WAL 75 BOROUGH OF WALTHAMSTOW Committee for Education REPORT of the BOROUGH SCHOOL MEDICAL OFFICER for the year 1948 A. T. W. POWELL, M.C., M.B., B.S., D.P.H. BOROUGH SCHOOL MEDICAL OFFICER BOROUGH OF WALTHAMSTOW Committee for Education REPORT of the BOROUGH SCHOOL MEDICAL OFFICER for the year 1948 A. T. W. POWELL, M.C., M.B., B.S., D.P.H. BOROUGH SCHOOL MEDICAL OFFICER 1 CONTENTS Accommodation 7 Attendance Officers 21 Artificial Light Treatment 17 Aural Clinic 14 Chicken Pox 18 Child Guidance 28 Clinics 5 Committee 2 Convalescent Home Treatment 36 Co-ordination 7 Crippling 25 Dental Defects 11 Dental Treatment. 43 Diphtheria 18 Diphtheria Immunisation 18 Ear Disease 11 Employment of Children 37 Exclusion 18 Eye Disease 10, 13 Following up 11 Hearing 11, 14 Heart Disease 11,17 Hospital Treatment 14 Hygiene 7 Impetigo 10, 12 Invalid Children's Aid Association 21 Infectious Diseases 18 Introduction 3 Meals, Provision of 20 Medical Examinations 37 Medical Inspections 9 Measles 18 Medical Treatment 11 Milk in Schools Scheme 21 Minor Ailments 10, 12 Mumps 18 N.S.P.C.C. 23 Nursery School 37 Nutrition 10 Open Air Education 19 Orthopaedic Treatment 25 Orthoptic Clinic 14 Parents, Co-operation of 21 Physical Training 20 Re-inspections 9 Rheumatism 17, 37 Ringworm 10 Scabies 10 Scarlet Fever 18 School Camps 19 School for the: Blind and Partially Sighted 23 Deaf 24 Educationally Sub-normal 27 Physically Handicapped 24 Skin Diseases 10, 12 Speech Therapy 33 Staff 4 Statistical Tables 42 Teachers, Co-operation of 21 Tonsils and Adenoids 10, 14 Tuberculosis 11, 17 Uncleanliness 10 Vaccination 19 Vision 10, 13 Voluntary Bodies 21 Whooping Cough 18 2 WALTHAMSTOW COMMITTEE FOR EDUCATION 1947 - 1948 Chairman: Alderman E. C. Redhead, J.P. Deputy Chairman: Alderman S. N. Chaplin, J. P. Ex-Officio: The Worshipful the Mayor: Miss D. Wrigley, J.P. Chairman of Finance Committee: Alderman Ross Wyld, O.B.E., J. P. Cty. Ald. P. Astins, C.B.E.,J.P. Coun. Mrs. B. E. Bottomley. Ald. W. B. Fitt. Ald. T. Fitzpatrick. Coun. H. C. Fisher. Coun. A. J. Llewellyn. Coun. G. S. Mace. Ald. A. E. Manning. Ald. Mrs. C. McEntee, J. P. Ald. Mrs. E. M. Miller. Coun. W. F. Savill. Coun. W. H. Shaw. Mrs. H. A. Christy. Mr. C. S. Garratt. Rev. D. A. King. Rev. J. E. McKinley. Rt. Rev. Mgr. W. O'Grady, V.G. Borough Education Officer: E. T. Potter, B.Sc. 3 To the Chairman and Members of the Walthamstow Committee for Education. Ladies and Gentlemen, I beg to present herewith a report on the School Health Service in Walthamstow during 1948. The Service continued on the lines adopted in previous years, but considerable work has been carried out for other Areas, notably in Child Guidance, investigation of cardiac defects, Orthoptic treatment and cleansing. A second Speech Therapist was provided. The total of inspections, treatments and visits covered by the School Health Service Staff were nearly 86,000, all of which were dealt with without any serious difficulty or complaint. The number of children examined at Medical Inspection is lower than in previous years through lack of medical staff. Fortunately, the staff is now at full strength and the arrears should soon be overcome. The nutritional assessment of children attending your schools continues to be wholly satisfactory and in no small part this is due to the school dinners and milk meals. Towards the end of the year, the number of school dinners reached a total of nearly 9,300 on December 22nd, or approximately 60 per cent. of attendances. Immunisation has now been so successful that the defeat of Diphtheria can virtually be recorded, provided the present rate of immunisation is kept up, particularly in the pre-school child, and that ' booster' doses are given as and when necessary. The report refers to an interesting holiday experiment at the Open-Air School, to a successful "School Journey" to Sweden, and to references made to the Walthamstow Rheumatism clinic at an International Congress in New York. I would wish to express my appreciation to your Chairman and to all Members of your Committee, to the Borough Education Officer and his staff, and to the Staff of the School Health Service, all of whom have contributed to the generally satisfactory position referred to in this report. I am, Your obedient servant, A. T. W. POWELL, Borough School Medical Officer. 4 1. STAFF OF THE SCHOOL MEDICAL DEPARTMENT. Borough School Medical Officer and Medical Officer of Health. A. T. W. Powell, M.C., M.B., B.S., M.R.C.S., L.R.C.P., D.P.H. Deputy Borough School Medical Officer— M. Watkins, M.R.C.S., L.R.C.P., D.P.H. Assistant School Medical Officers— Miss M. Sheppard, M.A., M.B., B.Ch., B.A.O., D.P.H., Barrister-at-Law. Miss D. B. Hudson, M.B., Ch.B., D.P.H. Specialist Part-time Medical Officers— Aural Surgeon: F. P. M. Clarke, B.A., B.Sc., L.R.C.S.(Ed.), L.R.C.P., L.R.F.P.S.(Glas). Orthopaedic Surgeon: B. Whitchurch Howell, M.B., B.S., F.R.C.S. Physician-in-Charge Rheumatism Clinic: MissM. Wilmers, M.D., M.R.C.P. Psychiatrists: Mrs. Helen Gillespie, M.R.C.S., L.R.C.P. Miss E. Whatley, M.B., B.S. Dental Surgeons: Mr. L. W. Elmer, L.D.S., R.C.S.(Eng.) (Senior). Mr. G. P. L. Taylor, L.D.S., R.C.S. Mr. C. Shamash, L.D.S., R.C.S., B.Ch.D. Mr. R. E. Hyman, L.D.S., R.C.S. Mr. R. V. Tait, B.Sc., L.D.S., R.C.S. (part-time). School Nurses and Health Visitors (Part-time to School Medical Service)— Miss A. C. Keenan, S.R.N., S.C.M., H.V.Cert. (Superintendent). MissR. Boyd, S.R.N., S.C.M., H.V.Cert. Miss E. L. Cunnington, S.R.N., S.C.M., H.V.Cert. MissE. duRANDT, S.R.N., S.C.M., H.V.Cert. 5 Miss D. G. Legg, S.R.N., S.C.M., H.V.Cert. Miss I. N. MacPherson, S.R.N., S.C.M., H.V.Cert. Miss 0. North, S.R.N., S.C.M., H.V.Cert. Miss J. M. Palmer, S.R.N., S.C.M., H.V.Cert. Miss A. Stuart, S.R.N., S.C.M., H.V.Cert., T.B. Cert. Miss A. Wright, S.R.N., S.C.M., H.V.Cert. Miss M. A. Young, S.R.N., S.C.M., H.V.Cert. Miss M. A. Campbell, S.R.N. (Whole-time School Medical Service) Dental Attendants— Miss D. Sanford. Miss S. Snowden. Miss G. M. Hutchins. Mrs. M. E. Wright. Masseuse— Miss H. E. Garratt, C.S.M.M.G. Orthoptist (part-time)— Mrs. K. S. Box, S.R.N., S.C.M. Speech Therapists— Miss V. Babington, L.C.S.T. Miss C. M. Gregory, L.C.S.T. Clerical Staff— H. J. Smith, Miss G. M. Baker, Miss J. W. Foster, Miss N. Lewis (part-time). Miss S. Martyn (part-time). SCHOOL CLINICS. Aural— Monday Child Guidance— Wednesday Thursday 2—4.30 p.m. 9.30 a.m.—1 p.m. 2—5 p. m. Town Hall. High Street. 6 Dental Clinics— Monday to Friday Saturday Monday Tuesday J Wednesday to Friday *Minor Ailments— Monday Wednesday Friday Saturday Tuesday } Friday Thursday Ophthalmic— Monday Tuesday Thursday Saturday Orthopaedic— Monthly Massage and Sunlight— Monday to Friday. Orthoptic— Monday Thursday J Speech Therapy— By appointment Rheumatism— Monthly *1 mmunisation— Tuesday 9 a.m.—4.30 p.m. 9 a.m.—12 noon. 2—4.30 p.m. 9 a.m.—4.30 p.m. 9 a.m.—12 noon 9 a.m.—11 a.m. 1.30 p.m.—2.30 p.m. 9 a.m.—11 a.m. 9 a.m.—12 noon 9 a.m.—12 noon. 9 a.m.—5 p.m. 9.30 a.m.—4.30 p.m. 2 p.m.—4 p.m. 2 p.m. Town Hall. Town Hall. Guildsway. Guildsway. Town Hall. Sidney Burnell School. Low Hall Lane. Town Hall. Open Air School. Open Air School. Town Hall. High Street. Open Air School. Town Hall. Town Hall. 7 * Scabies and Infectious Disease— Wednesday 11 a.m. Town Hall. All Clinics, except those marked * are "Appointment" Clinics- 2. CO-ORDINATION. Co-ordination is secured by the fact that all the school medical staff also carry out duties for other health services. The school nursing staff is equivalent to five whole-time nurses. 3. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. School Hygiene and Accommodation.—The following table shows the number of schools in the Borough at the 31st December, 1948:— Boys. Girls. Mixed. Infants. Nursery. County Secondary Grammar 1 2 — — — County Secondary Technical — — 2 — — County Secondary Modern 2 2 6 — — County Primary Junior 2 2 12 — — County Primary Infants — — — 15 — Voluntary Secondary Modern — — 1 — — Voluntary Primary — — 3 2 — County Nursery — — — — 1 Special Schools for:— Blind and Partially Sighted – — 1 — — Deaf — — 1 — — Educationally Sub-normal — — 1 — — Physically Handicapped — — 1 — — 1948 1947 1946 1945 1944 Number of Children on Register, 31st December 17,154 16,463 15,776 12,753 9,236 Average attendance 14928.9 14470.6 14004.6 10189.2 8488.5 Percentage attendance 86.7 86.9 86.0 80.0 78.4 Mr. Frank H. Heaven, A.R.I.B.A., Architect to the Education Committee contributes the following:— Additions and Alterations.—Improvements have been effected at Primary and Secondary Schools in the form of removal of galleries in classrooms (2); new floor to a classroom; conversion of classrooms into a biology laboratory (1) and a science room (1); provision of an iron fire escape. Central Kitchens.—The existing kitchens have been maintained, and additional equipment provided to meet the increased needs. Heating.—Many heating defects which have arisen have been remedied, including replacement of sections and in some cases complete boilers. Supplementary heating by gas-operated space heaters have been installed where 'background' heating has been 8 found to be inadequate. Additional radiators have been provided at one infants and one junior school, and a complete gas-operated system installed at a branch of the Technical School. Electric space heaters have been installed in a school canteen. Hot Water Supplies.—Additional equipment and new supplies have been installed at three schools for the washing of hands before and after meals, and a gas-operated boiler system installed at one school to provide full facilities to all sanitary fittings. Lavatories.—Re-modelling has been effected at one of the older schools for both sexes. Lighting.—Additional lighting facilities have been provided to lavatory blocks. A complete system of fluorescent lighting has been installed at a branch of the Technical College. Maintenance.—All the educational properties and play areas have been maintained in repair within the limits of the expenditure provided in the annual estimates, including fences, surfaces, removal of obstructive walls, and provision of new floor coverings. Medical Services.—A scheme of alterations and improvements at the Child Guidance Clinic at 263, High Street has been carried out, which provides increased accommodation to meet the extended demands on this service, with better heating, lighting and play facilities. New Buildings.—Two prefabricated buildings to contain classrooms and science rooms with lavatory accommodation are in course of erection at the Technical School in Hoe Street. Play Fields.—These have been maintained in good condition, chiefly by direct labour. An additional playing area has been acquired at one school and put in reasonable condition, pending a larger scheme of levelling and turfing and fencing. The grass lawns at the Nursery School, Special School and at one infant school have been relaid, and new grass areas and flower borders provided at another infant school. The netting to fifteen tennis courts has been renewed. Provision of Meals and Milk.—The kitchens and sculleries at all the schools have been maintained. One new scullery has been provided, and additional equipment supplied at others as the need has arisen. 9 An additional scullery has been provided at one 3chool and an additional dining room and scullery at another. Two new prefabricated dining rooms and kitchens and one new dining room and scullery have been erected. The latter is in operation. The two former have not been opened owing to lack of equipment to be supplied by the Ministry concerned. Plans for a number of prefabricated and ad hoc two-storey buildings for erection on restricted sites have been put forward and await allocation with the building programme for the area. Renovations.—Extensive repairs and complete renovations have been carried out at seven schools for exteriors and two schools for interiors. Owing to high costs, progress in this direction is somewhat hampered; but as prices come down work will be put in hand each year in order to overcome the loss of activity during the war years. Sanitary Fittings.—Improvements have been effected at the Special School for sub-normal children. Additional sinks with cold and hot water services have been provided at two secondary schools. Sites and Properties.—Three schools at which Civil Defence, N. F. S. or other war-time services were conducted have been renovated and made serviceable again for school purposes and gates and fences restored at four other schools. War Damage Repairs.—A very large amount of this work has been carried out during the year at ten schools, involving the expenditure of many thousands of pounds. 4. MEDICAL INSPECTION. The following gives a summary of the returns:— A. Routine Medical Inspection:— Entrants 627 Second Age Group 1,502 Third Age Group 1,590 Total 3,719 B. Other Inspections:— Special Inspections 141 Re-inspections 100 Grand Total 3,960 10 5. REVIEW OF THE FACTS DISCLOSED BY INSPECTIONS (a) Classification of the Nutrition of Children inspected -during the year in the routine age groups:— Number Inspected. "A" (Good) " B" (Fair) "c" (Poor) No. % No. % No. % Entrants 627 251 40.0 348 55.5 28 4.4 Second Age Group 1502 707 47.0 733 48.8 62 4.1 Third Age Group 1590 853 53.6 696 43.7 41 2.5 Totals 3719 1811 48.6 1777 47.7 131 3.5 (6) Uncleanliness.—The following table gives comparative figures for the past two years:— 1948 1947 Average number of visits to schools 4 4 Total examinations 32,897 32,671 Number of individual children found unclean 970 939 Percentage uncleanliness of average attendance 6.4 6.5 (c) Minor Ailments and Skin Defects.—The following is the number of skin defects found to require treatment:— 1948 1947 Ringworm—Head 2 6 Body 13 11 Scabies 21 84 Impetigo 48 88 Other skin diseases 326 307 (d) Visual Defects and External Eye Diseases.—The number of patients requiring treatment and observation was as follows:— 1948 1947 Treatment. Observation. Treatment. Observation. Visual Defects 292 203 146 206 Squint 44 6 31 31 External Eye Disease 388 9 261 9 (e) Nose and Throat Defects.—The number of patients requiring treatment and observation was as follows:— 1948 1947 Treatment. Observation. Treatment. Observation. Chronic Tonsillitis 98 54 71 106 Adenoids 8 4 5 — Chronic Tonsillitis and Adenoids 18 10 15 27 Other conditions 487 75 261 12 11 The 487 cases of "other conditions" are made up of sore throat and defects requiring diastello treatment. (/) Ear Disease and Defective Hearing.—Patients requiring treatment:— 1948 1947 Defective Hearing 31 26 Otitis Media 33 64 Other Ear Diseases 259 152 (g) Orthopaedic and Postural Defects.—A total of 326 deformities were found to require treatment. (h) Dental Defects.— Inspection. Requiring Treatment. Per cent. Actually Treated. Fillings. Extractions. General Anaesthetics. Other Operations. 3523 2783 78.9 6583 4275 4502 2972 5187 (i) Heart Disease and Rheumatism.—The findings were as follows:— 1948 1947 Treatment. Observation. Treatment. Observation. Heart Disease—Organic 9 12 11 4 Functional 9 4 8 8 Anaemia 58 24 84 3 (j) Tuberculosis.—All children suspected either of pulmonary or glandular tuberculosis are referred to the Chest Physician for final diagnosis. (k) Other defects and diseases.—The following table shows the number of various other defects which were found to require treatment:— Enlarged Glands 88 Epilepsy .. 5 Bronchitis 88 Other defects . 2,466 Speech 73 6. FOLLOWING UP. The School Nurses paid a total of 1,176 home visits during 1948. 7. ARRANGEMENTS FOR TREATMENT. (a) Malnutrition.—The following shows the quantities of tonics issued during 1948:— 12 Cod Liver Oil. Parriah' a Food. Syrup Lactophosphate. Cod Liver Oil and Malt. Cod Liver Oil and Malt and Parriah's Food. Emuleion. 54 lbs. 271 lbs 58 lbs. 956 lbs. 1,260 lbs. 148 lbs. (b) Uncleanliness.—Treatment with lethane was carried out extensively with satisfactory results and advice and treatment is now available at all clinics and welfares. Steel combs are supplied at cost price, and on loan in cases of necessity. Special treatment is available at the Borough Council's Cleansing Centre. (c) Minor Ailments and Diseases of the Skin.—Treatment of minor ailments is carried out at the seven sessions of the school clinics, all of which are in charge of a medical officer. The number of cases of skin disease treated is shown in the table detailing the work done at the school clinics:— Conditions. First Inspections. Re-inspections Number Excluded. Number Not Excluded. Boys. Girls. Boys. Girls. Boys. Girls. Ringworm 3 1 4 3 7 5 Scabies 6 8 3 — 15 11 Rheumatism — — 7 13 35 39 Impetigo, Sores, etc. 23 11 87 60 279 129 Skin 5 12 204 193 719 482 Verminous Head, etc. 9 93 39 182 126 1407 Sore Throat 42 48 22 19 79 96 Discharging Ears and Deafness 21 31 197 62 610 616 Defective Vision — 1 45 51 11 14 External Eye Disease 23 19 87 97 124 129 Tonsils and Adenoids 8 6 97 56 106 90 Mumps 9 9 1 1 7 10 Various 172 184 1421 1391 3163 3095 Totals 321 423 2214 2128 5281 6123 Number of children seen at first inspection 5,086 Number of children sent by Attendance Officers and Attendance Committee 61 Number of attendances made by children 16,490 Number of children sent by Head Teachers 1,469 Number of Swabs taken 327 Number of specimens of hair examined for Ringworm Number of children seen by Ophthalmic Surgeon:— New cases 536 Prescribed for 695 Total inspections 3,039 13 First attendances number 5,086 against 4,776 in 1947, and re-attendances 11,404 against 11,018, the total attendances being 16,490 against 15,794. (d) Visual Defects and External Eye Disease.—Dr. Sheppard has kindly contributed the following account of the work done during 1948:— There were 585 new cases seen at the Eye Clinic during 1948 and these, as well as the ordinary periodic inspections, made 3,378 attendances. The following tables summarise the defects found in the new cases:— Condition. Under 7 years. 7—11 years. Over 11 years. Secondary Schools. Total. Boys. Girls. Boys. Girls. Boys. Girls . Boys. Girls. Boys. Girls. Hypermetropia 9 6 9 10 13 9 7 6 38 31 Hypermetropic Astigmatism 3 3 10 10 12 12 3 10 28 35 Myopic Astigmatism 1 – 2 4 4 5 5 7 12 16 Mixed Astigmatism – – 2 3 4 5 2 2 8 10 Myopia – 3 6 8 43 37 32 21 81 69 Various 30 35 9 10 48 86 16 23 103 154 Totals 43 47 38 45 124 154 65 69 270 315 The details of the group described as various are made up as follows:— Defects. Boys. Girls. Total. Squint 36 46 82 Headaches, anaemia, styes, debility, amblyopia, etc. 34 58 92 No visual defects 33 50 83 Totals 103 154 257 Lately, in many cases, there has been a long delay in obtaining glasses after they have been ordered, but this appears to be inevitable in consequence of the introduction of the National Health Service Act, 1946. In the case of partially sighted children however, delay is often serious, and greater priority should exist for such children to obtain either new or replacement glasses. The facilities for the higher education of the partially sighted child with vision which is not very defective appear to be somewhat unsatisfactory. Children with a high degree of defect, say 6/60 or 6/36 are well provided for at the Residential Schools of the National Institute for the Blind, i.e. Chorley Wood for girls and Worcester for boys, but there does seem to be difficulty in providing further education for children with visual defects of say 6/24 or 6/18 in order to fit them to proceed to Universities. 14 Another difficulty is the provision of school books with large point type, i.e. say 18 to 24 point type, in contrast with the ordinary school context book of 12 to 14 point type. An attempt has been made to overcome this deficiency by the use of large lenses, but not altogether satisfactorily. In the meantime, the shortage of large point type text books continues in view of the expense involved in their production both in quantity and variety. (e) Orthoptic Clinic.—Mrs. K. S. Box, S.R.N., S.C.M., has contributed the following report on the work done at the Clinic:— Number of patients treated for squint and heterophoria 64 Number discharged cured 26 Number improved 17 Still under treatment 21 Number of patients with amblyopia 18 Number discharged cured 15 Number improved 3 Number cured by operation 7 Number awaiting operation 2 Number of new cases 63 Total number of attendances 827 Of the total of six sessions per week, two were allocated to patients from Ilford. The total number of attendances made by Ilford patients was 416. (/) Nose and Throat Defects.—146 Children received operative treatment at Connaught Hospital during the year, as compared with 181 in 1947. (g) Ear Disease and Defective Hearing.—Ear Clinic. Dr. Francis Clarke reports as follows:— "The attendances at the weekly Ear, Nose and Throat Clinic during 1948 have been well maintained and the majority of children referred for a course of special treatment, such as diastolisation, nasal douche and colloidal silver drops, tonsil treatment, ear suction and acute otorrhoea, etc., have attended satisfactorily to complete their treatments. In all only 22 cases failed to attend for the full course, and of these some left school and some left the district. "Looking over the figures in the returns for the year we find in all school and pre-school children, only 21 cases of chronic 'running ears' and of these only 9 had complications accompanying the otorrhoea, and of these last, two were chronic mastoid cases which had previous operations. Of the total 12 were cured and quite 'dry,' two had not fully completed their treatment by the end of the year and three were referred to hospital for further operation. All these 'cured' were treated by zinc ionisation. 15 "The fall in the incidence of chronic otorrhoea is very satisfactory, and we would wish again to repeat what we have stated in our previous reports, that zinc ionisation is the best, most rapid and lasting method of treatment for the majority of chronic discharging ears. Some of those treated and cured had already been given prolonged treatment at hospital by other methods without any effect on the discharge. "There were in all, school and pre-school, 51 cases of acute otorrhoea (discharging ears). 39 were quickly cured with treatment at the clinic during the year, and six, late cases, continued under treatment at the end of the year. Three were referred to hospital as acute mastoids. These results are also very satisfactory. We cannot emphasise too strongly the importance of immediate and correct treatment in the case of acute discharging ears and that is why we invariably insist on every case attending for daily treatment at the clinic where all the required facilities are available for efficient treatment. For various reasons, home treatment is not successful; the ears continue to discharge and then become chronic, seriously affecting the hearing and making final cure much more difficult. We have found, as stated in previous reports, that ear suction with Albucid or Penicillin, is a most excellent method for getting these ears 'dry' quickly. Any nasal complications present must receive, as well, suitable attention. ' 'As in previous years, most of the new cases seen at the Clinic during the year were for affections of the nose and throat. Of the total, 18 were cases of sinus infection. This condition is much commoner in children than is supposed and accounts for a number of children suffering from 'frequent colds', 'catarrh,' 'headaches' and 'recurring attacks of tonsillitis.' Many such patients are often advised removal of tonsils and adenoids to relieve the condition and the resultant failure of the operation to have this effect is not surprising when it is remembered that the tonsils and adenoids are not the primary cause of the trouble. "Proetz 'sinus displacement' is the best method now available both for diagnosis and treatment. The marked change in many of these cases after a few treatments is very remarkable. We use a 10 per cent. Albucid solution after Ephedrine solution to fill the sinuses. "130 cases were treated by the French method of diastolisation. In cases of deafness associated with rhinitis this procedure gives by far the best results we have seen. 16 "One of the commonest defects we see in children is faulty nasal respiration. It is quite surprising to find the number of children who do not know how to breathe correctly. Diastolisation is aimed at correcting this, but it would be advisable wherever possible, in such cases, that the child should have a suitable scientific course in the practice of correct breathing, such as the French Desfosses technique. Correct, efficient nasal respiration is exceedingly important and a large number have to learn how to do it. A number of ailments attributed to various other causes are due to defective respiration. "In the case of enlarged tonsils we have followed along the lines taken in previous years. Only a small number of those children seen complaining of 'enlarged tonsils' were found suitable for operation—22 during the year. There should be clear and definite clinical indications and as near as possible, a certain objective in view before the removal of tonsils can be advised. We regularly find many cases of 'tonsils' referred for operation as 'diseased,' when the tonsil is not the disease but the sign, and consequently, the removal of the sign will not cure the disease—hence the failure, in so many instances, of the operation to effect any improvement of the complaint. "The cases requiring tonsillectomy are now operated on at Whipps Cross Hospital, and the Hospital E.N.T. Department has been exceedingly helpful and co-operative. The greatest care is taken in the selection of cases for operation and the excellent afterresults which we have seen emphasise the desirability of suitable and careful selection. "A certain number of children suffering from defective "hearing have had hearing tests done with the Gramophone Audiometer. It has not been possible as yet, due to shortage of staff, to conduct a total Audiometric survey of each school for instances of defective hearing but arrangements for such a survey in the coming year are under consideration. "The general standard of health of the children has been well maintained. They appear, in general, well cared for and the parents and teachers have been very co-operative in the matter of treatment and following out the advice given in the various conditions present." TABLE 'A ' ACUTE OTITIS MEDIA WALTHAMSTOW, 1948 SCHOOL CHILDREN Diagnosis. Total (Ears). Tonsils and Adenoids. Treatment. Results. Zinc lonisation. Antiseptic Treatment. Tonsils & Adenoids Treatment: Nasal Treatment, etc. Tonsils & Adenoids Operation. Cured. Improved. Still under Treatment or Observation. Left School or Treatment Lapsed. Referred to Hospital for Operation. Did not attend or Declined Treatment. a b c d e f g h i j k l Acute Non-Suppurative Otitis Media 10 2 Operation before Clinic — 2 — — 2 — — — — — 8 No Operation — 8 — — 8 — — — — — Acute Non-Suppurative Otitis Media with Nasal Conditions: Enlarged Tonsils and Adenoids. 1 — Operation before Clinic — — — — — — — — — — 1 No Operation — 1 1 — 1 — — — — — Acute Suppurative Otitis Media 16 (3) — Operation before Clinic — — — — — — — — — — 16 No Operation — 15 — — 10 — 3 — 3 — Acute Suppurative Otitis Media with Nasal conditions : Enlarged Tonsils and Adenoids 13 (2) 2 Operation before Clinic 1 2 2 — — — 1 1 — — 11 No Operation — 11 11 — 8 — 2 1 — — Totals 40 1 39 14 — 29 — 6 2 3 — PRE-SCHOOL CHILDREN. Acute Non-Suppurative Otitis Media — — Operation before Clinic — — — — — — — — — No Operation — — — — — — — — Acute Suppurative Otitis Media 9 (1) — Operation before Clinic — — — — — — — — 9 No Operation — 9 — — 8 — — 1 — — Acute Suppurative Otitis Media with Nasal Conditions: Enlarged Tonsils and Adenoids 2 — Operation before Clinic — — — — — — — — 2 No Operation — 2 2 — 2 — — — — — Totals 11 — 11 2 — 10 — — 1 — — Grand Totals 51 1 50 16 — 39 — 6 3 3 — *The figures in brackets indicate the number of cases with Bi-lateral Otorrhoea. TABLE 'B' CHRONIC SUPPURATIVE OTITIS MEDIA SCHOOL CHILDREN WALTHAMSTOW, 1948 Diagnosis. Totals (Ears). Diagnosis. Treatment. Results. Chronic Tympanic Sepsis, Complicated by:— Granulations: Simple Polypii. Mastoid Disease. Enlarged Tonsils and Adenoids. Nasal Catarrh: Rhinitis: Sinusitis. External Otitis, Eczema. Tonsils and Adenoids. Primary (Ear). Collateral (Nose and Throat). Cured. Improved. Still under Treatment: Observation. Left School or Treatment Lapsed. Referred to Hospital for Operation. Did not attend or Declined Treatment. Old Operation. No Operation. lonisation. Antiseptic Treatment. Cautery, etc. Mastoid Operation. Tonsils/Adenoids. Conservative Treatment. Nasal Treatm. Tonsils and Adenoids Operation. school. A B c D E F G H I J K L M N O P A Granulations: Simple Polypii 2 (1) – – – – – – Operation before Clinic – – – – – – – – – – – – – – – 2 – No Operation 2 2 – 2 — 2 — – – – – B Mastoid Disease 2 (2) — 2 – — — – Operation before Clinic 2 2 – – – 2 – – – – – – – – – – – No Operation – – – – – – – – – – – C Enlarged Tonsils and Adenoids — – – – – – – Operation before Clinic – – – – – – – – – – – – – – – – – No Operation – – – – – – – – – – – D Nasal Catarrh: Rhinitis: Sinusitis 3 (1) – – – – – – Operation before Clinic 2 3 – 3 — — — 2 – 1 — – – – – 3 – No Operation – – – – – – – – – – – E External Otitis : Eczema 2 (1) – – – – – – Operation before Clinic – – – – – – – – – – – – – – – – 2 No Operation 2 2 – — — 2 – — – — — Chronic Suppurative Otitis Media, solely 10 (2) – – 5 – – – Operation before Clinic 1 2 – — — 3 — — – 2 – – – 5 – – – No Operation 4 1 – — — 3 — — 1 — 1 Totals (School) 19 — 2 — — 5 2 13 12 – 5 — 12 — 2 1 3 1 PRE-SCHOOL CHILDREN –PRE-SCHOOL.. Chronic Suppurative Otitis Media, solely .. 2 – – — – – Operation before Clinic – – – – – – – – – – – – – 2 – – No Operation — 2 – – – – – – 2 – – Chronic Suppurative Otitis Media, with Nasal Conditions : Tonsils/Adenoids – – – – – – Operation before Clinic – – – – – – – – – – – 2 – – – – – – No Operation – – – – – – – – – – – –Totals (Pre-School) 2 — — — — — — — 2 — — — — — — 2 — — Grand Totals 21 – 2 – – 5 2 13 14 – 5 — 12 – 2 3 3 1 *Figures in Brackets—Cases of Bi-Lateral Otorrhoea or Mastoid. TABLE 'C' NOSE AND THROAT CONDITIONS WALTHAMSTOW, 1948 SCHOOL CHILDREN Diagnosis. Primary Conditions. Totals. Tonsils and Adenoids. Secondary Conditions. Treatment. Results. Otitis Media. Deafness. Nasal Catarrh, etc. Enlarged Tonsils and Adenoids. Diastolisation. Antiseptic Treatment. Proetz Displacement. Tonsils and Adenoids. Cured. Improved. Still under Treatmentor Observation. Left School or Treatment Lapsed. Referred Hospital for Operation. Did not attend or Declined Treatment. Conservative Treatment. Operative Treatment. a b c d e f g h i j k l m n o p q r Sinusitis: Rhinitis 18 Operation before Clinic 5 – — – – 1 4 3 — – 1 2 1 — 1 – No Operation 13 1 – – 1 4 13 5 1 — 6 1 4 — 1 1 Nasal Obstruction: Rhinitis 74 Operation before Clinic 9 – 2 – — 4 7 — — – 6 3 — — — – No Operation 65 1 6 – 13 39 46 3 8 1 40 5 6 7 2 5 Nasal Catarrh 96 Operation before Clinic 17 – 6 – – 7 – – — — 13 2 1 — — 1 No Operation 79 1 18 – 6 71 13 — 7 — 67 1 1 5 — 5 Enlarged Tonsils and Adenoids 47 Operation before Clinic – – – – – – – – – – – – – – – – No Operation 47 – 1 10 – 3 9 — 26 3 13 7 7 2 18 — Totals (School) 235 3 33 10 20 129 92 11 42 4 146 21 20 14 22 12 PRE-SCHOOL CHILDREN Nasal Conditions : Sinusitis : Rhinitis 5 Operation before Clinic – – – – – – – – – – – – – – – – No Operation 5 — 1 – – 1 4 – – — 4 – – 1 — — Enlarged Tonsils and Adenoids 2 Operation before Clinic – – – – – – – – – – – – – – – – No Operation 2 – – – – – – – 2 – 2 – – – – – Enlarged Tonsils and Adenoids with Nasal Conditions 1 Operation before Clinic – – – – – – – – – – – – – – – – No Operation 1 – – – – – 1 – 1 – – – – 1 – – Totals (Pre-school) 8 – – – 1 — — 1 5 — 3 — 6 — — 2 — — Grand Totals 243 – – 3 34 10 20 130 97 11 45 4 152 21 20 16 22 12 17 TABLE 'D' —MISCELLANEOUS. Conditions. Total. Tons/Ads. previously removed. PreSchool. Examined for:— Affections of the ear, nose, throat; special cases of deafness for admission to Deaf School; re-examination; observation of cases previously treated; colds and other conditions 45 3 7 Advised; Recommendations and reports made. Clinic treatment not required. Epistaxis 3 — — Treated. Foreign body in nose 1 — 1 Removed. Wax in ears 6 — 1 Removed. 55 3 9 (h) Orthopaedic and Postural Defects.—Details of the work done under the scheme are given in the section dealing with Defective Children. (i) Heart Disease and Rheumatism.—The following is a report of the work done at the Rheumatism Clinic during 1948:— Number of sessions 12 „ „ new cases 57 „ „ old cases 140 „ attendances 160 „ discharged 46 „ still under treatment 37 „ of new cases with rheumatism or cardiac defect.. 10 „ referred for tonsils and adenoids 3 „ excluded from games and exercises 3 „ to begin games and exercises . 1 „ referred for convalescent home treatment 3 „ referred to hospital as out-patients 1 „ „ „ in-patients 1 „ referred from Forest Division 9 (j) Tuberculosis.—The number of school children examined during the year was 131 boys and 128 girls, of which 22 boys and 29 girls were referred by the School Medical staff. 69 of these cases were sent by private practitioners and 139 were examined as contacts. (k) Artificial Sunlight Treatment.—The total attendances for treatment were 3,141. 18 8. INFECTIOUS DISEASES. Notification in the 5-15 years age group during 1948 was as follows, the figures for 1947 being shown in parentheses: Scarlet Fever, 168 (175); Diphtheria, 1 (Nil); Pneumonia, 21 (20); Erysipelas 1 (2); Cerebro-spinal Meningitis 1 (1); Measles 632 (388); Whooping Cough 558 (62); Dysentery 2 (Nil); Anterior Poliomyelitis 2 (8). Non-notifiable infectious diseases are chiefly brought to light by the weekly returns made by Head Teachers under the local "Regulations as to Infectious Diseases in Schools." The following are the weekly average numbers of children away from school owing to exclusions and the non-notifiable infectious and other diseases named :— Exclusions Chicken Pox Measles and G.M. Whooping Cough Sore Throat Influenza Diarrhoea Mumps Scabies Ringworm Various Total 1948 17 41 19 73 58 18 3 48 1 1 418 698 1947 21 14 79 32 50 49 3 6 2 2 410 668 Immunisation and Infectious Diseases Clinic.—Follow-up arrangements were as detailed in the 1939 Report. The following table shows the work done at the Immunisation Clinic:— Total immunisations completed during 1948 2,712 (a) School age 662 (b) Pre-school age 2,049 (c) Over school age 1 Immunisation at Schools (included above):— Number completely immunised 454 Number partly immunised 78 Number already immunised given an extra dose 1,940 During the past four years the percentages of children protected in the various age groups were as follows:— Year. Population. Under 5 years Percentage Immunised. 5—15 years. 0—15 years. 1945 103,320 40.7 80.4 65.7 1946 118,660 50.3 77.4 67.7 1947 123,100 52.4 86.0 72.2 1948 123,960 61.5 91.5 79.2 19 Excluding 1932, i.e. the first year of immunisation, there were during the eight years 1933-40, a total of 31 deaths from Diphtheria, and during the eight years 1941-48 a total of 15 deaths from Diphtheria. During the last two years, i.e. 1947-48 there were no deaths, but the year 1946 was a bad year, when there were 6 deaths from Diphtheria in unprotected children in the reception areas. During 1948, out of 34 patients admitted to hospital for suspected Diphtheria, only one was confirmed as such. This very favourable result was largely due to immunisation and to the fact that over 60 per cent of the children under five years of age and over 90 per cent of children between five and fifteen years of age have so far been protected in Walthamstow. This virtual elimination of Diphtheria can only continue if the percentage of young children protected can be kept up, or better, increased, especially in regard to the under-fives. Vaccination.—The vaccinal condition of each child examined at routine inspections was noted, and a summary shows the following:— Number examined. Number found to be vaccinated. Percentage vaccinated. Entrants Boys 333 124 37.2 Girls 294 98 33.3 2nd Age Group Boys 731 162 22.1 Girls 771 146 18.9 3rd Age Group Boys 928 189 20.3 Girls 662 199 30.0 Totals 3,719 918 24.6 9. OPEN AIR EDUCATION. From March onwards arrangements were made for the medical examination of parties of 35 boys and 35 girls each four weeks, before proceeding to the permanent school camp at Itchingfield, Sussex, and three parties of 11 boys and 11 girls before proceeding to the permanent School Camp at Kennylands, Reading. School Journey.—In December, 1947, your Committee agreed to the provision of £720 in the estimates for the following year towards the expenses of some 60 children and necessary escorts from secondary schools in Walthamstow, in proceeding to Sweden under a holiday scheme arranged by the Swedish/British Society. Later, a method of selection was decided on in regard to children in the 14-15 years age group. 20 In September your Committee considered a report made by Mr. F. J. Speakman, the leader of the party on the visit which extended between 19th July and 20th August, and resolved that the report be noted and that your Committee's thanks be conveyed to all concerned on the success of the visit. The following extracts are taken from Mr. Speakman's report:— "Viewed as a five week's holiday our stay in Sweden was, I believe, an outstanding success. But its measure is not to be taken merely by the friendliness and generosity with which we were everywhere met, but by our lasting and growing understanding and appreciation of a people's way of life, and our affection for that people. "English children are approximately one year more mature than Swedish children of the same age—a point to remember if the chance should recur to send a party. "Such a holiday, of course, was not arranged without much hard thinking and hard work. Commodore Oberg, who organised the broad scheme from Stockholm, worked out also most of the details. One-time Naval Attache in London, he was, during the war, in charge of the fleet for the defence of the Stockholm Archipelago; organising is his second nature. His was the master mind behind the whole Swedish arrangements. "Commodore Oberg, in replying to the letter from the Borough Education Officer, included the following paragraph:— 'I also want you to know that the children themselves, almost without exception, made a very good impression from the moment of their arrival and throughout the visit, and that they are kept in good memory by their hosts and by all members of our organisation who got into personal touch with them. They were excellent ambassadors of their families and of their country'." 10. PHYSICAL TRAINING. Your Committee share the services of two whole-time Organisers with a neighbouring area. Co-operation has continued along the lines of previous years. 11. PROVISION OF MEALS. The average number of meals supplied daily to school children in December, 1948, was 9,043. The quality of the food supplied and the standard of cooking have been maintained at the previous high level. 21 Milk in Schools Scheme.—The arrangements detailed in previous reports were continued in 1948, all the milk supplied being pasteurised milk sold under licence. Particulars of samples of milk taken in schools during the year are as follows:— Pasteurised, for bacteriological examination 15 for biological examination 4 Test Results: Bacteriological—Methylene Blue & Phosphatase All satisfactory. Biological—No adverse information received 12. (a) CO-OPERATION OF PARENTS. The following Table shows the attendance of parents during 1948 :— Number 'Inspected. Number of Parents. Per cent. 1948. Per cent. 1947. Entrants Boys 333 315 94.8 79.9 Girls 294 269 91.4 89.5 2nd Age Group Boys 731 493 67.4 71.3 Girls 771 543 70.4 81.5 3rd Age Group .. Boys 928 199 21.4 29.9 Girls 662 294 44.4 54.7 (b) CO-OPERATION OF TEACHERS. Renewed and grateful acknowledgment for the co-operation of Head Teachers and their staffs must be made. Generous help and co-operation has invariably been experienced. (c) CO-OPERATION OF SCHOOL ATTENDANCE OFFICERS. The Superintendent Attendance Officer and his staff have again co-operated with the work of the School Health Service. (d) CO-OPERATION OF VOLUNTARY BODIES. (a) The Invalid Children's Aid Association.—Mrs. Osora, Secretary of the local branch has kindly contributed the following report:— Number of new cases 244 Number of old cases 51 295 22 Number of weeks convalescence provided 1,627 Number of children sent away convalescent 249 Number of home visits paid 499 Cases Referred by: Over 5 yrs. Under 5 yrs Hospitals 50 21 Private Practitioners 31 10 School Health Services 130 11 Local Authority under schemes for:— (a) Rheumatismiii 4 — (b) Orthopaedic care 11 6 (c) Child Guidance 3 — Child Welfare Centres — 1 Voluntary Bodies 2 3 Parents 8 2 Transferred from I.C. A. A. Branches 2 — 241 54 Over Under 5 yrs 5 yrs Suffering from:— Anaemia, debility, malnutrition 55 6 After-effects of acute or infectious illness or operation 54 13 Bronchitis and pneumonia 39 8 Asthma 10 1 Rheumatism, chorea and heart 13 1 Other crippling defects (non-T.B.) 16 12 Nervous conditions 16 3 Diseases of: (a) Ear, nose and throat 15 4 (b) Eyes 5 — (c) Skin 7 — Accidents 4 — T.B. contacts 1 — Tuberculosis (a) Lungs 1 2 (6) Various 2 — Various 3 4 241 54 Help given to old and new cases :— Children sent to Convalescent Homes and Residential Open Air Schools 213 36 Provided with surgical appliances 3 10 Transferred to other agencies 9 5 Referred for visiting and advice 27 10 252 61 23 (b) National Society for the Prevention of Cruelty to Children.—The following is a summary of the work done in Walthamstow during 1948:— Nature of Offence. Neglect 26 Advice sought 16 Ill-treatment 8 50 How dealt with. Warned 34 Advised 16 50 Number of Children dealt with :— Under five years. Over five years. Boys. Girls. Boys. Girls. 27 23 43 26 126 supervisory visits were made during the year, and 130 miscellaneous visits were made. HANDICAPPED CHILDREN. (i) School for the Blind and Partially Sighted.—The following table shows the classification of children at the end of the year:— Walthamstow pupils. Essex County pupils. Out County pupils. Blind Partially Sighted. Blind Partially Sighted. Blind Partially Sighted. Boys — 9 — 1 — 8 Girls — 11 1 2 1 11 Mr. G. M. Williams, the Head Teacher, reports as follows:— This year has been one of change for the school. Owing to pressure of space upon the facilities at the Hale End site, the School was transferred to premises at the Wood Street Primary School. This entailed a major upheaval but the school quickly settled in. The school was visited by parties of students from Teacher Training Colleges and also by Student Health Visitors. Dr. Sheppard visited the school and examined the children and also made many special examinations at the Clinic. Our grateful thanks are due to her for her continued interest. At the end of the year Miss Balls, Headmistress, and Miss Mahoney, Assistant, retired after almost 30 years of service to the school. We should like to record our appreciation of their services. During the year the average attendance was 36.2 and the average number on roll was 39. 24 (ii) School for the Deaf.—Mrs. I. J. M. Burt, the Head Teacher, reports as follows:— In January 1948 there were 18 pupils in the school—14 boys and 4 girls. Their ages ranged from 3 years 2 months to 11 years 1 month. Of these 18, one was partially deaf, 16 were totally deaf and one was severely retarded mentally and only partially deaf. One partially deaf child was admitted in June. She was very backward indeed, but this was due entirely to her inability to follow instruction in a large class of a school for normal children. She has made rapid progress in the understanding, speaking, reading, and writing of language, and her progress in number work is only a little less rapid. She has become an expert lip-reader, and when she has attained the standard of a hearing child of her age, and when she is in possession of a hearing aid, she should be able to take her place in a school for normal children. At present we feel she is better in this school, until her confidence in her own ability is more firmly established. Her attendance at this school has been of very great benefit to her, but her association with the totally deaf would be to her detriment. In September, 1948, a totally deaf boy was admitted who has been in residence at the Royal Schools for the Deaf, Margate. He is boarding in Walthamstow so that he may attend a day school. The numbers, therefore, at the end of the year were 15 boys and 5 girls, of ages from 4 to 12 years. My predecessor, Miss Mitchell, left during the year to become the Headmistress of Tunmarsh Lane School for the Deaf, West Ham. (iii) School for the Physically Handicapped.—Mr. Williams, the Head Teacher, reports as follows:— The work of the school has continued at the Hale End site, some adjustment of accommodation taking place owing to the removal of the Partially Sighted School to Wood Street. This enabled us to take more advantage of open air activities when the weather conditions were favourable. This year an experiment was made in the summer holiday when the school was opened on a voluntary basis for a fortnight; it was felt that the long vacation broke the continuity of medical supervision. The attendance was maintained at over 90 per cent during the whole period and was of undoubted benefit to the children. Parties of Students from Training Colleges and Student Health Visitors visited the school during the year. 25 Swimming has now been arranged for selected children and several certificates have been won. During the winter months a hot drink and biscuit have been supplied to each child before morning school commences. Generally the health of the children has been maintained at a high level, but accommodation difficulties militate against the work of the school. During the year 36 children (including 6 re-admissions) were admitted and 36 were discharged. The average attendance was 60.3 and the average number on roll 74. At the end of the year the classification of cases was as follows:— Orthopaedic 20 Delicate 24 Cardiac 8 Chest (Asthma and Bronchitis) 18 Miscellaneous 4 Dr. Watkins has made weekly visits and by his personal interest and helpful advice has contributed greatly to the work of the school. I would also wish to thank all staff, medical, teaching, welfare and domestic for their valued co-operation during the year. (iv) Orthopaedic Scheme.—The Scheme is under the Clinical charge of Mr. B. Whitchurch Howell, F.R.C.S., Consulting Orthopaedic Surgeon. The following table shows the work done at this clinic:— 26  Boys. Girls. 5-16 years. Under 5 years. Over 16 years. 5-16 years. Under 5 years. Over 16 years. Anterior Poliomyelitis 11 5 4 14 2 11 Surgical Tuberculosis 2 — 4 2 — 3 Scoliosis, Lordosis, Kyphosis 21 — — 15 1 2 Arthritis 2 — 2 — — 4 Rickets:— (a) Genu Varum 7 19 — 7 8 — (6) Genu Valgum 42 28 —' 36 30 — Pes Piano Valgus 122 25 5 98 22 — Spastic Paralysis 9 2 2 6 4 — Progressive Muscular Atrophy 2 1 — — — — Osteo Genesis Imperfecta — 1 — — — —' Talipes:— (a) Equino Varus 13 3 3 5 5 1 (b) Calcaneo Valgus — 9 — 1 15 — (c) Pes Cavus 2 — — 1 — — Torticollis 7 2 — 7 4 — Osteomyelitis — — 1 — — 1 Congenital Dislocation of the Hip — — — 3 1 2 Hallux Valgus 2 — — 12 — — Hammer Toe 4 — — 6 — — Perthes Disease — — — 1 — 2 Achondroplasia — — — 2 1 1 Digitus Varus 2 1 — 4 — — Amputation of Leg — — — — — 1 Congenital Defects 11 7 6 14 6 — Miscellaneous 33 6 — 24 9 3 Totals 292 109 27 258 108 31 Number of cases seen by the Surgeon:— From Physically Defective School 36 From other Schools 324 Under School age 168 Over School age 41 569 New cases seen by the Surgeon:— School age 76 Under School age 96 Over School age 1 173 27 Total examinations made by the Surgeon 742 Total number of cases discharged by the Surgeon 143 Average number of examinations made per session 53 Number of treatments given 2,382 Number of attendances for after-care . 2,342 Number of ultra-violet light treatments 3,141 Total number of treatments 7,865 Average number of attendances per session 17.7 Number of sessions held—Inspections 14 Treatment 445 Total number of visits by Instrument Maker 4 Admissons to Queen Elizabeth Hospital for Children 9 Admissions to Black Notley 11 Operations performed 22 Defects seen at Orthopaedic Clinic in Children under 5 years of age:— Anterior Poliomyelitis 7 Scoliosis, Lordosis, Kyphosis 1 Rickets—(a) Genu Varum 27 (6) Genu Valgum 58 Pes Piano Valgus 47 Spastic Paralysis 6 Progressive Muscular Atrophy 1 Osteo Genesis Imperfecta 1 Talipes—(a) Equino Varus 8 (b) Calcaneo Valgus 24 Torticollis 6 Achondroplasia 1 Congenital Dislocation of the Hip 1 Digitus Varus 1 Congenital Defects 13 Miscellaneous 15 217 (v) School for the Educationally Sub-Normal.—Miss R. E. A. Lock, Head Teacher of the School for Educationally Sub-Normal Children, reports as follows:— The number on roll during the year averaged 58, with intelligence quotients ranging from 46 to 75. Nine boys left during the year—four were transferred to residential schools, one returned to normal school on six months trial, one was excluded as ineducable, and three proceeded to full-time employment. Of the four girls who left, two removed to another area and two are now employed in local factories. During the year H.M. Inspector visited the school. 28 A small observation class has been formed from the lower age group (5—7 years of age). The children in this group are mainly those sent on trial, and are usually unfit for the more formal methods of the junior classrooms. (vi) Child Guidance Clinic.—Dr. Helen Gillespie, Psychiatrist to the Child Guidance Clinic, submits the following report:— TABLE 1 Analysis of problems referred to the Clinic. 1948. Borough of Walthamstow. Borough of Leyton and Forest Div. I. Nervous disorders, e.g., fears; depression apathy; excitability 22 6 II. Habit disorders and physical symptoms, e.g. enuresis; speech disorders; sleep disturbances; feeding difficulties; tics; fits, etc. 29 15 III. Behaviour disorders, e.g., unmanageable; tempers; stealing; lying; sex problems; etc. 44 27 IV. Educational, e.g., backwardness; failure to concentrate 10 8 V. Court cases 1 2 Total 106 58 TABLE II. Analysis of cases closed during 1948 (including cases referred in previous years). Borough oj Walthamstow. Borough of Leyton and Forest Div. Adjusted after treatment 15 4 Improved after treatment 47 16 No change after treatment 10 – Interrupted due to non-co-operation 29 9 Placed away from home 7 5 Approved school placing 1 — Diagnosed and closed 33 2 Spontaneously adjusted after partial service 12 7 Recommended E.S.N. School 4 — Recommended P. D. School 1 — Miscellaneous causes and removal 6 3 165 46 29 Staffing. At the end of 1948 Dr. Whatley resigned her position as Psychiatrist at the Child Guidance Clinic. Dr. Whatley has given many years' work to the Clinic and has helped to establish it firmly on its feet through many of the initial difficulties. She will continue her work as a Child Psychiatrist in other areas and we wish her every success in the future. Mrs. I. Seglow, Psychiatric Social Worker to the Outer Areas, also resigned at the end of 1948 to take up a post abroad. She also helped to establish the new field of work on sound lines, and our thanks are due to both her and Dr. Whatley. In April Mr. P. Secretan was appointed Educational Psychologist to the Walthamstow area to replace Miss Hammond, and from then to the end of the year both the Walthamstow and Outer area had a full team of workers. Since Mrs. Barker's appointment as play therapist for five sessions per week in October, 1947, it has naturally been possible to treat a larger proportion of the children referred. Selection of Cases. It is sometimes a very difficult matter for a person not closely connected with the work of a Child Guidance team to decide whether a child is suitable for Child Guidance referral or not, and whether the necessary co-operation from the home will be forthcoming. In order to eliminate that difficulty as much as possible, an attempt has been made during 1948 to select the cases for referral by means of joint discussion between the Educational Psychologist, the School Medical Officer, the Head Teacher and the parents. The final decision to refer a child to the Child Guidance Clinic thus becomes a joint one, and leads to a certain amount of pre-selection of cases. Throughout the year the number of cases accepted has thus been confined to the more serious and urgent ones. Owing to the delay in starting the structural alterations, the limited space available held up the work considerably.* The referral waiting list was actually closed for two periods during the year, owing to the large outstanding number of cases awaiting diagnosis or treatment. During the year nine members of the staff have been working in four rooms. It will be appreciated that in work of this nature the staff need rooms to themselves when interviewing or treating patients. We endeavoured to round off the work for 1948 as far as possible by the end of the year, in order to avoid interruption of many cases during the unavoidable slowing down in the work while alterations 30 were being made. This means that fewer new mothers and children were taken for treatment towards the end of the year to enable us to concentrate on current cases. * Note.—Completed early in 1949. REPORT OF EDUCATIONAL PSYCHOLOGIST. Borough of Walthamstow. General. A Psychologist was appointed in April in place of Miss Hammond. He spent the first few months in getting to know the schools and altogether 183 visits were made. Pupils tested. Average visits per school. Infants 40 2 Juniors 84 4 Secondary 47 2.5 Special 12 3 Total 183 The Psychologist saw and individually tested the following number of children:— No. Percentage. Boys 152 75 Girls 52 25 204 100 There were, therefore, three boys to every girl seen, and it seems to be typical to find more educational and behaviour problems amongst the boys than the girls. Though the children seen are a selected and not a typical sample of the school children, it is interest ing to notice the I.Q. distribution amongst them. No. Percentage. Bright 116 plus 30 14 "Average" 86—115 101 50 Dull .. .. 65—85 73 36 204 100 Of the total seen 14 were judged educationally sub-normal, i.e. 7 per cent. 31 The referral sources were as follows:— Source. No. Percentage. Head Teachers 131 65.0 S.M.O 54 25.5 Speech Clinics 7 3.5 Parents 6 3.0 Other 4 2.0 Court 2 1.0 204 100.0 Backwardness and Retardation. Altogether 43 children were referred for "backwardness" alone. Their I.Q. distribution is shown as:— I.Q. No. Percentage. 114 plus 5 12 71—113 24 55 70 and below 14 . 33 43 100 Thus only one out of three referred because of backwardness was actually very dull and more likely to do better at an E.S.N, school. Some of these children were already working fully up to the level to be expected from their mental age. The most serious problems of retardation concerned reading. Twenty children, all boys, were referred because they were poor readers. Their I.Q.'s are shown below:— I.Q. No. Percentage. 116 plus 2 10 86—115 12 60 65—85 6 30 20 100 The average retardation, judged by their mechanical Reading Age compared to their Mental Age was 5.4 years. Thus 10% of the children who were individually tested by the Psychologist are retarded by at least five years on the average. This makes it quite clear that Reading Retardation is a most serious problem at all the types of schools, i.e. Infant, Junior and Secondary. 32 The Psychologist has given advice on materials, readers, and method where asked for. One of the great difficulties is the old stocks of quite unsuitable readers in the schools. A complete Backward Class was tested individually for I.Q.'s, Reading Age and Arithmetic Age, and retardation or otherwise, in one Junior School. Not one of them was E.S.N., and over half were of about average intelligence. Their school classification could not, therefore, be attributed to dullness alone. Advice was given on teaching approach to these children. Coaching. Thirteen boys were taken on for reading coaching by the Psychologist with an average retardation of 5.4 years. In five months they made an average increase of 1.9 years in Reading Age. REPORT OF PSYCHIATRIC SOCIAL WORKERS. The Psychiatric Social Workers are mainly concerned with interpreting the Clinic approach to the parent-child problem, and supporting parents in the difficult situations which may arise during treatment. When a child is anxious and disturbed it often seems apparent that the possibility of his adjusting depends in a large measure on home atmosphere. Recovery may be hastened if parents can modify their attitudes and demands until the child is able to adjust. Such periods can be very trying and parents can gain much needed support by free discussion with the Psychiatric Social Worker. Interviewing at the Clinic is found to be more effective generally than home visiting and is to be preferred for several reasons. It makes it possible for an interview to be carried out without interruption and the attendance of parents is some evidence of their willingness to co-operate. There are cases, however, where environment factors can only be assessed by visiting the home. The load of cases makes it impossible for the Psychiatric Social Workers to keep pace adequately with this and motor transport would greatly facilitate the work. REPORT OF PLAY THERAPIST. Most of the children attending the Clinic this year for play sessions have been seen individually. In cases of educational difficulties and backwardness, the play treatment has been designed to provide outlets fcr frustrated energies with encouragement of special abilities. 33 Children with fear and anxiety problems have been given the opportunity to express and to gain insight into their fantasies to give them creative form. Where the anxiety has shown itself in over-aggressiveness or in otherwise difficult behaviour, children have been allowed to release their turbulent emotions in play with primitive material such as sand and water, before being encouraged to direct their energies into creative handling of paint and modelling materials. It has been found necessary for older children to bring more conscious understanding of their problems into the situation and so to obtain their active co-operation in dealing with their anxieties and difficulties. In most cases the parents of children attending for play sessions have been seen by the Psychiatric Social Worker, and it has been interesting to note that where parents have been persuaded to modify their attitude a positive reflection has shown itself in the behaviour of the children in their play. No. of cases treated during 1948 35 „ „ closed „ „ 17 Reason for closure:— Adjusted 5 Improved 5 Interrupted due to non-co-operation 4 Placed away from home 1 No change 2 (vii) Speech Therapy.—Treatment centres are provided at the Old Education Offices, High Street, and at the Open Air School. Miss C. M. Gregory reports as follows:— "During the past year 186 children have been treated for various defects. Approximately 110 children are treated weekly— of these there were about 80 stammerers of all ages, and 105 speech defects comprising stigmatism and dyslalics. These children were treated in classes varying in number from four to eight at a time. "Attendance was extremely good as the younger children, approximately eighty per cent. of the clinic, are transported by bus to and from the clinic. "There has been no appreciable change in the number or ages of the various speech defects as compared with the previous year. "Heads of schools have been most helpful with their interest and co-operation when school visits have been made—on the average once or twice per term. 34 "There has been a great improvement in the working conditions of the clinic since it has been re-decorated." Statistical Report and Clinical Analysis. No. of cases in attendance at beginning of year 42 „ „ during year 67 Transfers from other clinics 1 110 Cases ceasing attendance before cure or discharge .. 8 Cases discharged as incapable of benefiting by treatment . 1 Cases temporarily discharged before cure, to resume treat ment later 7 Cases discharged cured 48 Transfers to other clinics 3 67 Cases still in attendance at end of year 43 Total attendances during the year 4675 No. of new cases suffering from:— Physiological disorders—Stammer 53 Clutter 3 Voice fiefects—Aphonia — Dysphonia — Rhinophonia 4 Defects of Articulation—Dysarthria — Dyslalia 40 Language defects—Idioglossia.. — Delayed speech 2 Aphasia—Congenital word deafness — Congenital word blindness — Other — Defects due to abnormality of special senses—Deafness . 2 Blindness . — Other — Probable mental deficiency 2 Other types of defect 4 110 Miss V. L. Babington reports as follows:— ' 'There has been an increase in the number of children referred this year and the average age of referral has dropped considerably. This suggests an increased awareness on the part of parents and teachers of speech defects and disorders, and a recognition of the 35 importance of early treatment. Attendances have again been regular, and I should like again to record my appreciation of the co-operation of Head Teachers. "The help of students of speech therapy working in the clinics has meant that individual treatment could be maintained. Tables showing the number of children, treated, discharged, etc., are given below, together with a clinical analysis of defects. "A number of home and school visits'have been paid in addition to the initial interviews with parents, and well repay the time expended in this way. "An innovation this year has been the opening of an evening clinic for adults at the Town Hall. This was primarily begun to enable patients who would otherwise have to stop treatment when leaving school to continue until ready to be discharged, but new patients are now admitted." Statistical report and Clinical Analysis. No. of cases in attendance at beginning of year 96 „ „ admitted during year 39 Transfers from other clinics 3 138 Cases ceasing attendance before cure or discharge 5 „ discharged uncured as incapable of benefiting by treatment „ temporarily discharged before cure, to resume treatment later 6 „ discharged cured 50 Transfers to other clinics 7 68 Cases still in attendance at end of year 70 Total number of attendances during year 2475 No. of new cases suffering from:— Physiological defects—Stammer 55 Clutter — Voice defects—Aphonia — Dysphonia 2 Rhinophonia 10 Defects of Articulation—Dysarthria 4 Dyslalia 57 Language Defects—Idioglossia — Delayed speech 4 36 Aphasia—Congenital word deafness — Congenital word blindness — Other — Defects due to abnormality of special senses—Deafness 1 Blindness — Other — Probable mental deficiency 5 Other types of defect. — 138 (viii) Convalescent Home Treatment.—248 children were sent away for treatment during 1948. There were 26 children remaining in convalescent homes and hospital schools on December 31st, 1948. The following is a summary of convalescent cases over the past 18 years:— Year. No. of cases sent away. No. of cases School age. Under School age. remaining in Homes at end of year. 1930 120 N/A 34 1931 211 N/A 97 1932 284 N/A 79 1933 249 26 77 1934 321 21 84 1935 318 19 79 1936 311 32 73 1937 206 26 56 1938 235 26 80 1939 156 20 70 1940 48 11 23 1941 53 9 23 1942 106 10 48 1943 69 9 33 1944 54 11 38 1945 65 5 26 1946 139 19 33 1947 228 28 45 1948 248 36 26 37 14. FULL TIME COURSES OF HIGHER EDUCATION FOR BLIND, DEAF, DEFECTIVE AND EPILEPTIC STUDENTS. The Authority for the provision of such courses is the Essex County Council. 15. NURSERY SCHOOL. Miss F. D. Harris, the Head Teacher of the Nursery School reports as follows:— The year 1948 was an exceptional one in the Nursery School from the point of view of infectious disease. During the whole year, out of a school of 90 children we had only 10 cases of Whooping Cough, 2 of Chicken Pox and one of Mumps. The clamour for admission to the Nursery School continues to increase and we are quite unable to satisfy the demand. 16. MISCELLANEOUS. (i) Employment of Children.—82 children were examined by the medical staff. (ii) Employment of Children in Public Entertainments.— No children were examined under these regulations. (iii) Medical Examinations.—The following examinations were made during 1948 by the Medical Staff: Teachers, 92; Others, 34. (iv) Rheumatic Fever.—Dr. Wilfrid Sheldon, M.D., F.R.C.P. who was specialist in charge of the Walthamstow Rheumatism Clinic until October, 1946 has referred to the work of the clinic in an address given to the Fifth International Congress on Pediatrics at New York in 1947. The following extracts are taken from his lecture:— ". . . . Fig. 2 shows the percentage annually of new cases found in Walthamstow to have heart disease, almost entirely due to rheumatism. From 1931 to 1935 roughly 40 per cent. of the new cases were found to be thus affected, but from 1935 the percentage steadily dropped, so that by 1939 the figure had halved itself, being 20.3. In the early years of the war, mass evacuation and bombing considerably lowered the attendances, and in order to obtain attendance figures comparable to the pre-war years it will be noticed that the years 1940 and 1941, and 1942 and 1943, have been added together. It is particularly noteworthy that in these years the decline persisted, although the cases were drawn from children whose parents had either refused to accept the offer of evacuation, or had soon recalled their offspring from the rural areas" 38 "a decline in mortality from rheumatic fever has been proceeding in England throughout this century. A decline in the incidence of acute rheumatic disease among London children was apparent before the war, and the decline accelerated during the war years. "The reasons for these changes offer a field for speculation and research. The lowered mortality during this century has coincided with a gradual rise in the standard of living. The lessening incidence just prior to the war occurred at the same time as a considerable rise in employment. It is tempting to think that the mass evacuation of children from cities and towns to rural areas, which took place at the outbreak of war, may have so reduced over crowding and the opportunity for droplet infection as to account for the accelerated decrease in rheumatism during the war years. The figures from Walthamstow however show that the decline went on among children who continued to dwell in their own homes, and spent many nights in air-raid shelters." Fig. 2. Walthamstow Rheumatism Clinic, 1931 -1943. 39 (v) Preventive Aspects of Deafness and Defective Vision in School Children.—The following are extracts from an article contributed by Dr. M. Watkins, Deputy Borough School Medical Officer, to a nursing periodical. THE PREVENTIVE ASPECTS OF DEAFNESS AND DEFECTIVE VISION IN SCHOOL CHILDREN. Defective hearing and vision in a school child reduce his ability to take full advantage of the educational facilities available to him, and interfere greatly with his physical, mental, and social development. The Education Act of 1944 requires local Education Authorities to ascertain, among other defects, those children handicapped by virtue of defective hearing and vision, and to make provision for their educational treatment. Most authorities have long-established regular clinics in charge of Aural Surgeons, and ophthalmologists, for the care and treatment of ears and eyes. DEAFNESS. The number of cases of acquired deafness is more than double that of congenital deafness. It is therefore with the former group that we are mostly concerned in the school health work. The commonest causes of acquired deafness are catarrhal and suppurative otitis media, meningitis, measles, scarlet fever, other infectious diseases, and injury. Otitis media accounts for nearly half the number of cases in the acquired group, and it is with this condition that preventive work can hope to obtain most success. The catarrhal and suppurative conditions of the middle ear may arise from a variety of sources, e.g., colds, nasal catarrh, septic conditions of the tonsils and adenoids, sinusitis, dental sepsis, etc. The catarrhal condition of the ear, nose, and throat are common in the community, but a child on entry to school is exposed, often for the first time, to massive cross infection from other children, and there is a consequent rapid rise of upper respiratory tract infections, and a compensatory hyperplasia of the lymphoid tissue, with a consequent risk of middle ear disease and deafness. This risk is even greater amongst the more immature child of nursery schools and day nurseries. Many other factors also influence the incidence of infections of the ear, nose, and throat, such as the general health of the child, his diet and environment. All children are, therefore, examined as soon after entry into school as possible and at very frequent intervals if at a nursery school or a day nursery. Any conditions likely to give rise later to deafness are further screened at minor ailment clinics where the 40 simpler treatments are carried out. Those needing more active treatment are referred to the specialist school aural clinics where emphasis is laid upon prompt early treatment. The nature of the work at these clinics is mostly of a conservative nature. Supplementary tonics such as cod liver oil are available free of charge, and if necessary the child may be referred to convalescence or placed in an Open Air School. Any child who has an infective condition of his ear, nose, or throat such as otorrhoea and tonsillitis is rigidly excluded from school. Infectious diseases comprise the other great group of causes of acquired deafness. It is therefore important to try to reduce their incidence among school children. This can only be done by a very close surveillance of both school and home by the school nurse and health visitor during an epidemic. Here detection and exclusion of all cases and of contacts is essential. The help of teachers at this stage is invaluable. They refer every child, who presents the least symptom either to the minor ai!ment clinic or to their own doctor before he is allowed to remain in school. A great deal of minor degrees of deafness may go unrecognised in schools unless the acuity of hearing is tested. The group method for testing is employed in the form of a gramophone audiometer. This instrument can examine as many as twenty-four at a time. It has a number of headphones, and speaks a series of numbers in a measured gradation of intensity or loudness. The children write down the numbers they can hear on a special form. From this it can easily be deduced whether the child has a normal range of hearing. If deafness cannot be improved, and is of such a degree that the child is unable to profit by education in a normal class, then he is referred to special classes or schools for the partially deaf, where special methods of teaching are used, or, if necessary, for the use of electrical hearing aids. DEFECTIVE VISION. Approximately 9 per cent. of school children show some defect of vision. For the efficient functioning of a preventive ophthalmic scheme, the earliest possible ascertainment of children needing that service is essential. The examination of children below school age is the responsibility of the Maternity and Child Welfare Authorities, and it is important that any found having defective vision are 41 reported to the Education Authority prior to admission to school, so that appropriate arrangements may be made for continued treatment and special education if required. The most important method of ascertainment during school age is the routine medical inspections, the most important of which is at entry. The vision of each child is assessed by the school nurse before being examined by the School Medical Officer. They are tested by means of the Snellen's long-distance chart illuminated toat least ten foot candles with a child twenty feet away. The disadvantage of this method is that a child does not always know its letters, and special charts using animal shapes, and the letter "E" in various sizes and positions, are employed to overcome this difficulty. Even so, this assessment, while embracing the majority presenting defects, will not include all, and the co-operation of teachers in this connection is invaluable. They refer any child who displays symptoms indicative of defective vision, e.g. headaches; holding the book close to the eyes; peering; obvious eye-strain; difficulty in seeing the blackboard; stooping over the desk, or signs of mental retardation. The school nurse who visits the school every term is also on the alert for such defects, and often makes vision surveys. All children who are found incapable of reading the sixth-twelfth line on the Snellen's chart with either eye are referred for fuller ophthalmoscopic examination. Thus the majority of children with defective vision will be picked out; but this test, however, does miss a very few who have low hypermetropia (long sight). Those found needing corrective glasses are provided with these free of charge. It is important to make a close and frequent follow-up of all cases prescribed glasses. This is usually done regularly by the school nurse to ensure they are being worn, and a prompt replacement is effected if found broken. GENERAL CONSIDERATIONS. Adequate natural illumination of all points in a class is essential. Sky should be visible at all desk heights, and the light should come from the left of the pupils. The lowest intensity of artificial illumination on desks should be ten foot candles. It is also important that the colouring of walls and ceilings be light, but glare from any source, either from reading material or from walls, should be avoided. 42 STATISTICAL TABLES. The statistical tables required by the Ministry of Education follow:— TABLE I. MEDICAL INSPECTION OF CHILDREN ATTENDING MAINTAINED PRIMARY AND SECONDARY SCHOOLS. A.—Periodic Medical Inspections. Number of Inspections in the Prescribed Groups:— Entrants 627 Second Age Group 1,502 Third Age Group 1,590 Total 3,719 Number of other Periodic Inspections B.—Other Inspections Number of Special Inspections and Re-inspections 241 TABLE II. CLASSIFICATION OF THE NUTRITION OF PUPILS INSPECTED DURING THE YEAR IN THE ROUTINE AGE GROUPS. Number of pupils Inspected A (Good) B (Fair) C (Bad) No. °/ /o No. °/ /o No. % 3719 1811 48.6 1777 47.7 131 3.5 TABLE III. TREATMENT TABLES. Group I.—Treatment for Minor Ailments (excluding uncleanliness for which see Table V.). Total number of defects treated or under treatment during the year under the Authority's scheme, 3924. 43 Group II.—Treatment of Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group I). Errors of Refraction (including squint) Other defects or diseases of the eye. Number of Children for whom spectacles were Prescribed. Obtained. 410 175 695 695 Group 111.—Treatment of defects of Nose and Throat. Received Operative Treatment. Received Other Forms of Treatment. Total. 146 552 698 Group IV.—Orthopaedic and Postural Defects: (a) Number treated as in-patients in hospitals or hospital schools 20 (b) Number treated otherwise 530 Group V.—Child Guidance Treatment and Speech Therapy: (o) Number treated under Child Guidance arrangements 118 (b) Number treated under Speech Therapy arrangements 324 TABLE IV. Dental Inspection and Treatment. (1) Number of children inspected by the Dentist:— (a) Routine Age Groups 2,263 (6) Specials 1,260 Total 3,523 (2) Number found to require treatment 2,783 (3) Number actually treated 6,583 (4) Attendances made by pupils for treatment 11,032 (5) Half days devoted to—Inspection 23 Treatment 1,804 Total 1,827 44 (6) Fillings—Permanent teeth 3,376 Temporary teeth 899 Total 4,275 (7) Extractions—Permanent teeth 1,018 Temporary teeth 3,484 Total 4,502 (8) Administration of general anaesthetics for extraction 2,972 (9) Other operations—Permanent teeth 3,541 Temporary teeth 1,646 Total 5,187 TABLE V. Infestation with Vermin. (i) Total number of examinations in the schools by the school nurses or other authorised persons 32,897 (ii) Total number of individual pupils found to be infected 970