Lybrary Ac 4411(1) WALTHAMSCOW WAL 44 BOROUGH OF WALTHAMSTOW Committee for Education REPORT of the BOROUGH SCHOOL MEDICAL OFFICER for the year 1956 A. T. W. POWELL, M.C., M.B., B.S., D.P.H. BOROUGH SCHOOL MEDICAL OFFICER wek 25/6/57 BOROUGH OF WALTHAMSTOW Committee for Education REPORT of the BOROUGH SCHOOL MEDICAL OFFICER for the year 1956 A. T. W. POWELL, M.C., M.B., B.S., D.P.H., BOROUGH SCHOOL MEDICAL OFFICER INDEX Section 1 — Staff 7 Section 2 — School Clinics 7 Section 3 — Co-ordination 7 Section 4 — School Hygiene and Accommodation 8 Section 5 — Medical Inspection 13 Section 6 — Review of the Facts disclosed by Medical Inspection 13 Section 7 — Follow-up 16 Section 8 — Arrangements for Treatment (Specialist Clinics) 16 Section 9 — Protection of School Children against Tuberculosis 31 Section 10 — Infectious Diseases 33 Section 11—Vaccination and Immunisation 38 Section 12 — Open Air Boarding School Education 39 Section 13 — Physical Training 39 Section 14 — Provision of Meals 39 Section 15 — Co-operation 41 Section 16 — Handicapped Children and Special Schools 44 Section 17 — Full-time Courses of Higher Education for Blind, Deaf, Defective and Epileptic Pupils 55 Section 18 — Nursery School 55 Section 19 — Miscellaneous 56 Section 20 — Statistical Summary 60 Accommodation 8 Audiometry 21 " Better Health" 58 Boarding School Education 39 B.C.G. Trials 32 B.C.G. at Schools 32 Cardiac Clinic 23 Child Guidance 24 Chiropody 16 Clinics 7 Colour Vision Tests 14 Committee Members 4 Convalescent Home Treatment 31 Dental Defects 15 Dental Treatment 18 Diphtheria Immunisation 38 Ear Disease 15 Ear, Nose & Throat Clinic 21 Employment of Children 59 Enquiry Officers 42 Eye Clinic 19 Eye Disease 14 Follow-up 16 Food Poisoning 33 Food Hygiene 39 Good Grooming 56 Handicapped Children— Deaf 47, 49 E.S.N. 44, 49 Epileptic 46 Partially Sighted 50 Physically Handicapped 45, 53 Health Education Lectures 56 Heart Disease 15 Hygiene 8 Invalid Children's Ald Association 42 Infectious Diseases 33 Liaison with Hospital Services 7 Lip Reading 21 Mass Radiography 31 Meals, Provision of 39 Medical Inspection 13 Medical Treatment 16 Milk in Schools Scheme 41 Minor Ailments 14 Mothercraft Lectures 56 N.S.P.C.C 44 Nursery School 55 Nutrition 13 Open Air Education 39 Orthopaedic Treatment 21 Orthoptic Treatment 20 Paediatric Clinic 28 Parents, Co-operation of Physical Training 9 Physiotherapy 21 Poliomyelitis 33 Pre-Nursing Courses 58 Problem Families 58 Re-inspection 13 Sanitary and Washing Accommodation 8 School Hygiene 17 Skin Diseases 48 Special Schools 7 School Clinics School for the— Deaf 49 Educationally Sub 49 normal 50 Partially Sighted 53 Physically Handicapped Specialist Clinics— Cardiac 23 Child Guidance 24 Ear, Nose and Throat 21 Ophthalmic 19 Orthopaedic 21 Paediatric 28 Spectacles 20 Speech Therapy 29 Staff 60 Statistical Summary 42 Teachers, Co-operation of Tonics 17 Tuberculosis 31 Ultra Violet Light Treatment 31 Uncleanliness 14 Vaccination— B.C.G. 32 Poliomyelitis 39 Smallpox 38 Visual Defects 14 Voluntary Bodies 42 Whooping Cough Immunisation 38 Wingfield Music Club 55 WALTHAMSTOW COMMITTEE FOR EDUCATION 1956— 1957 Chairman: Alderman S. N. Chaplin, j.p. Deputy Chairman: Councillor J. W. Pringle Ex-Officio: The Worshipful the Mayor: Alderman G. R. Lowton, j.p. The Deputy Mayor: Alderman Lady C. McEntee, o.b.e., j.p. Chairman of the Finance and General Purposes Committee: Alderman Ross Wyld, o.b.e., j.p. Ald. Mrs. L. P. Bailey, j.p. Ald. W. B. Fitt, o.b.e. Ald. H. Fulton Coun. Mrs. S. Candy. Coun. A. W. Ellis, m.b.e. Coun. J. Hammond. Mrs. H. A. Christy Rev. Canon K. H. Druitt, m.a., r.d. Mr. L. V. Head, j.p. Ald. G. S Mace Ald. A. E. Manning Ald. W. F. Savill. Coun. Mrs. E. M. Miller Coun. Mrs. W. M. Palethorpe Coun. A. F. Whicher. Mr. R. Lamb Rev. Canon Prendergast Rev. R. Waters. Borough Education Officer: E. T. Potter, B.Sc., j.p. 5 To the Chairman and Members of the Walthamstow Committee for Education. In the following pages I submit a report on the School Health Service in the Excepted District of Walthamstow for the year 1956 and I offer the following comments. There were comparatively few changes in the staff, the most notable being the resignation on retirement of Mr. L. W. Elmer, L.D.S., Senior Dental Surgeon, who was appointed to the service of the former Walthamstow Education Committee in April, 1932. Mr. Elmer has guided the development of the Dental Service in Walthamstow and leaves behind him a well integrated department. He has rendered fine service to the people of Walthamstow, and notably to the children. Fortunately Mr. Elmer continues with his work in a part-time capacity in the General Dental Service. The improvement of the sanitary accommodation in six departments is recorded, but on the other side is the non-approval of your Committee's schemes totalling nearly £27,000 for further improvements. The teaching of hygiene in schools with antiquated sanitary accommodation borders on the humorous. A new low record was established in regard to uncleanliness. An investigation into the incidence of verrucae at a Junior School is described, and it was disquieting that at the end of the year there were 106 children affected with this condition at twentyfive school departments. For reasons given in the interesting report by Dr. Mary Wilmers, F.R.C.P., the Rheumatism and Cardiac Clinic begun in 1932 was merged with the Paediatric Clinic. This clinic was commenced by Dr. Wilfrid Sheldon, F.R.C.P., and it was almost incredible to look back to the dreadful days of the early 1930's when so many cases of diphtheria and scarlet fever were followed by damaged hearts. Dr. Hinden in his report on the Paediatric Clinic refers to "the rising standard of health, which throws into strong relief the few chronic ailments in childhood which still defy control." The Speech Therapists describe the advantages of the parental escort of children for speech therapy. Rather slow progress is being made towards the ideal of an annual chest X-ray examination for all staff in close contact with groups of children. Unfortunately progress is not helped by the continuing inability to refer examinees to the static miniature Odelca Unit at the Chest Clinic. Prevention of tuberculosis by B.C.G. vaccination increased from 728 in 1955 to 1053 in 1956. 6 Three outbreaks of food poisoning due to Clostridium welchii were investigated. The first of five cases was at a special school and was most probably due to this organism. The second at a secondary school involved about thirty-five cases and was fully investigated and reported upon by Dr. Betty Hobbs of the Central Public Health Laboratory, Colindale. The third and largest outbreak involved at least fifty-two cases at a girls' high school and came to light almost accidentally. Quite apart from these outbreaks, opportunity was taken to instruct the School Meals Staff in clean food hygiene. Vaccination against poliomyelitis was begun in the appropriate age group and 205 children of school age received two doses and 11 received one dose. The arrangements for the ascertainment of handicapped children are reviewed and reference is made to the Wingfield Music Club, which is associated with the school for the physically handicapped. A recording was televised by the B.B.C. in Children's Hour before Christmas. Finally, reference is made to Health Education, the pre-nursing courses at three schools, and to children of school age in problem families. Once again I wish to express my appreciation of the help given by the Chairman and Members of the Committee, the Borough Education Officer and his staff, and the good work of the staff of the Department. I am, Your obedient Servant, A. T. W. POWELL, Borough School Medical Officer. 1. STAFF OF THE SCHOOL MEDICAL DEPARTMENT Appointments. Appointed Miss C. Dooley, l.r.c.p. & s.i., d.p.h. Asst. Cty. Medical Officer 1.6.56 Mrs. R. Reed, s.r.n. School Nurse 31.12.56 Resignations. Date Resigned Mrs. R. Bulsara, mi.d., m.s.. m.r.c.o.g Asst. Cty. Medical Officer 29.3.56 Mrs. H. Hammond, s.r.n. School Nurse 28.11.56 Mr. L. W. Elmer, l.d.s., r.c.s.(eng.) Senior Dental Officer 31.12.56 2. SCHOOL CLINICS Early in 1956 the Minor Ailments and Dental Clinics previously accommodated at the Sidney Burnell Secondary School were transferred to the adjacent Health Services Clinic at Silverdale Road. 3. CO-ORDINATION (a) Staff.—Co-ordination was secured by the fact that all the school health staff also carried out duties for other health services. The School Nursing staff was equivalent to seven whole-time nurses. (b) Family Doctors.—In 1953 one of the items noted in one of the periodical circulars to Family Doctors referred to the availability of School Medical Records at school leaving. An undertaking was given that these records would be sent forward on request, but few such requests have been received. It is desirable to send to Family Doctors a summary of a child's medical history before or shortly after leaving school and it is hoped to try out such a scheme during 1957. Whenever a consultant opinion is obtained through the School Health Service, a copy of the report is always sent to. the Family Doctor. (c) Reports from Hospitals.—Few hospitals send a summary on discharge of children from their wards. When such summaries were received they were of great value and were attached to the appropriate medical files. The hospitals which were outstanding in this respect during 1956 were Whipp's Cross, St. Ann's and Ilford Infectious Diseases Hospitals, Canadian Red Cross and Prince of Wales Hospitals. 8 (d) Liaison with Hospital Services.—The medical and nursing staff continued to visit in turn the ward rounds of Dr. Hinden, Paediatrician, at Whipps Cross Hospital. 4. SCHOOL HYGIENE AND ACCOMMODATION Accommodation.—The following table shows the number of schools in the Borough at the 31st December:— 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:— Deaf — — 1 — — Educationally Subnormal — — 1 — — Partially Sighted — — 1 — — Physically Handicapped — — 1 — — 1956 1955 1954 1953 1952 Number of Children on Register, 31st December 20224 20072 20157 20174 19975 Average attendance 18328.2 18014.0 18139.6 17936.9 16587.8 Percentage attendance 90.6 89.7 90.0 88.9 82.9 The increase in the number of children on the school registers over the last ten years amounts to 3,761, i.e. 22.8% of the 1947 roll. Mr. T. L. Rampton, A.R.I.B.A., A.R.I.C.S., Architect to the Committee for Education, reports as follows:— New Buildings. The first instalment of the additions to Blackhorse Road Secondary School, one classroom and one craftroom, was completed. A second instalment of the project at Chapel End Secondary School has been completed and equipped as a Science Room. The third instalment—a woodwork room—is in course of erection. Two classrooms are in course of erection at Sidney Burnell Secondary School, and will, when completed, assist in meeting the problem of shortage of accommodation. The first instalment of the additions to Wm. McGuffie School 9 on the Greenleaf Road site was completed, providing a metalwork room. A second instalment, a woodwork room, is in course of erection, and will be completed shortly. Construction of three additional classrooms at Co.ppermill Road Secondary School is nearing completion, the additional projects as conversion of classrooms to woodwork and metalwork rooms which are integrated with the former scheme will be commenced soon. Additions and Alterations. The provision of a staff room at Marsh Street Schools Library has filled an urgent need, and alterations to provide a children's lavatory have also been completed. New windows have been inserted at the St. Mary's C. of E. Infants' School ; these give improved lighting and ventilation to the Classrooms. Additional washing facilities have been provided at Markhouse Road Infants' School. This was coupled with alterations to cloak accommodation. The provision of additional washing facilities at Maynard Road Junior Boys' School was carried out in two stages. The difficulties with regard to water supply at the Sir George Monoux Grammar School were partly overcome by the installation of additional water storage. Since then an additional water main has been lAld into the school. A further instalment for the conversion of sliding doors to windows at Hale End Special School has been completed. A number still remain to be converted. The work of remodelling lavatories at St. Mary's C. of E. Infants' School has been completed. The second instalment of remodelling of ablution accommodation at Coppermill Road Junior Mixed and Infants' School has been completed. Remodelling of lavatories to Higham Hill Junior Boys' and Infants' School was carried out in the summer holiday. Renewal of urinals to the boys' lavatory at Thorpe Hall Infants' School has been completed. A start on the new washing facilities and provision of staff lavatory at Pretoria Avenue E.S.N. School will be made shortly. Maintenance. The severe weather conditions during the winter produced the usual frozen water supplies and difficulties in lavatories, the older 10 type of school with external lavatories make this problem a recurrent one. No real effective answer is possible other than remodelling. During the year annual renovations as internal and external painting were carried out on a rota basis. A number of floors were sanded and sealed, but this type of work is limited by availability of money, and also lack of suitable labour during the summer holiday. Removal of galleries was carried out at a number of schools during the holidays. The annual distempering of out offices was carried out. Vacuum cleaning of the schools was not carried out this year, as it was felt the expenditure was not reflected in the results. As an alternative, a number of machines have been purchased, and the schoolkeepers now carry out this work. At a number of schools the walls of classrooms have been washed down as in many cases the surface of the paint is still in good condition, but dirty. The trial has to date been successful, the only difficulty being the ceilings, as these in many cases cannot be washed. The clean walls show a marked contrast to the apparently untouched ceilings, although these are brushed off. The four regular cleans a year to all windows has been carried out. During the summer holidays all play areas, entrance drives, and footway approaches requiring attention were repaired and resurfaced so as to maintain in good condition. Heating. The first stage of remodelling the heating and hot water system at Chapel End Secondary & J.M. Schools has been commenced. The change over from solid fuel to oil firing follows present day practice, and when completed will result in a more efficient system. The second stage is scheduled, subject to approval, to be carried out in the year 1957/58. The scheme for improvements to Maynard Road Infants' School heating was completed in the autumn. The breakdown in the installation at Winns Avenue Infants' School caused great difficulties to all concerned. Temporary heating by oil heaters met the situation, but was far from satisfactory. Remodelling was successfully completed by autumn. Supplementary heating has been installed in one or two 11 rooms at a number of schools during the year, and this has brought about an improvement in conditions. New sections have been fitted to a number of boilers and existing systems maintained. Lighting. The remodelling of electric light and power installation is now complete at Woodford High School for Girls. The obsolete electric light installation at Pretoria Avenue E.S.N. School has been replaced with a new system. A section of the electric light and power installation has been remodelled at Sir George Monoux Grammar School. Minor improvements have been carried out at various schools and the existing systems maintained. Playfields. Normal maintenance has been carried out by the ground staff. A start has been made on the layout of the playfield at Sidney Burnell Secondary School. Provision of Meals. Improved conditions for the staff at Higham Hill Central Kitchen have been provided by the alteration to windows, and condensation and steam is no longer a serious problem. A start on the canteen at Pretoria Avenue E.S.N. School will be made shortly, a much overdue improvement. Normal maintenance to buildings has been carried out, repairs to and replacement of equipment by the Maintenance Engineer, and sundry improvements made. The appointment of a private architect to prepare schemes for and supervise the construction of sculleries is a contribution to an improved service at the following schools:— Roger Ascham Junior Mixed. Markhouse Road Secondary. Gamuel Road Junior Mixed. Geo. Gascoigne Secondary. Higham Hill Infants. A private architect was appointed to prepare a scheme for a dining room and kitchen at Selwyn Avenue Schools. The Ministry of Education's directive has meant that the project is deferred for the present. 12 The ceiling of £1,500 has resulted in similar projects at Coppermill Road Secondary School and Wm. McGufEe Secondary School being postponed. Major Projects. The lack of technical staff in the department made necessary the appointment of private architects for the projects approved. A start was made on the first instalment of North Walthamstow Technical School in March, 1955, and completion is scheduled for September, 1957. The second instalment is included in the 1957/58 programme. This school with both instalments will provide 891 places. The first instalment as addition at Joseph Barrett Secondary School was commenced in March, 1956, and is due for completion in January, 1957. The new Joseph Barrett Secondary Girls' School will shortly be commenced. A start on the Folly Lane Secondary School has been delayed, the original tender accounting for a higher cost per place than that allowed by the Ministry of Education. Economies have been made, and preliminary work is due to be started at once. Minor Projects. For a similar reason to that in the previous section a private architect was appointed to prepare a scheme for the remodelling of lavatories and additional washing facilities at Wood Street Schools. This project is nearing completion and will provide much improved facilities. Sanitary and Washing Accommodation. The improvement effected in the sanitary and washing accommodation in six departments was a welcome feature and work was proceeding at the end of the year at another department. The projects envisaged for 1957/58 in regard to sanitary improvements covered some eight departments and another six departments in regard to washing accommodation with a further scheme at one department covering both. The estimated costs were £16,506 in regard to sanitary accommodation, £6,730 in regard to washing accommodation, with £3,550 in respect of the combined scheme for sanitary and washing accommodation. In December, the Committee for Education noted that none of their recommendations regarding improvements to lavatory and washing facilities urgently required at certain schools had been 13 approved. It was agreed that the position be noted and kept under review. Unfortunately, owing to financial stringency, a great deal of leeway remains to be made up and conditions in many schools still tend to reduce lessons in hygiene to a farce. Ideally sanitary blocks should be adequate in layout and size with provision to offset winter frost, connected by a covered corridor to the classrooms and with washing accommodation which will literally invite the children to wash after using the toilet, and again before meals. Unless such a standard is secured, outbreaks of bacillary dysentery, amongst other diseases, will occur with monotonous regularity. 5. MEDICAL INSPECTION The following gives a summary of the returns A. Periodic Medical Inspections— 5 year age group 1,025 10-12 year age group 2,280 14 year age group 1,277 Others 1,106 Total 5,688 B. Other Inspections— Special Inspections 2,113 Re-inspections 2,364 Total 4,477 Owing to the increase in the number of children on the school rolls (22.8%) since 1947 and the consequent crowding of accommodation it was not always possible for medical inspection to take place under satisfactory conditions. Special facilities have been provided in the newer schools. 6. REVIEW OF THE FACTS DISCLOSED BY MEDICAL INSPECTION (N.B.—The numbers given below refer to medical and special inspection at schools and do not include other examinations at clinics). (a) Classification of the Nutrition of Children inspected during the year in the routine age groups:— Number Inspected Satisfactory Unsatisfactory No. % No. % 5 year age group 1,025 994 96.98 31 3.02 10-12 year age group 2,280 2,256 98.95 24 1.05 14 year age group 1,277 1,259 98.59 18 1.41 Others 1,106 1,078 97.47 28 2.53 Totals 5,688 5,587 98.22 101 1.78 14 (b) Uncleanliness.—The following table gives comparative figures for the past two years:— 1956 1955 Average visits to schools 4 4 Total examinations 20,443 28,666 No. of individual pupils found unclean 97 106 Percentage uncleanliness of average attendance 0.5 0.6 The number of individual children found unclean during 1956 was 97, i.e. a percentage of 0.4 of the number of children on the roll. This is a new low record and compares very favourably with some areas where it is understood up to 15 per cent. of children are involved. The unclean children form the hard core of uncleanliness still left in the Borough and the continuation of even this comparative handful of unclean children is a matter for great regret and a reflection on the few dirty homes which continue to exist in spite of all the efforts of the social services. The Superintendent School Nurse and Health Visitor reports as follows :— "The low percentage of uncleanliness in the Borough is worth noting in relation to that of the country as a whole. The School Nurses are to be commended in this sphere of their work. Their close followup of cases and visits to the parents to advise and help have contributed greatly towards this achievement. The hard core of uncleanliness has now been reached." (c) Minor Ailments and Skin Defects.—The following was the number of skin defects found to require treatment or observation:— Treatment Observation Ringworm—Head 1 — Body — — Scabies — — Impetigo 1 Other skin disease 230 116 (d) Visual Defects and External Eye Defects.—The number of patients requiring treatment or observation was as follows:— Treatment Observation Visual Defects 792 186 Squint 94 28 External Eye Diseases 81 32 Colour Vision Testing. — Testing is carried out with the Ishihara test cards by the School Nurse at the periodic medical inspections for the leaver age group. Any doubtful case is reported to the School Medical Officer. (e) Nose and Throat Defects.—The number of patients requiring treatment or observation was as follows:— 15 Treatment Observation Enlarged Tonsils 42 180 Adenoids 14 9 Enlarged tonsils and adenoids 28 22 Other conditions 128 131 During the year the medical inspection schedules were scored to show those children who had been subjected to tonsillectomy. The resultant analysis is as follows:— Number Inspected Tonsillectomy Boys Girls Boys % Girls % 5 year age group 532 493 38 7.1 21 4.2 10-12 year group 1,181 1,099 222 18.8 189 17.2 14 year age group 657 620 164 24.9 117 18.8 Others 547 559 105 19.2 71 12.7 Totals 2,917 2,771 529 18.1 398 14.4 (f) Ear Disease and Defective Hearing.—All school medical officers are provided with electric auriscopes and a full examination of the ears is carried out at each medical examination. The incidence of chronic otorrhœa in Walthamstow is considered to have been particularly low, largely owing to the success which has resulted from skilled treatment at the specialist ear, nose and throat clinic with zinc ionisation. The number of patients requiring treatment and observation was as follows:— Treatment Observation Defective Hearing 79 59 Otitis Media 19 72 Other Ear Disease 31 11 (g) Orthopaedic and Postural Defects.—A total of 231 defects were found to require treatment. (h) Dental Defects:— Inspected Inspection at Schools Requiring Treatment Per cent. Children actually treated Fillings Extractions General Anaesthetics Other Operations 10,529 5,634 53.5 7,892 7,809 7,148 3,844 3,754 (i) Heart Disease and Rheumatism.—The findings were as follows:— Treatment Observation Heart disease—Organic 9 24 Functional — 42 Anaemia 16 7 (j) Tuberculosis.—All children suspected of either pulmonary or other tuberculosis are referred to the Chest Physician for final diagnosis. 16 The notifications of tuberculosis in the age group 5—15 years have been as follows:— 1951 1952 1953 1954 1955 1956 Pulmonary 9 5 3 — 1 — Non-pulmonary 4 4 4 — 1 2 Total 13 9 7 — 2 2 (k) Other Defects and Diseases.—The following shows the number of various other defects which were found to require treatment:— Enlarged Glands 2 Bronchitis 57 Speech 39 Epilepsy 11 Other defects 250 7. FOLLOW-UP The School Nurses pAld a total of 288 home visits during 1956. 8. ARRANGEMENTS FOR TREATMENT (a) Chiropody.—Up to 1945 children requiring chiropody were treated with adult patients, but it then became desirable to set aside a special session once a week and this has continued since. 2,591 attendances were made by children during 1956. In December an increasing prevalence of verrucae was reported by the Head Teacher of a junior school with a suggestion that it was related to one of the local swimming baths. There were about six cases in the school during school term, and almost double the following term. The Headmistress had assured herself that no slippers were exchanged for physical education, that all children wore socks and that a foot inspection was carried out by the class teacher before each child was taken to the swimming bath. All children found with abnormal foot conditions were referred for treatment to the chiropody clinic. In view of the increase in verrucae, the Chief Chiropodist was asked to inspect every child attending this school with the following result:— "The entire school of 526 children was inspected. 40 children were found to be in need of treatment, 38 at the Chiropody Clinic and 2 at the Minor Ailments Clinic. Apart from these cases there were two children with verrucae and one with tinea pedis under the treatment of the family doctor. "The number of plantar warts discovered was 14, and with 7 under treatment and 2 under the care of family doctors, this made a total of 23 cases of verrucas at this one department. 17 "Since the beginning of the year 32 children from this school have been treated at the Foot Clinic, 22 with warts and 10 with other conditions." With regard to the treatment of children generally, a total of 659 received 2,591 treatments, or 3.9 per child. 1,718 of the treatments were for girls and 873 for boys, the ages concerned being 2 treatments under five years, 2,576 between 5-15 years, and 13 over 15 years. There were few children with orthopæsdic defects who had attended or had been referred in error. A disquieting feature was that at the end of the year no fewer than 106 children from 25 departments were attending the clinic suffering from verrucas; in six of the departments there were six or more cases, and the possibility of a complete foot inspection in each of these schools is being considered. (b) Tonics.—The following shows the quantity of tonics issued during 1956:— Cod Liver Oil Parrish's Food Syrup Lacto Phosphate Cod Liver Oil and Malt Cod Liver Oil and Malt and Parrish's Food 21 lbs. 105 lbs. 3 ½ lbs. 311 lbs. 1,379 lbs. (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 diseases is shown in the following table detailing the work done at the school clinics:— First Inspections Re-inspections Boys Girls Boys Girls Ringworm—Scalp — — — — Body 1 2 — 6 Scabies 1 — 2 1 Impetigo 13 13 40 33 Other Skin Defects 45 51 88 109 Orthopaedic conditions 18 18 14 9 Tonsils and Adenoids 25 19 32 32 Other E N.T. conditions 22 30 40 37 Defective Vision (including squint) 45 78 9 9 External Eye Diseases 35 48 16 29 Nervous and Psychological Disorders 20 12 7 8 Various 606 463 835 793 Totals 831 734 1,083 1,066 (d) Uncleanliness.—Treatment with Suleo was carried out with satisfactory results, and advice and treatment is available at all clinics and welfares. Steel combs are supplied at the various centres at cost price, and on loan in cases of necessity. Special treatment is available at the Hackney Borough Council's Cleansing Centre. 18 First attendances number 1,565 against 2,017 in 1955, and re-attendances 2,149 against 3,780, the total attendances being 3,714 against 5,797. The following table shows the new cases and attendances at Minor Ailment Clinics since the "appointed day" in July, 1948. The decrease reflects the tendency for children to be taken to family doctors. 1948 1949 1950 1951 1952 1953 1954 1955 1956 New cases 5,086 3,757 3,356 3,106 2,990 2,397 1,782 2,017 1,565 Attendances 16,490 14,112 11,515 10,000 10,634 8,544 7,019 5,797 3,714 (e) Dental Treatment. — Mr. L. W. Elmer, Senior Dental Surgeon, submits the following report:— "During the year under review 10,529 children were inspected at schools. This is rather less than had been anticipated, partly owing to the absence of one of the staff who attended a course of instruction in America. Of this number a total of 5,634 were found to require treatment and 3,824 were offered it. Owing to the increasing demand for conservative work it was found necessary to use some discretion in offering this treatment to those children and their parents who showed a lack of interest in dental care. All children were, of course, given emergency treatment if required. The number requiring emergency treatment was 2,639 and of these 2,394 were treated during the year. "The difference between those offered treatment after school inspection (3,894) and those given treatment (5,498) represents the back-log resulting from the number of inspections in the previous year. "With regard to the number of "units" representing fillings and extractions carried out, the total per session is 14. However, if allowance is made for those sessions when other work, such as orthodontic work or general anaesthetics administration, is carried out, the figure is 18. "Upon the conclusion of my 25 years in Walthamstow, may I be allowed to make the following comments. Upon my appointment, I was given to understand that your Committee wished the children of Walthamstow to receive not only the best of treatment but also as much consideration as possible. In carrying out this policy to the best of my ability I have received unchanging support at all times from the Walthamstow Borough Council and the Medical Officer of Health and I should like to record the deep appreciation of my staff and myself. It is largely due to this co-operation that, in these difficult times of staff shortages, a dental staff has been recruited and retained which is, apart from quality, numerically superior to many other areas.'' 19 The following report has been submitted by Mr. R. V. Tait, the visiting orthodontist:— "This year 106 patients were discharged from the clinic as needing no further orthodontic treatment, 71 of these having worn appliances. 106 removable and 25 fixed appliances were fitted. "The number of completed cases is misleadingly high and results from the new system of records in the clinic, whereby it has become possible to keep a closer check on patients for whom treatment is terminated. Many orthodontic patients discharge themselves when satisfied with the result of treatment and fail to attend for their final visit. In this year's figures are included a number of patients who have received active treatment with satisfactory results in 1955 but were not included in last year's figures. "During this year, 99 new patients were accepted for observation or treatment in the clinic and a further 167 children were examined and advice given to the school dental officers regarding their orthodontic treatment. "The following figures show the work done during 1956:—" Total number of sessions 135 Appointments—Made 1,239 Kept 1,034 Cases brought forward from previous year 250 New cases commenced during year 99 Cases completed during year 106 Cases for which treatment was completed with appliances 71 Cases discontinued 17 Removable appliances fitted 106 Fixed appliances fitted 25 Cases seen in consultation with School Dental Officers 167 SPECIALIST CLINICS (All Specialist Clinics are staffed as to Consultants by the Regional Hospital Board. Day to day administration has continued unaltered.) (a) Eye Clinic.—Visual acuity is tested in regard to all children at entrant medical examinations, but even so this may mean several months delay after admission. "Toddler" examinations 20 are held before school entry, not only to test visual acuity, but to detect the defects which many children are known to show at entry to school. Dr. Hilton Ho states that "we have already cut down on the use of Atropine as a cyclopegic except in young children (under 5 years). For children above five years of age, we are using Homatropine and Cocaine drops followed by Eserine drops after the examination is completed; thus, the child's near vision is affected for 4—6 hours only." The following table shows the work done during 1956:— New cases Under 7 years. 7-11 years. Over 11 years. Total Boys Girls Boys Girls Boys Girls Boys Girls Hypermetropia 8 4 14 17 4 11 26 32 Hypermetropic Astigmatism 3 6 14 22 12 14 29 42 Myopic Astigmatism 6 1 15 13 13 22 34 36 Mixed Astigmatism - 1 5 6 6 3 11 10 Myopia 8 3 35 29 21 33 64 65 Other Eye Defects 18 18 25 25 16 26 59 69 Totals 43 33 108 112 72 109 223 254 Number of children for whom glasses were- Prescribed 1,104 Obtained 966 Number of re-inspections 4,181 Total attendances 4,658 Supply of Spectacles.—The attendance at Eye Clinics of the dispensing optician provided by the Hospital Management Committee was of very great advantage to all concerned. There was no compulsion to obtain spectacles through official sources and parents were free to go to their own opticians if they preferred. (b) Orthoptic Clinic.—The following shows the work done at the clinic:— Number of cases investigated 144 Number of cases treated for the first time 48 Number referred to Hospital for operation 55 21 Number discharged 176 Total attendances during the year 1,236 (c) Ear, Nose and Throat Clinic.—The usual report provided by Dr. Francis Clarke is not available owing to his unfortunate absence from duty through sickness. The help of Mr. C. Hamblen' Thomas, F.R.C.S., and Dr. R. D. Henderson, M.A., in carrying on the clinic during Dr. Clarke's absence was very welcome. Arrangements for the Ascertainment and Treatment of Children with Defective Hearing.—At the request of the Principal School Medical Officer a review of the arrangements in force was made and the following are the provisions which operate. Audiology Centre.—Since 1926 a "Specialist" Ear, Nose and Throat Clinic has operated in Walthamstow. In addition there is a well staffed and equipped centre at Whipps Cross Hospital under the clinical charge of C. J. Scott, Esq., F.R.C.S., who is always ready to help. Audiometric Testing.—Since 1933 a gramophone audiometer has been available and before the war routine surveys were made at school. Since the war the services of a County Audiometrician have been available and she has carried out complete surveys of children attending junior and secondary schools. The last surveys were made in 1949 and 1955. Children with defective hearing were treated either at school clinics or at the Ear, Nose and Throat Clinic. Auditry Training and Instruction in Lip Reading.—Facilities are available at the William Morris Special School for the Deaf and Partially Deaf at Wingfield House, Hale End Road. This school was opened in 1900 (one of the first in the Country) and is staffed by four recognised teachers. In addition the two speech therapists are available to instruct in lip reading. (d) Orthopaedic and Physiotherapy Clinic.—The Clinic is under the clinical charge of Mr. G. Rigby Jones, M.C., F.R.C.S., Consultant Orthopaedic Surgeon to the Connaught Hospital. Mr. Rigby Jones reports that the clinic has continued to run very smoothly and satisfactorily. The following tables compiled by Miss Garratt, C.S.P., Physiotherapist, show the work done at the Clinic:— 22  Boys Girls 5-16 yrs. Under 5 yrs. 16-18 yrs. 5-16 yre. Under 5 yrg. 16-18 yrs. Anterior Poliomyelitis 10 3 — 11 2 2 Surgical Tuberculosis — — — — 1 — Scoliosis, Lordosis, Kyphosis 75 2 — 81 2 — Arthritis 1 — — 1 — — Genu Valgum 18 10 — 12 6 — Genu Varum — 4 — 1 — — Pes Valgus and Valgus ankles 82 8 — 37 3 — Spastic paralysis 12 — 1 12 — — Schlatters disease 2 — — 3 — — Progressive muscular atrophy 2 — 1 — — — Osteo genesis imperfecta 2 — — 1 — — Talipes—(a) Equino varus 9 — — 3 — — (b) Calcaneo valgus — — — — 1 — (c) Pes cavus 4 — — 2 — — (d) Metatarsus varus 1 2 — 1 2 — Torticollis - 1 - — — — Congenital dislocation of hip — — — 1 1 1 Hallux rigidus — — — 5 — — Hallux valgus 2 — — 13 — — Spina bifida 3 — — 1 — — Perthes disease — 1 — 2 1 — Achondroplasia — — — 1 — — Diaphyseal aclasis 2 — — — — — Digitus varus 2 — — 7 — — Overlapping toes 2 2 — 3 1 — Hammer toe 2 — — 4 — — Claw toes 2 — — 5 1 — Arthrogryposis multiplex congenitae 1 1 — — — — Slipped epiphysis — — — 1 — — Transverse myelitis — — — 1 — — Polymyositis 1 - - - - - Other congenital deformities 7 1 - 5 1 - Miscellaneous (including chest conditions) 81 6 - 63 10 — Totals 323 41 2 277 32 3 New cases seen by Surgeon— School age 111 Under school age 27 Total 138 Number of cases seen by Surgeon— From Physically Defective School 35 From other schools 422 Under school age 66 Over school age 7 Total 530 23 Total number of examinations made by Surgeon 668 Total number of cases discharged by Surgeon 88 Average number of examinations per session 44.5 Number of treatments given 8,236 Number of attendances for after-care 1,762 Number of sessions held— Inspection 15 Treatment 441 Number of visits by Instrument Maker 40 Admissions to Hospital 24 Operated on in out-patient departments 5 Operations performed 23 Children transferred from Connaught Hospital 25 (e) Cardiac Clinic.—The Clinic continued under the clinical charge of Dr. Mary Wilmers, F.R.C.P., who reports as follows:— "The Walthamstow Cardiac Clinic, which was started in 1931 under the title of Walthamstow Rheumatism Clinic to fill an urgent need for the supervision of children with rheumatic disease, especially carditis, was closed at the end of 1956 for lack of patients. Closure of the Clinic left a total of nine children to be transferred to various paediatric clinics; this surely bears eloquent witness to the decrease in the incidence of acute rheumatism over the last two decades. Some interesting facts emerge from more detailed consideration of the attendances, types of cases seen, reason for referral, and seem worth commenting on, although the reason for the changes noted are by no means always clear. 1932 was the first full year of the clinic and 45 sessions were held, approximately one per week. The total attendances for the year were 795 in the proportion of three new to five old cases. In 1946 sessions were held roughly every six weeks, eight in all. The total attendances were 142 and the proportion of new cases to old was 5 to 4. Further analysis of the figures shows that whereas just under half the new cases in 1932 were considered to have acute rheumatism or heart disease, in 1946 less than one in 11 of new cases were so diagnosed. This difference alone would account for a considerable falling off in attendances as children with non rheumatic limb pains or functional cardiac murmurs would not, as a rule, be accepted for supervision. One regular source of new cases in the early years of the clinic was the Isolation Hospital. In 1932 nineteen children were referred after scarlet fever (of which ten had cardiac lesion), sixteen after diphtheria (eleven had evidence of heart disease) and three children after both scarlet fever and diphtheria (all three had heart disease). In 1946 no child was referred as a result of either of these diseases. In 1956, the last year of the clinic, only four sessions were held and there was a total of 34 attendances, of which only two were new cases. Neither of the new cases was considered to have organic disease. While the decline in referral of new cases during the last year may have 24 been in part due to the long interval between sessions, the same trend has become increasingly evident for some years. "The figures quoted above give an overall picture of the work of the clinic and of how the numbers changed, but the change in type of case was equally striking, although actual figures to substantiate this are lacking. In the latter years the majority of the children attending with organic heart conditions had congenital lesions. New cases of rheumatic carditis were few and the old ones grew up and left school or died (two cases). New cases of congenital heart disease were still referred and were kept under observation, but at long intervals. "Some cases of congenital heart disease were deemed suitable for surgery and admission to hospital was arranged for them. One boy with severe cyanotic heart disease died after operation but the other cyanotic cases were all benefitted by surgery and follow-up was continued at the Walthamstow Clinic. In the acyanotic group the only surgery carried out was for closure of patent ductus arteriosus and although the children were all seen at the clinic after operation they were usually discharged within a year. "To sum up then: the main cause for the great fall-off in attendances at the Walthamstow Cardiac Clinic seems to have been the decrease in acute rheumatic disease in childhood. This decline is world-wide and the reasons for it are not clear but certainly improved economic conditions and improved housing play a large part in limiting the streptococcal infections which precede and 'trigger off' both the first attack of acute rheumatism and the relapses. The more efficient treatment of streptococcal infections with sulphonamide and antibiotics is probably not an important factor because the decrease was already well under way before these became freely available, but sulphonamide and penicillin have a valuable part to play in preventing second attacks in the known rheumatic child and prophylaxis by continued oral administration of either sulphonamide or penicillin has been shown to be effective in this respect in the U.S.A." (f) Child Guidance Clinic.—The Consultant Psychiatrist, Dr. Helen Gillespie, reports as follows:— "Our lay psychotherapist, Miss E. Daunton, left in July to take up a teaching appointment at the University of Cleveland, Ohio. We were sorry to lose her services, and we wish her every success in her new post. Her departure created a vacancy for four sessions per week, three of which were filled by Miss H. Carr, the remaining session being still vacant. "Miss Lacquer, one of our psychiatric social workers, has been away on sick leave from June to September and was very much missed. We welcome her return to the clinic. 25 "We are pleased that the pressure of work on the existing clerical staff will be relieved when Mrs. Terry, the newly appointed third clerical assistant, takes up her duties. "The waiting list is ever with us. The population served by this clinic has grown from 48,440 in 1948 to 68,980 in September, 1956. Additional psychiatric social worker and psychotherapist personnel are urgently needed if we are to cope with the demands made on us. "With an increase in the staff there have been some difficulties over accommodation and the use of one or two additional rooms would be welcome. "References from general practitioners suggest that they might be made more aware of the fact that the Child Guidance Clinic is open to children of all ages, including the under fives, as well as school children. For the latter, while it is recognised that they are free to refer children to whatever clinic they think fit, it would be as well for them to know that the more centrally situated London hospital child psychiatric clinics are saturated for purposes of treatment, and that children in this area so referred are usually re-referred to this clinic. Both Dr. Casimir and I feel that this dual referral militates against successful treatment." (The position was referred to in one of the periodical circular letters to medical practitioners A.P.). The following tables show the work of the clinic during the year. Figures for Walthamstow cases only are shown:— TABLE I Analysis of Figures for 1956 Number of cases referred to the clinic 111 Number of cases diagnosed at the clinic 67 (a) Psychiatrists Diagnostic interviews 67 Cases taken on for treatment 26 Treatment interviews 320 Other interviews 3 No. of psychiatric sessions per week 4 (b) Psychologists Clinic cases tested 73 Cases given remedial education 17 Treatment interviews (remedial education) 157 School visits on behalf of clinic cases 40 Other interviews at clinic 54 26 (c) School Psychological Service Individual cases seen 307 Number referred to clinic 13 (d) Play Therapists Cases treated 15 Treatment interviews 306 (e) Psychiatric Social Workers Interviews at clinic 730 Interviews elsewhere 12 (f) Waiting List Cases for diagnosis 41 Awaiting treatment 4 (g) Total cases treated during the year 151 TABLES II and III Analysis of Problems referred and Cases Diagnosed Referred Diagnosed I. Nervous disorders, e.g. fears, depressions, apathy, excitability 27 27 II. Habit disorders and physical symptoms, e.g. enuresis, speech disorders, sleep disturbances, tics, fits, etc. 30 11 III. Behaviour disorders, e.g. unmanageable, tempers, stealing, lying, sex problems, etc. 42 19 IV. Educational, e.g. backwardness, failure to concentrate 11 1 V. No basic disturbance of child, i.e. mainly parental over'anxiety — 1 TABLE IV Analysis of Cases Closed during the Year (Including cases referred in previous years.) Improved and recovered after treatment 17 Improved after partial service, i.e. before diagnosis 13 Diagnosis and advice only 18 Interrupted, e.g. on parents' initiative 28 Closed for miscellaneous causes (removed from area, placement in E.S.N. School, etc.) 7 27 REPORT OF THE EDUCATIONAL PSYCHOLOGIST FOR 1956 Miss E. M. Smith, M.A., reports as follows:— "During the year the psychologist has paid 133 visits to schools, and has given individual tests to 307 children (198 boys, 109 girls) of whom 13 were referred for psychiatric help. Eleven pre'school children were tested in their homes and advice was given to 32 parents. "Numbers seen in the different types of schools were as follows:— Type of school Number of children tested Pre-school 11 Infant 77 Junior 125 Secondary Modern 36 Grammar and Technical 9 Special 49 307 "The following table gives the range of I.Q. among the children tested:— I.Q. No. Per cent. Below 70 (E.S.N.) 55 17.9 70—75 (In need of special education) 32 10.4 76—89 (Dull) 69 22.5 90—115 (Average) 120 39.1 Above 116 (Superior) 31 10.1 Seventeen children have been receiving education from the psychologist and have attended for 157 sessions. The reading ability of children leaving infants' schools has again been under survey, and is the subject of an independent report. During the year lectures were given to two parent'teacher groups, and to a Home Office Course held at Wansfell. A lecture course arranged for secondary modern teachers was not supported and was therefore cancelled. Three students visited the psychologist during the year to learn about Child Guidance work. 28 (g) Paediatric Clinic.—The clinic was continued under the clinical care of Dr. Elchon Hinden, Paediatrician to Whipps Cross Hospital, who reports as follows:— "The work of the school consultative clinic has not altered materially from that in previous years. Perhaps there is rather less of it. I think there are two causes for this—the big numbers of children born towards the end of the war (the "bulge" in the birth-rate) are now entering adolescence, when they are so healthy they rarely trouble doctors; and the rising standard of health. The latter throws into strong relief the few chronic ailments of childhood which still defy our control. "Asthma is a disease which causes much invaliding in school life. It often starts much earlier, even in infancy, when it is frequently labelled bronchitis; but when the child is four or five the diagnosis is plain. We are not clear as to the causes of asthma. Basically it appears to be an excessive reaction to the minor irritants which we are all subject to: house dust, animal dandruff, unusual foods, trivial infections. Sometimes the trigger is an emotional one —frustration or even pleasurable excitement. We know that this tendency to "explode" runs in families, showing itself as infantile eczema or hay fever, as well as asthma—but we cannot understand the nature of this excessive sensitivity. The children who suffer from this disease often lose much time from school, and even when they are able to attend, their work is not at its best because their nights are disturbed by asthma. However, the majority of children recover as they grow up, and most are free by the time of adolescence. Infantile eczema is of bad omen, and usually babies with this complaint who contract asthma suffer from it for many years. "An intractable variety of asthma is when the exciting cause is a disturbance of the relationship between the child and the rest of the household. Treatment is of little avail, for the very air the child breathes in his own home is vitiated. The diagnosis is often made by the mother, who has noticed that the child improves out of all recognition when he goes on holiday. I feel that the best treatment for such a child, and the only one that can afford him an undisturbed education, is boarding school. The temporary respite given by a spell at a convalescent home is usually too short-lived to be of real benefit. "I should like to thank the Assistant School Medical Officers for referring the children to me, and the general practitioners for granting them permission to do so ; and my colleagues, the Pathologist and Radiologist at Whipps Cross Hospital for kindly offering me the facilities of their departments." Over 5 years Under 5 years New cases 69 28 Total attendances 108 57 29 Over 5 years Under 5years Physical Defects: Number of cases 51 28 Referred to Hospital 21 11 Discharged 14 8 Psychological Disorders: Enuresis 18 — Other — — Referred to Hospital 7 — Discharged 6 5 (h) Speech Therapy.—Treatment centres are provided at the Old Education Offices, High Street, and at the Wingfield House School. The arrangements of previous years have continued in regard to the selection and reference of children for speech therapy. Miss C. M. Borthwick, L.C.S.T., reports as follows:— "Individual treatment and the parental escort of children to the clinic has proved a great success. This is indicated by the higher number of discharged cases this year. All children now receive treatment for half'hourly periods and only seven have to be transported. The new arrangement has been advantageous as parents are able to follow the work in detail and are better able to carry out home practice. Absenteeism has dropped from 23 per cent. in 1955 to 15 per cent. in 1956. Holiday attendances have improved, e.g., Easter 1955, 71 per cent.; Easter 1956, 84 per cent. "Eleven children have this year been referred to the clinic before reaching school age. Eight have been treated and two are under observation. Only in one case was treatment not considered necessary. Generally speaking an articulatory defect would not be treated till four years of age, and then only if affecting more than one or two sounds. A younger child would only be treated if language development was also delayed and was not associated with mental deficiency. Nevertheless I find it helpful to interview all cases, as often the mother is over-anxious and is helped by a few words of advice. All cases where treatment has been given have made excellent progress." Miss A. M. Hemmings, L.C.S.T., reports as follows:— "1956 has been the first full year which the majority of children have been brought for treatment by their parents, only a few being transported. This step has proved most successful, since personal contact with the parents has brought more cooperation and in consequence additional useful information which would not have been obtained at the first interview. Instructions for practice have also been explained more fully. It was thought at first when this project was under consideration that there might be an increase in absenteeism, but actually the reverse has happened, as often parents know of a forthcoming absence and so enable me to fill the vacant appointment. 30 "The new treatment room mentioned last year is almost completely furnished and now can operate as a separate entity. "Examination of the figures reveals that just under 20 per cent. of the total cases are children from the Special Schools. The majority of these are long term and somewhat complicated cases. The close proximity of Wingfield House School for the Physically Handicapped is a great advantage since these children are available for any additional treatment that it is possible to give. "The system of recording certain cases is still being carried on, but under somewhat trying circumstances, since Miss Borthwick and I have to use a machine which is also available for other parts of the county. My thanks are due to the Education Department who at very short notice let me have the use of one of their machines to record a rather rare case. "The accompanying figures include only those children interviewed in the clinic and accepted for treatment. Many more children were examined during the course of school visits which took place throughout the year." Annual Report and Clinical Analysis. High St. Clinic Open Air School Clinic Number of cases in attendance at beginning of year 78 70 New cases admitted during year 54 45 Transfers from other clinics — 4 132 119 Cases ceasing attendance before cure or discharge 9 13 Cases discharged improved and incapable of fiting from further treatment 6 9 Cases temporarily discharged before cure, to resume treatment later 7 7 Cases discharged cured 45 36 Transfers to other clinics 1 — Cases still in attendance at the end of the year 64 54 Total attendances during year 2,302 2,155 No. of cases suffering from:— 1. Physiological or Psychological Defects: (a) Stammer 40 26 (b) Clutter — 1 2. Voice Defects—Dysphonia — 1 Rhinophonia 7 5 5. Defects of Articulation: Dysarthria 1 5 Dyslalia—Simple 23 15 Multiple 57 58 4. Language Defects (Delayed speech) 1 2 5. Aphasia — 1 6. Probable mental deficiency 3 4 7. Other defects - 1 132 119 31 (i) Convalescent Home Treatment.—65 children were sent away for convalescence during 1956. There were two children remaining in convalescent homes and hospital schools on December 31st, 1956. (j) Tuberculosis.—The number of school children examined for the first time during the year was 112 boys and 138 girls, of whom 19 boys and 27 girls were referred by the school medical staff and 66 boys and 69 girls by private practitioners. 27 boys and 42 girls were examined as contacts. (k) Ultra Violet Light Treatment.—The total attendances for treatment were 751. 9. PROTECTION OF SCHOOL CHILDREN AGAINST TUBERCULOSIS (a) Chest X-ray Examination of Teachers on Appointment.— There has been no difficulty in insisting that all teachers on appointment in Walthamstow be required to undergo a chest x-ray examination. During 1956 the total of such examinations was 114. Although the local Chest Clinic has been equipped with an Odelca miniature x-ray apparatus, it has so far not proved possible for staff to be referred as a routine. Instead staff are referred to the Mobile Mass Radiography Units and the static unit at Holloway Road, but the difficulties in such an arrangement are obvious when compared with local facilities. The Mass Radiography Unit visited Walthamstow between the 17th and 30th January and was stationed at the Old Monoux School Buildings in High Street adjacent to the Chest Clinic. Adults only were examined although children over 14 years of age were able to attend the public sessions. The Borough Education Officer in a circular to schools stated:— "It is the earnest wish of the Committee that as many as possible of their staffs in all grades and especially those who have never had a chest examination previously and those who suffer from chronic or winter bronchitis will take advantage of the visit of the unit and attend for examination." Three afternoon sessions were reserved for teachers and another three for other staff. Response from both teachers and 32 staff was most gratifying, and two extra sessions were allocated. In all, 366 teachers and 186 other staff were examined. (b) Tuberculosis Vaccine Trials (Medical Research Council). Extracts from the press release issued by the Medical Research Council in February, 1956, were published in last year's report. During 1956 participants in the scheme continued to return for x-ray satisfactorily. (c) B.C.G. Vaccination of School Children. The scheme followed was described in the Report for 1954 and continued during the year under review. Unfortunately it has been considered necessary by the Ministry of Health to supply the vaccine through the Local Health Authority at Chelmsford, instead of direct, and on one occasion special arrangements had to be hurriedly improvised to obtain an alterna' tive supply, since the regular supply had not arrived. The Heaf multiple puncture apparatus has been used exclusively for testing during 1956 and with complete success. All secondary schools have been visited during the year, and of the 1,591 children invited 1,268 accepted, giving an acceptance rate of 79.7 per cent. 1956 1955 Number of Heaf positive 176 109 Percentage positive 14.2 13.0 Number of Heaf negative 1,064 740 Number absent 28 8 B.C.G. given 1,053 728 Absent or not done 11 12 By arrangement with the Chest Physician all the Heaf positive children were offered chest x-ray at the Chest Clinic. One was found to have active disease. No complications as defined in Section 18 of the Ministry of Health Memo 324/BCG have arisen, although many children have been seen with small ulcers which are a normal concomitant of successful vaccination. These children have been seen mainly owing to parental apprehension, although a fully explanatory leaflet is given to each child vaccinated. Arrangements have continued for family doctors to be notified when children on their lists in this age group are Heaf positive or have been vaccinated. 679 conversion tests were carried out on children who were given B.C.G. in 1955. 24 gave a negative result to the test but all these showed a good vaccination scar. 33 10. INFECTIOUS DISEASES Notifications from general practitioners of infectious diseases in the 5-14 year age group were as follows:— 1956 1955 Measles 286 577 Whooping Cough 185 45 Scarlet Fever 75 105 Pneumonia 6 7 Bacillary Dysentery 21 8 Tuberculosis 2 2 Food Poisoning 4 3 Erysipelas 2 — Poliomyelitis — 9 Paratyphoid — 1 581 757 School ' Outbreaks ' The following are brief particulars of what might be regarded as outbreaks:— March:Nine cases of scarlet fever at Woodford Green Primary School, seven living in the Borough of Woodford and two in Walthamstow. The parents and guardians of every child on the school register were notified by circular letter as to symptoms and signs and the precautions to be taken. April: It was reported that five children were absent from one of the Special Schools on account of diarrhoea. The District Public Health Inspector visited the school and the kitchens and the School Nurse visited absentee children living in Walthamstow. Specimens of food consumed by the children were sent for analysis and faecal and/or rectal swabs were taken from affected children, but all were negative for pathological micro-organisms. The condition was apparently due to Ch. welchii. May : Food Poisoning at a Secondary Mixed School. (Report to School Management Committee 11.6.56.) On Friday morning, May 4th, the Headmaster reported that 12 children had been sent home on account of feeling unwell and that 18 were absent for reasons unknown. As many as possible of these absentees were visited by the Medical, School Nursing and Sanitary staffs of the Department, 34 specimens were taken and enquiries made at the adjoining modern school kitchen and dining-room. All the cases were apparently associated with the second sitting and none from the first sitting, nor from the same meal sent out to the adjoining infants department and St. George's R.C. school. The enquiries at the school kitchen revealed that a female worker had recently been unwell and that a male porter suffered from cracked hands following from his employment. The specimens from the former were later reported to be negative, but the man with cracked hands revealed the presence of faecal streptococci and he was put off work. The visits paid to the absentees revealed that abdominal pains started on the afternoon of the previous day with diarrhoea during the night and a quick recovery on the Friday. The suspected meal on the Thursday consisted of boiled boned mutton with gravy and vegetables, bakewell tart with custard. In accordance with the usual practice, the sample meal which is always retained, was sent for examination together with 35 other specimens from patients, i.e., three adults and 32 children. The outbreak proved to be due to a bacterium known as C1. welchii which is comparatively common in meat as supplied from trade sources. A major difficulty is that this bacterium, under certain conditions, transforms itself into what is known as a spore, which is then heat resistant. As soon as conditions become more favourable for growth, the spore germinates and the bacterium multiplies. Fortunately most cases are comparatively mild and no more cases were reported after those of the first day. The bacteriological examinations have been carried out at the Central Public Health Laboratory, Colindale, and Dr. Betty Hobbs, the authority on food poisoning, has been good enough to visit Walthamstow for a full discussion including a visit to the school kitchen. Dr. Hobbs has emphasised that the essential measure necessary is to cut down as far as possible the interval between cooking and consumption. The great difficulty is the time taken to carve meat for, say up to 300 portions. The sliced meat is placed in covered containers on a hot-plate, but unfortunately the temperature maintained on those containers is not sufficiently high to prevent the growth of this particular bacterium. Certain suggestions have already been made including the retention of the gravy at near boiling point and its addition to the meat at the last possible moment. The surfaces of the hot-plates do not appear to maintain a sufficiently high temperature, but Dr. Hobbs proposes to visit the kitchen to carry out further investigations. 35 Dr. Betty Hobbs later reported as follows:— "A summary of our findings up to date is given below:— "The effect of different temperatures of storage on germination of the spores and the multiplication of the bacillary forms of CI. welchii inoculated onto slices of freshly boiled lamb and into gravy was investigated in the School Kitchen. "Legs of lamb boiled on the morning of the experiment were sliced automatically at about 10.30 a.m. Three slices were placed into each of four tins and each slice was inoculated with approximately 10,000—16,000 viable spores (two experiments), or approximately 260,000 viable organisms including bacilli and spores (one experiment). "The tins were left in the hot-plate, on top of the hot-plate with and without gravy and at room temperatures. The three slices were removed at hourly intervals and stored in the cold pending examination, temperatures were recorded at the same time ; control slices of inoculated and uninoculated meat were also examined. Gravy was inoculated immediately after preparation and allowed to stand on the hot-plate for three hours. Portions were removed each hour. Ultimately the gravy was incubated overnight and examined the following day. The temperatures varied from 39°—49°C. on top of the hot-plate, from 62°—94°C. inside the hot-plate and from 18°—26°C. in the kitchen. "The results were most striking from the meat slices inoculated with mixed bacilli and spores. The count of C1. welchii for those standing on top of the hot-plate without gravy increased to 19.5 million in three hours, the count for those on the hot-plate with gravy increased to 2.5 million in two hours and 46 million in three hours ; there was no corresponding rise in aerobic organisms. "Inside the hot-plate conditions were evidently lethal, because no count was obtained from these slices. "At room temperature the counts remained the same throughout, there was neither rise nor fall. "In the experiments where spores only were used the inoculum was too low and although the trend was the same, that is, germination of the spores and multiplication of the resultant bacilli on the slices kept in gravy on top of the hot-plate, the results were not so striking. Increase in the count of CI. welchii in the gravy was shown only when the inoculum was a mixture of bacilli and spores when the count increased from 500 per ml. to 100,000 per ml. in three hours. After overnight incubation at 37°C., however, the gravy counts in two experiments were 105 and 250 million per ml. of gravy. 36 "The results of these experiments showed that C1. welchii could multiply rapidly on meat slices kept at 39°—49°C. and that even in 2—3 hours the numbers of organisms could change from what might be considered a subinfective dose to one which must be assumed could give rise to symptoms. "This phenomenon is likely to be true also for other meat dishes prepared by steaming or boiling, such as minces, pies, and pasties. "As it seems fairly certain that a proportion of meats are reaching canteens already contaminated with heat-resistant C1. welchii, then measures to protect consumers against this hazard must be taken. "Such measures may be described as follows:— (1) Cook the meat in such a way that all heat-resistant spores are destroyed, i.e., by pressure cooking or by the thorough roasting of small-sized joints. (2) Cook, cool rapidly and maintain in the refrigerator until required. (3) Cook and keep hot above 60°C. either inside a hot-plate or in the steamer when the presence of gravy should make little difference. "The same recommendations should apply to gravies and stews also. "The results of our experiments in this School Kitchen are of much practical use and we are most grateful for the willing help of all concerned." Sidney Burnell Infants' School Three cases of vomiting and 2 of diarrhoea were reported. The usual visits and inspections were carried out by the District Public Health Inspector and the cases were considered to be ' Winter vomiting.' October Mission Grove Infants' School Eight cases of vomiting were reported in one class. The school was visited by the District Public Health Inspector and specimens of food were sent for analysis. Several other cases were reported from the Junior Department, but all tests were negative. Apparently * Winter vomiting.' 37 High School for Girls At the beginning of October a parent reported that she suspected her daughter to be suffering from food poisoning. Immediate investigations were made and the diagnosis was later the same morning confirmed by the Family Doctor. Enquiries were made at the school which ultimately revealed that 52 members of the staff and pupils were affected over the weekend, but all were back at school except for the first case reported. All those affected had partaken of the school meal cooked at the school kitchen on the previous Friday and eaten at the first sitting. None who had taken the meal at the second sitting and which had been cooked at the central kitchen was affected. The meal at the first sitting consisted of cold roast pork and salad, followed by a chocolate pudding and sauce. The Deputy Chief Public Health Inspector who investigated the outbreak reported as follows:— "The roast pork consisting of four legs boned and rolled by the butcher were delivered to the canteen on Thursday morning, 27th September. They were cooked in a moderate oven for hours approximately and then placed in the food store to cool. This room faces North and is reasonably cool. After several hours cooling the pork was placed in the refrigerator when the canteen closed for the day about 4 p.m. It was taken out of the refrigerator for slicing at 11 a.m. on Friday and was eaten at 12.15 p.m. The chocolate sauce was made of fresh milk, dried milk powder, cornflour, sugar and cocoa. This was prepared from 10.30 a.m. onwards and according to the manageress, was kept at a temperature at or near boiling point until it was actually served at 12.30 p.m. "The incubation period, symptoms and duration of illness point to an infection with C1. welchii. If that is the case then the cold roast pork is the most likely vehicle of infection. As 52 of the 233 persons who partook of this food were infected and the meat was cut from four separate joints, it may be that only one joint of meat was responsible. The technique of cooking does not appear to be at fault and it would seem possible that one of the joints was infected during the boning and rolling process and that the heat during cooking did not penetrate to the centre of what was known to be a thick joint sufficiently to kill the organism, with the result that the C1. welchii multiplied during the cooling process. "This outbreak would never have been discovered but for the persistence of Mrs. S. It is interesting to note that a food hygiene lecture was given to a Women's Organisation at Mrs. S.'s house two years ago, and it would appear that Health Education does sometimes prove effective." 38 Faecal specimens were obtained from " P.S." and another child and both showed heat resistant CI. welchii which proved untypable. Dr. Betty Hobbs in commenting on the outbreak wrote as follows:— "This is one of the rare occasions when the temperature of roasting was inadequate because the heat penetration to the inner surface of the roll failed to kill CI. welchii spores—as the Deputy Chief Public Health Inspector points out. It is again obvious that mild outbreaks can be overlooked even in schools and factories. "It is a pity that the specimen meal was thrown away, because the infecting strain of welchii was untypable and not agglutinated by any of our 11 sera. If the food strain had been available, we could have a new typing serum, but it is taking too big a chance to prepare a serum from one out of two untypable faeces strains." 11. IMMUNISATION (a) Against Diphtheria.—94 primary immunisations were done in children of school age and 764 "booster" doses were given in school immunising sessions. (b) Against Whooping Cough.—Immunisation against whooping cough has been available for many years to children of preschool age but in April, 1953, immunisation was made available to children of all ages. Nine children over five years were immunised against whooping cough during 1956. It is stressed that the main effort was directed towards children of pre-school years, of whom 1,015 were immunised. (c) Vaccination against Smallpox.—The vaccinal condition of each child examined at routine medical inspection was noted, and a summary shows the following:— Number inspected Number found to be vaccinated Percentage vaccinated Entrants Boys 532 136 25.6 Girls 493 128 25.9 10-12 year Age Group Boys 1,099 426 38.8 Girls 1,181 491 41.6 14 year Age Group Boys 657 187 28.5 Girls 620 178 28.7 Others Bovs 638 240 37.6 Girls 468 149 31.8 5,688 1,935 34.0 The percentage in 1955 was 29.8. 39 (d) Vaccination against Poliomyelitis.—205 children in the school age group concerned, i.e., 5'9 years, were given two doses of vaccine against poliomyelitis, and 11 were given the first dose which is to be followed by the second dose early in 1957. 12. OPEN AIR BOARDING SCHOOL EDUCATION During the year five boys and two girls were medically examined prior to returning each term to Kennylands Park School, Reading, Berks, and a further three boys received examinations before proceeding to Elmbridge Boys School, Cranleigh, Surrey, for the Spring, Summer and Autumn terms. Premises at the Jubilee Retreat have again been used by parties from most of the special schools. 13. PHYSICAL TRAINING The Committee shares the services of two whole-time Organisers with two neighbouring areas. Co-operation has continued along the lines of previous years. 14. PROVISION OF MEALS During October and November the daily number of meals exceeded 9,000 or some 40 per cent. of the numbers on the school roll. During the same period the daily milk meals averaged over 15,000 per day, or some 75% of the total on the school roll. Food Hygiene In March the Borough Council's District Sanitary Inspectors (now Public Health Inspectors) were asked to report on the measures necessary to ensure that all persons engaged in food handling in establishments maintained by the Committee for Education fully understood the extent of their responsibilities in order to comply with the Food Hygiene Regulations. The inspectors were also asked to report what structural alterations or items of equipment were required. At the same time sufficient copies were distributed by the School Meals Organiser (through the co-operation of the Borough Education Officer) of a summary of the Food Hygiene Regulations which had been prepared by the Chief Sanitary Inspector. In August and October two Food Hygiene Lecture Demonstrations were given to kitchen staff by the Deputy Medical Officer of Health and the Chief Public Health Inspector. Dr. Poole reports as follows:— 40 "At the request of the School Meals Organiser a lecture demonstration was arranged for approximately one hundred kitchen staff on Friday, 31st August, 2 p.m.-4.15 p.m. in the Sir George Monoux School Hall. "The lecture illustrated with diagrams prepared in the Department dealt with the local and general incidence of food poisoning including the alarming increase in the number of cases in recent years. The nature and sources of the organisms, the factors controlling their rate of growth and the responsibilities of all food handlers were described in simple terms. "The Chief Public Health Inspector then gave a talk detailing the practical methods of sterilisation, the correct techniques applicable to susceptible foods and the importance of strict compliance with the regulations dealing with personal and general food hygiene. "During a short tea break demonstrations were given to groups of about twelve at a time, of actual culture plates showing colonies of various bacteria grown from such sources as dirty tea towels and unwashed hands. Sterile plates were inoculated from a tea towel, tea from a cup, a handkerchief, from ordinarily clean hands, hands recently washed and from unwashed hands after visiting the w.c. "This demonstration was followed by two film strips "Control of Bacteria in Food" produced by a well-known catering firm, and "Food Poisoning" prepared by the Ealing Health Department; and by the sound film "Another Case of Food Poisoning." "Finally a summing up was given by the School Meals Organiser and a number of questions answered by the Chief Public Health Inspector. The experimentally contaminated plates were incubated and subsequently shown to the staff upon whom a very deep impression had quite evidently been made. "The films, projector and projectionist (together with posters) were kindly loaned by the County Medical Officer through the County Health Education Officer and the bacteriological demonstration material was supplied by the Central Public Health Laboratory, Colindale. "The demonstration was considered to have been very successful and was repeated at half term to a further 100/150 personnel including dining room staffs." In October reminders were sent to all persons working in canteens as to the need to report at once any enteritis and to remain away from work until permitted to resume by the Medical Officer of Health, Any similar illness in other persons living in the same dwelling were also to be reported. 41 In November reminders were sent that a complete specimen meal should be kept for at least 48 hours and if possible in a refrigerator. Each item of the meal was to be kept separately in glass jars which were supplied. Ideally a specimen meal should be kept from each service, especially if from different kitchens, but obviously there is a limit to what can be done in order to preserve laboratory specimens in case of any subsequent food poisoning. Inspection.—Mr. W. Richards, Chief Public Health Inspector, reports as follows:— "During 1956, the following inspections were carried out:— Schools 45 School Kitchens 68 "Various types of defects were found as a result of these inspections; those of a minor character being reported direct to the Education Architect. "Major defects found included insufficient sanitary accommodation and washing accommodation. These were reported through the School Medical Officer to the Borough Education Officer. "Unsatisfactory conditions mainly in respect of food handling and equipment were found in the school kitchens. Advice and instructions were given to the staff in respect of these matters. "Lectures in respect of clean food (see above) were given to the school kitchen staff by Dr. Poole and myself on two occasions. These lectures were attended by most of the staff, and it is hoped that considerable benefit was obtained by them." Milk in Schools Scheme.—The arrangements detailed in previous reports were continued in 1956, all the milk supplied being pasteurised milk sold under licence. Nine samples of pasteurised milk were taken by the Public Health Inspectors for bacteriological examination during the year. All satisfied the methylene blue and phosphatase tests. Sampling for biological tests (tuberculosis) has also been carried out at one local dairy on delivery of milk from various farms. This dairy supplies the milk to. some schools. Of 69 results from these samples, only one was unsatisfactory and this was duly reported to the County Medical Officer of Health for appropriate action at the farm in question. 15. CO-OPERATION (a) Co-operation of Parents'. The following table shows the attendance of parents during 1956 at the periodic medical inspections:— 42  Number Inspected No. of Parents Per cent. 1956 Per cent. 1955 Entrants— Boys 532 500 93.9 93.2 Girls 493 450 91.3 92.9 10-12 year Age Group— Boys 1,099 924 84.1 83.4 Girls 1,181 932 79.0 85.9 14 year Age Group- Boys 657 183 27.8 19.0 Girls 620 215 34.7 37.5 Others— Boys 638 211 3 3.0 70.4 Girls 468 153 32.7 76.7 The importance of parental attendance at medical inspections cannot be overstressed. It is regrettable, but understandable, that the percentage should decrease with the increasing age of the child, and with the considerable employment of mothers. The "leaver" inspections are of importance in regard to fitness for employment, and the attendance of parents at these inspections is to be encouraged. Tests for colour blindness are done at these inspections. (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, especially in the use of their private and staff rooms for medical inspection—often at great inconvenience. The circulars issued each week by the Borough Education Officer to Head Masters and Head Mistresses of schools in the Borough were, with his co-operation, utilised in disseminating information. (c) Co-operation of School Enquiry Officers. The Senior School Enquiry Officer and his staff have again co-operated most effectively with the work of the School Health Service. (d) Co-operation of Voluntary Bodies. The existing arrangements for the admission of pupils to holiday convalescent homes by arrangement with the local branch of the I.C.A.A. continued. (i) The Invalid Children's Aid Association.—Mrs. Dick, Secretary to the local branch, has kindly contributed the following report:— 43  Under 5 years Over 5 years Children referred by:— Hospitals 1 4 School Health Services 2 21 General Practitioners 4 52 7 77 Classification of above cases:— Anaemia, debility 1 19 After effects of acute or infectious illness or operation 2 12 Bronchitis or pneumonia — 10 Asthma — 2 Rheumatism, chorea, heart — 3 Nervous conditions — 7 Accidents — 2 Diseases of—Ear, Nose and Throat 3 18 Skin — 1 Other defects 1 3 7 77 Children sent for convalescence 5 65 Children sent to Regional Hospital Board Homes 1 1 6 66 Children referred for visiting, advice, help or follow-up:- Hospitals — 1 Local Authority under schemes for:— (a) Rheumatism — — (b) Orthopaedic care — 3 Voluntary Bodies 1 — General Practitioners — 3 Parents — 4 Health Visitors and Head Teachers — 11 1 22 Number of visits paid 355 Office interviews with parents 191 44 (ii) National Society for the Prevention of Cruelty to Children.—The following is a summary of the work done during 1956:— Nature of Offence Neglect 17 Ill-treatment 4 Advice sought 16 Totals 37 How dealt with Warned 20 Advised 17 37 Number of Children dealt with:— Under 5 years Over 5 years Boys Girls Boys Girls 23 25 27 24 16. HANDICAPPED CHILDREN. The following number of special examinations were carried out by the medical staff in respect of the categories stated:— (a) Blind — (b) Partially Sighted — (c) Deaf — (d) Partially Deaf — (e) Educationally Subnormal 44 (f) Epileptic 3 (g) Maladjusted 4 (h) Physically Handicapped 5 (i) Speech 1 (j) Delicate 11 Four children were known to be suffering from diabetes and all except one were at ordinary schools. (a) Educationally Sub-Normal Children. During the year and at the request of the Principal School Medical Officer, the arrangements for the ascertainment of such children were reviewed, the position being as follows:— 45 1. All children failing to make normal progress in school are referred by Head Teachers to the School Medical Officer. Where physical factors may be contributory the child is first medically examined at a School Clinic. Otherwise, or subsequently, an intelligence assessment is made by the Educational Psychologist. Those children considered unsuitable for normal schooling, either because of mental dullness or for any other reason are referred for examination, if necessary on Form 2 H.P. by the approved Examining Medical Officer. Pre-school children who have shown any retardation of development are reported from the Infant Welfare Clinics, or by the Health Visitors and are placed on a pre'handicapped register. Children on this register are constantly reviewed with the object of ensuring their correct placement when of appropriate age. 2. In addition to pupils of low intellectual ability those show ing specific difficulties, e.g., with reading, and those who are excessively timid are placed in the Special School so far as vacancies permit. In the latter two cases every effort is made to fit them for return to normal school as quickly as possible. Undue reliance is not placed on the actual intelligence quotient, very careful consideration being given to the child's ability to make progress, even slowly, in a normal school although failure to do so may be due to emotional immaturity rather than inherent mental defect. It is not possible to admit to the Special School for the E.S.N, all pupils who might benefit since the accommodation available is for only approximately 100. 3. No application for residential placement is made for educationally sub-normal pupils unless there is some additional factor such as severe epilepsy or maladjustment present to such degree as to make it impracticable for them to attend the day Special School. (b) Physically Handicapped Children. Subsequently the arrangements were reviewed in regard to special educational treatment of such children, especially those suffering from cerebral palsy, and the following report was made:— 1. Spastics on Register— (a) School age 17 (b) Pre-school 1 Of the 17 school-age children, 11 are additionally handicapped either by speech defect, perceptive defect or mental retardation and three have been notified as ineducable. 46 2. (I) Number attending ordinary schools 2 (II) Number attending special schools for physically handicapped children— (a) Day 7 (b) Boarding — 3. (a) Ideally placed 9 (b) Would benefit more by attending a day special unit for spastics if such were available — 4. Pre'school children— (a) Receiving special educational treatment — (b) Who would benefit from 3 (b) 1 5. (i) Children admitted to Ilford Cerebral Palsy Unit 4 (a) Retained 3 (b) Found unsuitable after trial 1 (ii) Found unsuitable for admission 3 (iii) Admitted to other C.P. units — SUMMARY Total on Register 18 At Ilford C.P.U. 3 Below school age 1 Home tuition 2 At ordinary schools 2 Notified 57(3) 3 At Hale End P.H. school 7 (c) Epileptic Children. Later the medical care of children suffering from epilepsy was reviewed and their placement, and the following was found to be the position:— Placement of Epileptic Children in Walthamstow Pre-school children (Suspected) 2 Children of school age 33 Attending— 1. Ordinary Schools 24 2. Physically Handicapped School 3 3. Lingfield Colony 1 4. Chalfont Colony 1 5. Condover Hall 1 6. Cairn Lee House School 1 7. St. Faith's Hospital School 2 47 The 24 pupils attending schools in this area were all reported to be satisfactorily placed. A circular letter was sent to all General Practitioners in the Borough setting out the advice of the Standing Medical Advisory Committee of the Ministry of Health and stressing the following recommendations of the Committee:— (1) The greatest care must be taken that children are not unnecessarily "labelled" as epileptics. (2) Sufferers from epilepsy should be encouraged to secure treatment for their disability and to follow the medical advice they are given. (3) The services of an educational psychologist should be available when the educational requirements of a child with epilepsy are being assessed. (4) Children suffering from epilepsy should, as far as possible, be educated at ordinary schools. (5) The general practitioner should inform the School Medical Officer of any child with epilepsy who is about to attain school age and is to attend an ordinary school. (6) The decision to send a child suffering from epilepsy to a special school should be taken only after assessment at a hospital diagnostic clinic. Close liaison is maintained with the Paediatric Department of Whipps Cross Hospital, and with the Queen Elizabeth Children's Hospital, Hackney Road, and the Hospital for Sick Children, Great Ormond Street. Pre-school children suspected of epilepsy and coming to the notice of the Health Visiting Staff are notified by them and placed on the pre-handicapped register and are subject to constant review. (d) Deaf Children. Finally the arrangements for the ascertainment and treatment for children with defective hearing was reviewed with the following results:— (a) Children who need only special placing in the classroom of an ordinary school 93 (b) Children who with the use of hearing aids are progressing satisfactorily in an ordinary day school 4 48 (c) Children receiving special education in a school for partially deaf children (including 45 out- area children) 50 (d) Children receiving special education in a residential school for deaf children 2 (e) Children awaiting special placement Nil The two children in residential schools are considered most suitably placed. One is totally deaf and additionally handicapped by a heart lesion. The other is also totally deaf and is due for review of her placement during the Christmas holidays. Neither would do as well at an ordinary school even with special teaching. Children in categories (a) and (b) have not been formally ascertained but this has been carried out for all the children in categories (c) and (d). Children under 5 years of age—Nil. Walthamstow Special Schools.—The number of children at the special schools in Walthamstow at the end of 1956 were as follows:— Partially Sighted Physically Percentage E.S.N. Handicapped Deaf Total Walthamstow 6 101 53 5 165 57.5 Forest 7 6 24 14 51 17.8 Middlesex 15 — 1 1 17 5.9 Romford 4 — — 7 11 3.8 Leyton 1 — 10 5 16 5.6 Dagenham 4 — — 2 6 2.1 Ilford 2 — — 10 12 4.2 South Essex 4 — — 2 6 2.1 Barking — — — 2 2 0.7 East Ham 1 — — — 1 0.3 Totals 44 107 88 48 287 100.0 The number of children in residential special schools and homes at the end of the year was as follows:— Maladjusted — 6 Delicate 3 Educationally Subnormal 6 Blind 5 Epileptic 2 Deaf 2 Speech 1 49 (a) School for the Deaf.—Mrs. L. Corner, Acting Headmistress of the William Morris School for the Deaf, reports as follows:— "The school re-opened on January 10th with 47 on roll, of whom 22 were deaf and 25 partially deaf. "During the absence of Miss Buckell in hospital, Mrs. Williams joined the staff. Mrs. Mitchell left after eleven years service as Welfare Attendant. Mrs. Burt left in July to become Head of the Ballarat Deaf School. "The Amplivox Auditory Speech Training Unit was again demonstrated to us. This unit is installed in most deaf schools now, and would be most beneficial to us. (Note.—The unit is being supplied early in 1957.) "On February 29th we had a visit from the Chairman and members of the Special Services Committee from Chelmsford, together with Lady McEntee and members of the Walthamstow Special Schools Sub-Committee. "Two of our congenitally deaf children passed the written examination for the Mary Hare Grammar School and one passed the oral. He left us in July for the same school. "The school re-opened in September with 50 children on roll. On September 25th we heard with deep regret of the death of Miss Buckell. On October 1st Mrs. Podd commenced duties as teacher of the younger partially deaf class. " On November 1st a general medical inspection was held. "Two classes who have for just over a year been accommodated in Thorpe Hall Infants have now returned to us, two rooms becoming available in Wingfield House. "We have had visits from doctors, both from this country and abroad, from health students and from o.ur managers. "Recently the school has undertaken to arrange for the repair of hearing aids. Our Welfare Worker attends Wanstead Hospital for this purpose, taking the children with her when necessary. She also accompanies them to the clinics ; thus we keep better in touch with the Health Department. "Our attendance rose in June to 52. There were 47 on roll an the 19th December when we broke up for Christmas." (b) School for the Educationally Sub-Normal.—This school is to be known in future as the " Margaret Brearley School." Miss Brearley was appointed Headmistress when the school was first opened in 1903. She retired in 1923, and during her long and 50 excellent service was responsible for the setting up of the Mental Welfare and After-care Committee in the Borough. Although now 87 years of age, Miss Brearley is still enjoying her retirement. Miss R. E. A. Lock, Headmistress, reports as follows :— "The number on roll has kept fairly steady at around the 100 mark. "During the year full use has been made of the large hall for physical education purposes. We have been provided with almost maximum equipment of all kinds (both indoor and outdoor)—climbing frames, a vaulting horse and springboard, Essex agility apparatus, net-ball and football necessities. In my opinion the effect of this has been excellent. The sluggish child now has the means for constant stimulation to overcome lethargy, whilst the excitable, unstable child is steadied by the need for concentrated effort. I offer my grateful thanks to Miss G. Powell (Physical Education Organiser) for her splendid help so freely given. "Last summer we were able to hold our own sports day for the first time, as the use of an adjacent park was granted to us. "The senior boys, of their own volition, started a bird and animal after-school club. Under the supervision of their class master, and with the aid of a film-strip projector, much interesting ground has been covered. "The senior girls have worked well with the school nurse, who visits on one half day per week for general hygiene and mothercraft instruction. I have noted an improvement in their personal habits and cleanliness. "My thanks are offered to the teaching and welfare staffs for their splendid co-operation throughout the year." (c) School for the Partially Sighted.—Mr. G. M. Williams, Headmaster of the Joseph J. Clarke School for the Partially Sighted, reports as follows:— "The Partially Sighted School situated in Pretoria Avenue, has accommodation for 45 children. "The premises consist of a large assembly hall, three classrooms, all separately wired for radio reception, a dining room, washrooms, a staff room which can be converted into a dark room for the use of the ophthalmologist, and a playground with a covered shed. "The children are taught in classes of which the maximum number of children per class is 15. "An important part of the teachers' work is observation of the children's sight in practical terms. All emphasis should be on 51 visual methods, making the best use in conditions of good illumination of the sight available. It is essential that a good and speedy optical service be available, and regular clinical supervision from the ophthalmic point of view. Annual medical inspection of each child is also valuable. "The best aid to seeing for the partially sighted child is a good standard of even illumination. The rooms should be well lit naturally and artificially—care being taken to avoid glare. Walls and ceilings should be in light shades with preferably a matt surface. An artificial lighting standard of at least 35 foot candles evenly distributed is essential for rooms where close vision work is done by partially sighted children, falling to 15 foot candles for assembly halls, etc. The blackboards used by the teachers should be well illuminated and free from reflection. If tube lighting is used, the standard of illumination should be checked periodically as tubes decrease in efficiency with use. "It is essential that a thorough check on the hearing of each partially sighted child should be made soon after admission, and a biennial group audiometric test as a routine during school life. "The special ophthalmic sessions held at the school in December showed that the range of visual acuity (Snellen) after correction was as follows:— 7 children with acuity less than 6/60 13 „ „ „ of 6/60 11 „ „ „ 6/36 5 „ „ „ „ 6/24 8 „ „ „ „ 6/18 12 children had monocular vision only. " Two children were recommended for transfer to ordinary school, and there is one child awaiting placement in a school for the blind. "As in previous years, the ophthalmic supervision has been well maintained. Dr. I. Gregory, M.B., D.O.M.S., has made two visits to the school for the purpose of examinations, and has given much helpful advice with certain selected cases. The medical staff at the Eye Clinic have also made regular ophthalmic examinations, whilst the optician (Mrs. Suckling) has assisted in a speedy supply and repair service of glasses. The ready and willing help of all staff at the Eye Clinic has been much appreciated. "In the Autumn term Dr. Dooley made a full medical examination of each child, and Mr. Elmer, Senior Dental Officer, also visited the school and referred six children for dental treatment. 52 "The school provided facilities for medical examination of children attending St. Patrick's R.C. School. "Miss Smith, the Educational Psychologist, and Miss Hemmings, the Speech Therapist, each made two visits to test selected children, and Mr. Berry, Youth Employment Officer, interviewed children leaving for employment. "The school has been equipped throughout with new furniture consequent upon the transfer to Pretoria Avenue premises. "Visitors to the school included the Chairman and Deputy Chairman of Essex Education Committee, the Deputy School Medical Officer of Tottenham, post-graduate medical students from Whipps Cross Hospital, a teacher from Sweden, Training College students and Student Health Visitors. "An analysis of children passing through the school during the last seven years (1950'1956) shows the following :— Left for employment 22 Returned to ordinary school (V.A. 6/18 to 6/24 with close vision at least J. 10) 18 Transferred to schools for the Blind (V.A. 4/60 or less) 15 Transferred to residential partially sighted schools 11 Left the district, usually for social conditions 8 Declared ineducable 3 Transferred to Grammar and High Schools 4 Transferred to Technical School 1 Deceased (malignant growth in nasopharynx) 1 "Of the children left for employment, ten were registered under the Disabled Persons Act and two under the Blind Persons Act. Employments were varied according to the visual acuity (from 3/60 to 6/24), intelligence and personal characterisation, i.e. factory work, 9; office work, 6; shop assistants, 3; horticulture, 2; porter and domestic in hospital, 2. "The eye conditions of the children returned to ordinary school were cataract, 3; myopic astigmatism, 3; congenital nystagmus, 2; myopia, 9 (where vision had been stabilised for at least twelve months); albinism, 1. "Although possessing a vested interest in the school, I would say that this work is valuable especially for the age range 5-12 years with visual acuities 6/60 to 6/24. The factor of intelligence is an additional consideration, a child of good intelligence and visual acuity of 6/24 would possibly manage in an ordinary school, but 53 many children of poor intelligence and visual acuity of 6/18 will fall behind their contemporaries and would benefit in early school years by special school. "I have to acknowledge my appreciation of the efforts of the teaching and welfare staff on behalf of the children in the school. "During the year the average number on roll was 42.8 with an average attendance of 38.0." (d) School for the Physically Handicapped.—Mr. G. M. Williams, Headmaster of Wingfield House School for the Physically Handicapped, reports as follows :— "The average attendance during the year has been well up on the general average of previous years, showing that the health of the children has been well maintained. "There has been a distinct but subtle change in the type of case admitted to the school, this being in keeping with the change of title from Hale End Open Air School to Wingfield House School for the Physically Handicapped. There are now no cases of tuberculosis contacts or tuberculosis glands, and only one of 'joints in the school; there are no cases of children suffering from maLnutrition. The chief cause of referral is now mainly respiratory— asthma, bronchitis and bronchiectasis, and an increasing number of children suffering from nervous conditions aggravated by minor physical disabilities. This latter group are usually extremely back' ward educationally. A recent survey of intellectual assessment gave a mean I.Q. of 87 for 47 in the school. "Three of the classrooms have had their folding doors, which opened to the weather, replaced by conventional fixed walls with sash windows, giving the benefit of fresh air and sunshine in better weather and providing more adequate protection against draughts in cold inclement weather. All classrooms were decorated internally and externally during the summer. "The Chingford Jubilee Retreat Centre was used sporadically by all classes during the period May to September, taking the advantage of free activity in the forest as the occasion arose. "During the summer holiday period the school was opened as usual on a voluntary basis, and an attendance of 91 per cent, was maintained. Visits were made to Thorpe Bay, Whipsnade Zoo, London Airport and to the forest, which gave the period a home holiday flavour. Miss Smith, the Educational Psychologist, made four visits during the year for the purpose of examination and advice, and Mr. Berry, Youth Employment Officer, interviewed all leavers. 54 "Visitors to the school during the year included the Chairman and Deputy Chairman of the Essex Education Committee, a Swedish teacher, Training College Students, Student Health Visitors and District Nurses. "The teaching staff was augmented by the appointment of Miss Foster, and Mrs. Teuber resumed full-time teaching early in the year. "Twenty-four children were taken off roll during the year, of whom 12 were transferred to ordinary school, three to E.S.N, schools , four to residential schools, two left the district, one died and two left for employment, both being satisfactorily placed in work. "Dr. Poole, Deputy School Medical Officer, made regular weekly visits to the school and gave much helpful advice. A total of 2,028 minor treatments have been given by the nursing staff at the school. "During the year the public ambulance service had to be used on 14 occasions to convey children home who had been taken ill during school hours. "Through the very helpful and valued co-operation with the local branch of the I.C.A.A., four children were sent away on convalescent holidays during the year. "The 'after-care' of the more seriously physically handicapped boy or girl leaving school, and for whom there are few prospects of employment, have been catered for by the strengthening of the existing ' After-Care Association' to deal specifically with this type of case. Three ex-pupils from the school, one a recent case, are being visited and assisted by these means. "As in former years, swimming instruction was continued at the Technical College baths. "The children on roll at the end of the year were classified as follows — Delicate (Ministry of Education category ' j') 37 Physically Handicapped do. ' h ') 49 Epileptic do. ' f') 2 "The average number on roll during the year was 91.7 with an average attendance of 67.3. "I must again put on record my appreciation of all my colleagues on the staff, teaching, nursing, welfare, domestic and transport for their valued co-operation in the work of the school." 55 Wingfield Music Club. "With the voluntary help of parents of the children attending the school and friends interested in music, under the aegis of Mr. Herbert Lyon a music club was set in being last year with the two-fold purpose of encouraging music both as an art and as a therapy. Mr. Herbert Lyon, the club leader, ably assisted by friends, has held a regular two-hour session every Monday evening at the school. Free tuition and loan of instruments is available to interested physically handicapped persons—violin, cello, piano, recorder, double bass, harmonica, flute and trumpet are taught in small groups and then combined together for orchestral purpose. "Several public performances have been given, and in December a film was made by the B.B.C. outside television unit for showing on Children's Television Hour. "Originally founded for the children at the school and for former pupils, the Club has now been opened to all in the area who are physically handicapped and interested in music. A parent and sympathisers association has been set up to strengthen the work of the Club, which has now grown beyond its original purpose. A one-handed girl cellist has had an audition for the National Youth Orchestra, and a violinist (severe asthma) has made good physical progress as her musical capacity has improved, enabling her to pass successfully from Grade I to Grade III examinations of the Royal Associated Board. "Miss Vera Kantrovitch of the Trinity College of Music has taken a keen interest in the Club from its formation and has been elected President of the Club, which has now received generous help from many well wishers in the area. It is felt that the results so far obtained justify an exploitation of the active participation in instrumental music as an adjunct to therapy in both the physical and emotional aspects of disability. "I would record my deep appreciation of the energy and enthusiasm of the founder of the Club, Mr. Herbert Lyon, and to the friends who have assisted him in carrying out this pioneer venture." 17. 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. 18. NURSERY SCHOOL Miss F. D. Harris, the Headmistress, reports as follows:— "The health record during the year was very good until October, when there was an outbreak of whooping cough. Many 56 of the children had been immunised in infancy, so only had a mild attack. This had its disadvantages in that they did not whoop and so were often in school spreading the disease before it was realised that they were suffering from whooping cough. "H.M. Inspectors from the Ministry of Education inspected the school in July. The medical supervision and attention available was approved, but the limitation of cloakroom, toilet and garden space was criticised." 19. MISCELLANEOUS (a) Health Education. (i) Good Grooming.—Ninteen lectures on good grooming were given at schools during the year. The demand for these lectures was so heavy that dates had to be fixed several months in advance. (ii) Parent/Teacher Association.—In July the Deputy Medical Officer of Health gave a talk to a Parent/Teacher Association. (iii) Advice on Sleep.—A previous edition of a leaflet entitled "Advice to Parents as to Children's Sleep" was revised and sufficient copies for each scholar were issued through the schools. (iv) Mothercraft Talks.—The Superintendent Health Visitor and School Nurse reports that mothercraft talks are now being given in all secondary modern schools in the Borough. A request was made by the Headmistress of the Margaret Brearley School for Educationally Sub-Normal children for appropriate talks to be given to the older girls. These were started at the beginning of the school year and are very popular. (v) Health Lecture.—One of the School Nurses gave a talk at George Gascoigne Secondary School to parents of children attending the school. (vi) Pre-Nursing Courses.— (a) Walthamstow High School : Miss M. M. Burnett, M.A., states as follows :— " In this school a one year's Pre-Nursing Course is organised for girls who have obtained the General Certificate of Education. Most of the members of the course intend to nurse but a few take it as general education. "The subjects are anatomy, physiology, hygiene, physics, chemistry, biology, physical education, music, scripture, domestic science or art, English and one other optional subject. "A very high percentage of the class passes the First Examination of the General Nursing Council at the end of the course." 57 (b) Woodford County High School: Miss K. M. Chapman, M.A., states as follows " With regard to Pre-nursing and tuition in allied subjects, our procedure until recently has been to have what is called a prenursing course, which is registered with the Ministry of Education and the General Nursing Council, and at times we use it. We still have a considerable number of girls each year taking what in one 6ense is a pre-nursing course, in that it gives them full exemption from Part I of their preliminary examination in hospital and which gives them a good sound varied education coupled with human biology. They take the Ordinary Level examination in human biology and this gives them the necessary exemption equivalent to taking Part I of the Pre-Nursing examination. (c) William Morris County Technical School.—Mr. H. P. Williamson, M.Sc. (Educ.), B.Sc., reports as follows :— "A most interesting and useful school course is one leading to exemption from Part I of the General Nursing Council's Preliminary Examination. "The curriculum includes English and other usual school subjects on its general side and on its "special" side the study of general science, anatomy and physiology, hygiene and the elements of public health. "Also necessary and most interesting features of the Course are visits to hospitals, welfare departments, milk pasteurisation plants, and public services such as water works and sewage disposal plants. Even visits to see the operation of ventilation systems are often undertaken. "Girls who have followed this Course have found it not only interesting in itself but of the greatest value to them when, at 18 years of age, they began their nursing training at a hospital. Time and again girls who have followed a pre-nursing course at school have stressed how much the knowledge gained had helped them and made easier their studies while training in hospitals. "Recognition by the General Nursing Council allows pupils to take the Council's Preliminary Part I Examination while still at school, this exemption from Part I of the examination also being possible through a G.C.E. pass in Human Biology. "William Morris Technical School, among others, offers these opportunities to girls—and for that matter boys—wishing to become nurses, and the Headmaster's regret is that not more girls and boys feel the call for the satisfying, though strenuous, career of nursing. Those who do, come back to see their old school from time to time and their enthusiasm is ample evidence of the rightness of their choice of career and of the sound basis laid by the Pre-Nursing Course at school." 58 Present Group—23 girls, seven of whom intend nursing, the others dental research, radiotherapy, laboratory technician, farming, physical training and teaching. June, 1956—Pre-Nursing Part I Examination held at Whipps Cross Hospital—three girls entered, all successful. 1956-1957—Five girls to Hospital. Girls from Pre-Nursing Course now in final year of Nurse Training—4. Former pupils who have entered Nurse Training—3 incl.: 1 in Final Year. (viii) "Better Health."—This journal was circulated each month to schools by the Borough Education Officer. (b) Problem Families. A joint circular, issued on 31st July, 1950, on children who were neglected or ill-treated in their homes, suggested various administrative measures which could be taken to avoid enforced removal of children from their homes. One of the recommendations was that local authorities should designate one of their officers to be responsible for securing "full co-operation among all the local services, statutory and voluntary, which are concerned with the welfare of children in their own homes," and that regular meetings of all concerned should be held to review cases. In November, 1954, the Ministry of Health issued Circular 27/54 to local health authorities, in which it was said :— "Problem families thus tend to reproduce themselves in the next generation and cost the community an expense out of all proportion to their numbers. Action to break this vicious circle by preventive measures would, in the Minister s view, be a proper exercise of the local health authorities'' powers under Section 28 of the National Health Service Act, 1946. The health visitor whose work now extends to cover the whole field of prevention of ill-health, including prevention of mental ill-health, is, by reason of her close contact with families with young children, particularly well placed to recognise the early signs of failure in the family which may lead to disruption of normal life with consequent risk to the mental health of the children." The need to correlate the action of all the agencies referred to above became so pronounced during 1956 that at the end of the year a conference was called in order to discuss what appeared to be the worst cases that were known. Nineteen representatives of 59 the statutory and voluntary services in the Borough attended, discussion ensued for some two and a half hours and it was considered that the meeting had been well worthwhile. The hope was expressed that further meetings would be called as and when necessary. Amongst the 14 families then reviewed there were 79 children, i.e., two over 16 years of age, 50 between five and 16 years, and 27 below five years of age. The chief factors emerging from the case-papers were illegitimacy and the number of children on probation. (c) Disinfection of Recorders. Attention was drawn in School Circular 33/56 (issued by the Borough Education Officer) to an abridged statement from the monthly bulletin of the Ministry of Health and published in March, 1956. In view of the necessity to share the use of recorders, the routine suggested in the bulletin for disinfection was recommended for adoption and especially the use of the plastic model which stands disinfection better than the wooden type. (d) Employment of Children.-—242 children were examined by the medical staff. (e) Employment of Children in Public Entertainment.—Two children were examined under these regulations. (f) Staff Appointments.—82 teaching staff and 300 other staff were examined during the year. (g) Medical Examination of Prospective Teachers.—50 candidates for admission to Training College were examined during the year. (h) Sanitary Towels in Schools.—All schools have means of issuing sanitary towels on request. Supplies are held by Head Teachers and Assistant Teachers. (i) The total number of the various items of consultation and treatment carried out in the School Health Service during 1956 have been extracted and are set out below:— Head Inspections 20,443 Dental Treatments 15,450 Dental Inspections 13,168 Orthopedic and Physiotherapy 11,417 Medical Inspections 5,688 Eye Treatments 4,658 Minor Ailments 3,714 Speech Therapy 4,457 Child Guidance 2,137 60 Other Inspections at Schools 1,537 Orthoptic 1,236 Aural Clinic 448 Home visits 288 Paediatric Consultations 165 Cardiac Clinic 34 84,840 20. STATISTICAL SUMMARY I. Medical Inspection. A. Routine Inspections 5,688 B. Special Inspections and Re-inspections 4,477 C. Pupils found to require treatment 1,821 II. Defects found at Routine Medical Inspection. Requiring treatment 2,053 For observation 2,307 Physical Condition of Pupils seen at Medical Inspection. Satisfactory 5,587 Unsatisfactory 101 III. Infestation with Vermin. Total number of examinations 20,443 Individual pupils found to be infested 97 IV. Treatment. (a) Minor Ailments—total defects treated 1,565 (b) Defective Vision and Squint. Cases treated for errors of refraction 1,689 Other defects — Pupils for whom spectacles—prescribed 1,104 obtained 966 Orthoptic clinic—cases treated 244 (c) Tsjose and Throat Defects. Number treated 203 Total attendances 448 (d) Orthopaedic and Postural Defects. Treated as in-patients 24 Treated otherwise 557 (e) Child Guidance and Speech Therapy. Number treated under Child Guidance arrangements 280 Number treated under Speech Therapy arrangements 251 (f) Dental Inspection and Treatment. Periodic Special Number of pupils inspected 10,529 2,639 Found to require treatment 5,634 2,610 Number offered treatment 3,824 2,600 Number actually treated 5,498 2,394 Attendances made for treatment 11,403 4,047 Half days devoted to—inspection 76 treatment 2,171 Fillings—permanent teeth 5,398 temporary teeth 2,411 Extractions—permanent teeth 1,624 temporary teeth 5,524 Anaesthetics—local 1,425 general — — 3,844 Orthodontics— Treated with appliances 253 Removable appliances fitted 203 Fixed appliances fitted 30 Total attendances 1,910 Artificial dentures fitted 31 Other operations—permanent teeth — 2,805 temporary teeth 949 61 j ' ,0 <•;) • : J 0 III... ■ '- - - - •,; . .. ..... ,i : ' i/.; ... : i I'S ■ y* C"V',V ; . . ... ■ I ■ .; *V■ .. . .. .; •. . . ' . ' • •' '< ' ' " ; • . : .