EAL 36 C439(1) EACINF Borough of Eling ANNUAL REPORT of the Medical Officer of Health AND School Medical Officer 1945 THOMAS ORR, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Medical Officer of Health, School Medical Officer and Medical Superintendent of the Isolation and Maternity Hospitals. Perry & Routleff Ltd., Printers, EAL 36 Borough of Ealing. ANNUAL REPORT of the Medical Officer of Health AND School Medical Officer 1945 THOMAS ORR, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Medical Officer of Health, School Medical Officer and Medical Superintendent of the Isolation and Maternity Hospitals. Perry & Routleff Ltd., Printers 3 To the Mayor, Aldermen and Councillors of the Borough of Ealing. I have the honour to present to you the Annual Report for the year 1945 on the work of the Health Department, the thirty-first that I have presented. I wish to direct your attention to the main features in it. The general death-rate remains low, 10.1 per 1,000 of population, the birth-rate of 17.2 is less than that for 1943 or 1944 hut is higher than in the 20 pre-war years and the infant death-rate of 40 per 1,000 births is equal to the lowest recorded in the previous ten years and compares well with the rate for the whole of England and Wales of 46 per 1,000 births. But the most remarkable feature is the entire absence of maternal deaths during the year. It may reasonably be claimed that this surprising absence of maternal mortality is the direct result of the well developed maternal health service which you have always so heartily encouraged. As to infectious diseases the number of cases of diphtheria has remained low with only one death ; scarlet fever though the number of cases was higher than in the previous year was very mild in character, there being no deaths in the 340 cases that occurred. With the cessation of hostilities the ambulance service had to be developed anew with the disbandment of the Civil Defence Services and it came within the province of the public health department. In the report the figures relating to the use made of the ambulances indicate what a valuable service it has become. In April of 1945 the School Health Service came within the general control of the Middlesex County Council but the change has meant little to the School Health Service which has been previously administered by the Council as the local education authority. The records of medical inspection and treatment in the report bear out this statement. I have the honour to be Your obedient Servant, Medical Officer of Health. Town Hall, Ealing, W.5. October, 1946. SUMMARY OF STATISTICS. Area (in Acres) 8,739 Population (Census, 1931) 117,707 Population (estimated middle of 1945) 160,830 Rateable Value, 1st April, 1945 £1,873,377 Net Product of a Penny Rate, 1944-45 £7,608 Live Births:— Legitimate Males, 1,341 Females, 1,244 Total, 2,585 Illegitimate Males, 91 Females, 92 Total, 183 2,768 Birth-Rate per 1,000 of Estimated Population 17.2 Still-Births:— Males, 32 Females, 31 Total 63 Rate per 1,000 total Births (Live and Still-Births) 22.3 Deaths: Males, 760 Females, 860 Total 1,620 Death-Rate per 1,000 of Estimated Population 10.1 Deaths of Infants under one year of age:— Legitimate Males, 65 Females, 36 Total, 101 Illegitimate Males, 3 Females, 6 Total, 9 110 4 Death Rate of Infants under one year of age:— All Infants per 1,000 Live Births 40 Legitimate Infants per 1,000 Legitimate Live Births 39 Illegitimate Infants per 1,000 Illegitimate Live Births 49 Deaths from Diseases and Accidents of Pregnancy and Childbirth:— From Sepsis Nil Death-Rate 1,000 Total Births Nil From other Causes Nil ,, ,, „ Nil Total Nil * Nil Total Deaths Measles 2 Whooping Cough 1 Diphtheria 1 Scarlet Fever - Influenza 10 Tuberculosis of Lungs 64 Other Forms of Tuberculosis 6 Diarrhoea (under 2 years of age) 13 5 Causes of Death, 1945. Cause of Death. Deaths, 1945 Total Deaths 1944 Male Female Total Typhoid and Paratyphoid Fevers - - - - Cerebro-Spinal Fever 1 1 2 1 Scarlet Fever - - - 1 Whooping Cough 1 - 1 2 Diphtheria 1 - 1 1 Tuberculosis of Respiratorv Svstem 34 30 64 66 Other Forms of Tuberculosis 3 3 6 5 Syphilitic Diseases 10 3 13 9 Influenza 4 6 10 12 Measles - 2 2 - Acute Infectious F.ncephalitis - - - - Cancer of B. Cav. and Oesoph. (M.), ; Uterus (F.) 10 16 26 33 Cancer of Stomach and Duodenum 27 16 43 42 Cancer of Breast - 33 33 34 Cancer of all other Sites 106 85 191 186 Diabetes 3 7 10 9 [ntra-Cran. Vase. Lesions 54 97 151 176 Heart Disease 182 245 427 415 Other Diseases of Circulatory System 31 45 76 64 Bronchitis 37 38 75 91 Pneumonia 46 37 83 79 Other Respiratory Diseases 10 13 23 22 Ulcer of Stomach or Duodenum 14 4 18 16 Diarrhoea (under 2 years) 9 4 13 12 Appendicitis 3 7 10 3 Other Digestive Diseases 10 20 30 31 Nephritis 14 17 31 34 Puerperal and Post-Abortive Sepsis - - - 1 Other Maternal Causes - - - 2 Premature Birth 17 11 28 36 Congenital Malformations, Birth Injury, Infantile Diseases 23 19 42 54 Suicide 6 2 8 12 Road Traffic Accidents 13 7 20 15 Other Violent Causes 25 31 56 98 All other Causes 66 61 127 129 Total 760 860 1,620 1,691 6 Table Showing Birth-Rate, Death-Rate and Infant Death-Rate for the Borough of Ealing. Period Birth-Rate Death-Rate Infant Death-Rate 1921—1925 15.4 10.7 58 1926—1930 14.5 10.9 49 1931—1935 14.2 10.1 46 1936—1940 14.7 10.1 45 1941 14.5 10.9 49 1942 17.2 10.3 48 1943 18.8 11.2 40 1944 19.4 10.9 41 1945 17.2 10.1 40 Maternal Mortality per Thousand Births. Period Ealing England and Wales 1931—1935 4.10 4.12 1936—1940 2.18 2.95 1941 1.53 2.23 1942 1.79 2.01 1943 2.95 2.29 1944 0.97 1.93 1945 — 1.79 HOSPITALS. Isolation Hospital. The Clayponds Isolation Hospital at South Ealing, which is under the control of the Ealing and Brentford & Chiswick Hospitals Committee, has a normal capacity of 142 beds. Only 34 beds were available for the treatment of cases of infectious disease. Maternity Hospital. The Perivale Maternity Hospital of 43 beds is also under the control of the Ealing and Brentford & Chiswick Hospitals Committee. Throughout the year this hospital was taxed to the uttermost by the demands for admission, the accommodation being fully booked months in advance throughout the year. 7 AMBULANCE FACILITIES. 1. For Infectious Disease. The Ealing and Brentford & Chiswick Hospitals Committee provide a motor ambulance for the removal of cases of infectious disease to the Clayponds Isolation Hospital at South Ealing. 2. For Accidents and Cases of Acute Illness. Before the outbreak of War in September, 1939, the Borough Ambulance Service was controlled by the Chief Officer of the Fire Brigade, but when War was declared the ambulances were returned to the Public Health Department and drivers and attendants drawn from members of the Civil Defence Ambulance Service were used to keep the ambulances running. In April this year with the end of the War and the disbandment of the Civil Defence Service, the Ambulance Service was re-organised on a peace-time basis. For this purpose six drivers and six attendants were appointed to man the ambulances and a temporary ambulance station was provided in Longfield Depot at the back of the Town Hall. Three suitably equipped ambulances were available and later a comparatively new Civil Defence Ambulance was purchased as a reserve. Another Civil Defence Ambulance was converted into a utility car which is used, amongst other things, for the conveyance of children to Health Centres or hospitals. The following table shows the extent of the calls made upon the Service during the year. Cases of Accident 470 Cases of Illness 3,821 Total cases 4,291 Number of journeys outside the Borough (included above) 657 Annual Mileage 29,943 8 MATERNITY AND CHILD WELFARE. The work of the Maternity and Child Welfare Service is largely governed by the number of births which occur annually. It follows, therefore, that the increased number of births in recent years has occasioned a corresponding increase in the demands on the maternity service. During the year under review there were 2,768 live births, this giving a birth-rate of 17.2 per thousand of population. This rate is below those for 1943 and 1944, which were 18.8 and 19.4 respectively. A very large proportion of the births, 76 per cent., occur in maternity hospitals and nursing homes, as shown by the following figures: Births in Perivale Maternity Hospital 691 Births in other hospitals 1,032 Births in nursing homes 380 Births at home 665 2,768 The infant death-rate of 40 per thousand births is low compared with that for England and Wales of 46 and is equal to the lowest recorded in Ealing during the past ten years. As far as maternal mortality is concerned, Ealing is in the surprising position of having no maternal deaths during the year. The attendances at the Health Centres have continued at a high level. Facilities have been made available in a Church Hall at West Twyford for the issue of National Dried Milk, fruit juices, etc., and also for the weighing of young babies. This arrangement obviates the mothers in this area, remote from any of the regular Centres, having to make frequent long journeys to obtain necessary supplies for their children. The arrangements made in 1944 for the care of illegitimate children, whereby the mothers can be admitted to pre-natal and post-natal hostels, have proved most useful. During the year 17 cases were admitted to one, or both, of the hostels. The scheme is operated locally in close co-operation with the Ealing Deanery Moral Welfare Association while the admissions to the hostels are arranged by the Middlesex County Council. There can be no doubt that the help given in these cases has proved of very great value to both mothers and children. Information is now obtained regarding weight at birth of all infants who are 5 lbs. 8 ozs., or less, when born. During the 9 year there were 51 such cases. Special provision is made at Perivale Maternity Hospital and at the County Hospitals for the care of premature infants. The Health Visitors are now responsible for investigating cases of adoption. Eight notices were received under Section 7 of the Adoption of Children (Regulation) Act, 1939, and in these cases the Health Visitors have carried out the supervision required by the Act. In addition, visits were made to 72 other cases of adoption in which notice had not to be given under the Act. In all cases, reports are submitted to the local Court, at which application is to be made for the Adoption Order, or to registered adoption societies who have asked for visits to be made. The special war-time services—the distribution of National Dried milk, fruit juice and cod liver oil and the booking of expectant mothers for evacuation have continued at the Health Centres, despite the cessation of hostilities. During the year, 33 expectant mothers took advantage of the opportunity to have their confinement away from London. When the Government Evacuation Scheme was terminated at the end of August, the scheme was continued by the Ministry of Health as an emergency measure to help meet the urgent need for maternity hospital accommodation. Local authorities booking accommodation under the new scheme had, however, to accept responsibility for the cost of treatment and maintenance. In December, the Middlesex County Council decided that they would accept responsibility for all cases booked under the scheme, whose homes are within the area of the County. During the year the Council decided that all the facilities for treatment of children under five years of age, should be offered free of charge. This measure, besides obviating the collection of many trivial sums of money, ensures that children are put forward for treatment without any delay caused by the completion of assessment forms and the payment of fees. It also brings the Maternity and Child Welfare Scheme into line with the School Medical Service, all treatment of school children having to be free, as from the 1st April, 1945. In February a scheme for the provision of domestic helps was brought into operation, the cost being borne by the Ministry of Health. Help in the home is provided in cases of illness and other emergencies and the assistance given in such cases proved very valuable. At the end of the year an average of twenty workers, mostly part-time, were employed, under the direction of a Supervisor appointed specially for the work. 10 Summary of the Visits made by the Health Visitors. Visits to children under 12 months: — (1944) (1945) First visits 2,456 2,617 Return visits 6,599 5,442 Visits to children 1 to 5 years of age 8,846 8,006 Visits to expectant mothers 1,359 1,572 Visits to investigate infant deaths and still-births 67 52 Special visits or investigations 327 207 Visits to cases of Ophthalmia Neonatorum 2 6 Visits to cases of Measles and Whooping Cough 325 269 Visits to cases of Scarlet Fever on discharge from the Isolation Hospital 84 97 Inspections of Women's Lavatories 67 37 Visits to children under care of foster-mothers 313 363 Other visits 117 326 Total Visits 20,562 18,994 Summary of the Work at the Health Centres. Mothers. (1944) (1945) Expectant Mothers attending Ante-Natal Clinics:- Attending for the first time 2,071 2,258 Total attendances 12,701 12,885 Nursing mothers attending Post-natal Clinics :— Attending for the first time 155 123 Total attendances 161 130 Children. Children attending Centres for the first time:— Under one year of age 2,406 2,275 One to five years of age 290 365 Total attendances made by children Under one year of age 30,069 28,629 One to five years of age 12,186 13,541 Medical Examination of Pre-School Children.—The number of complete medical examinations of children from one to five years of age are indicated in the following table:— Age-Group No. of Examinations (1944) (1945) 1 year to 18 months 964 1,318 18 months to 2 years 474 723 2 years to 3 years 374 602 3 years to 4 years 389 524 4 years to 5 years 283 388 2,484 3,555 11 DENTAL TREATMENT. The number of new mothers inspected and treated during the year totalled 522, a few less than in the previous year. The number of children inspected and treated amounted to 196. This figure is greater by 47 than in the previous year. Attendances made by mothers for treatment totalled 2,211 and by children 365. Fillings inserted in permanent teeth amounted to 281, and 16 temporary teeth were filled. Extractions of permanent teeth totalled 2,101 and temporary extractions amounted to 480. This figure for extractions is larger in each case than the figures for 1944. The figure for fillings is smaller in each case than that of the preceding year. Treatment for gum infections in mothers was given in 166 separate cases, and 78 mothers had their teeth scaled. The number of mothers who were supplied with full or partial dentures totalled 131, a slight increase over those fitted in 1944. Other operations were dressings for painful teeth and for ulcers of the tongue and inner cheek and applications for the various gum conditions. These items of treatment required 1,209 separate treatments. WAR-TIME NURSERIES. Nine nurseries continued in operation throughout the year. Seven of these are classed as whole-time nurseries, being open from 6.30 a.m. to 6.30 p.m. from Monday to Saturday, while the remaining two are classed as part-time, being open from 9 a.m. to 4 p.m. on Mondays to Fridays. There was little reduction in the demand for admission after the War had ended. In fact, when the future policy with regard to Nurseries came under consideration in January, 1946, it was decided that all seven whole-time nurseries should be continued as part of the Council's Maternity and Child Welfare Service, while the two part-time nurseries should be taken over by the Education Department and continued as nursery classes. One of them, however, St. John's, was later restored as a day nursery with an experimental period of six months, after which the position would be reconsidered. The attendances at the nurseries during the year were at follows:— [##] Date opened Capacity Days open Total attendances Average attendance Stanhope 17/11/41 70 302 15,831 52 Culmington Road 26/1/42 85 303 16.189 53 Cuckoo 9/3/42 70 301 14,063 47 Perivale 5/10/42 58 301 9,280 31 Northolt 26/10/42 40 302 8,435 28 St. Mark's 4/1/43 44 301 11,061 37 Oldfields 19/7/43 50 301 12,275 41 St. John's 5/10/42 60 251 10,074 40 Wood End 5/10/42 28 251 5,149 21 12 CHILD LIFE PROTECTION. The work of supervision of foster-mothers, carried out by the Health Visitors who have all been appointed Child Protection Visitors, is summarized in the following table:— Number of children on the register at the beginning of the year 70 (Number of fostermothers having care of the above children, 61). Number of children registered during the year 38 Number of children removed from register during year 71 Number of children on register at end of year 39 (Number of fostermothers having care of the above children, 36). Number of visits made by Health Visitors 363 MIDWIFERY SERVICE. At the end of the year, 11 midwives were employed by the Council in connection with the domiciliary midwifery service. The cases attended by the midwives were as follows:— Number of Confinements attended:— (a) as midwife 406 (b) as maternity nurse 97 503 During the year the Council decided upon an alteration in the charge for the services of the midwives. Formerly the fee for the services of the midwives, whether engaged as a midwife or as a maternity nurse with a doctor in charge of the case, was £2. 10s. Od. In cases where the nurse was engaged without a doctor and medical aid was necessary, the husband was then required to meet the cost of the medical fees, either in whole or in part. Now, the fee for the nurse engaged as a midwife has been increased to £3, but this fee also covers the cost of any medical aid which the nurse has to call in. Whenever necessary this fee can be reduced in accordance with the family circumstances. The shortage of candidates having made it difficuit to fill vacancies in the midwifery staff, and the added shortage of housing accommodation made it almost impossible to secure midwives. To meet this situation the Council were asked to provide housing accommodation for new midwives, as recommended by the Midwives Salaries Committee and in this way three midwives have been provided with suitable homes and the staff made complete. An alteration in the rules of the Central Midwives Board regarding the qualifications of the second person present during the 13 administration of nitrous oxide and air analgesia, has made practicable the giving of this additional facility at confinements in the home. Steps are being taken to complete the training of the staff and when this has been done every mother will be able to have an analgesic in her own home. SUPERVISION OF MIDWIVES. Number of midwives practising at end of year :— Midwives in service of Council 11 „ at Perivale Maternity Hospital 9 „ in independent practice 5 „ in private nursing homes 6 All of these midwives possessed the certificate of the Central Midwives Board. Number of births attended by midwives:— When acting in the capacity of midwife:— (a) In private Nursing Homes 94 (b) At the patient's home 438 When acting in the capacity of maternity nurse (a doctor being in attendance :) (a) In private Nursing Homes 229 (b) At the patient's home 120 The following table gives information regarding nursing homes in the Borough:— No. of Homes No. of Beds Number of Nursing Homes on Register at beginning of year 14 (6) 212 (61) Number of New Homes registered — — Number of Homes discontinued — — Number of Nursing Homes on Register at end of year 14 (6) 212 (61) The figures in brackets indicate the number of Homes and the number of beds wholly or partly devoted to the reception of maternity cases. The Medical Officer in charge of the supervision of Nursing Homes made 15 special visits during the year. SUPERVISION OF NURSING HOMES. 14 PREVALENCE OF, AND CONTROL OVER INFECTIOUS AND OTHER DISEASES. Cases of Infectious Disease occurring in the Borough. Disease 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 Smallpox — — — — — — — — — — — — — Diphtheria 71 195 228 52 123 142 92 33 48 28 13 17 14 Scarlet Fever 476 493 400 408 317 383 303 116 166 180 448 228 340 Enteric Fever (including Paratyphoid) 4 3 7 8 5 2 5 4 5 — 1 — — Puerperal Fever 3 3 7 3 4 — — — — — — — — Puerperal Pyrexia 28 14 11 9 24 46 40 30 30 39 41 42 47 Pneumonia : Primary 56 72 59 85 60 83 50 66 97 105 123 142 110 Influenzal 32 17 11 14 37 18 26 10 27 17 40 9 14 Acute Poliomyelitis 3 — 1 2 7 6 1 1 9 2 2 2 3 Cerebro-Spinal Fever — — — — 1 1 — 7 15 5 1 — 6 Malaria 1 1 — 1 — — — 1 1 2 — — — Dysentery — — 1 1 5 12 2 — 3 6 5 24 60 Erysipelas 36 43 28 28 27 41 37 29 26 36 41 30 26 Polio-Encephalitis — 1 — 1 — — — — — — 1 — — Tuberculosis : Pulmonary 154 139 157 139 178 142 149 156 195 223 233 173 194 Non-Pulmonary 23 24 23 22 37 33 38 30 28 38 51 30 23 Ophthalmia Neonatorum 8 5 3 4 7 15 16 5 2 8 4 3 3 Total 895 1010 936 777 832 924 759 488 653 689 1004 700 810 The following non-civilian cases of infectious disease are included in the above table : Scarlet Fever, 3. Diphtheria, 2. Pneumonia, 1. Dysentery, 37. Cerebro Spinal Fever, 1. Scari.et Fever.—Out of 340 cases of scarlet fever only 125 cases were removed to hospital. Accommodation for cases of scarlet fever at the Isolation Hospital has been much reduced and only in exceptional circumstances have cases been admitted. There were no deaths from this disease. Diphtheria.—All the cases of diphtheria were removed to hospital. There was one death from this disease. Diphtheria 1 minimization.—The protection of children by means of immunization is considered on page 31. 15 Measiles Whooping Measles and whooping rough became notifiable under the Measles and Whooping Cough Regulation, 1939. The following number of cases were notified:— Measles 2,330 Whooping Cough 236 There were two deaths from Measles and one death from Whooping Cough during the year. The number of cases of Measles admitted to hospital was 35. Tuberculosis.—The number of cases of Tuberculosis notified during the year and the number of deaths which occurred were as follows :— Age Periods New Cases Deaths Pulmonary Non-Pulm'y Pulmonary Non-Pulm'y Male F'male Male F'male Male F'male Male F'male 0—1 — — — — — — — — 1—5 4 — 1 — 1 — — — 5—10 3 — — 1 — — — — 10—15 1 4 1 2 —• — — — 15—20 11 16 2 1 — — — 20—25 12 17 — 1 2 6 — — 25—35 24 33 2 5 5 9 1 1 35—45 22 15 2 3 5 6 1 1 45—55 7 4 — 1 5 2 1 55—65 16 1 — — 12 3 1 — 65 upwards 1 3 — 1 4 2 — Total 101 93 8 15 34 30 3 3 16 SANITARY CIRCUMSTANCES OF THE BOROUGH. Sanitary Inspection of the Borough.—The following is a summary of the work carried out by the Sanitary Inspectors during the vear:— General. Number of Premises inspected on Complaint 2,085 Number of Nuisances observed by Inspectors 49 Number of Premises inspected in connection with Infectious Disease 424 Number of Premises visited by Periodical Inspection (Cowsheds, Dairies, Slaughterhouses, Factories, etc.) 175 Number of Houses inspected under House-to-House Survey — Food Inspections 1,155 Total Number of Re-inspections 6,391 Other Inspections 813 Total Number of Inspections and Re-inspections 11,092 Number of Intimation Notices given 788 Number of other Letters written 1,059 Number of Statutory Notices served 166 Proceedings before Magistrates — Complaints received during the year were 785 in excess of the number dealt with in 1938. This increased considerably the work of the Sanitary Inspectors and was no doubt due to the neglect of property which was inevitable during the war owing to the shortage of labour and materials. This applies particularly to the Greenford area where deterioration has occurred in property which was in comparatively good condition before the war. Control of Civil Building. In connection with the Regulations for the Control of Civil Building, Certificates of Essentiality have been issued in respect of 348 houses at an estimated cost of £18,100 7s. 7d. The inspections which had to be made for this purpose added further to the work of the Sanitary Inspectors as a large proportion of these repairs to property would have been done in the ordinary course by the property owners without reference to the Health Department. The Sanitary Inspectors have dealt with all applications for Building Licences which involved work for which Statutory Notices under the Public Health Act could have been served. 17 INSPECTION AND SUPERVISION OF FOOD. Meat and Other Foods.—There were no infringements of the Public Health (Meat) Regulations. No meat is sold from stalls in the Borough. There are three private slaughterhouses but no animals were slaughtered in them during the year. There is no public slaughterhouse in the Borough. The Meat Depot which was established in a central position at the beginning of the war served a large area in Middlesex including Ealing. A large quantity of meat has been inspected there by the Sanitary Inspectors necessitating almost a daily visit. The following table indicates the amount of various foodstuffs which have been condemned by the Sanitary Inspectors as unfit for food in the course of their inspections at the meat depot and at the various food premises in the Borough:— lbs. Beef 4,264½ Pork 944 Mutton 1,091½ Veal 5 Offal 542 Bacon 144½ Fish 5,678½ Sausage Meat 229 Tinned Meat 7,911¾ Fruit and Vegetables 18,132 Confectionery 1,462 Cocoa 5,330¼ Cereals 1,162½ Assorted Food 26,842 73,739½ Meat (tins) 1,858 Milk (tins) 3,688 Fish (tins) 2,195 Assorted Articles 720 Eggs 2,864 Assorted tins, jars and packets 912 Tinned Fruit and Vegetables 1,097 18 The following is a summary of the work carried out by the Rodent Operative, acting under the direct supervision of the Chief Sanitary Inspector. Complaints 500 Premises inspected 583 Premises found to be infested with : (1) Rats 409 (2) Mice 45 Estimated number caught : (1) Rats 686 (2) Mice 429 Fees received for treatment . £301 10s. Od. Premises treated free of charge 37 SCHOOL HEALTH SERVICE. The School Health Service continued to function as in the previous years except with the necessary modifications of procedure brought about with the coming into operation of the Education Act, 1944, on the 1st April. Dental work was continued by the Senior Dental Surgeon with the assistance of three part-time Dental Officers. Diphtheria immunization proceeded on the lines previously described. The Child Guidance Centre staffed by a team consisting of a Psychiatrist, a Psychologist and a Psychiatric Social Worker, continued its work as in the previous year. STAFF. Dr. Scott, part-time Psychiatrist, resigned at the end of the year and Dr. Portia Holman was appointed in his place. Mrs. Anthony, part-time Psychologist, and Mrs. Irvine, Psychiatric Social Worker, also resigned and were replaced by Dr. Bick and Miss M. Browne respectively. Miss M. G. Penny, School Nurse, resigned, and was replaced by the temporary appointment of Miss B. Cassell. Miss D. Bissell, the Speech Therapist, resigned at the end of September and her place was taken by Miss E. J. Haw ley. 19 MEDICAL INSPECTION. Medical Inspection included (1) the routine inspection in the schools of children in the.two age-groups, (a) entrants, and (b) children at 13 years ; (2) the special inspection of children referred by the Head-teachers, School Nurses and School Enquiry Officers and (3) the annual examination of physically handicapped children and of children requiring to be kept under observation. FINDINGS OF MEDICAL INSPECTION. Among the 5,440 children examined in a routine manner there were 478 defects, excluding uncleanliness and dental disease, requiring treatment and 872 requiring to be kept under observation. The examination of the 8,165 children submitted specially revealed 3,562 defects requiring treatment and 661 requiring to be kept under observation. Of the 5,440 children examined at the routine inspections, 456 or 8.4 per cent were found to require treatment for one or more defective conditions, other than defective teeth or verminous condition. NUTRITION. The state of nutrition of the children examined at routine medical inspection is shown in Table II. The classification is in accordance with the suggestions of the Board of Education as set out in Administrative Memorandum No. 125 of 1935. Of the 5,440 school children examined 8.7 per cent, were classified as of excellent nutrition, 88.5 of normal nutrition and 2.8 slightly subnormal. The School Nurses continued to visit the schools at monthly intervals to survey the children and to enquire from the Headteachers whether there were any children whose condition was not entirely satisfactory. Appointments were made where necessary for selected children to be seen at the Health Centres by the Medical Officers. UNCLEANLINESS. Cleanliness surveys were made as usual on three occasions during the year and additional visits were paid at the Headteacher's request where the usual standard of cleanliness was not being maintained. The results of these were found to be very satisfactory, only 2.6 per cent, of the children being found to have nits or vermin on the head. In the following table the results are tabulated for comparison with those of previous years. 20 Year Average Number on Rolls No. of examinations for verminous condition Number of children excluded Number of warning notices issued T otal Number of unclean children excluded or warned Percentage of children unclean whether excluded or not Legal proceedings taken under attendance Bye-laws 1938 18,107 43,372 731 584 1,315 3.0 18 1939 18,174 (End of (August.) 29,357 520 303 823 2.8 6 1940 8,600 (Nov.) 25,615 466 325 791 3.0 1 1941 14,100 25,956 557 480 1,037 4.0 6 1942 16,542 39,937 674 639 1,313 3.3 61 1943 16,900 44,607 675 646 1,321 3.0 32 1944 14,367 38,546 535 447 982 2.5 25 1945 19,500 43,563 595 563 1,158 2.6 — ARRANGEMENTS FOR TREATMENT. Minor Ailments and Diseases of the Skin.—The treatment of minor ailments carried out at the Health Centres is shown in Table 3, Group 1 (page 34). As many as 86.3 per cent, of the children found to be suffering from minor ailments on medical inspection attended the Health Centres for treatment. The number of cases treated and the total number of attendances made were as follows :— Conditions Treated No. of cases treated Total attendances made Skin: Ringworm 26 110 Scabies 345 482 Impetigo 156 1,262 Others 282 1,500 Minor eye defects 167 900 Minor ear defects Miscellaneous : 228 2,516 Minor injuries 1,268 7,617 Sores Others Total 2,472 14,387 21 SCABIES. The treatment of Scabies was continued with benzyl benzoate. During the year there were treated 345 school children, 149 preschool children and 468 cases referred by General Practitioners and Factory Medical Officers, making a total of 962 cases treated. Forty-three of these cases required re-treatment. All who attended the Health Centre for treatment were encouraged to bring their relatives or others living in contact with them, if there was any likelihood that they were suffering from the same condition. The following table shows that the number of cases of scabies in school children has been decreasing since 1943 :— Number of School Children treated for Scabies. Year At Health Centres Otherwise Total Cases 1934 12 2 14 1935 12 — 12 1936 25 — 25 1937 97 — 97 1938 128 7 135 1939 86 23 109 1940 141 8 149 1941 328 19 347 1942 501 — 501 1943 622 3 625 1944 473 — 473 1945 345 — 345 Defective Vision and Diseases of the Eye.—The following is the report of the Ophthalmic Surgeon, Dr. Freeman Heal During the year 1945, 606 new cases were examined. Of these 352 were seen at Mattock Lane, and 254 at Ravenor Park Health Centre. Re-inspections numbered 822, of which 423 were at Mattock Lane and 399 at Ravenor Park. Summary of work :— Prescriptions for glasses were given in 1,005 cases. The number of pairs of glasses obtained was 933. 22 Abnormal eye conditions, other than refractive errors, were as follows :— Congenital abnormalities : Re- New Cases inspections Squint 82 240 Congenital Nystagmus ... 6 9 Obstruction of nasal duct 7 3 Coloboma of oveal tract... 2 Aniridia ... 1 — Congenital Cataract — 3 Progressive Myopia — 1 Abnormalities due to Infections : Blepharitis 5 3 Styes 4 — Chronic conjunctivitis 2 — Sub-acute conj unctivitis 1 — Keratitis — 1 Corneal scarring — 2 Phthisis buibi — 1 Retinitis proliferans 1 Abnormr lities due to Trauma : Foreign Bodies in Eye 3 — Abnormalities of unknown etiology : Optic Atrophy — 2 Paralvsis of External Rectus 1 — Apart from congenital abnormalities few eye diseases were seen, an indication that the general health and nutrition of the children is satisfactory. Defects of Ear, Nose and Throat.—The examination and treatment of children suffering from defects of the ear, nose and throat was continued during the year by Mr. Arthur Miller, F.R.C.S. During 1945, 293 new cases were examined at the Mattock Lane and Ravenor Park Health Centres. Of these 254 were school children referred from routine and special school inspections and 39 from the Child Welfare Centres. The children were referred on account of : 1. Deafness due to otorrhoea, either acute or chronic, and chronic catarrh of the middle ear and eustachian tube. The former condition was treated by cauterization if there were any granulations and polypi, by ionization if the perforation was a big one. Otherwise eardrops were used at regular intervals and insufflation of iodised boric acid. The deafness caused by chronic catarrh was treated by politzeration, eustachian cathetherisation, diastolization and breathing exercises. 23 2. Nasal catarrh and catarrhal sinusitis : these were treated with nasal drops and douching as well as diastolization and breathing exercises. 3. Epistaxis : this was treated by cauterizing the nasal septum. 4. Enlarged tonsils and adenoids : These were treated in certain cases with breathing exercises, and where necessary operation was recommended. Removal of Tonsils and Adenoids was recommended in 232 cases, 31 being children under five years of age. The new cases were classified as follows :— Past-suppurative otitis media... 3 Chronic otitis media suppurativa 26 Acute otitis media suppurativa... 8 Cyst, external auditory meatus... 1 Deafness ... 15 Unhealthy and enlarged tonsils and adenoids 183 Nasal obstruction 16 Nasal Catarrh 17 Dry perforations ... 2 Chronic Sinusitis ... 1 Cerumen ... 4 Epistaxis ... 3 Deflected septum... 6 Mouth breathing ... 6 Rhinitis 2 Operations for the removal of lonsils and Adenoids at the Clavponds Hospital were temporarily discontinued in November, 1945. • Dental Defects.—The report of Mr. C. Colenso, the Senior Dental Surgeon, is as follows :— The County Schools came under the New Education Act on April 1st, 1945. For purposes of statistical reports, the dental treatment of these children up to March 31st, will therefore, for this period be given separately, although the dental inspection will be included in the figures for general dental inspection of all schools in the Borough. Dental inspection was carried out in all schools, Primary and Secondary, during the year. A total of 17,139 children were inspected. This figure is greater by 453 than that in the preceding year. The number found to require treatment was 8,035, this number being greater by 1,779 than that for the year 1944. The number of children actually treated amounted to 5,564, this figure being larger by 743 than the number treated in the previous year. 24 The treatment was carried out by one whole-time dentist and four part-time dentists. The number of sessions given to inspection was 96, and the number given to treatments totalled 827. The actual figures that follow apply to treatment for the year of primary school children. The number of fillings inserted in the permanent teeth totalled 3,750, this figure being greater by 669 than that of the preceding year. The average number of fillings per ordinary session amounted to approximately five and a quarter fillings. Also other treatment was given at each session, including extractions, gum treatment, scaling and impression-taking for orthodontic appliances. Extractions were performed under both general and local anaesthesia ; 806 permanent teeth were removed for gross caries and for regulation purposes ; the number of temporary teeth removed amounted to 6,171, making a total of 6,977 for the year ; 52 new cases were fitted with orthodontic appliances during the year, compared with 21 in the preceding year. Many of the irregularities could have been avoided if suitable treatment could have been obtained in the early stages. Another disturbing condition was found during the year, and that was the increase in the number of children with gum infections. This was probably due to nutritional disturbances and lack of cleaning. The number of children suffering from this condition totalled 120. They were successfully treated with chromic acid and hydrogen peroxide, and other drugs. Several visits were required to complete the treatment in the more advanced cases. Other operations included adjustments to orthodontic appliances, dressings of silver nitrate to temporary teeth and ulcers of the mouth, temporary dressings to relieve pain in the teeth, scaling of the teeth and application of drugs to gum infections. The total number of treatments for these amounted to 1,420 for the complete number of children treated. In the coming year it might be possible to inspect the children leaving school, as was done in the years before the war, when the percentage number of children leaving school was approximately 81 with sound mouths. The number of County School children treated from January 1st to March 31st totalled 571, which is smaller than the number seen in the preceding year, when 663 were treated. Extractions totalled 122 permanent and 39 temporary teeth. The number is smaller than the extraction figure for the year 1944. Fillings were inserted in permanent teeth and a few temporary teeth. The number of fillings inserted amounted to 668. 25 Other operations amounted to 72 separate items of treatment. They included scaling, dressing to painful teeth, applications of drugs to various gum conditions, adjustments to orthodontic appliances and impression taking. There were three children fitted with orthodontic appliances and three had artificial dentures fitted. Defective Speech.—Treatment was given during the year at the following Health Centres : Mattock Lane Perivale Cherington House Ravenor Park Greenford Green Oldfields School Twice weekly Once a week The following children received treatment :— Stammerers 61 Speech Defects 52 Cleft Palates 5 Others 4 Total 122 Many of the children attended twice weekly. The attendance varied during the year, owing to illness in the winter terms, and holidays with parents during the summer term. On the whole, attendance was very good. Students from the Central School of Speech Training and Dramatic Art attended sessions at the Health Centres at Hanwell and Ravenor Park. Forty-one school visits were made during the year, when new cases were seen and advice was given for the children that were unable to be admitted owing to the large numbers already undergoing treatment. Thirty-five visits to the children's homes were made during the year to ensure that the children were being helped as much as possible in their own homes. Discharged as cured 17 Left school 9 Left the area or discontinued treatment 7 26 CHILD GUIDANCE CENTRE. The report of Ur. Portia Holman, the Psychiatrist is as follows :— 1945 has been this Centre's first full year, but unfortunately, the working of the Centre was interrupted by resignations of members of the original team during the second half of the year. This has led not only to a gap in the activities of the Centre but also, inevitably, to reconsideration and changes of policy. Hence it is not easy to give a very full report, neither can the account of this year's work be taken as a reliable basis on which to estimate the extent of the Centre's work in the future. In the report submitted at the end of 1944 only cases seen by the Psychiatrist were discussed. It seems better for 1945 to include all cases referred, as this gives a clearer picture of the problems confronting those availing themselves of the Centre's services and will serve for purposes of comparison next year. Table I. Analysis of Work. During the year 276 children were referred of whom 180 cases were seen by some member of the Centre's team. They also saw 22 cases carried over from 1944, making the total of those claiming attention during the year 298, and of those receiving it, 202. The 96 not seen by the end of the year include 26 children who were withdrawn either because their parents were unwilling or unable to bring them to the Centre, or because their symptoms had cleared up spontaneously in the interim. In addition, 55 cases were judged to be partially or wholly " educational," and were left to be dealt with by the Educational Psychologist who was to be appointed early in 1946. Of the 202 cases seen, 43 were discussed by the Child Guidance team and then advised by the Psychiatric Social Worker, as full examination did not seem necessary ; 90 were given Intelligence Tests and discharged after advice from the Psychologist to parents and teachers. This leaves 84 who were in need of the full services of the Centre : of these 29 were discharged after diagnosis and advice from the Psychiatrist and 40 were put down for treatment. Of the last 22 were treated in 1945 and 17 were still awaiting treatment at the end of the year ; 15 remained on the waiting list to be seen in 1946. Of the 90 children discharged after Intelligence Tests 84 were referred specifically for educational backwardness and of these 44 were found to have I.Q.'s below 70 (i.e., to be in need of special education). A high proportion of those referred to the new Educational Psychologist may also be presumed to be of less than average intelligence. These are not, of course, the children for whom Child Guidance Services are designed. In future, when the 27 Educational Psychologist receives and " screens " the cases referred by the schools, these large numbers of poorly endowed children should not reach us. The number in 1945 reflects the extent of the problem experienced by the teachers and shows the need for a fulltime Educational Psychologist to help the schools with the problems of classification and special provision for children of less than normal promise. Leaving out of account the children referred because of backwardness, about one-third of the children seen have been judged to be in need of some form of treatment in the Centre. This is in agreement with the findings in other Child Guidance Centres. Twelve cases were closed in 1945 and of those 11 benefited considerably from their attendance at the Centre. In one case only was treatment broken off at a time when, in our judgment, the child could profitably have continued. Clinic Staff.—Dr. Scott and his team left us at the end of the summer; a new Psychiatrist took over in October and other workers were subsequently added, two, however, only in the capacity of locum tenentes until the end of the year. A permanent Psychiatric Social Worker and Play Therapist had been appointed by the end of the year, so that there is the expectation of stability and continuity in 1946. The Psychiatrist has been giving two 2-hourly sessions per week and the Play Therapist 2 sessions of 2f hours. The Psychiatric Social Worker is the only full time member of the team. Arrangements are in hand to increase the amount of time available for play Therapy and the appointment of the Educational Psychologist will concentrate the work of the Centre on the diagnosis and treatment of children exhibiting disturbances and abnormalities of behaviour. Table II. Symptoms. The most striking fact about the symptoms for which children were referred to the Clinic is the number of those referred on account of backwardness, to which reference has just been made. Apart from this, the most frequent symptom is " difficulty in management at home," closely followed by " difficulty in management at school." This is perhaps accounted for by the terminology used, as the description may cover a multitude of symptoms. Next in order of frequency comes enuresis, closely followed by delinquency (which includes lying and pilfering). Table III. Intelligence Quotients. The average I.Q. is much lower than that usually found among referrals to Child Guidance Centres, and indicates to what degree the distribution is weighted by the number of " backward " children referred. Of the 44 children seen who had I.Q.'s of under 28 70, one was recommended for residential care ; 38 were recommended for attendance at a Special School ; and 5 were considered unsuitable for formal education. Table IV. Ages. An analysis of the ages at which children were referred to the Centre shows that we have a peak at 10 - 12 years, and another at 7-8 years. The distribution seems to be fairly even over the whole of the 5-14 year range, but this would not necessarily be the case if the purely educational problems had been excluded. Changes in Environment. A change of environment was recommended in 43 cases. This includes the 38 children recommended for a Special School, and the one child recommended for residential care. Of the remaining 4 children, one was recommended for a school for maladjusted children, one was recommended for a school for epileptics, and in two cases a change of school was recommended. TABLE I. Analysis of Work. Total number of cases referred to the Centre in 1945 276 Total number of cases brought forward from 1944 waiting list 22 298 Total number of new cases dealt with by Psychiatrist or Psychologist : Boys 119 Girls 83 202 Number of cases investigated by Social W orker but not seen at the Centre (included above), 43. Number of cases withdrawn before investigation 26 Number of cases referred to Educational Psychologist 55 Nunber of cases remaining on waiting list for interview at the Centre 15 298 Analysis of Cases seen at the Centre. Total number of new cases seen 159 A. Diagnosis and Advice only 29 B. I.Q. and Advice only (including 44 with I.Q. below 70) 90 C. Treatment : (1) Psychiatrist 5 (2) Psychologist (Play Therapy) 12 (3) Remedial Teaching 5 Failed to attend for treatment after diagnosis 1 On Waiting List for Treatment in 1946 17 159 29 Analysis of Treatment Cases. Number of cases carried over from 1944 3 Number taken on in 1945 22 25 Discharged, much improved 4 Discharged, improved 7 Treatment broken off 1 — 12 Number of cases current on December 31st, 1945 13 25 TABLE II. Table of Symptoms. (Including those for which the children were referred and others which were discovered at the diagnostic interview—202 children). 1. Nervous Disorders. Fears and Anxiety 12 Depression and lethargy 2 Unsociability 1 15 2. Habit Disorders and Physical Symptoms. Enuresis 20 Sleep disorders 3 Asthma 3 Epilepsy 3 Speech disorders 2 Food fads 2 Hysterical symptoms, including headaches and " fainting " 2 — 35 3. Behaviour Disorders. Difficult to manage at home 32 Difficult to manage at school 27 Delinquency, including stealing and lying 19 Truancy and wandering 6 Sex difficulties 5 Temper tantrums 4 Bizarre symptoms, (?) prc-psychotic 3 Aggressiveness 3 — 99 4. Educational Difficulties. " Backward," including 44 defectives 84 School failure 14 Vocational guidance 3 — 101 250 30 Orthopaedic Treatment.—The Orthopaedic Surgeon attended the Mattock Lane Health Centre once every month in 1945. The Masseuse attended on five sessions in each week. The work of the Orthopaedic Clinic during the year may be summarised as follows :— Orthopaedic Clinic. School children Children under five Total Attendances by Surgeon 12 Number of children seen for first time... 254 39 293 Total number of children examined ... 631 65 696 Attendances by Masseuse 238 Number of cases treated 213 16 229 Number of attendances by children ... 1,335 385 1,720 Children admitted to hospital for special treatment 16 5 21 Children supplied with special boots or surgical appliances 34 6 40 INFECTIOUS DISEASE. The returns forwarded each week by the head-teachers giving particulars of all new cases of infectious disease coming to their knowledge included 1,369 cases of measles, 148 of whooping cough, 261 of chickenpox and 412 of mumps. Children to the number of 367 were excluded under Article 20 (b) of the Education Code for the following conditions :— Impetigo 148 Ringworm of body 2 Scabies 195 Other skin disuses 1 Ringworm of head 7 Conjunctivitis 10 Mumps 1 Conjunctivitis and Impetigo 2 Septic Spots 1 - 367 No closure took place under Article 22 or 23 (b) of the Code Grant Regulations. No certificate was issued under Paragraph 15 (ii) of the Administrative No. 51 of the Board of Education, 31 Diphtheria Immunization. Immunization of school and pre-school children was continued at the Health Centres and when the numbers justified it the Medical Officers attended the various schools for the purpose. The following table shows the amount of immunization work carried out in 1945 :— Schick tests 68 School children immunized 335 Children under 5 years immunized 2,022 Children re-immunized 4 Children given a Stimulating dose 25 The total number of children of all ages immunized at the Health Centres and in the Schools in 1945 was thus 2,361. MILK AND MEALS FOR SCHOOL CHILDREN. The drinking of milk by school children is strongly recommended to the parents at routine medical inspection in the schools and at the Health Centres. Milk was supplied in one-third pints at a cost of a halfpenny or free of charge according to the level of the family income. The following figures supplied by the Borough Education Officer show the number of children receiving milk on a day in October :— Number of children on roll 14,444 Number of children receiving free milk 1 /3rd pint 286 Number of children receiving free milk 2/3rd pint 128 Number of children paying for milk l/3rd pint 5,876 Number of children paying for milk 2/3rd pint 4,913 School meals are provided at a cost to the parents of 6d. or at half price or free of charge according to the level of the family income in the same way as school milk. The following figures supplied by the Borough Education Officer show the number of children who were receiving meals in school on a day in October :— Number of children on roll 14,444 Number of children receiving free meals 194 Number of children paying for meals 6,616 32 SECONDARY SCHOOLS. Work was carried out on behalf of the Middlesex Education Committee in the five County Schools in the Borough for the first quarter of the year, after which the Education Act, 1944, came into operation. Ophthalmic examination was made of 49 pupils and for these glasses were prescribed, 46 being supplied through the school medical department before the end of the year. The Orthopaedic Surgeon examined 6 pupils and 4 of them made 16 attendances at the Centre for massage and special exercises. Thirty children made 153 attendances for treatment of minor ailments. EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. The number of children examined in connection with their employment out of school hours was 113 and of this number 3 were found to be unfit for employment. The nature of the ment of those considered as fit was :— Boys. Errand boy 42 Milk round 27 Newspaper round 27 Baker's round 6 Others — Girls. Shop assistants 3 Others 5 110 These children are submitted to re-examination when routine medical inspection is being carried out in the school and if it is found that employment is detrimental to their health, sanction to employment out of school hours is withdrawn. At routine inspection 45 children were found who had not obtained the necessary permission to engage in employment; 6 of these were found to be unfit for employment and one was under age. MISCELLANEOUS. It is usual to group under this heading the medical inspections which are made of candidates prior to their appointment on the teaching staff of the Education Committee and of other candidates on appointment to various branches of the Council's technical and clerical staff and of manual workers. All these examinations are carried out by the school medical staff assisted by the school nurses. During the year 73 teachers and 18 other candidates were medically examined. 33 STATISTICAL TABLES. The Tables required by the Ministry of Education are as follows : TABLE I. MEDICAL INSPECTIONS OF CHILDREN ATTENDING PUBLIC ELEMENTARY SCHOOLS. A. Routine Medical Inspections. Number of Inspections :— Entrants 2,406 Second Age Group 488 Third Age Group 2,546 Total 5,440 Number of other Routine Inspections — B. Other Inspections. Number of Special Inspections and Re-Inspections 8,165 TABLE II. CLASSIFICATION OF THE NUTRITION OF CHILDREN INSPECTED DURING THE YEAR IN THE ROUTINE AGE-GROUPS. Number of Children Inspected A (Excellent) B (Normal) C (Slightly sub-normal) B (Bad) No. 0/ /o No. % No. % No. % 5,440 474 8.7 4,812 88.5 154 2.8 – 34 TABLE III. Group I.—Treatment of Minor Ailments (excluding Uneleanliness). Total number of Defects treated or under treatment during the year under the Authority's Scheme 2,811 Group II.—Treatment of Defective Vision and Squint. Under the Authority's Scheme Errors of Refraction (including Squint) 1,368 Other defect or disease of the eyes (excluding those recorded in Group I) 28 Total . . 1,396 Number of children for whom spectacles were (a) Prescribed 1,005 (6) Obtained 933 Group III. -Treatment of Defects of Nose and Throat. Received Operative Treatment 166 Received other forms of treatment — Total number treated 166 35 TABLE V. VERMINOUS CONDITIONS. (1) Average number of visits per school made during the year the School Nurses or other authorised persons by 3 (2) Total number of examinations of children in the Schools School Nurses or other authorised persons by 43,563 (3) Number of Individual children found unclean 961 (4) Number of Individual children cleansed under Section 87 and (3) of the Education Act, 1921 (2) None (5) Number of cases in which legal proceedings were taken :— (a) Under the Education Act, 1921 None (b) Under School Attendance Byelaws None TABLE IV. DENTAL INSPECTION AND TREATMENT. (1) Number of children inspected by the Dental Surgeons : (a) Routine age-groups 17,031 (6) Specials 108 (c) Total (Routine and Specials) 17,139 (2) Number found to require treatment 8,035 (3) Number actually treated 4,816 (4) Attendances made by children for treatment 7,552 (5) Half-days devoted to:— Inspection 106 Treatment 827 Total 933 (6) Fillings:— Permanent Teeth 3,750 Temporary Teeth 26 Total 3,776 (7) Extractions:— Permanent Teeth 806 Temporary Teeth 6,171 Total 6,977 (8) Administrations of general anaesthetics for extractions (9) Other Operations :—- 2,035 Permanent Teeth 1,420 Temporary Teeth Total 1,420 36 TABLE VI. BLIND AND DEAF CHILDREN Number of totally or almost totally blind and deaf children who are NOT at the present time receiving education suitable for their special needs. 1 At a Public Elementary School 2 At an Institution other than a Special School 3 At no School or Institution Blind Children — — 1 Deaf Children — — 5