead as to how to prevent it. Work is being done at the present time but there are some special difficulties in any research which depends upon the diagnosis of this disease. The fact is there are children who cough and who "whoop" but who are not suffering from Whooping Cough, and there are children who cough and who do not "whoop" who are suffering from Whooping Cough. Scientific investigation entails hours and hours of work on each individual case. Incidentally it is my personal view that many mothers keep their children home from school when they know Whooping Cough is prevalent—and small blame to them—and that these parents, when they have to give a reason for Tommy or Mary not being at school so often say that he or she is suffering from Whooping Cough, a very understandable but sometimes inaccurate statement. With all these difficulties it is well nigh impossible to assess the prevalence of Whooping Cough, a disease which is so very often intensely distressing and can, of course, be fatal. Measles is another disease which can be spread in school although, as with other diseases, it can be spread elsewhere and—indeed—is often spread elsewhere. Fortunately the type of measles which has prevailed has not been particularly severe, 20 but we do not seem to be able to control this disease in a way in which some other diseases have been controlled. It is very important that Measles should be prevented, of course, under all circumstances, but it is particularly important that Measles should be prevented among young children, not altogether so far as Measles, as such, is concerned, but by reason of the complications which are likely to arise—such as bronchitis. One factor which has made the control of Measles particularly difficult is that the case can be and—indeed—is infectious before the rash develops whilst yet it looks as though the child is suffering from a cold. Even twenty-four hours or so before the rash can be seen with the naked eye it can be detected by taking a photograph of the child; whether this will ever prove of any practical worth in the early detection of Measles I do not know, but we may try it when, having more beds for such cases, early detection can be of real value by leading to early isolation. Another factor which militates against us reducing the incidence of Measles is that it is so often a mild disease and the parents of children who are only mildly affected think lightly of it and allow their children to play with other children before they should. The small incidence of Diphtheria is, of course, one of the remarkable achievements of the age. We diminished the dangers of Diphtheria before the introduction of inoculation, but the introduction of inoculation has chained the disease and, indeed, so far as we can see, could stamp it out if only people were one hundred per cent. determined to get one hundred per cent, of their children inoculated. Inoculation as carried out today is simple; in the vast majority of cases it is all but painless ; it should be undertaken long before the child attends school but when the child does attend school or otherwise begins to come in contact with large numbers of other children, it should have a boosting dose which will see it through the greater part of its school life, after which Diphtheria is not a major problem. One of the greatest tributes we have had recently to the work of inoculation in Diphtheria is that what, years ago, would have been a very minor outbreak— something to be looked upon as quite normal to the time of year—people of Barking now speak of as an epidemic. I hope the public will remain so alive to the value of inoculation and that the knowledge of its value will spread throughout the whole of the public. INFANTILE PARALYSIS. Question:—What was done in Barking to stop the recent outbreak of Infantile Paralysis ? Answer:—This again is a question not of my asking, but one which was put to me and one which I will try to answer faithfully although it does not represent medicine in a very favourable light. 21 The difficulty about Infantile Paralysis is that no one has yet discovered quite all the facts about how it is spread, and it is only when we understand how the disease is spread that we begin to learn how we may control the spread of this disease. I do not think there is any reasonable doubt but that a person suffering from an acute attack of Infantile Paralysis is infectious, and at this stage the infection is carried by invisible droplets which are inevitably spread from our mouths every time we speak. In other words it comes within the same category as the coughs and colds, concerning which it has been said " coughs and sneezes spread diseases", but it seems quite certain also that this is not the whole of the picture, and particularly in times when there are not a large number of cases the spread takes place in quite another way. What way this may be is not very well known although it is suspected that the infective agent remains in the bowels long after the acute stage of the attack of Infantile Paralysis has passed off. Of course, if this be so, personal hygiene must be a very important point in stopping the spread of Infantile Paralysis. What we can do in the present time is to isolate so soon as possible people who may be suffering from Infantile Paralysis, and here I want to say how thankful I am that the people of Barking have whole-heartedly co-operated with us and have allowed their children to go into an Isolation Hospital, even where we have not been able definitely to say this is a case of Infantile Paralysis. This early isolation is the best protection for the children as a whole in curbing an outbreak of Infantile Paralysis. The liaison with our colleagues in general practice was good. We were privileged to be able to co-operate with them almost instantly—cases were brought to our notice even before a diagnosis could be definitely made, and the intelligent co-operation of the public most certainly tended to diminish considerably the outbreak of Infantile Paralysis. IMMUNISATION. Question:—Is immunisation proof against infectious disease ? Answer:—This is an actual question which has been put to me—indeed it is a question which is always cropping up, and sometimes people take a very poor view when in answer I say " it all depends". Generally speaking the public can rest assured that if you are dealing with a disease which people rarely have more than once in a lifetime, it can be hoped either that there is immunisation which will give protection against that disease or that such an immunisation may be discovered at a reasonably early date, but where you find you are dealing with a disease which occurs time and time again during the course of a lifetime, then the problem of creating protection by some method of immunisation is almost sure to be remote. 22 Thus for instance, with regard to Smallpox, the number of people who get this disease twice in a lifetime is infinitesimally small. This was true in England in pre-vaccination days when England was riddled with Smallpox. It is, I believe, true in those countries today where it is prevalent. It is, therefore, quite in accordance with the principles I have set out above that something has been found which does give immunity against Smallpox, which is of course an infectious disease. As I have shown elsewhere immunisation against Diphtheria is simply wonderful; at the other end of the scale immunisation against the common cold is by no means successful, and between these two extremes there are diseases in an intermediate class so far as immunisation is concerned. SKIN DISEASES. Question:—I am always afraid of my children catching some skin disease. Is this likely to happen in Barking? Answer:—As a matter of fact the answer is " No Compared with a generation ago Ringworm is uncommon. There were only 9 cases of Ringworm of the head and 13 cases of Ringworm of the body which came to our notice during the year and I think we see most of these cases. As I have said elsewhere Scabies is getting less frequent. For the three previous years we were seeing about 250 cases a year; in 1947 we saw but 110 cases. Regarding the masses of scabs and sores which doctors call Impetigo, the figures fell from 401 in 1945 to 257 in 1946 and down to as low as 138 in 1947. Question:—Should we have special Hospitals set aside for diseases of the skin, for out-patients as well as in-patients? Answer:—There are, of course, special Hospitals for skin diseases, but this is not entirely satisfactory because the skin is one of the organs of the body, and it is rarely the skin is diseased unless the whole body suffers also. What is done in Barking is that once a week a Consultant visits the Barking Hospital and there sees cases of skin disease. In between the visits treatment is maintained at the Barking Hospital, and in this way, and because at the Central Clinic there is a special room for " Skins a number of cases are kept from attending at your ordinary Clinics, save only that there must, of necessity, be cases which come up for the first time to an ordinary Clinic before they are sent to the Special Department. Scabies Year 1945 261 1946 231 1947 110 23 Modern dressing makes it much easier to deal with the skin diseases than it was twenty years ago. Twenty years ago I have seen children with skin diseases of the face tied up in bandages which were very possibly disarranged before the children had left the Clinic very long. Now with special adhesive dressings, it is possible to cover these sore places in a satisfactory way, which means that the children are much less likely to spread the contagion (if it be a contagion) and be a source of trouble to other children as they were many years ago. You will remember that during the war Scabies became quite prominent, and that last year I was able to say the incidence of Scabies was definitely on the decline. In my last report I said it was too early to " Halloa " until we were out of the wood, but having regard to the fact that only no cases were known in 1947 I think we can look upon the situation with some minor satisfaction. Scabies, by the way, is caused by a mite which wanders on the surface of the body very much like mites crawl over cheese. When I was a young man this mite was called an acarus, but the people who deal with the classification of these little mites have changed the name to sarcoptes scabiei. The wedding takes place on the surface, the father wanders off, and the mother burrows away into the skin. This does not cause much trouble, but she lays her eggs just under the surface of the skin and when all the little sarcoptes scabiei begin to wiggle about, that is when the skin begins to itch, and Scabies as you know itches quite a lot, so much so it has been properly known as the " itch NUTRITION. Question:—Do you think as a result of the war and our post-war difficulties, the nutrition of the children is being maintained? Answer:—The answer to this is "Yes", but that does not mean to say we can rest content. A friend of mine who for many years lived in Canada in days which can almost be looked upon as the pioneering days, and who was a very observant fellow, noted how the people who came out from mid-Europe—themselves of stunted growth—had fine, strapping, upstanding children, but if they had brought children out with them to Canada those children did not profit much, except the very young ones, whereas those born in the wide open spaces were upstanding, strong and healthy. I am afraid we must accept the fact that there are differences in standards of growth and development in different parts of Europe and, indeed, in different parts of England, and I am convinced that as a matter of fact the children of Barking are taller and heavier than children in less fortunate districts. Personally I am of the opinion that further advances in the science of feeding can make children yet unborn even taller and heavier than children of today. There are, therefore, no grounds whatsoever for " resting on our laurels". 24 Question:—How is my child standing up to the present food shortage? Answer:—I am very much afraid I must incur the possible animosity of many mothers and fathers when I ask " Is there a food shortage "? Certainly the physical condition of the boys and girls of Barking does not lead me to believe there is such a shortage. It may take, and I am sure it does take, much more time now to do shopping than it did years ago. I am equally quite sure that mothers cannot always get just the food they want at the time they want it, but this does not mean to say there is a shortage from the standpoint of a Medical Officer. Now I think you will understand what I mean if I ask you to bear with me when I put before you a few facts and figures. During the year 1947 there were no less than 8,970 medical examinations to enquire into the nutrition of the children, and only in 25 cases was it found that the nutrition was sub-normal. It is this simple information which makes me say I am very doubtful whether we can speak of a food shortage as such. Herein I have set forth detailed figures and the student will no doubt analyse these figures critically. Age Groups Number of Pupils Inspected A. X (Good) B.+ (Fair) C.— (Poor) No. % of col. 2 No. % of col. 2 No. % of col. 2 Entrants 1,786 562 31.47 1,218 68.20 6 .33 Second Age Group 2,047 672 32.83 1,371 66.98 4 .19 Third Age Group 1,700 602 35.41 1,091 64.18 7 .41 Other Periodic Inspections 3,437 1,138 33.11 2,291 66.66 8 .23 Total 8,970 2,974 33.15 5,971 66.57 25 .28 X A. = Excellent Nutrition. + B. = Normal Nutrition. —C. = Slightly sub-normal Nutrition. Children with " bad " Nutrition (classification D year 1946)—NIL, 25 To obtain these figures it is just as necessary to examine the healthy children as children who are not so healthy. Standards of nutrition, however, depend upon the personal idiosyncrasy of the doctor making the assessment. You may take it that doctors generally have a very good knowledge of pre-war conditions and have due regard to this in making their present day assessment. Moreover, although during the past years our medical staff has been constantly changing, the relatively favourable opinion expressed for the year 1947 is consistent with what we have constantly found during the last few years. Incidentally I may mention that having regard to the heights and weights which have been recorded over many years, we believe positively that children today generally are inches taller and pounds heavier than they were a generation ago. SCHOOL MEALS. Question:—What is done and what is going to be done, about School Meals? Answer:—There is no doubt that the first approach to a healthy meal is to have a healthy appetite and, of course, we know only too well that where appetite approaches hunger, it can be the dominating issue to any meal. Neither cooking, table appointments nor congenial company can be factors of real importance if once a person is desperately hungry. In the ordinary way when people take meals the way in which the food is cooked and otherwise prepared, the way in which it is served and the company in which it is eaten, are very important factors indeed. I do believe our schools have enormous difficulties in front of them with all this school feeding, but at the same time they have glorious opportunities, of which I have no doubt our teachers will take the fullest advantage, so soon as the necessary equipment and staff can be put at their disposal. I look forward to the time when school meals can be served at small tables seating not more than eight children. I hope that the meals will not only be balanced dietetically, but served in such a way that a meal time becomes a period of enjoyment. It is a curious thing—two people eat similar meals, the same proteins, fats and carbo-hydrates and alike in every other way by which the scientist can judge— including calorific value—but if the one person eats it quietly in good company Average Number of School Meals served each week during 1947 30,000 26 and good fellowship, and the other eats it standing up from the dirty corner of an overloaded table, the one person has a meal and the other person has something less than a meal. All the Centres where food is provided for children are visited by members of my staff from time to time and every necessary help is given those in charge of this great work. UNCLEANLINESS. Question:—The other day when I was brushing my daughter's hair, I saw what I believe to be a louse, and was horrified. I was ashamed to tell my husband, but I did so, and we began talking matters over and ended up by asking how much time I had spent keeping my child's head clean and what the Public Health Department were doing about this, because quite frankly we felt it was wrong for the louse to be there at all, and if there were not such a possibility of a louse being there I should be spared a lot of time and, incidentally, my daughter would be spared much inconvenience. Answer:—The answer is that a lot of work is done, but as you will see from this answer it is a very difficult problem; thus in the table on this page which sets forth the amount of work we did last year you will note that only 460 children were found to be unclean, and when you realise that a child with just a few nits in the head is classified unclean you will see that the situation is not altogether bad. The trouble is that the number of uncleanliness findings is much higher than the number of individual children who have been cleansed during the year, which means that the real offenders are the repeated offenders. The difficulty, of course, is a family one. Rarely is a child repeatedly verminous unless the mother or an elder sister is also verminous, so that if a child were cleansed as frequently as twice a week, there is no reason for supposing the child will be clean on the whole of the remaining five days. If you will ask your hairdresser about it you will be surprised, (that is, if you can get your hairdresser to talk confidentially) that quite a number of people who are smartly dressed, with a chic " hair do " have not got clean heads. I see that some of the papers which advertise permanent waving point out that the permanent UNCLEANLINESS Total Number of examinations in the schools by the School Nurses or other authorised persons 14,280 Total Number of individual pupils found to be infested . . 460 Number of individual pupils in respect of whom cleansing notices were issued (Section 54 (2), Education Act, 1944) 39 27 waving is all the more permanent for being carefully brushed. I hope this is true, and I hope the public will believe it, but the majority of people who spend a lot of money on a so-called permanent wave do not believe it at this time. If there is a reservoir of infestation in a house I certainly think it would do no harm to deal drastically with such a social circumstance, providing always it is the parents of the children who have to bear the stigma and not the children themselves. A larger number of these cases, however, are where mother has given up the fight and, quite frankly, I cannot help believing that the words of Dr. Ben Johnson were fall of significance when he said—" There, but for the grace of God, go I Not all these people who have given up the fight have given it up without a struggle. Some of them started their married lives with quite high ideals but the babies have come rather quickly; the housing circumstances are poor; nor always are the financial arrangements within the home so good as they might be, and although something must really be done about it whatever is done in such cases must be done with sympathy and understanding. Where, of course, it is found that boys have either nits or lice (or both), I would recommend the sternest measures be undertaken forthwith because, of course, there is no excuse for a boy's head becoming verminous. It is easy to keep the hair short enough—that really is no problem—or, contrariwise, the problem is such a simple one that it can be overcome in a few minutes. Personally I would suggest teaching the elder girls in every school hairdressing. They could practise upon one another and on the younger girls, and should be encouraged to practise on their mothers and their elder sisters. To make this attractive a classroom devoted to this could be called a "Beauty Parlour". I feel sure this would be of enormous help, particularly if in the course of lessons on hairdressing, girls were specially taught how to deal with customers whose heads were not in all respects satisfactory. NURSERY CLASSES. Question:—I do not believe in Nursery classes. I think that up to the age of five years a child is better in his mother's care than in a Nursery. What are the supposed benefits of Nursery classes? Answer:—In the first place I want to say I have a great deal of sympathy with the person who has propounded this question, and there can be no doubt that if mother has a large family and she has enough help in the home, there should be no need for Nursery classes. A child, however, requires company—children of about his own age whom he knows personally, and insofar as families are small, the child brought up at home definitely suffers from lack of this companionship. These little people who have 28 been kept at home suffer mentally when they begin to ask questions. If these questions are not answered to their satisfaction they suffer acutely by feeling a sense of repression. It is not to be expected in these days that the mother will be prepared at all times, or indeed that she can possibly at all times answer all the questions of an enquiring mind. I want to make it quite clear that whilst this is to be said on the credit side, there is a debit side which has to be faced, and that is the children come into contact with mass infection at an age younger than the sixth year which is the normal time for a child to go to school. I do believe there are more running noses and catarrhal conditions among children who go to school at a very early age than amongst the stay-at-homes, but generally speaking their mental and physical vigour compares more than favourably with that of the children who are kept at home. There is something to be said for the mother also. It is only, comparatively speaking, yesterday that man became civilised. In his natural state the care of the child was not the all absorbent twenty-four hour job it is for a mother in the 20th century. She had in her primitive state, as need she must, periods of relaxation, and today it is just as necessary for the mother's mental health as for the child's mental health that arrangements be made for The child to be cared for under such circumstances. A colleague of mine, learned in literature, sums up the situation by saying "Hamlet never went to a Nursery Class". Had he done so, I have no hesitation in saying Shakespeare would have been robbed of his "Prince of Denmark". Quite frankly children are essentially imitative, they develop most naturally by imitating other children, usually a little older than themselves; children kept at home imitate people much older than themselves—they become quaint—but are not normal. Number of Nursery classes in Barking 20 Number of children attending 620 SPECIAL SCHOOLS AND SPECIAL CHILDREN. Question:—How do Special Schools meet the needs of " Special " Children? Answer:—Faircross School was opened in the year 1922 since when a great deal of very useful information has been acquired. There is in my opinion no doubt that where a child can be taught in an ordinary school that child should be taught in such a school because, as I have said 29 elsewhere, it is at school that a child learns its niche in life, and that very possibly this is the most important thing that any child does learn at school. Where you have schools with a sufficient number of children in each age group to have "A", "B" and "C" classes it is amazing the wide variation of intelligence that can be taught in one and the same school and, of course, in some of your schools in Barking special arrangements have been made for children who are even lower than the " C " streams, and this—with certain reservations—I believe to be good. There are, however, some backward children who cannot keep step with even the lowest grade children to be found in ordinary schools, and these must unquestionably be taken away from the ordinary schools, or otherwise the whole of their mental outlook on life is going to be warped. Many of them too must, of course, be taken away because they require individual tuition and there literally is not the staff in an ordinary school to educate these children who do require special individual attention. I am strongly of opinion that the intelligence of the child, as such, is only one factor in determining whether he can remain at an ordinary school or must go to a Special School. I think the child's adaptability must be taken into account; so, also, his reaction to school life, particularly as to whether he is conscious or not of his deficiency when compared with the other children. Faircross School does also meet the special needs of delicate and physicallyhandicapped children who, because of their physical disability are unable to fit into the life of the ordinary school, but there have been many happy instances where, after a time at Faircross under open-air conditions and constant medical supervision a child has made such progress physically that it has been possible to allow him (or her) to transfer back to an ordinary school. Question:—What provision is made for the blind children of Barking? Answer:—It makes me very happy to be called upon to answer this question because although tragically it is still a problem which has to be faced, the problem has been so reduced that, compared with when I was a young man, it seems as though we have no problem at all. As a matter of fact, out of all the thousands of school children in Barking, there are only 3 partially blind requiring special educational treatment, and one only who is totally blind—this last case is particularly tragic because it was as the result of war injury. FAIRCROSS SPECIAL SCHOOL Number admitted 43 Number discharged 30 30 The story of the prevention of blindness belongs to my report on the health of the people of Barking. I can, however, briefly say that the prevention of blindness depends on meticulous attention to the eyes of the child at birth, and to very special treatment whenever such special treatment is required. I am happy to be able to say that after over a quarter-of-a-century in Public Health I personally have never known one child whose acuity of vision was impaired by reason of what was once a terrible disease—to wit—Ophthalmia Neonatorum— that is, eye disease of the newly born. Question:—What provision is made for deaf children among the school children of Barking? Answer:—I am happy to say that we have not a sufficient number of deaf children to justify a special school or class for them in Barking, and arrangements are therefore made either for their admission to a Boarding Special School, or to the Tunmarsh Lane Deaf Centre (Day) at West Ham, where with hearing aids and special tuition in lip reading suitable education is given to our deaf and partially deaf children. DEAF CHILDREN Attending Tunmarsh Lane Deaf Centre 5 At Boarding Special Schools 1 DIFFICULT CHILDREN. Question:—What should we do with difficult children? Answer:—A great law-giver once said they should be put to death. The procedure was for their fathers and mothers to indict them before a Court of Summary Jurisdiction and the penalty (the charge being proved) was death. This was all a very long time ago; the law-giver was a very wise man; there is no recorded history of the penalty being enforced, because the wise man knew that so-called difficult children are the product of difficult parents and that the last thing the parents would ever do would be to join together and bring an indictment. To talk of children of ten, eleven and twelve being out of hand is banally stupid; it is the parents—very possibly because they have been squabbling between themselves or for some other reason—who have never laid the foundations of confidence, admiration and love which alone are the grounds which any child can have for respecting its parents. The time is coming when, if the janitor of the Town Hall runs off with the Mace, it will be said to be due to the fact that when he was a lad he was not allowed to have a spoon to stir the sugar in his tea, or if an important officer is known to get frightfully annoyed when he loses his spectacles it will be ascribed to the fact that 31 his mother would not let him sit up one night to see something he wanted to see. As a matter of fact children with normal upbringing overcome these disabilities with very little difficulty and it is among children whose upbringing has been at fault that these disabilities rise like clouds in their adult lives. I have recently been looking at a picture of Croydon as it was 120 million years ago when the Dinosaur commonly lived there and the Pterodactyl had learned to fly; compared with these long ages civilisation only began—as it were—yesterday. Man, however, is much older than civilisation and for aeons of time the youngsters were, like destructive little monkeys, able to go to the fore-shore and elsewhere and enjoy themselves to their hearts' content, smashing pebbles against boulders, and father and mother never worried at all. What we have done in civilisation is to rob the child of the sea-shore as it were, so that instead of on stones children practise their native destructiveness on things that cost time and labour to create. We must remember that destructiveness is a necessary phase in natural development, not only the destruction of physical things but the destruction of ideas also; and we must share any blame when children get into mischief. Nothing in what I have written means I suggest a great Charter allowing children to do wanton destruction, because all children expect, when annoying their elders, to face condign punishment, unless of course, they are nimble enough to escape. OPEN-AIR EDUCATION. Question:—Why is it that the playing-fields attached to some schools and the playgrounds of others, are not used more when the schools are not in session? Answer:—So far as the playing-fields are concerned there is not much difficulty in answering this question, because grass is a very difficult thing to grow, so that quite apart from the question of expense the main difficulty is that it can be so easily destroyed by over-use. With regard to the ordinary playgrounds the difficulty is, I believe, one of supervision, both to avoid injury among players and, incidentally, injury to premises, but I do hope these difficulties will be overcome. The Iron Duke said that "the Battle of Waterloo was Won on the playing-fields of Eton Very possibly he thought he was making one of his usual ordinary commonsense statements, but his words became the common parlance of snobs, and although oft-quoted when I was a boy had fallen very much into disrepute. 32 As a matter of fact the truth of these words is as true today as it was in the days of the Iron Duke. The battles of the world are fought not only on the playing-fields of Eton but also in the playgrounds of our ordinary schools. What a boy does at an examination will, of course, be very largely determined by his work in the classroom, but what manner of man he is to be is worked out largely, if not entirely, in the playground. It is in the playground that the qualities of leadership are fostered; that the habit of self control is engendered, and the team spirit built up; in other words it is here—in the playground—we find opportunity for natural growth. You will, I think, agree that the proper use of these playgrounds after school will require supervision, but the supervisor need not be a man who by reason of his wonderful games record inspires the boy with hero worship. He or she need not be a psychologist. What is wanted is people who have a genuine love of children and who are loved by children and who understand children, not by reason of their learning in the abstruse sciences, but by reason of the fact that they are sympathetic towards children and can sense their point of view. I am not representing these people in any way of necessity as less intelligent than the people who have to do with more formal education, but I do submit that as in the case of all teachers they must have common sense and I use this word in its proper meaning, that is, a sense which is common to all senses and which binds them together into a united whole. Question:—I have seen photographs in the Press showing children at their lessons in the heart of the country-side. My children aged seven and ten years respectively have never had such an opportunity. Why is this? Answer:—Children in the Senior Schools may be sent to Hydon Heath Camp for a period of four weeks during term time or for periods of two weeks during the school holidays. Approximately 500 children were so accommodated from Barking during the year 1947. Hydon Heath Camp which is a National Camp for children, was used for school purposes during the war. It was staffed from Barking and mainly, although not altogether, the children at the Camp school were Barking children. To this school children were sent on what was more or less a long term policy but, since the war, so that a larger number of children would benefit, the period for each individual child has been cut down. The Camp is situated on the upland near Godalming in the heart of Surrey. I do trust there will be a sufficient number of Camps in the country to accommodate a larger number of children for long periods instead of short periods of time. 33 SEX EDUCATION. Question:—Should Senior Schools be taught the elementary facts of sex life? Answer:—Personally I would deprecate any special course or courses devoted to the biology of sex. Any teaching about sex should be purely incidental. In nature study classes it is possible to include teaching on sexual reproduction in plants and some members of the animal kingdom. With such basic training adolescents readily appreciate any further teaching about the physiology of human reproduction—indeed this follows so naturally that there will scarce be need for further training. The art of teaching is a life-long study and while I feel it proper for me to advise generally, final decisions as to how to draw up such a curriculum and how to teach must be left entirely to those professional people who have made this their special study. RADIOGRAPHY. Question:—Is it possible for all children to be X-rayed? (The man who asked this question added " I think it is the finest thing out "). Answer:—It is possible for all school children to be X-rayed, and it is intended that this shall be done as opportunity permits. During the latter part of the year the Mobile X-ray Unit attended at the Barking Hospital where 1,387 school children were X-rayed. Because it was not possible to do all the children on this occasion it was decided to concentrate on the older children who would be leaving school at an early date. 34 SCHOOL HEALTH SERVICE. MEDICAL INSPECTION RETURNS Year ended 31st December, 1947. TABLE I. Medical Inspection of Pupils attending Maintained Primary and Secondary Schools. A.—PERIODIC MEDICAL INSPECTIONS. Number of Inspections in the prescribed Groups: Entrants 1,786 Second Age Group 2,047 Third Age Group 1,700 Total 5,533 Number of other Periodic Inspections 3,437 Grand Total 8,970 B.—OTHER INSPECTIONS. Number of Special Inspections 10,531 Number of Re-Inspections 11,768 Total 22,299 C.—PUPILS FOUND TO REQUIRE TREATMENT. Number of Individual Pupils found at Periodic Medical Inspection to Require Treatment (excluding Dental Diseases and Infestation with Vermin). Group (1) For defective vision (excluding squint) (2) For any of the other conditions recorded in Table IIA. (3) Total individual pupils (4) Entrants 29 234 246 Second Age Group 68 158 209 Third Age Group 89 165 242 Total (prescribed groups) 186 557 697 Other Periodic Inspections 116 441 529 Grand Total 302 998 1,226 35 TABLE II. A.—RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION. Defect Code No. Defect or Disease (1) Periodic Inspections Special Inspections No. of defects No. of defects Requiring treatment (2) Requiring to be kept under observation, but not requiring treatment (3) Requiring treatment (4) Requiring to be kept under observation, but not requiring treatment (5) 4 Skin 113 12 936 8 5 Eyes a. Vision 302 15 161 11 b. Squint 34 4 61 3 c. Other 26 6 500 25 6 Ears a. Hearing 11 2 15 5 b. Otitis Media 5 — 32 - c. Other 38 3 335 33 7 Nose or Throat 307 128 231 34 8 Speech 21 11 18 3 9 Cervical Glands 11 9 62 24 10 Heart and Circulation 17 22 26 15 11 Lungs 55 34 46 31 12 Developmental— a. Hernia 3 3 5 — b. Other 9 13 6 — 13 Orthopaedic— a. Posture 26 29 11 — b. Flat foot 62 13 16 1 c. Other 115 38 61 2 14 Nervous system— a. Epilepsy 2 9 4 — b. Other 14 6 12 4 15 Psychological— a. Development 25 9 30 1 b. Stability - - 19 18 16 Other 761 104 3,913 362 36 TABLE II. B.—CLASSIFICATION OF THE GENERAL CONDITION OF PUPILS INSPECTED DURING THE YEAR IN THE AGE GROUPS. Age Groups Number of Pupils Inspected A.x (Good) B.+ (Fair) C.— (Poor) No. % of col. 2 No. % of col. 2 No. % of col. 2 (1) (2) (3) (4) (5) (6) (7) (8) Entrants 1,786 562 31.47 1,218 68.20 6 .33 Second Age Group 2,047 672 32.83 1,371 66.98 4 .19 Third Age Group 1,700 602 35.41 1,091 64.18 7 .41 Other Periodic Inspections 3,437 1,138 33.11 2,291 66.66 8 .23 Total 8,970 2,974 33.15 5,971 66.57 25 .28 X A.=Excellent Nutrition. + B. = Normal Nutrition. —C. - Slightly sub-normal Nutrition. Children with " bad" Nutrition (classification D year 1946) = NIL. TABLE III. Treatment Tables. GROUP I.—MINOR AILMENT S (excluding Uncleanliness, for which see Table V). (a) Number of Defects treated, or under treatment during the year. Skin— Ringworm—Scalp— (i) X-Ray treatment 6 (ii) Other treatment 3 Ringworm—Body 13 Scabies 110 Impetigo 138 Other skin diseases 752 Eye Disease (External and other, but excluding errors of refraction, squint and cases admitted to hospital). 497 Ear Defects 394 Miscellaneous (e.g. minor injuries, bruises, sores, chilblains, etc.) 3,845 Total 5,758 (b) Total number of attendances at Authority's minor ailments clinics 27,156 37 GROUP II.—DEFECTIVE VISION AND SQUINT (excluding Eye Disease treated as Minor Ailments—Group I.) No. of defects dealt with. ERRORS OF REFRACTION (including squint) 749 Other defect or disease of the eyes (excluding those recorded in Group I) — Total 749 No. of Pupils for whom spectacles were (a) Prescribed 414 (b) Obtained 503 GROUP III.—TREATMENT OF DEFECTS OF NOSE AND THROAT. Received operative treatment:— Total number treated. (a) for adenoids and chronic tonsilitis 223 (b) for other nose and throat conditions — Received other forms of treatment 308 Total 531 GROUP IV.—ORTHOPAEDIC AND POSTURAL DEFECTS. (a) No. treated as in-patients in hospitals or hospital schools 7 (b) No. treated otherwise e.g. in clinics or out-patient departments 908 GROUP V.—CHILD GUIDANCE TREATMENT AND SPEECH THERAPY. No. of pupils treated (a) under Child Guidance arrangements — (b) under Speech Therapy arrangements 37 38 TABLE IV. Dental Inspection and Treatment. (1) Number of pupils inspected by the Authority's Dental Officers— (a) Periodic age groups 5,438 (b) Specials 746 (c) TOTAL (Periodic and Specials) 6,184 (2) Number found to require treatment 3,366 (3) Number actually treated 2,548 (4) Attendances made by pupils for treatment 10,511 (5) Half-days devoted to: (a) Inspection 33 (b) Treatment 966 Total (a) and (b) 999 (6) Fillings: Permanent Teeth 3,715 Temporary Teeth 1,282 Total 4,997 (7) Extractions: Permanent T eeth 1,669 Temporary Teeth 5,100 Total 6,769 (8) Administration of general anaesthetics for extraction 3,089 (9) Other Operations: (a) Permanent Teeth 2,851 (b) Temporary Teeth 22 Total (a) and (b) 2,873 TABLE V. Infestation with Vermin. (i) Total number of examinations in the schools by the school nurses or other authorised persons 14,280 (ii) Total number of individual pupils found to be infested 460 (iii) Number of individual pupils in respect of whom cleansing notices were issued (Section 54 (2), Education Act, 1944) 39 (iv) Number of individual pupils in respect of whom cleansing orders were issued (Section 54 (3), Education Act, 1944) -