AC 44112 WHAM 27 County Borough of West Ham ANNUAL REPORT ON THE HEALTH SERVICES FOR THE YEAR 1955 BY F. ROY DENNISON, M.D., D.P.H. Medical Officer of Health and Principal School Medical Officer Mr,Mayor, Ladies and Gentlemen, I have the honour to present my Annual Report for the year 1955. The population, estimated by the Registrar General at 167,900 showed a small decrease, continuing the slow trend which has become apparent during the past few years. The birth rate was a little lower and the death rate a little higher than in the previous year, but in neither case was the variation big enough to be significant. The all-important infant mortality remained very close to the low record reached in 1954. Maternal mortality was also low, a single death being notified. Experience with infectious disease was somewhat chequered. The one disturbing feature was the recrudescence of diphtheria, which gave rise to more cases than in the whole of the previous five years. The circumstances appeared to show that an unusually virulent infection had broken through the partial protection of an incompletely immunised community. An intensive immunisation campaign was, therefore, launched towards the end of the year and subsequently, up to the time of writing, the Borough has remained free of this disease. The inference to be drawn, I think, is that the more severe types of diphtheria infection can only be kept at bay by universal immunisation of young children, reinforced by booster doses at intervals during school life. Changes of organisation to facilitate this objective have already received consideration. Fuller details of the episode will be found on page 8. In relation to the other Infectious diseases, 1955 was an epidemic year for measles and at the same time whooping cough was also more prevalent, which is a frequently observed association. Poliomyelitis also increased from 8 cases in 1954 to 22 this year, but there were no deaths. Dysentery, though lower than in 1954, remained higher than in the immediately preceding years, in conformity with the national experience. The reduction in scarlet fever was within the normal range of fluctuation, but tuberculosis showed a decline which may prove to be of more significance. No clear-cut trends in incidence, however, have become apparent. Those sections of the report dealing with the personal health services have a number of developments to record. The domiciliary midwifery service was transferred from Plaistow Maternity Hospital to the direct control of the local health authority, and the services provided by the Silvertown and North Woolwich District Nursing Association were also taken over: the accounts of these changes are given on page 58. The maternity and child welfare service began to offer simple tuberculin jelly tests to young children at their toddler examinations in order to detect early tuberculous infection and then trace its source (page 4-6). An audiology unit, for testing the hearing of very young children, was also established under the same auspices with the co-operation of the Education Department and the Hospital Services, I would like to express our great appreciation to the Chief Education Officer and those members of his staff - particularly the Head Teacher of the West Ham School for the Deaf - who have given the Unit so much help and support; and also to Mr.C.J.Scott, the consultant otologist who has taken a close personal interest as its medical director, and the hospital Board and Committees who so generously made his services available. We are hoping much for the success of this pioneer venture, of which more Information is given on page 4-8. 1 Unfortunately, we still have to record difficulties in recruitment of home nurses (page 66), and the first indications are becoming apparent of impending shortages of student health visitors (page 62 ). The latter is a particularly disturbing prospect since an adequate health visiting service is the very foundation of the care of mothers and young children, and is essential for the success of many other sections of the personal health services. The other development of interest comes within the after-care services but also depends upon the health visitor for its operation. I refer to the liaison with the geriatric unit at Langthorne Hospital designed to preserve continuity of care between hospital and community health services for old people. This also seems a promising venture which is described on page 98. The school health service, which now administers the dental and the physiotherapy services on behalf of both Education and Health Committees, has to tell rather of a steady consolidation and improvement of schemes already established than of any fresh developments, but it can nevertheless look back with pride on a year of steady achievement. The environmental health services also record a year of solid progress, with increasing attention to slum clearance proposals. In this section, the Chief Public Health Inspector (as he is now called) gives an interesting account of the Government's Clean Air Bill which is undoubtedly the major sanitary advance of recent years. If full advantage is taken of its provisions now that they are through Parliament, it may well haye as favourable an influence on the public health as the great sanitary measures of the past century which gave us safe water, innocuous sewerage and wholesome food. We now take all these for granted: when we have come to look upon clean air as the rule and smoke as a breach of the sanitary code we shall indeed have achieved something of a revolution, not only in the field of health but also in the appearance of our towns. It Is to be hoped that the technical difficulties involved will not unduly delay progress. Finally, the Health Committee asked for the Inclusion in this year's report of special articles on cancer and on liaison within the health services. Dr.C.H.Phillips, the Deputy Medical Officer of Health, kindly offered to write on both subjects, and the contributions will be found under his name on pages 8l and 97. The work recorded in this report could not have been achieved without the fullest support from the Committees and the unsparing efforts of the staff. To all I would express my grateful thanks for their part in what we have accomplished. I am, Mr.Mayor, Ladies and Gentlemen, Your obedient Servant, F. ROY DENNISON. Medical Officer of Health and Principal School Medical Officer. Health Department, 225, Romford Road, Forest Gate, E.7. 2 CONSTITUTION OF COMMITTEES. (May. 1955 to May. 1956) The Mayor (Alderman D. Thorogood, J.P.,) Health Committee Chairman-Alderman E.C. Cannon, J.P. Vice-Chairman:Councillor R.J.Stubbs. Alderman Mrs.V.Ayres, J.P. Alderman Mrs.A.A.Barnes. Alderman Mrs.E.C.Cook. Alderman W.A.Gillman, J.P. Alderman Mrs.D.Parsons, M.B.E.,J.P. Alderman Mrs.M.Scott, J.P. Alderman Miss D.L.Smith. Councillor H.J.Bates. Councillor A.E.Bigg. Councillor Dr.L.Comyns, J.P. Councillor Mrs.A.A.Gannon. Councillor E.S.C.Kebbell. Councillor P.M.Murphy. Councillor S.W.Whitear. Co-opted Members:Dr.J.F.G.Garden, Mr.A.G.Lunt and Mr.E.H.Turner. EDUCATION COMMITTEE Chairman:Alderman Mrs. M. Scott, J.P. Vice-Chairman:Alderman Mrs. V. Ayres, J.P. The Mayor (Alderman D.Thorogood, J.P.,) Alderman Mrs.A.A.Ba,rnes. Alderman S.Boyce, Alderman Mrs.F.Harris. Alderman C.F.Lowe, J.P., Alderman A.C.Moorey, J.P. Alderman Mrs.D.Parsons, M.B.E..J.P. Alderman M.J.Sullivan. Alderman F.A.Warner. Councillor F.T.Burt. Councillor Dr.L.Comyns, J.P. Councillor J.Crone. Councillor M.Davidson. Councillor A.F.G.Edwards. Councillor E.G.Goodyer. Councillor A.J.Hughes. Councillor J.Marshall. Councillor L.L.McGuire. Councillor T.C.McMillan. Councillor W.Moat. Councillor S.W.Whitear. Co-opted Members: Rev.D.Rooke, Rev.Canon P.O'Donnell, Messrs.E.P.Bell, D.L.Dally, E.P.Hart-Wilden, F.Samuels, C.W.Thurston, H.C.Willig and Professor J.W.H.King. 3 SENIOR OFFICERS OF THE HEALTH SERVICES. MEDICAL OFFICER OF HEALTH AND PRINCIPAL SCHOOL MEDICAL OFFICER. F. Roy Dennlson, M.D., D.P.H. DEPUTY MEDICAL OFFICER OF HEALTH AND DEPUTY PRINCIPAL SCHOOL MEDICAL OFFICER, A.P.Curran, B.Sc,, M.B., Ch.B., D.P»H. CHIEF ASSISTANT SCHOOL MEDICAL OFFICER. Austin Furnlss, L.R.C.P., L.R.C.S., L.R.F.P.S., L.M.S.S.A., D.P.H., L.D.S. SENIOR ASSISTANT MEDICAL OFFICER, MATERNITY AND CHILD WELFARE, Miriam Florentln, M.B., Ch.B., D.P.H. SENIOR DENTAL OFFICER. S.M. Young, L.D.S., R.C.S. (Eng). CHIEF SANITARY INSPECTOR. H. Ault, M.S.I.A, CHIEF ADMINISTRATIVE ASSISTANT. Stanley Johnson, B.A. (Admin.) SUPERINTENDENT NURSING OFFICER. Miss D.L.Fraquet, S.R.N., S.C.M., H.V's Cert., S.I's Cert. 4 STATISTICAL SUMMARY 1255 Area of Borough 4,689 acres Population (R.G's mid-year estimate) 167,900 Live Births 2,590 Crude birth rate (per 1,000 population) 15.43 Adjusted birth rate (per 1,000 population) 14.04 Stillbirths 51 Stillbirth rate (per 1,000 total births) 19.3 Deaths 1,641 Crude death rate (per 1,000 population) 9.77 Adjusted death rate (per 1,000 population) 11.43 Deaths of Infants under 1 year 56 Infant mortality rate (deaths per 1,000 live births) 21.6 Deaths of infants under 4 weeks of age 40 Neonatal death rate (deaths per 1,000 live births) 15.4 Maternal deaths 1 Maternal mortality rate (per 1,000 live & stillbirths) O.38 VARIOUS DISEASES:Cases and Deaths. Cases Case rate per 1,000 population Deaths Death rate per 1,000 population Smallpox - - - - Scarlet Fever 112 O.67 - - Diphtheria 14 0.08 1 0.006 Dysentery 111 0.66 - - Pood Poisoning 20 0.12 - - Measles 3,169 18.87 - - Acute Poliomyelitis (paralytic) 15 0.09 - - do. (non-paralytic) 7 0.04 - - Whooping Cough 288 1.71 - - Meningococcal Infections 4 0.02 1 0.006 Typhoid and Paratyphoid Fevers 2 0.01 - - Pneumonia: Acute, primary and influenzal 94 0.56 All forms - - 87 0.52 Bronchitis - - 126 0.75 Tuberculosis: Respiratory 145 0.86 29 0.17 Other forms 7 0.04 1 0.006 Cancer - - 321 1.91 5 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. SITE AND AREA. The County Borough of West Ham lies in the County of Essex within an area about 4 miles from north to south, and about 2 miles from east to west (4,689 acres). It is bounded on the north by the Boroughs of Leyton and Wanstead and Woodford, by the County Borough of East Ham on the East, on the south by the River Thames, and to the West by the Metropolitan Boroughs of Poplar and Hackney. The area is flat and low lying varying from 5 to 45 feet above sea level. POPULATION, The estimated home population in 1955 was 167,900. This is a decrease of 700 on the estimated population for 1954• BIRTH RATE. Live Births. The number of live births during the year was 2,590 (males 1,337 and females 1,253). This gives a crude rate of 15.4 per 1,000 total population; the rate for 1954 was 16.2. The adjusted birth rate for 1955 is 14.0 per 1,000 population which compares with a rate of 15.0 for England and Wales and 14,9 for the 160 County Boroughs and Great Towns (including London). Illegitimate births account for 14-7, or 5.6 per cent, of all live births-the rate for 1954 was 4.9 per cent. Still Births. There were 51 stillbirths (24 males and 27 females) giving a rate of 19.3 per 1,000 total births compared with a rate of 23.2 for England and Wales. DEATHS. During the year l,64l (males 903 females 569) West Ham residents died, giving a crude death rate of 9.7 per 1,000 population. The adjusted death rate per 1,000 population is 11.4 which compares with the death rate of 11.7 fox England and Wales and 11.6 for the 160 County Borough and Great Towns (including London). The causes of death at different periods of life, distinguishing male and female, are given in Appendix I, page 156. INFANT MORTALITY. The deaths of children under 1 year of age numbered 56 (males 33 and females 23) giving an infant mortality of 21.6 per 1,000 live births as against 21.5 for 1954. The rate for England and Wales was 24.9 and for the l60 County Borough and Great Towns (including London) 25.1. The list of causes of death can be found in Appendix I, page 156. of this report. MATERNAL MORTALITY, During the year there was 1 death from maternal causes, as against 2 deaths in 1954. The maternal mortality rate for England and Wales was 0.64. See page 56 of this report for further details. ADJUSTED BIRTH AND DEATH RATES. In order to make an approximate allowance for the way in which the sex and age distribution of the local population differs from that for England and Wales as a whole, each authority is given an area comparability factor. This factor enables the local crude birth and death rates to be adjusted to compensate for these local characteristics. When so adjusted the rates are comparable with the crude rate for England and Wales or with the corresponding adjusted rate for other areas. 6 INFECTIOUS AND OTHER DISEASES (a) Infectious Diseases. GENERAL. The Puerperal Pyrexia (Amendment) Regulations, 1954, came Into operation on 1st March, 1955. These Regulations amended the principal regulations by prescribing a new form of certificate for the notification of Puerperal Pyrexia by medical practitioners, who are now requested to state the cause of the disease, if known. Table showing Cases of Infectious Disease Notified & Confirmed. 1955. Diseases All Age Groups Ages 1954 1955 0-1 1-3 3-5 5-10 10-15 15-25 Over 25 Deaths Smallpox - - - - - - - - - - Cholera - - - - - - - - - - Diphtheria 1 14 - - - 9 4 - 1 1 Erysipelas 21 18 - - - - - - 18 - Scarlet Fever 225 112 - 15 25 56 15 1 - - Typhoid Fever 1 1 - - - - - - 1 - Paratyphoid Fever - 1 - - - - - - 1 - Typhus - - - - - - - - - - Relapsing Fever - - - - - - - - - - Plague - - - - - - - - - - Ac.Poliomyelitis (Para.) 5 15 2 2 2 5 2 - 2 - " " (Non-Para.) 3 7 - - - 6 - - 1 - Ophthalmia Neonatorum - 1 1 - - - - - - - Malaria - 1 - - - - - 1 - - Dysentery 162 111 5 15 12 43 8 7 22 - Acute Pneumonia 136 94 8 9 7 13 1 8 48 87 (all forms) Tuberculosis Respiratory 167 145 - 4 4 4 5 29 99 29 „ Meninges - — - - - - - - - - „ Other 22 7 - - - - 4 1 2 1 Puerperal Pyrexia 54 62 - - - - - 27 35 - Measles 71 3,169 128 773 902 1,334 28 3 1 - Whooping Cough 163 288 36 73 60 110 6 - 3 - Pood Poisoning 27 20 1 4 3 5 - 1 6 - Leprosy - - - - - - - - - - Meningococcal Infection 8 4 - 3 - 1 - - - 1 Ac.Encephalitis Infective - - - - - - - - - - " (Post Infectious) - - - - - - - - - - TOTALS: 1,066 4,070 181 898 1,015 1,585 73 78 240 119 The following table shows the age Incidence and case rate per 1,000 population of Scarlet Fever, Measles and Whooping Cough. Age Scarlet Fever Measles Whooping Cough Under 1 year • 128 36 1-4 years 40 1,675 133 5-9 years 56 1,334 110 10-14 years 15 28 6 Over 15 years 1 4 3 Case Rate/1000 population 0.67 18.87 1.71 Scarlet fever has assumed a mild form during the past few years and the number of notifications does not give a true picture of the Incidence of the disease. Many cases may be missed or are diagnosed only after the event by the peeling of the skin. 7 DIPHTHERIA Fourteen cases occurred during the year, the highest total since 1948. The annual Incidence of diphtheria during the past ten years is indicated below:- YEAR NO. OP OASES 1945 133 1946 98 1947 33 1948 41 1949 4 1950 1 1951 5 1952 - 1953 1 1954 1 1955 14 The disease appeared In two phases, the first from February to July involving a total of 8 cases, the second in November and December when there were a further 6 cases. Two further cases occurred in January, 1956, but are excluded from the present report. All the cases occurred in closely related areas of the Borough. The numbers in the affected Wards Is given below and the distribution of the cases Is indicated on the accompanying map:- West Ham 8 Broadway 2 Plashet Road 2 High Street 1 Plaistow 1 8 First Phase:February-July, In the first phase there were 7 children aged between 5 and 12 years, and one adult, 43 years (the mother of one of the children). With the exception of one case of post-diphtheritic paralysis, all had positive cultures for C. diphtheria, five being gravis strain (all virulent) and two intermedius strain (one virulent). One child, 7 years, attended Greengate County Primary School, two children, both 12 years, attended Holbrook County Secondary School, three, aged 5, 6, and 9 years, attended Bridge County Primary School and one attended Napier County Primary School. All these schools are situated in areas adjoining each other. On receipt of a first report of a case of diphtheria from the practitioner or hospital the home was immediately visited by the Deputy Medical Officer of Health who took a history of the case, the recent movements, contacts, etc. Throat and nose swabs were taken from all family contacts and from teachers and children at school. Case 3 had left a nursery school just eight days before. The children attending this nursery school were all swabbed and family contacts had three negative swabs before being pronounced clear. Wherever necessary, especially in the case of food handlers, adult contacts were advised not to go to work, in which case the co-operation of employers was readily forthcoming. Other school children in the households of the cases were excluded from school until negative throat and nose swabs had been obtained. Second Phase. The second phase occurred in November (1 case) and December (5 cases) and extended into January, 1956, (2 cases). This outbreak overlapped the same area in which the earlier outbreak had occurred. The six cases under consideration were all school children aged 10, 9, 6, 5, 12, and 7 years (4 males and 2 females). One attended West Ham Church School; one attended Napier County Primary School where a previous case had occurred at the end of August; two occurred on the same day at Portway County Primary School; one occurred at Holbrook County Secondary School where previous cases had occurred in February and May. This girl died the day after admission to hospital and was the sister of a further case attending Manor Road County Primary School. 9 Five of the cases in this outbreak resulted from a gravis strain all virulent. The remaining case (case 7) did not have a positive swab and was diagnosed on the history and on clinical grounds, namely palatal and ocular pareses. Only in the sister and brother, (cases 13 and 14) in December, and the mother and son (cases 5 and 6) in May was there direct evidence of cross connection between the cases. In some of the cases the school attended by the children appeared to be the only common factor. It is, however, interesting to note that of the three cases attending Holbrook County Secondary School, that occurring in February gave an intermedius strain, while those in May and December were gravis strain. Similarly, of the two cases at Napier County Primary, one in July was an intermedius strain while the other in December was a gravis strain. Immunisation. A matter of interest is the immunisation state of the children in the two outbreaks. In the second, outbreak only one of the children was "stated by parent to have been immunised in infancy". In the remaining five cases there is a record of each having been given a primary immunisation within the previous five years. Table II shows the dosage and antigens used. Only one of these children is "stated to have had a booster", but no record is available. However, in the earlier outbreak the picture is somewhat different. Here, only one of the children had been immunised previously (3x1 c.c. D.P.P. in 1954)• The remainder were "stated by parent to have been immunised in infancy". One of these children had a reinforcing dose of 0.5 c.c. A.P.T. in 1954 Investigations. The same investigations were carried out in the second outbreak as in the first and suitable precautions were taken. Throat and nose swabs were taken in 268 family and school contacts and no pathogenic organisms were isolated. Enquiries as to possible common sources of infection from milk, ice cream and other foodstuffs were made, but all proved negative. Immunisation Campaign. By the end of December it was evident that the disease was resulting from a particularly virulent gravis type, having broken through comparatively recent immunisations (two in 1954, one in early 1955 and one in 1951 with a 'booster' in 1954) All six cases had occurred in the West Ham Ward or adjacent areas and attended five different schools in that area. It was, therefore, decided to endeavour to secure the immunisation or re-immunisation of all school and pre-school children in this area. 10 To that end the neighbouring school clinic was opened all day from Wednesday afternoon, 28th December, for the remainder of that week, including Saturday morning. All available Health Visitors and School Nurses were mobilised to visit the homes of all pre-school children whose addresses were known and to make a house to house oranvas to contact the school children whose addresses could not be obtained quickly enough. Attendance during the first week was as follows:- Wednesday, 28th December (half-day) 73 Thursday, 29th December 423 Friday, 30th December 986 Saturday, 31st December (half-day) 812 TOTAL:2.364 During the succeeding few weeks the campaign was extended to the rest of the Borough and many thousands of injections were given. Circular letters were sent to all practitioners in the Borough on the 21st and 28th December, the first informing them of the presence of diphtheria in the Borough; and the second of the decision to launch an immunisation campaign and inviting their cooperation. This resulted in general practitioners carrying out about three thousand immunisations to add to the thousands done by the Council's own health services. At a meeting of the informal Medical Liaison Committee the opportunity was taken to give the general practitioner representatives fuller details of the situation and of the objectives at which the Immunisation campaign was aiming. In the light of the total number of consents received and the numbers from the individual schools it was clear that the most expeditious and the most efficient use of the resources would be for teams to visit the schools while the two special clinics remained open. An indication of the scope of the Immunisation measures is given by the following comparative figures. Normal consumption antigens (15 week period) 2,500 c.c's. Emergency consumption from 28th December, 1955, (3 week period) 20,000 c.c's. The amount of work involved was considerable and I would like to express my sincere appreciation of the efforts of the doctors, nurses, medical auxiliaries, administrative and clerical staff, driver and messengers and, on occasion, dentists and dental attendants who displayed a remarkable team spirit in dealing with the immunisations at clinics or schools or in shouldering as great a burden in keeping going, with depleted numbers, the other essential health services. The caretaker of Bridge County Primary School was especially helpful in many ways and showed great initiative and resourcefulness. 1 would also like to express my appreciation of the help given by the general practitioners, the Public Health Laboratory Service and the Press. Worthy of note was the appreciable delay in one or two cases between onset of symptoms and admission to hospital, and the tendency to await the result of the swab before giving appropriate treatment or admitting the case to hospital. 11 The following two tables give details of the type of organism and immunisation state of the cases. TABLE I. Case Bate of Onset Age Sex Strain School or Occupation 1. 2.2.1955 7 F. Gravis, virulent Greengate County Primary 2. 7.2.1955 12 M. Intermedius, virulent Holbrook County Primary 3. 27.4.1955 5 F. Gravis, virulent Bridge County Primary 4. 7.5.1955 6 F. „ „ „ „ „ 5. 9.5.1955 12 M. „ „ Holbrook County Secondary 6. 43 F. „ „ Housewife 7. 30.5.1955 9 M. Clinical diagnosis by post diphtheritic paralysis. Bridge County Primary 8. 21.7.1955 8 M. Intermedius, nonvirulent Napier County Primary 9. 28.11.1955 10 M. Gravis, virulent West Ham Church 10. 11.12.1955 9 F. „ „ Napier County Primary 11. 14.12.1955 6 M. „ „ Portway County Primary 12. 14.12.1955 5 M. C.Diphtheria (? Strain) Portway County Primary 13. 20.12.1955 12 F. Gravis, virulent (Died 22.12.1955) Holbrook County Secondary 14. 20.12.1955 7 M. Gravis, virulent Manor Rd.County Primary (Brother of case 13) TABLE II. Immunisation State Year of Birth Primary Immunisation Date and Dose Booster 1. 1947 - - 2. 1942 - - 3. 1950 1951. D.P.P. 3x1 c.c. - 4. 1948 - - 5. 1943 - - 6. 43 years (mother of Case 5.) - - 7. 1946 - - 8. 1947 - 1954 9. 1945 Said to have been immunised in Infancy. - 10. 1946 1954. T.A.P. 3x1 c.c. - 11. 1950 1955. D.P.P. 3x1 c.c. - 12. 1950 1951. D.P.P. 3x1 c.c. Stated to have had booster. 13. 1943 1945 A.P.T. 0.3 c.c. - A.P.T. 0.5 c.c. 14. 1948 1994 A.P.T. 0.3 c.c. - A.P.T. 0.5 c.c. 12 WARD MAP SHOWING DISTRIBUTION OF DIPHTHERIA CASES 13 MENINGOCOCCAL INFECTION. There were four cases of this disease (2 males and 2 females). The age Incidence was 1 at one year, two at 2 years and one at seven years, There was one death, a girl aged 7 years. ACUTE POLIOMYELITIS. There were 22 confirmed cases during the year (15 paralytic and 7 non-paralytic), an increase of 14 on the previous year. Twenty other suspected cases were reported but were found not to be suffering from the disease. All cases were admitted to hospital. There were no deaths. The cases were widely distributed over the area and all occurred during four months of the year-5 in July, 10 in August, 4 in September, and 3 in October. Follow-up of the contacts was carried out by a medical officer, usually the Deputy Medical Officer of Health. Two cases occurred in one family, one non-paralytic and one paralytic. The nonparalytic case was the earlier onset and was diagnosed in hospital in a neighbouring authority. The arrangements for gathering the weekly notification figures from surrounding areas and distributing the tabulated results to the contributing Health Departments continued as in the previous year; this gave a valuable picture of the overall incidence at any one time to the responsible Authorities concerned. The age and sex incidence of the confirmed cases was as follows: Male Female Under 1 year 1 1 1-4 years 2 2 5-9 years 3 8 10-14 years 1 1 15-24 years - - Over 25 years 2 1 ERYSIPELAS, Eighteen cases of this disease were notified. The age and sex incidence was as follows:- Age Male Female 0-14 years - - 15-44 years 2 7 45-64 years 3 4 65 years+ 1 1 TOTAL: 6 12 The occupational incidence for males included a hairdresser, an ambulance driver, a dock labourer, a storekeeper, a railway worker and a timber porter; for females, an ex-nurse, a factory hand, domestic workers, a packer, and housewives. The seasonal incidence was as below. January/March 3 cases April/June 6 cases July/September 2 cases October/December 7 oases 14 PUERPERAL PYREXIA. Sixty-two cases were notified during the year, 55 from maternity hospitals and 7 domiciliary cases from general practitioners. DYSENTERY. One-hundred-and-eleven cases of Sonne Dysentery occurred during the year. Fifteen of these were associated with a small outbreak at Park School, involving 9 children at the School and 6 family contacts. The remaining 94 cases were sporadic and involved 11 families. Through the co-operation of the food trade there has been a marked improvement in the general standard of hygiene in the production, transport and retailing of food products. In spite of this there were an appreciable number of families involved which is perhaps a reflection of the standard of hygiene maintained by the housewife in the home, not only In the storage and handling of food but also in the cleanliness of the home, especially of the lavatory. It is unfortunate that under the present housing conditions many families have to share lavatory accommodation with the result that the cleanliness of the communal lavatory is left to the other person and provides a potent cause of spread of infection to other families, especially children. The age and sex incidence was as follows Age March June September Pecember Total M. F. M. F. M. F. M. F. M. F. Under 5 years 1 - 4 6 3 1 12 5 20 12 5 - 14 years 1 1 5 5 5 12 12 9 23 27 15 - W- years 1 3 2 3 2 3 2 8 7 17 45 - 64 years - - - 1 - 3 1 - 1 4 65 + - - - - - - - - - - Totals: 3 4 11 15 10 19 27 22 51 60 FOOD POISONING. Twenty cases of food poisoning were notified during the year. Eight of these cases were associated with three outbreaks, whilst the remaining 12 cases, in spite of full investigation and Inquiry including laboratory investigation of close contacts, were deemed to be Isolated instances of infection for which no cause could be found. Salmonella Typhi-murium was confirmed as the infecting organism in 17 cases. In the three separate family outbreaks involving eight cases (4, 2, 2,) Salmonella typhi-murium was responsible but no definite vehicle of infection could be implicated. 15 Annual Return of Food Poisoning Notifications, for the year 1955. Food Poisoning Notifications (Corrected). 1. 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Jan/March April/June July/September Oct/Dec. TOTAL NIL 3 11 6 20 2. Outbreaks due to Identified Agents Total Outbreaks Total Cases 3 8 3. Outbreaks of Undiscovered Cause Total Outbreaks Total Cases 4. Single Cases Agents Identified Unknown Cause 9 3 (Salmonella Typhi-murium) TYPHOID FEVER. One case was notified and confirmed during the year. A woman of 55 years had been a patient in Plaistow Hospital from 5th-27th July, 1955 with pyrexia of unknown origin, no diagnosis being established. On discharge she again became unwell and was re-admitted to Plaistow Hospital in August, when a diagnosis of typhoid fever was eventually established. Routine epidemiological action by this department in respect of the only other family contact-her husband-revealed that he was a probable typhoid carrier, specimens of stool being confirmed for S.typhi on 7.9.55, and Widal agglutination tests of the 6th and 8th September also producing positive results. Arrangements were made for his admission to Ilford Isolation Hospital on 12th September, 1955, where the diagnosis was confirmed. Following treatment in hospital 3 consecutive negative stools and a negatine urine examination were obtained and he was discharged on 3rd October, 1955. It appears that he returned to work shortly after this date and evidently did mention the fact that he had been considered a typhoid carrier to his employers. Follow up specimens taken by this department on 5th November from both husband and wife showed that the husband was still positive for S.Typhi. His own doctor, in consultation with the Infectious Diseases Consultant for the area arranged for the organism to be tested for sensitivity to antibiotics in the hope that a further course of suitable antibiotic treatment under domiciliary care might help In clearing the condition. The husband was permitted to continue his employment as a storekeeper in a steel firm while he had further treatment from his general practitioner. PARATYPHOID FEVER. The single case that occurred was a housewife of 56 who had been in hospital since April for chronic rheumatoid arthritis and there developed loose watery stools at the end of June. Examination of stools showed Paratyphoid B organisms and she was transferred to an Isolation Hospital. Further investigation showed the organism to be Phage type Dundee. The organism was cleared with difficulty after two courses of treatment with different drugs. 16 PNEUMONIA. Acute Primary and Influenzal. Ninety-four cases (56 males and 38 males) were notified during the year and 87 deaths from all forms of pneumonia were registered. The age and sex Incidence of these deaths was as follows:- Age Groups M. F. 0-4 1 3 5-14 - - 15-24 2 - 25-44 - 1 45-64 3 3 65 years and over 42 32 Total: 48 39 5.3 per cent of deaths from all causes in the Borough were due to pneumonia. TUBERCULOSIS Details of the work of the Health Department, in conjunction with the Chest Physician, for the prevention and control of tuberculosis are given on pages 73-79. (a) NOTIFICATIONS. One hundred and fifty-two new cases of tuberculosis {89 males and 63 females) were notified during 1955, a decrease of 27 cases on the previous year's figure of 189. The age and sex distribution of the cases notified was as follows Age Groups Respiratory Non-respiratory M. F. M. F. 0-4 4 4 0 0 5-14 4 5 0 5 15-24 10 19 1 0 25-44 17 21 1 0 45-64 46 6 0 0 65 years and over 6 3 0 0 TOTALS: 87 58 2 5 The following table shows the totals of primary notifications of tuberculosis among children up to 5 years. PRIMARY NOTIFICATIONS OF CASES OF TUBERCULOSIS. (Children under 5) Age 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 Under 1 year 2 1 1 2 2 2 1 1 2 - - 1 year ) 3 6 7 1 3 3 2 4 ) 8 5 21 2-4 years ) 7 13 10 9 5 9 7 4 10 6 22 12 21 19 11 9 14 9 8 17 Sources of primary notification were from Chest Clinic, Hospitals and Sanatoria and general practitioners. The 7 non-respiratory cases notified are as follows Abdomen - 1 Bones and joints - 3 Glands - 2 Skin or deeper tissues - 1 (b) DEATHS. During the year 30 cases died from tuberculosis compared with 28 deaths in the previous year; only one of these deaths was caused by a non-respiratory form of the disease. The 29 deaths thus ascribed to respiratory tuberculosis gave a death rate of 0.17 per 1,000 of the population. The death rate for England and Wales for this form of the disease was 0.15. The table below shows the age and sex distribution in respect of the deaths from tuberculosis during the year. Age Groups Respiratory Non-re spiratory M P. M. P. 0-4 - — = = 5-14 — - - - 15-24 - - - — 25-44 — 3 - - 45-64 12 3 1 - 65 years & over 10 1 - - TOTALS: 22 7 1 - 1.82 per cent, of the deaths in the Borough from all causes was due to Tuberculosis 18 The incidence of notifications, and of the deaths from tuberculosis in the Borough over the past 11 years can be compared from the figures given below. The rates per 1,000 of the population in each case are also shown. (a) notifications of Tuberculosis. Respiratory Non-respiratory Year Number Rate per 1,000 population Number Rate per 1,000 population 1945 178 1.32 34 0.25 1946 178 1.09 23 0.14 1947 167 0.97 24 0.14 1948 192 1.10 36 0.21 1949 173 0.99 36 0.21 1950 158 0.91 20 0.12 1951 192 1.13 18 0.10 1952 130 0.76 19 0.11 1953 199 1.18 18 0.11 1954 167 0.99 22 0.13 1955 145 0.86 7 0.04 (b) Deaths from Tuberculosis. Respiratory Non-Respiratory Year Number Rate per 1,000 population Number Rate per 1,000 population 1945 107 0.79 15 0.11 1946 122 0.74 10 0.06 1947 109 0.63 13 0.08 1948 95 0.55 11 0.06 1949 85 0.49 10 0.06 1950 68 0.39 6 0.03 1951 50 0.29 8 0.05 1952 39 0.23 5 0.03 1953 34 0.21 2 0.01 1954 27 0.16 1 0.006 1955 29 0.17 1 0.006 19 20 (b) CANCER. The number of deaths attributed to cancer was 321. The following table gives an analysis of the age and sex distribution as well as the localisation of the disease in all persons certified as dying from cancer during the year. Age Groups Malignant Neoplasms Other Malignant & Lymphatic Neoplasms TOTAL Stomach Lung & Bronchus Leukaemia & Aleukaemia Breast Uterus M. F. M. F. M. F. F. F. M. F. 0-14 - - - - 1 - - - 1 2 4 15-24 - - - - - 1 - - - - 1 25-44 3 - 4 - - - 2 1 4 5 19 45-64 20 5 40 3 - 2 4 3 22 18 117 65-74 9 6 23 6 2 - 6 1 33 17 103 75 & over 5 10 8 1 1 - 3 2 28 19 77 Total 37 21 75 10 4 3 15 7 88 61 321 Nineteen per cent of the deaths from all causes in the Borough were due to cancer compared with 17 per cent for all deaths registered in England and Wales. 21 (c) VENEREAL DISEASES. The Special Clinic for the Investigation, follow-up and treatment of venereal diseases is held at Queen Mary's Hospital, Stratford, under the direction of the Consultant Venereologist, Dr.F.G.MacBonald, to whom I am indebted for the following report. (The figures in brackets are the corresponding ones for 1954). The total number of patients who attended was 603 (553). This includes 120 already under treatment or observation at the beginning of the year. New Patients 483 (411) Total attendances 3,036 (2,759) The diagnosis was as follows:- Syphilis in the primary or secondary stage 1 (1) Syphilis in the early latent stage 0 (l) Syphilis in the later (non-infective) stages 9 (12) Congenital Syphilis 5 (1) Gonorrhoea 51 (26) Urethritis 36 (35) Other conditions 347 (299) Cases previously treated elsewhere 16 (15) Return Cases 17 (27) Five cases of Syphilis came under treatment as the result of routine ante-natal testing. Three of them were congenital in origin, one being an Italian and another a Jamaican. It Is satisfactory to be able to record that all those pregnant were delivered of healthy Infants. It will be noticed that the Gonorrhoea cases were nearly doubled. Some of these were superinfections and were an illustration of the care-free attitude, now unfortunately common in patients, Induced by the rapid response of the condition to penicillin. The total has been partly swelled by natives from the West Indies. As the Infection was invariably acquired in this country, the fact that they are attending as patients is an unwelcome reminder of the untreated reservoirs of infection which still exist. Contact tracing has generally been impossible where these West Indians are concerned as the infection is nearly always acquired as the result of a casual encounter. Other conditions also show a marked Increase. These, as usual are mostly cases of vaginitis, cervicitis and other conditions of infective, but not necessarily venereal origin although this possibility has always to be investigated. New cases by Area (Excluding Return and Previously Treated eases) were:- West Ham 220 (148) East Ham 38 (36) Essex 156 (149) Other Areas 36 (42) 22 SANITARY CIRCUMSTANCES OF THE AREA Report of the Chief Sanitary Inspector H. Ault, M.S.I.A. I have pleasure in submitting the Annual Report on the work of the Sanitary Inspectors during the year ending 31st December, 1955. Opportunity is taken to express my appreciation of the co-operation and services rendered by the Technical and Clerical Staff. Some comment on items of particular interest is provided in addition to the statistical tables. The number of dwelling houses in the Borough is 42,308 and the population is 167,900. Water Supply. The Metropolitan Water Board are the Statutory Undertakers throughout the County Borough and the water has been satisfactory in quantity and quality. There is no evidence of plumbo-solvent action and no cases of contamination were reported. All the houses except 2 are supplied directly by pipes. In these two instances water is supplied to standpipes situated in the yards. Factories Act. 1937. Generally speaking, if a factory is equipped with and uses mechanical power, the administration of the Factories Act, 1937, is the responsibility of the Factory Inspectors of the Ministry pf Labour and National Service, with the exception of the enforcement of the provision of sanitary accommodation, which is dealt with by the Sanitary Inspectors. In non-mechanically operated factories, the provisions relating to cleanliness, overcrowding, temperature, ventilation and drainage of floors is dealt with by the Sanitary Inspectors. In the case of factories belonging to the Crown, however, the powers and duties of district councils are administered by the Factory Inspectors and the Sanitary Inspectors have no power with regard to these factories. In the case of food factories, all matters relating to the inspection of food for unsoundness or disease, and the prevention of contamination, are the province of the Sanitary Inspectors in any diss of factory. Daring the year 760 visits were made for the purpose of the Factories Act, 1937, to factories, and 28 written notices were served in respect of contraventions. In no case was it necessary to institute proceedings. In the past 25 years a situation has arisen with regard to the administration of chis Act, whereby the majority of the work connected therewith has passed into the control of the Factory Inspectorate. 23 Originally, the passing of the Factories Act, 1901, divided factories and workshops by definition. This separation, repeated in amended form by the 1937 Act has meant that by the increase in motive power many more premises are now equipped with mechanical devices and are, therefore, supervised by the Factory Inspectors. Nowadays, the Factory Inspector has to deal with premises which originally were classed as workshops where a small drill or sewing machine has been installed and is electrically operated. The Factory Inspector is therefore responsible for the cleanliness, overcrowding, temperature, ventilation and drainage in addition to any safety measures necessary. At.the same time the Sanitary Inspector might be dealing with those items in larger businesses where no mechanical power is employed. In the opinion of many leading sanitarians it is a waste of manpower to allow a Sanitary Inspector to deal with sanitary accommodation and not allow him to deal with washing facilities - if there is mechanical power used in the factory. Mechanical power, once the exception, is now the rule and the time is opportune for a review of the functions of both H.M.Factory Inspectors and Sanitary Inspectors in respect of this work. 24 The following table shows the work carried out during the year under the Factories Acts, 1937 and 1948:- FACTORIES ACTS. 1937 & 1948. Part I 1.- INSPECTIONS for purposes of provisions as to health (including inspections made by Sanitary Inspectors). Premises Number on Register Number of Inspections Written notices Occupiers prosecuted (i) Factories in which Sections 1,2,3,4 and 6 are to be enforced by Local Authorities. 86 148 1 - (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority. 860 612 27 _ (iii) Other Premises in Which Section 7 is enforced by the Local Authority (excluding out-workers' premises) - - - - TOTAL 946 760 28 - 2.- CASES IN WHICH DEFECTS WERE FOUND (If defects are discovered at the premises on two, three or more separate occasions they should be reckoned as two, three or more "cases".) Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspector By H.M. Inspector Want of cleanliness (S.1) 1 1 - 1 - Overcrowding (S.2) - - - - - Unreasonable temperature (S.3) - - - - - Inadequate ventilation (S.4) - - - - - Ineffective drainage of floors (S.6) - - - - - Sanitary Conveniences (S.7) (a) Insufficient 4 4 - 3 - (b) Unsuitable or defective 48 48 - 6 - (c) Not separate for sexes - - - - - Other offences against the Act (not including offences relating to Outwork) - - - - - TOTAL 53 53 - 10 - 25 Part VIII OUTWORK (Sections 110 and 111) Mature of Work SECTION 110 SECTION 111 No. of outworkers in August list required by Section 110 (1) (c) No. of cases of default in sending lists to the Council No. of prosecutions for failure to supply lists No. of instances of work in unwholesome premises Notices served Prosecutions (1) (2) (3) (4) (5) (6) (7) Wearing apparel Making, etc. Cleaning and washing 335 Household Linen 6 Lace,lace curtains and nets 2 Furniture and upholstery 1 Umbrellas, etc. 3 Artificial flowers 5 Paper bags 5 The making of boxes or other receptacle: or parts thereof made wholly or partially of paper 40 Brush making 1 Feather sorting 1 Stuffed toys 25 Chocolates and sweetmeats 7 Cosaques, Christmas crackers, Christmas stockings, etc. 75 Lampshades 9 TOTAL 515 _ _ _ _ _ 26 Smoke Abatement. During the year the Sanitary Inspector made 257 visits to industrial premises concerning smoke emission, and to give advice generally on the working of the plants. It was obvious that the management of the firms were aware of the national and local interest in cleaner air, and a general all-round improvement has resulted. There is, however, still room for considerable further improvement, which will no doubt follow as supplies of smokeless fuel are more readily available and obsolete plants are modernised in accordance with the provisions of the new Bill, (assuming it becomes law), which allows owners 7 years to do so. Among the large Industrial firms in Custom House and Silvertown it is gratifying to note that an increasing number are making use of the facilities available at the Fuel Research Station, Greenwich, for smoke abatement. There has been marked improvement by firms acting on the advice given by the Research Station. On the other hand, some firms are experiencing difficulty in recruiting suitable stokers, particularly in the smaller plants which are still hand-fired. This is due in the main to two factors:- (a) Full employment - tendency of staff to leave on the slightest provocation, including criticism of methods of stoking and (b) Failure on the part of a few firms to recognise a stoker as a skilled craftsman, capable by reason of his efficiency to save, in terms of fuel, much more than his wages. The lowest rate of pay is all that many firms offer to stokers and then express surprise at the lack of quantity and quality of the response. The Clean Air Bill. The Clean Air Bill containing the Government's proposals for eliminating air pollution, was published on the 26th July, 1955. The object of the Bill and its four main purposes are contained in the explanatory and financial memorandum which prefaces it. The Bill implements the principal recommendations of the Beaver Comsittee, which were generally accepted as satisfactory. The four main purposes of the Bill are:- (1) to prohibit the emission of dark smoke from chimneys, railway engines and vessels, subject to certain qualifications. (2) to prohibit the installation of new industrial furnaces, unless they are capable, as far as practicable, of being operated without emitting smoke. (3) to require that the emission of grit and dust from existing industrial furnaces shall be minimised and that new industrial furnaces burning pulverised fuel or large quantities of other solid fuel, shall be provided with grit arresting equipment. (4) to empower local authorities by order, subject to confirmation by the Minister concerned, to declare "smoke controlled areas" in which emission of smoke from chimneys may constitute an offence. 27 The Bill also provides for the payment of grants by the Exchequer and the Local Authorities towards the cost of converting appliances in private dwellings in smoke controlled areas; amends and extends the Alkali Etc. Works Regulations Act; and provides for application to Crown premises and naval vessels. The areas in England, Scotland and Wales most likely to be declared as smoke controlled areas are the main industrial areas in the vicinity of Birmingham, Bristol, Cardiff, Edinburgh, Glasgow, Liverpool, London, Manchester, Newcastle-upon-Tyne and Sheffield. In these densely populated areas old-fashioned coal fires will be replaced by smokeless fuel burners.,The Government and Local Authorities will share the main burden of the expense involved. The Chancellor of the Exchequer is to provide 40% and the Local Authorities at least JO% of the cost of each new grate or cooking stove installed. A very wide estimate for converting household fires in the main industrial areas mentioned above is £3,000,000 a year payable by the Government and £2,000,000 by Local Authorities over a period of from 10 to 15 years. This estimate Is influenced by a number of important factors such as the speed with which Local Authorities declare their areas to be smoke-controlled, the ready co-operation of owners and occupiers and, more important still, the amount of smokeless fuel available. When the provisions of Section 8 & 9 are applied to West Ham, it is estimated very widely that some 20,000 dwellings will be dealt with. This figure is arrived at after deducting the number of Council houses and unfit houses dealt with under Slum Clearance procedure. The Clean Air Bill has received wide publicity, and on the whole, the comment is favourable. There is general agreement that public opinion would be in favour of the legislation, and that although there are many problems still to be solved, much is being done to improve the cleanliness of the atmosphere generally. One of the most important problems which faces the persons responsible is the production of more, and still more, smokeless fuel. Domestic Fires. During the winter months the smoke emitted from flues of domestic buildings is one of the worst, if not the worst, causes of air pollution in West Ham. To appreciate the amount of smoke emitted from these buildings, it should be viewed from the top of a high building during a calm day. The smoke emitted is extremely bad from a pollution point of view, as it is emitted at low level, and this applies particularly to the flues of the several colonies of pre-fabrlcated dwellings, as the smoke from these buildings is emitted at an even lower level than the ordinary dwelling house. Introducing the Clean Air Bill to the House of Commons, the Parliamentary Secretary to the Ministry said, "The prevention of domestic smoke will be a major operation, involving radical changes in fuel use, involving problems of supply, large scale alterations of domestic appliances and, of course, a great degree of public willingness. We propose that this operation should be carried through by the gradual extension of smoke controlled areas, similar to the smokeless zones already established In a number of towns under Local Authority powers." One of the most important aspects of the cleaner air campaign is to draw the attention of the public, local authorities and all others Interested to the extensive range of modern improved fires, heating stoves, boilers and other appliances now available to householders, which use solid fuel more efficiently and economically than the old-fashioned types. 28 Although many of these appliances have been Installed in homes since the war, there remains many thousands of houses in West Ham, where old grates and kitchen ranges are still being used. Prior to the war, when coal was plentiful and of a consistently good quality, these old fires burned cheerfully enough but unfortunately with considerable waste. At the present time, owing to the fact that many of the beat coal seams have been worked out, and that mechanisation of the mines is increasing, the coal which reaches domestic consumers is often much smaller in size and will not burn so satisfactorily in the old types of appliances. Aided by scientific research, manufacturers have with increasing success since the war tackled the problems of producing solid fuel appliances which measure up to modern requirements of higher efficiency and greater economy, and will burn a wide variety of solid fuels, including small coal. These appliances incorporate the most important development in the design of domestic solid fuel appliances, namely effective draught control. Whereas the pre-war fires blazed away virtually without control, the new types can be so controlled that the fuel is consumed at an economical rate when the room is not in use, or when it becomes too hot to be comfortable. One of the effects of the development of new domestic solid fuel appliances since the war has been to increase the need for an advisory service to help the public to choose the kind of fire, stove, boiler or cooker to suit individual needs. If, however, the public are to make the best possible use of the new equipment they must also be advised as to the correct fuels for it. The Coal Utilisation Service has recognised the need for such a service and has started a Technical Diploma Scheme for merchants. The diploma is awarded to merchants with a requisite number of staff who have been awarded the C ,U.C. Certificate of Proficiency. The object of the course is to ensure that sales staff have sufficient knowledge of solid fuels and of modern appliances to be able to advise their customers on matters affecting either. Food Inspection. In the Borough there are approximately 1750 establishments where food is sold or prepared for sale, and during the year, 3640 visits were made to these premises. Of this number, 735 are registered under the West Ham Corporation Act 1937, Section 67, in connection with the sale of ice cream or preserved foods. The types of registered premises are as follows:- Butchers Wet & Pried Pish Shops Ice Cream Establishments 125 63 312 Greengrocers Grocers 43 192 The number of licensed distributors of milk is 261 and 535 licences have been issued in relation to designated milk sold by them. One establishment is registered for the sterilisation and sale of sterilised milk. 29 I append a list of various foodstuffs condemned during the year:- FOODSTUFFS CONDEMNED DURING 1955. Meat 3,113 tins Cream & Milk 3,607 tins Meat 5,773 lbs. Vegetables 3,689 tins Bacon 85^ lbs. Vegetables 3,585 lbs. Onions 4,200 lbs. Cake 16 lbs. Tomatoes 1,896 tins Tomatoes 7,652 lbs. Cheese 313 lbs. Cereal 17 pkts. Cheese 183 boxes Sausages 27½ lbs. Soup 69 tins Chocolate (Nut Whirls) 252 Fruit 6,155 tins Salt 2½ lbs. Fruit (fresh) 400 lbs. Egg Albumen 167 lbs. Jam & Marmalade 454 jars Ham 197 lbs. Fish l,4l6 tins Ham 205 tins Fish 226 lbs. Fats 18 lbs. Chlnese Egg Albumen. With reference to the 167 lbs. of Chinese egg albumen contained in the above list, bacteriological investigations into samples of this commodity imported into this country during 1955 revealed the presence of the Salmonella group of organisms. This group of organisms is one of the three chief groups which cause bacterial food poisoning, and the illness is characterised by acute gastro-intestinal disturbances. Egg albumen is used largely by bakers and confectioners in the preparation of marshmallow, macaroon paste, meringue powders and similar products and can also be used by confectioners In the manufacture of sweets such as nougat. The finding of food poisoning organisms in samples taken prior to general distribution caused Medical Officers of Health of neighbouring boroughs to notify the Department and give details of consignments to retailers in this Borough. On receipt of this information the shops and food manufacturing establishments were visited and the managements were advised that unless their manufacturing processes ensured that the albumen was subjected to a temperature of at least 212° F. for at least 10 minutes it was not advisable to use it. A number of manufacturers surrendered their stocks immediately as a safety precaution and purchased albumen imported from either France or Sweden.- In cases where the processing would not include complete sterilisation and the albumen had not been delivered, the Medical Officer of Health notifying the Department was advised and permission to deliver was withheld. Experience has shown that although samples taken from a particular consignment have proved negative, a test on limited samples is not conclusive evidence that the bulk Is fit for food. Food Samples. Details of the number of samples taken during the year are contained in the Annual Report of the Public Analyst, in this report the Public Analyst gives a table of figures for the last 5 years showing the percentage of adulteration of the samples submitted to him for analysis. The percentage of adulteration for the years 1954 and 1955 show a comparatively sharp rise over the three preceding years. This Is accounted for by circumstances outside the normal rate of adulteration as commonly understood, inasmuch as during 1954, 35% of the total foods found to be adulterated were oranges 30 containing thiourea, and a further 25% of the total were sausages, containing excess of the preservatives allowed by the Preservatives Regulations, which is 450 ppm of sulphur dioxide. The 1955 figure also reveals that sausages comprise 25% of the total adulteration as in 1954 for the same reason, and 37# is accounted for by analytical confirmation of unsound foodstuffs. In explanation of the latter figure, it quite often happens that an article of unsound food is brought to the notice of the Department and although the Sanitary Inspector may be certain in his own mind what is the cause of the unsoundness, a certificate from the Analyst to confirm his opinion is often helpful if legal proceedings are contemplated. During 1955 an unusually large number of articles of unsound food, in comparison with other years, were submitted to the Public Analyst and these were included in the adulteration rate. The high rate of adulteration in sausages is due to a change of policy with regard to sampling. During the past two years, instead of concentrating on such articles as milk, butter, margarine, etc., where the risk of adulteration is remote, more attention has been paid to the sampling of sausages and cooked meats, and similar articles which, in general, are manufactured within the Borough and sold loose to the public. The meat content of the sausages was found to be satisfactory, although the examination revealed an excess of preservative above that allowed by the Preservative Regulations. This contravention is regarded as minor, for it is well known that the preservative, sulphur dioxide, evaporates quickly, particularly in warm weather. For instance, if a sausage contained 500 ppm immediately after manufacture, within 24 hours that figure may have dropped to 425, and within several days may have disappeared entirely. It is common practice with manufacturers to add a slight excess of preservative during manufacture in the knowledge that this will have been reduced by evaporation within a few hours. There are, in addition, several items arising from the report which are also of interest. Milk. 44 samples of milk were taken in course of delivery to the Schools and hospitals in the Borough, 25 for chemical analysis and 19 for bacteriological examination. All were returned as satisfactory. Sausages. A total of 53 samples of sausage were taken of which 31 were pork and 22 beef. The average meat content of the pork samples was 66.4% and that of the beef 57.3% These averages are above the unofficial standards of 65# pork and 50# for beef. In one instance a sample of beef sausage revealed only 35# meat but as the sale price was lower than the normal price per pound of beef sausages containing at least 50% of neat, and bearing in mind that the standard of 50# is unofficial, legal proceedings were not practicable. Ice Cream. 27 samples of ice cream were purchased for chemical analysis, all of which complied with the standards laid down for this commodity by the Food Standards (Ice Cream) Order 1953. 31 The Order provides, inter alia, that ice cream must contain at least 5% fat, 10% sugar and 7½% milk solids other than fat. An analysis of the figures returned by the Analyst of the 27 samples submitted show an average of 10.6# fat, 14# sugar and 11.9# solids not fat, which is greatly in excess of the minimum required by the law. The fat content in ice cream is not necessarily fat derived from milk and the use of the word "cream" is apt to be misleading. Margarine is the ingredient very largely used to supply the fat content. Cream derived from milk is sometimes used if a high class product is required. This is not in common use, however, as the cost of the completed article would be prohibitive. In addition to the abovp, 43 samples of ice cream were submitted to the Public Health Laboratory Service for bacteriological examination and the following results were returned:- Grade 1 2 3 4 Number of Samples 32 6 4 l Samples are subjected to the Methylene Blue Reductuse Test and graded 1, 2, 3 and 4, according to the time taken for the colour of the test solution to disappear. This gives an approximate indication of the number of bacteria present, and samples are divided broadly into the categories, Good, Average, Bad and Very Bad. Where samples consistently fail to reach Grades 1 and 2, it is reasonable to regard this as indicating defects of manufacture or of handling, which necessitates further investigation. In the case of samples falling into Grades 3 or 4, which is deemed unsatisfactory, the premises were visited and the cause of the trouble investigated, after which further samples were taken to ensure that conditions were satisfactory. Iced Lollies. 21 samples of iced lollies were also submitted for bacteriological examination and all were pronounced satisfactory. Foreign Master in Articles of Food. In the course of duty the presence of foreign matter is frequently found in articles of food delivered to the consumer. Such articles take the form of glass splinters in bottles of milk, pieces of wood in toffee, nails in lard and margarine, and unfortunately others such as used and dirty finger bandages in bread and cakes and cigarette ends in loaves. Section 3 of the Food & Drugs Act, 1938, provides that if a person sells to the prejudice of the purchaser any food or drug which is not of the nature, or not of the substance or not of the quality of the food or drug demanded by the purchaser, he shall, subject to the provisions of Section 4, be guilty of an offence. 32 Section 9 provides that a person who (a) sells or offers or exposes for sale, or has in his possession for the purpose of sale or of preparation for sale; or (b) deposits with, or consigns to, any person for the purpose cf sale or for preparation for sale, any food intended for, but unfit for, human consumption shall, subject to the provisions of the Section be guilty of an offence. In the High Court on the l4th October, 1955, in a case in which the problem was whether a piece of metal in a bun rendered the bun "unfit for human consumption" or whether the bun was "not of the nature, substance or quality demanded by the purchaser", the Lord Chief Justice gave a Judgment which should be a guide to all future prosecutions. In ruling that the bun was not unfit for human consumption the Lord Chief Justice quoted the custom of placing threepenny pieces in Christmas puddings, and pellets in shot pheasants and rabbits, and said that this did not render the food unfit. It would appear, therefore, that providing the offending matter is purely extraneous and does not render the food itself unsound or unfit, or have any effect on Its composition, that action can no longer be taken under Section 9. This would cover also such articles as glass splinters in milk. It is also doubtful whether the provisions of Section 3 are appropriate in all such circumstances. The Section refers to food, etc., not of the nature or not of the substance or not of the quality of the food demanded. An analytical examination of the food in question may not substantiate any of these contentions, although physical examination clearly shows the presence of foreign matter. The foreign matter may not be in the nature of an adulterant to the food, and may not affect it as such, but rather is an additional substance and likely to be consumed with it but not as part of It. On the other hand, if a liquid, say milk, contains splinters of glass which could be inadvertently taken into the mouth and cause damage it might be argued under Section 3 that the milk was not of the quality demanded. In a more recent case before the High Court, however, In which a firm appealed against their conviction by a Court of Summary Jurisdiction under Section 9, the Lord Chief Justice made it quite clear that where the foreign matter did contaminate the food a contravention of Section 9 was proved. He did not hesitate to dismiss the appeal and remarked that it was not necessary even to deliver a Judgment. The facts in this ease were that a loaf had a 3 inch long piece of bandage, containing a piece of yellow dressing, adhering to the crust, and Counsel submitted that there was no contamination or pollution to the loaf. The Lord Chief Justice, however, was of opinion that a bandage with septic matter on it would contaminate the loaf. Sale of Meat Pies. During the year two successful Court actions followed complaints concerning the sale of mouldy meat pies. In one instance the vendors were fined £5.0s.0d. and £9.3s.Od. costs and in the other a fine of £5.0s.0d. with 2/- costs was imposed. 33 The period during which meat pies should be stored varies from one to three days and is materially affected by climatic conditions and storage facilities. Pie makers as a general rule are careful to advise their retalleirs that pies are a perishable commodity and should be sold within two or three days of delivery, depending on climatic conditions. In several cases which have been brought to the notice of the Department the fault has clearly lain with the vendor, for on investigation the arrangements for the storage and control of the sale have been most careless. In some retail shops nobody on the staff has been detailed to give special attention to the pies or received instructions about withdrawing from sale and disposing of pies which have become stale. On the other hand many shops have an orderly method for dealing with the problem. Code numbers of the pies are taken and they are examined each day and those which have been on display for a reasonable length of time are withdrawn in case of doubt. In others the trays on which they are displayed are marked with the date of delivery and any pies left after say, two days, are withdrawn from sale and destroyed. A number of firms enclose their pies in a cellophane wrapper, and while this method is hygienically sound, there is a danger that the pies may have been wrapped before they were properly cooled. It is probable that the heat rising from the pie finds no outlet and condensation, which is set up in such circumstances, is trapped by the wrapping and conditions suitable for mould formation are created. Many retailers, almost always against the advice of the makers, store pies in a refrigerator. This is unsatisfactory, for there is a tendency for the pie crust to absorb moisture from the atmosphere and more so from the air in the refrigerator and again conditions favourable to the growth of moulds are set up. The only safe way of dealing with perishable foods such as meat pies is a prompt sale and a quick withdrawal from sale of all those which are doubtful. Sousing. During the year the slum clearance campaign, which was interrupted by the war, and delayed in the immediate post war years, owing to the acute shortage of housing accommodation was renewed. In this Borough cleared land is in such short supply that it was found necessary to concentrate on unfit houses which border on to open sites and which, when embodied with the latter in a compulsory purchase scheme will result in a gain of housing units. Although It was essential to adopt this policy at this stage, it has the disadvantage that the worst slums in the Borough are not necessarily taken first. It is hoped that the very bad houses will be dealt with systematically as soon as the situation allows, meanwhile if a house In this category becomes dangerous or conditions worsen owing to other reasons, it is dealt with by demolition order and the occupants re-housed. During the year the following areas were officially represented by Clearance Order proc edure:- Area Houses Capel Road, Forest Side 15 Edward Street 8 Langthorne Street 13 Waddlngton Street (No. 1) 11 Waddington Street (No. 2) 14 34 Objections to the Orders were dealt with by public enquiry in the cases of Capel Road, Forest Side and Langthorne Street. The former was confirmed, without modification. The result of the latter was not to hand at the end of the year. During the year 11 individual houses and parts of buildings were reported to the Housing Committee as being unfit and not capable of being rendered fit at reasonable cost. Twenty-four demolition Orders and three Closing Orders were made during the year in respect of dwellings previously reported to the Housing Committee. The Housing Repairs and Rents Act, 1954. Part 1. Clearance of Unfit Houses. Under Section 1 it is the duty of every local authority within one year after the commencement of the Act, that is 30th August, 1954, to submit to the Minister their proposals for dealing, under Part 2 & 3 of the Housing Act, 1936, with houses within their districts which appear to the authority to be unfit for human habitation and which ought to be dealt with either as individual unfit dwellings under Section 11 of the Housing Act, 1936, or by Clearance Area procedure. The Inspection of houses in accordance with this Instruction was begun in 1954, when to the 31st December of that year 1390 visits had been made. The survey was continued during 1955 when a further 443 visits were recorded. In compiling the list every endeavour was made to render it as comprehensive and decisive as possible. There are, however, many houses in the Borough which are substandard and of obsolete design, which in the light of experience in the administration of the Act together with Ministry and High Court decisions, it may be possible to include in slum clearance schemes at a later date. The question of including these border-line cases was considered very carefully, but it was felt that as a doubt existed they should be excluded from the list at that stage. This is permissible under Section 1(4) which states that the local authority may at any time submit further proposals for amplifying or modifying any proposals previously submitted and approved. The total number of houses and the ward in which they are situate are set out below:- Ward Houses Beckton 276 Bemersyde 36 Broadway 202 Canning Town & Grange 186 Custom House & Silvertown 455 Forest Gate 120 High Street 220 Hudson' s 173 Newtown 269 Ordnance 282 Park 14 Plaistow 165 Plashet Road 190 Tidal Basin 160 West Ham 115 Total 2,863 The estimated number of families residing in the above houses is 4,009. 35 Part 2. Certificates of Disrepair. The main task which fell upon the Department under Part 2 of the Act, was to deal with applications from tenants for Certificates of Disrepair, where the landlord claimed a repairs increase in rent, and the tenant was of opinion that the house was not in a sufficiently good condition to justify it. With regard to old controlled houses the provisions relating to Certificates of Disrepair under this Act replaces those relating to the 40% increase of rent permitted under the Increase of Rent and Mortgage Interest (Restrictions) Act, 1920. Thus if a tenant of a house not subject to an increase of rent under this Act applies for a Certificate of Disrepair under the 1920 Act, the same criteria must be adopted as regards the condition of the house as is carried out under this Act. Before a landlord is entitled, in pursuance of Section 23 of the Act, to Increase the rent payable in respect of a dwelling house to which the Rent Acts apply, the following conditions must be fulfilled. 1. The dwelling house must be in a good state of repair. 2. It must be reasonably suitable for occupation, having regard to the following:- (i) Stability, (ii) Freedom from damp. (iii) Natural lighting. (iv) Ventilation. (v) Drainage and sanitary convenience and (vi) Facilities for the storage, preparation and cooking of food, and for the disposal of waste water. (Section 9). In addition to the above, in accordance with the second Schedule of the Act, the landlord must produce satisfactory evidence that work of repair to the value specified in the Schedule has been carried out at the dwelling house during the period so specified. In determining whether or not to recommend to the Council to issue a certificate, the above conditions must be taken into consideration by the officer, with one variation. This variation arises because under Section 9 the property's state of "repair" of which there is no definition in the Act, has to be considered, whereas under Section 26 it is the state of "good repair" which is pertinent. "Good repair" is defined under Section 49 as meaning "having regard to the age, character and locality of the premises they are in good repair both as to structure and as respects decoration". The reference to age, etc., of premises in relation to good repair, would seem to suggest that standards are likely to vary from one district to another and a house which in its present condition might warrant a Certificate of Disrepair in one area need not necessarily do so in another. In considering whether a house is in "good repair" any defect due to the act, neglect or default of the tenant is to be disregarded. Inspectors, when preparing Schedules of Disrepair following applications for certificates, must bear in mind the important fact that a higher standard than that obtaining in the neighbourhood cannot be insisted upon. It is thought by many people that such items as the provision of bathrooms and additional water closets are reasonable items to include on a certificate. This is not so, and also in a recent Court decision it was decided that the inclusion of a garden fence and gate were not reasonable. 36 During the year 177 applications from tenants were received. Before being reported to the Housing Committee each house was visited and of this total 142 certificates were issued, 27 were refused, and 7 were withdrawn. One was outstanding at the end of the year. Where, after the giving of a certificate the landlord has satisfactorily executed the works necessary to render the house fit, he may apply for the certificate to be revoked. During the year 203 such applications were received of which 179 were granted, 23 were refused, and one was withdrawn. Houses Visited. The number of houses visited on complaint and by house to house visitation was 6,316 and as a result of this visitation 3,565 Notices were served and 257 summonses were issued in respect of non-compliance. Samples of Water from Swimming Baths. During the summer months 14 samples of water were taken for bacteriological examination from the swimming baths in the Borough as follows Beckton Road Lido 9 Romford Road 4 Balaam Street 2 and In all cases the samples were found to be of excellent quality and free from any harmful bacteria. The method of purification of the swimming bath water is by the closed circulation filtration system and it is sterilised by chlorine. Water drawn from the pools is pumped through the filter and returned to the pools at the shallow ends. Before passing through the filter the chemical coagulant, sulphate of alumina, is added, which has the effect of binding the impurities together, and forms the gelatinous bed which is the real filtering medium. On the water leaving the filters, the chlorine sterilising agent is added. In addition to the samples taken by the Sanitary Inspectors, the Baths Superintendent frequently tests the water to ensure its cleanliness. Rodent Control, Disinfestation and Disinfection Section. The trend of work again shows a slight decrease, and the tables show an increase in the number of investigational visits as against a decrease in the number of operational visits. Routine visits have been made to ascertain whether or not there is an infestation in order to prevent a build up and a long series of operational visits. The largest single infestation by rats occurred in the premises of a firm dealing in the processing of waste meat bones and the like, and in land and properties adjoining. The full resources of the Section were employed and in the first week of treatment 255 bodies were found, and at the end of three weeks nearly 500 bodies had been picked up. post baiting showed a few survivors which were poison and trap shy, and which eluded capture by the cats kept by the firm. After an interval of some months a further operation was carried out resulting in the collecting of about 50 bodies. Further post baiting showed extremely slight infestation. 37 In conjunction with the work of the operatives, the Sanitary Inspectors following up complaints, instigated 382 drain tests, resulting in the repair or relaying of 49 drainage systems, comprised of 138 properties. During the year it was found necessary to serve 15 intimation notices under Section 4 of the Prevention of Damage by Pests Act, 1949- The work of the Section has been made somewhat easier as the policy on drainage repairs, established some five years ago, is bearing fruit. It will be some years yet before the majority of the defective drainage systems are located and repaired, but it is felt that as this work continues, the problem of rodent control will be lessened considerably, until a basic inescapable minimum is reached. With regard to bed bug infestation, the numbers do not show the reduction hoped for following the use of the chlorinated hydrocarbon insecticides, but as slum clearance is proceeded with, a reduction will be noticed in the number of properties dealt with by this department. It is felt, however, that the number of properties dealt with by the staff of the Estates Branch of the Borough Engineer's Department will show an increase, as at present no compulsory treatment is carried out to the goods and chattels of the persons displaced, only a warning given, if evidence is noticed when accommodation is offered, that they will be responsible should any bugs be found in the new premises, and that they would be advised to avail themselves of the services of the Estates Branch to have their furniture disinfested on removal. Tribute must be paid to the Rodent Control Officer for the experimental work carried out by him personally to improve the technique of disinfesting premises, by which it is felt the efficiency of the Section will be improved and the ultimate cost to the Council reduced. The statistics relating to the activities of the Section are given in the tables below:- RODENT CONTROL Investigational visits to premises Operational visits to premises Houses 1,752 6,768 Factories 216 406 Shops 255 338 Cafes 6 23 Public Houses 13 41 Other business premises 75 219 Churches 1 7 Schools 32 158 Hospitals 20 39 Corporation properties 42 205 Bomb sites, tips, allotments and ditches 117 82 Bakeries 3 10 Hostels 3 29 Clubs 8 10 2,543 8,335 Resulting from the above investigational visits, 805 premises were found to be infested with rats, and 692 infested with mice. 38 DISINFESTATIONS - VERMIN Invest igational visits to premises Operational visits to premises Houses 651 520 Factories 17 9 Hospitals 18 13 Bakeries 7 4 Hostels 1 - . Shops 36 7 Other business premises 11 7 Schools 12 13 Nurseries 1 1 Clubs 4 3 Corporation property 6 2 Bomb sites, tips, allotments & ditches 4 1 Clinics 3 3 Static Water Tanks 20 6 791 589 Treatment against vermin includes cockroaches, ants, bugs and mosquitoes etc. DISINFECTIONS No. of Premises visited Operational visits Houses 29 29 Hospitals 1 1 30 30 No. of articles disinfected Sacks 15,000 Felt hats 1,200 Plimsolls 165 pairs 16,365 Report of the Public Analyst (By Albert E.Parkes, F.I.C., F.C.S.) During the year 502 samples were examined under the Food and Drugs Act. Of these 191 were formal samples and 311 informal. All samples were submitted by the Inspectors. Sixteen samples were found to be adulterated or otherwise unsatisfactory, six formal and ten informal. The adulteration was at the rate of 3.2 per cent. 39 The adulteration in the Borough for the past five years was as followss- Year Number of Samples Percentage Adulteration 1955 502 3.2 1954 502 4.0 1953 501 1.4 1952 502 1.0 1951 819 0.7 Average 565 2.1 Ninety-six samples of milk were examined, seventy-two formal and twenty-four informal. One formal sample was found to be adulterated. The milk adulteration in the Borough for the past five years was as follows:- Year Number of Samples Percentage Adulteration 1955 96 1.0 1954 105 0.0 1953 108 0.9 1952 101 0.0 1951 151 0.0 Average 112 0.4 Condensed Milk. Six samples, all informal were examined. These consisted of two full-cream and four machine-skimmed. All these complied with the Regulations. Dried Milk. One informal sample was examined and found to be satisfactory. Ice-Cream. Twenty-seven samples were examined, seventeen formal and ten informal. All these were satisfactory. Ice Lollies. Twenty informal samples were examined for metallic contamination. One of these was found to contain an excessive amount of copper. Drugs. Twenty-four samples were examined, two formal and twenty-two informal. One formal and one informal sample were found to be adulterated. Preservatives. There were two contraventions of the Preservatives Regulations. 40 Fertilisers & Feeding Stuffs Act. Three fertilisers were examined, one official and two unofficial. All these were satisfactory. Eleven feeding stuffs were examined, all official. Two of these were unsatisfactory. In addition to the above, the following samples were also examinedsFor the Public Health Department. 4 Waters. 5 Swimming Bath Waters. For the Borough Engineer's Department. 20 Effluents. 1 Deposit from Drain. 2 Washing out waters. 1 Tank Water. 1 Liquid from Sump, For the Borough Architect. 6 Soils. 3 Ground Waters. 4 Sub-soil waters. 1 Water from bore-hole. SAMPLING OF FOOD AND DRUGS. Heat Treated Milk. The Milk (Special Designation) (Pasteurised and Sterilised Milk) Regulations 19^9 to 1953:- Particulars are given below regarding the various types of heat treated milk which were sampled during the year and submitted to the appropriate tests:- Type of Milk Number supplied Results of Examination Phosphatase Test Methylene Blue Test Turbidity Test Satisfactory Unsatisfactory Satisfactory Unsatisfactory Satisfactory Unsatisfactory Pasteurised 44 44 Nil 44 Nil _ - Sterilised 15 - _ - - 15 Nil Tuberculin Tested (Pasteurised) 7 7 Nil 7 Nil - - Tuberculin Tested (Sterilised) - - - - - - - Total 66 51 Nil 51 Nil 15 Nil 41 FERTILISERS & FEEDING STUFFS ACT, 1926. Particulars are given below of the samples taken during the year:- Type of Sample No. of samples taken Analysis agreed Analysis disagreed Fertilisers. Official 3 3 - Unofficial - - - Feeding Stuffs. Official 11 10 1 Unofficial - - - Total 14 13 1 RAG FLOCK AND OTHER FILLING MATERIAL ACT, 1951. Eleven rag flock samples were examined - all were satisfactory. 42 SUMMARY OF SANITARY INSPECTORS' WORK. For the period from 1st January, 1955 to 31st December, 1955. Visits to private houses following complaints 6,316 House to house inspections under Public Health or Housing Acts 833 Inspections under the Housing Act, 1936. Closing, Demolition or Repair (Sections 9, 11 & 12) Inspections under the Housing Act, 1936, re Clearance Areas (Section 25) 637 Initial Survey inspections under the Housing Repairs & Rents Act, 1954 443 Inspections re overcrowding 219 Inspections re advances by Local Authority under Housing Act, 1949 213 Inspections re issue and revocation of Certificates of Disrepair 591 Certificates of Disrepair issued 142 Certificates of Disrepair revoked 179 Inspections following infectious disease 658 Visits to filthy and verminous premises 89 Smoke observation and visits re smoke nuisances 257 Visits re offensive trades 107 Visits to Factories (mechanical) 612 Visits to Factories ' (non-mechanical) 148 Visits to workplaces and outworkers premises 136 Inspections of watercourses, ditches, etc. 31 Inspection of Hairdressers and Barbers premises 87 Inspections under Prevention of Damage by Pests Act 242 Visits under Bye-laws - re tents, vans and sheds 619 Visits under Pharmacy and Poisons Act 73 Visits to places of public amusement 103 Visits under Shops Act, 1950 24l Visits to Bakers and Bakehouses 144 Visits to Butchers 325 Visits to kitchens of Canteens, Cafes and Restaurants 485 Visits to Licensed Premises 115 Visits to Fish Shops 101 Visits to Fried Fish Shops 92 Visits to Retail Milk Distributors 520 Visits to Ice Cream Manufacturers and Dealers 231 Visits to Registered Premises for storage of food 119 Visits to Registered Premises for preparation of foodstuffs 147 Visits to hawkers of food 96 Visits to street markets 251 Visits to slaughterhouses 121 Visits to provision shops 679 Visits to greengrocers 114 Visits to condemn unsound food 411 No. of certificates issued 1,877 Reinspectlons 13,172 Drainage Inspections 2,638 Drain tests by Sanitary Inspectors 289 Drain tests by Borough Engineer's staff 382 Miscellaneous Interviews 848 Miscellaneous visits 885 43 NATIONAL HEALTH SERVICE ACT, 1946 SECTION 22s CARE OP MOTHERS AND YOUNG CHILDREN EXPECTANT AND NURSING MOTHERS. Facilities provided for Ante-Natal and Post-Natal Care were continued with ten weekly combined ante-natal and post-natal sessions at the Municipal Centres and one at the South West Ham Health Society's Clinic. The clinic held in the Silvertown area is now combined with the Child Welfare session. Patients attend by appointment and in each ease the medical examinations are undertaken by the Council's Medical Officers. In February, the transfer to the Council of the Domiciliary Midwifery Service previously given by Plaistow Maternity Hospital, afforded the opportunity for some reorganisation of the work at the municipal ante-natal clinics. The three small houses in Eldon Road previously owned by the hospital were acquired by the Council and the ante-natal clinic continued on a weekly basis (the accommodation In Eldon Road is now used partly for clinic purposes and partly as accommodation for midwlves.) Arrangements were made for all the municipal midwlves to conduct the examination of their patients at the Maternity and Child Welfare Centres at the same session as the ante-natal clinics conducted by the Medical Officers. This has fostered close and friendly co-operation between the midwlves (and their pupils) and the doctors, as well as with the Health Visitors who also have duties at the ante-natal clinics. These arrangements are greatly to the advantage of the mother who can in this way visit the doctor and the midwife together on a number of planned occasions. Should the midwife wish the doctor to examine the patient on any other occasion, this can easily be done without inconvenience. Patients requiring specialist's advice are usually referred to a consultant at one of the three Maternity Units in the Borough. Arrangements are made for those women who book a domiciliary midwife from the Essex County Council or Silvertown and North Woolwich District Nursing Association to attend the Municipal Clinics for their medical examinations. One thousand four hundred and sixty four expectant mothers have made a total of 7,263 attendances. Three hundred and six mothers attended for examination during the post-natal period and made a total of 322 attendances; this is 79% of the total of 389 domiciliary confinements, and does not include post-natal examinations undertaken by the family doctors. Blood tests are carried out on all patients attending these clinics and include a Kahn, Rhesus factor, Blood group and Haemoglobin estimation in every case. Anaemia in the expectant mother may have serious implications for both mother and baby. For this reason mothers are encouraged to take iron regularly during pregnancy, particularly in the last three months. Any mother who shows a tendency to anaemia is kept under careful observation, which includes further blood examinations. 44 It is of interest to know that of 247 expectant mothers examined during the three months March - May 1955 33% had a Haemoglobin level of over 90% 6l% had a Haemoglobin level between 70 and 90% and 6% had a Haemoglobin level below 70% The proportion below 70# compares favourably with some published figures, but it must be remembered that there is a greater tendency for anaemia to occur in women who have had several children and to develop in the later stages of pregnancy. The 247 mothers referred to Include mothers expecting their first baby as well as some with families, and also includes mothers at different stages of pregnancy. It should be our aim to achieve a Haemoglobin level of 90# or over at term. It is hoped to undertake more detailed surveys of this nature, with a view to assessing how far this object can be achieved. Chest X-rays started in 1953 for all expectant mothers have continued. Every expectant mother attending the ante-natal clinics who has not already been X-rayed during her present pregnancy, is offered an appointment for chest X-ray at a special session of the Mass Miniature Radiography Unit held at one of the Welfare Centres. Mothers booked for Plaistow Maternity Hospital and the Essex County Council Leyton Health area also attend these sessions. Unmarried Mothers. Close co-operation has been maintained with the Moral Welfare Worker employed by the Chelmsford Diocesan Moral Welfare Association, who Is resident in the Borough at St.Agatha's Hostel. During the year nine West Ham mothers, who were in need of care and accommodation, were admitted to St.Agatha's. Of these, eight were admitted before and one after the birth of the baby. Four West Ham unmarried mothers were admitted to hostels outside the area. When necessary the Council has contributed towards the maintenance charges. CHILD WEIFARE Infant Welfare Sessions. As in previous years the needs of the area have been met by a total of 20 sessions per week held at the Municipal Centres and at the South West Ham Child Welfare Centre. In the Silvertown area the Child Welfare Session is combined with ante-natal and immunisation clinics, as it has been found that this is sufficient to meet the needs. Fourteen children and 3 expectant mothers resident in neighbouring areas attended West Ham clinics, and 8 children and 2 expectant mothers resident in West Ham are known to have attended clinics in other areas. Toddlers' Clinics. The 20 sessions mentioned above include the special toddlers' clinics at which 2,898 children attended in response to the 8,006 invitations to come for examination on their 2nd, 3rd or 4th birthday. There were 2,410 children whose general condition was regarded as good, 451 children in whom it was recorded as fair, and 37 In whom it was recorded as poor. In the same group of children there were 2,647 whose cleanliness of body and clothing was recorded as good, 241 in whom it was found to be not entirely satisfactory, and 10 in whom it was poor. There was 1 child who was found to have infestation of the head. Defects or deviations from normality found in the same group of children are shown below. It includes conditions observed by the doctor or described by the mother and recorded at the time of the examination. The classification of defect in these pre-school children is in line with that prescribed by the Ministry of Education for school children. 45 No differentiation is made between major and minor defects, but no defect is recorded unless it is considered necessary to advise treatment or to keep the child under observation. Defect No. of children in which found Teeth 485 Skin 93 Eyes (a) Vision 9 (b) Squint 113 (c) Other 13 Ears (a) Hearing 13 (b) Otitis media (R 14 (L 6 (c) Other 7 Nose or Throat 70 Speech 90 Cervical Glands 26 Heart and circulation 34 Lungs 40 Development (a) Hernia 16 (b) Other 9 Orthopaedic (a) Posture 98 (b) Feet 169 (c) Other 73 Nervous System (a) Epilepsy 8 (b) Other 8 Psychological (a) Mental Development 27 (b) Stability (Behaviour Difficulties) 201 Other Defects 30 Forty-nine per cent of the children were found to be in satisfactory health and free from any defect and there were 14% in whom there was no defect except for carious teeth. There are two noteworthy changes from defects found in 1953:- an increase in dental defects from 390 to 485, and an increase in defects of hearing from 7 to 13. The latter may well be due to a more careful search for impairment of hearing which has resulted from the opening of the Audiology Unit referred to later. The increase in dental decay is greatly to be deplored. With the continued shortage of dentists in the Council's service it has not been found possible to make much progress with a scheme whereby every toddler can be offered regular dental Inspection at the Maternity and Child Welfare Centre. This is unfortunate because the preservation of healthy temporary teeth is important both in maintaining the child's general health, and for the formation of sound and well shaped permanent teeth. The Health Visitors have persevered in their efforts to give guidance to mothers on how to preserve their children's teeth through suitable diet and cleansing, but there is little doubt that they would be more effective if supported by timely advice, examination, and any necessary treatment given by the dentist. Jelly Tests for Tuberculosis. After consultation with the Chest Physician it was decided to offer "jelly tests" to all children attending Forest Street Child Welfare Centre for a "birthday examination". This is intended as a "pilot scheme" and if successful will be extended to all parts of the borough. The response was good. Out of 828 children examined, 683 were tested, and out of this 677 were negative, showing they had not yet acquired the infection. 46 The object of the testing is twofold; to discover unrecognised tuberculosis in the community and to help the child with a recently acquired infection to overcome it. Sooner or later each one of us comes into contact with tuberculosis. Most of us overcome the infection and acquire immunity, but some succumb and show signs of the disease. It is not usual for a child under five to pick up the infection, and if he does, the source can often be found within the family circle. When the jelly test is positive, a careful search is made to find the source of infection if this is not already known. The child himself is thoroughly investigated and every effort is made to. help him to overcome the infection by building up his general health in every possible way and by treatment when necessary. Out of the six children under five years found to have positive jelly tests, one was found to show signs of the disease. Attendances at all the Child Welfare Sessions (including the Toddlers' Clinics) are set out below for the period 1951 - 1955. The percentage of children in both age groups who have attended shows very little variation from the previous year. Children under 1 Year Children 1-5 Years Number of Individual children 1951 1952 1953 1954 1955 1951 1952 1953 1954 1955 2,4-06 (83%) 2,042 (74%) 2,336 (81%) 2,309 (85%) 2,166 (84%) 5,917 (41%) 5,596 (44%) 5,526 (46%) 5,169 (47%) 5,012 (45%) Number of 25,731 26,024 25,592 25,969 23,774 14,676 14,038 13,596 11,384 10,998 attendances (10.7) (12.8) (10.0) (11.2) (10.9) (2.5) (2.5) (2.5) (2.2) (2.2) Notes:- * Figures shown in brackets indicate the approximate percentage of available children within the age groups who attended the Clinics. †Figures shown in brackets indicate the average number of attendances made by each child. Consultant Clinics. The number of pre-school children referred to the specialist clinics available on local authority premises (through the School Health Service) during 1955 were as follows:- Ophthalmic 143 Ear, Nose and Throat 11 Paediatric 48 Child Guidance 1 Speech Therapy 15 With certain agreed exceptions, there is consultation between the clinic medical officers and the family doctor, before a child is referred to a specialist clinic or hospital. A copy of the report is sent to the family doctor. 47 Audiology Unit. The detection and assessment of deafness in a very young child is no easy matter, and it is only in recent years that specialist techniques have been developed at certain centres. Prior to May 1955, babies and pre-school children from West Ham had been referred to the Audiology Unit of the Royal National Ear, Nose and Throat Hospital, Gray's Inn Road, W.C.l. where a great deal of help was given in assessing the extent of hearing defect, and in subsequent training; sometimes with the assistance of a hearing aid. Experience has shown that much help can be given even to very young infants, mainly by teaching the mother to make the most of any available hearing' and to train her baby to listen. If this can be done before the age at which speech normally develops, then the chance of eventually achieving good speech is greatly increased.' Because of long waiting lists and of the inconvenience and expense caused to mothers in keeping appointments at Gray's Inn Road, and with the encouragement of the Director of the Unit, the West Ham Council was recommended to establish its own centre staffed by its own existing personnel. An Audiology Team was formed and a centre for children under five was established at Maybury Road Maternity and Child Welfare Centre, Plaistow, in May of this year. The staff consists of two health visitors who have received special training, the head teacher of the West Ham School for the Deaf and the Audlometrieian. The Director of the Unit is Mr.C.J.Scott, consultant ear, nose and throat surgeon of Whipps Cross Hospital whose services were already available to the West Ham Specialist Clinics. The services of the Educational Psychologist are available as required, and the administration of the centre is under the guidance of the Senior Assistant Medical Officer for Maternity and Child Welfare. The centre is open approximately once a month on Tuesday mornings, the intervals being varied to meet the needs. The main objectives of the centre are (a) early detection of deafness or impaired hearing and (b) auditory training to develop hearing and speech. In the case of infants, this is largely given through the mother. For children over two years of age considered to be deaf, ascertainment is carried out and the child's name put on the waiting list for the School for the Deaf, If the child is partially deaf, training and guidance, where necessary, are given at the clinic or in the child's home. In the occasional difficult case the child may be asked to attend the School for the Deaf for observation over a whole day. The staff of the centre work as a team and in close association with the Regional Hospital Board operating within the framework of the School Health Service and with the West Ham School for the Deaf. The Audiology Unit is still in the process of developing its techniques and co-ordinating the team work of its staff, and has not yet necessarily reached a settled routine. It seems reasonable to hope that with early diagnosis and auditory training and with the help of a suitable hearing aid, it may be possible for some children with defective hearing to be educated in an ordinary rather than a special school, thus giving the child the advantages of a more normal environment. 48 Five sessions were held during the year and 13 children were seen, 2 of whom were examined on two occasions. Of these 13 children 1 was deaf 3 partially deaf 2 required speech training 2 were suffering from a catarrhal condition of the middle ear and were referred for treatment 1 was placed on the waiting list for the removal of tonsils and adenoids 1 showed general backwardness (rather than impairment of hearing) 1 was referred for further observation 2 were found to be normal. Physiotherapy. The following table shows the number of pre-school children who have attended the Council's Physiotherapy Clinics, which are administered by the School Health Service:- Sunlight Massage Exercises Np. of individual children who attended 151 2 23 No. of attendances made by above children 2,572 5 194 Handicapped Children. The improved techniques for accurate diagnosis and better facilities now available for the treatment and training of handicapped children have underlined the importance of finding these children early - in infancy whenever possible. Wise counselling of parents can do much to shape their attitudes in a way which will be constructive and will help their child to lead as full a life as his endowments will permit. For this reason, health visitors are asked to refer to the Senior Assistant Medical Officer the records of any children whose development does not seem to be proceeding along normal lines, or who seem to have some potential handicap. The medical officer is then able to collect all available information (such as specialists reports) to co-ordinate the efforts of persons interested in the child, and to see that the necessary guidance is available to the family. When it appears to be in the interests of the child, or when requested by the parents, children over two years are referred to the School Health Service so that the advantages of possible "ascertainment" may be considered, and, if necessary, reviewed from time to time. In this way also the School Health Service is made aware of the children for whom special education may be required in the future. Certain detailed tests are now available for assessing the mental development of very young children. Too great a reliance must not be placed on them in predicting the child's ultimate achievement, although they are very helpful. They can be used to reassure an anxious parent, or to differentiate the child who is mentally backward from one who has a physical handicap, such as deafness. The Educational. Psychologist has given much help in applying these tests to selected children under five years, sometimes at regular intervals, so as to assess the rate of development. The mothers have expressed much appreciation of the interest shown and of the opportunity of being able to discuss their problems with an understanding expert. 49 At the end of the year there were 87 such children who were being kept under careful observation. Of these 13 had been ascertained. Ascertained Not Ascertained Total Aged 4- - 5 years 7 20 27 " 3-4 " 4 21 25 " 2-3 " 2 19 21 " 1-2 " - 11 11 " Under 1 year – 3 3 13 74 87 The 13 children "ascertained" were placed in the following categories:- Deaf 5 Physically Handicapped 4 3 Cerebral Palsy +1 Congenital Defect. Mentally Defective 3 Blind 1 13 The 74 children not yet ascertained would appear to come within the following categories:- Mentally Retarded 43 Physically Handicapped 16 - 15Congenital Defect +1 Poliomyelitis. Epileptic 7 Defective Speech 4 Deaf 2 Partially Deaf 1 Blind 1 74 There were 5 children under 5 years attending the School for the Deaf, 3 of whom were admitted for the first time during the year. There were 5 children under 5 years of age attending the Spastic Unit. Of these 2 were admitted to the nursery class. The Educational Psychologist tested a total of eighteen children under 5 years, two of whom she examined twice. The ages of children seen by the Educational Psychologist are as follows:- Age First Exam. ReExam. 4 - 5 5 1 3 - 4 7 1 2-3 4 — 1-2 2 — Total 18 2 50 Premature Infants. Place of Birth and Deaths under 1 month of Premature Infants. Number of Infants Number died within 24 hours Number died within 28 days Number survived 28 days Born & nursed at home 15 – _ 15 Born & nursed in hospital 168 10 6 152 Born at home & transferred to hospital 7 1 2 4 TOTAL: 190 11 8 171 The number of premature births was the same as last year, but with approximately 150 fewer total births the proportion has increased from 6.9% to 7.3%. Out of a total of 56 deaths of infants under 1 year, 19 (34%) occurred in premature infants who died within the first month of life. An analysis of causes of these 19 deaths is as follows:- Prematurity 11 Prematurity associated with Congenital deformity 4 Prematurity associated with Atelectasis 2 Prematurity associated with Rhesus Incompatibility and Kernicterus 1 Prematurity associated with Bronchopneumonia 1 19 Day Nurseries and Child Minders. Two Day Nurseries remained open during the whole of 1955: the following table shows the average attendances:- Nursery No. of Approved Average Daily Attendance Places Under 2 years Over 2 years Total Litchfield Avenue 51 11 20 31 Plaistow Road 54 10 24 34 The number of children in attendance at each nursery has varied considerably throughout the year and has reached 48 at Litchfield Avenue and 52 at Plaistow Road. This fluctuation can be attributed partly to some children being admitted on a temporary basis for short periods (to give help at times of family difficulty) and partly to absence during holidays, and illness of children or parents. 51 There were 127 admissions to Day Nurseries during 1955. All children accepted for admission come within the priorities defined by the Council as follows:- First Priority: Parents separated 16 children Mother unmarried 9 " Mother widowed 8 " Father in prison 6 " Father in H.M.Forces 5 " Children deserted by father 4 " Children deserted by mother 2 " Parents divorced 2 " Health of child 1 child TOTALS 53 Second Priority: (Financial grounds etc.) 55 Temporary admissions 19 TOTAL: 127 The following is an analysis of the temporary admissions and the average number of days the children spent in the Nurseries. Mother's Confinement in Hospital 10 admissions - average stay 15 days Mother in Hospital for treatment 3 " " " 7 " Mother in Hospital for Investigation 2 " " " 9 " Mother in Mental Hospital 2 " " " 28 " Mother in Hospital prior to confinement 1 " " " 51 " Both parents ill 1 " " " 4 " On 31st December 1955, there were 76 children on the Day Nursery Registers. One of these was under 6 months of age, 2 were between 6 months and 1 year, 15 were between 1 and 2 years and 58 were between 2 and 5 years. The length of stay of these children in the Day Nurseries is as follows:- 4-5 years 1 child 3-4 years 1 child 2-3 years 7 children 1-2 years 20 children Under 1 year 47 children TOTALS 76 It can thus be seen that the Council's two day nurseries are fulfilling a real social need, and in some cases they are providing an alternative to residential care and so preventing the break-up of the family. Of the large group admitted on financial grounds (whose income is within the level accepted for 2nd priority) a considerable number are seeking to increase the family Income in order to buy a house or to furnish recently acquired accommodation. During the year there were 16 cases of Gastro Enteritis, 39 Measles, 5 mumps, and 3 Influenza amongst the children at the two nurseries. The Gastro Enteritis cases were all mild, and in the main occurred individually throughout the year. All bacteriological investigations were negative, so that it was not possible to trace either the source or the method of spread. There was no evidence to suggest that the children were Infected in the Nursery. The cases of measles were distributed almost equally between the two Nurseries and occurred at a time when this illness was prevalent in the Borough. 52 The Day Nursery at Cumberland Road, which is under the auspices of the Canning Town Women's Settlement, has provided places for up to 30 children throughout the year. There are only two child minders on the statutory register, neither of whom received any children during the year, WELFARE FOODS. The distribution of Welfare Foods from the Child Welfare Centres, the Public Hall, Canning Town, and the local W.V.S. Headquarters has continued throughout the year. Owing to the very small uptake from the Silvertown Library Premises, distribution from this Centre was no longer made after 23rd June, 1955. In order to assist the residents in the south of the Borough a further distribution centre at the Rosetta Road Clinic was opened on the 15th June, 1955. CONVALESCENCE. The following are the numbers of mothers and children sent for recuperative holidays during 1955:- Unaccompanied children under 5 years 35 Mothers with Children 32 67 The number of unaccompanied children is almost the same as in the previous year, but there were seven more mothers with children. The generally accepted policy of avoiding the separation of mothers from their young children, when either is in need of a recuperative holiday, has been implemented to a greater extent this year. This has been made possible because the Council has been able to use the facilities offered in the holiday homes administered by two other Local Authorities. These two homes have given excellent service, not only in providing holiday facilities, but also in giving guidance to the mothers in the understanding and management of their children. Once again the administrative arrangements for convalescence have been in the capable hands of the West Ham Branch of the Invalid Children's Aid Association. LIAISON WITH CHILDREN'S OFFICER. Close and friendly co-operation is maintained with the Children's Officer and many problems relating to the care of deprived children are discussed by the staff of the two departments. Occasional meetings to consider problems related to children neglected or illtreated in their own homes are convened, as necessary, by the Children's Officer. The Medical Officer of Health has taken the chair at these meetings which have been well attended by officers of the departments concerned, and by representatives of other official and voluntary organisations. 53 VITAL STATISTICS. The following are the statistics for 1955 compared with the provisional rates for England and Wales which have been published by the Registrar General For West Ham For England & Wales Stillbirth rate per 1,000 total births 19.3 23.2 Infant Mortality rate per 1,000 live births 21.6 24.9 Neonatal Death rate per 1,000 live births 15.4 17.3 Maternal Mortality rate per 1,000 live births and stillbirths 0.38 0.64 The infant mortality rate is the second lowest on record for West Ham. With the inclusion of 3 babies whose bodies were found in the area, (with no indication that they were actually West Ham babies) the rate is still only 0.1 above last year's record figure. The stillbirth rate (19.3) is the lowest on record, but is only Just below the rate for 1949 (19.8). The causes of stillbirths are often difficult to assess, and some, though known, are difficult to prevent. There is little doubt however that the standard of obstetrics and in particular of ante-natal care, are important factors. The credit for this year's low rate must go to all those concerned with the maternity services, and they would probably be the first to agree that there is still room for improvement. This year's stillbirth, infant mortality, neonatal and maternal mortality rates for West Ham are all below the national figures. The total infant deaths and stillbirths combined, are shown in the diagram on page 57 the number being 107 (56 deaths and 51 stillbirths), a decrease of 28 from the previous year (in which there were 59 deaths and 76 stillbirths). Perinatal Mortality - It is becoming customary to refer to the total loss of infant life before, during and shortly after birth, as "perinatal mortality". To quote from the report of the Ministry of Health for the year ending 31st December, 1954".... it is probably most usefully defined as including stillbirths and deaths within the first week of life. To consider these two groups together allows of a better assessment of problems of causation that are common to both. Despite great improvements in the general infant mortality and maternal mortality rates, the perinatal mortality has fallen only slowly. Since 1948 the rate has been virtually stationary at about 38 per 1,000 total births". In West Ham the perinatal mortality rate was 40.1 in 1954 and 33.3 in 1955. The Ministry report also points out that the outstanding problem of perinatal death is premature birth. Half the total number of stillbirths are premature, and well over half the deaths which occur in the first week of life are in premature infants. Good progress has been made in saving the lives of premature infants, but the root of the problem lies in the prevention of premature birth. For about half the premature births no medical cause can be assigned, but of the known medical causes toxaemia of pregnancy is pre-eminent. Of the 37 West Ham children who died in the first week of life in 1955, 17 were premature. 54 The Classification of causes of deaths in infants under 1 year is as follows:- Pneumonia 4 Eronchitis 2 Other diseases of respiratory system 1 Gastritis, Enteritis and Diarrhoea 3 Congenital Malformations 9 Other Defined & Ill Defined Diseases 35 Accidents 2 56 Although the full details from which the Registrar General compiles his statistics are not accessible to the Health Department, it would appear from such information as is available that the 35 infant deaths classified as "other defined and I11 Defined Diseases" are made up as follows:- Prematurity 14 Prematurity and atelactasis 2 Atelectasis 7 Rhesus Incompatibility 5 Intracranial Birth Injury 3 Acute Suppurative Meningitis 1 Intussusception 1 Cerebral Haemorrhage 1 Intra Uterine Asphyxia 1 35 Of the 56 infant deaths, 40 occurred in infants who were under 4 weeks of age, and of these infants 19 were premature. Detailed information is available in respect of the 40 deaths of infants under 4 weeks of age, and is shown in the following tables- Age Weight Place of birth * Under 12 hours 16 Over 5½ lbs. 18 Born in Hospital 32 12 - 24 hours 2 Not known 3 Born at home 5 1-7 days 19 Premature Mot known 3 1-2 weeks 2 Under 2 lbs. 4 3-4 weeks 1 2 lbs. - 3 lbs. 4 3 lbs. - 4 lbs. 6 4 lbs. - 5½ lbs 5 40 40 40 x Of which 3 were newborn, and one was 7 minutes respectively. Of the 32 born in hospital 31 died in the hospital in which they were born, and 1 was transferred to another hospital. 55 Of the 5 born at home all were admitted to hospital. The 3 newborn are those in respect of whom the birth weights and places of birth and death are unknown, and as previously mentioned their bodies were found within the area of the Borough. The proportion of neonatal deaths was much the same whether the babies were born at home or in hospital} and the greater number of these deaths among the hospital babies is due to the high percentage of babies born in hospital. Deaths of children aged 1-5. An increasing interest is being taken in the deaths of children in this age group, as this is now being regarded as a very sensitive index of the general health and social wellbeing of a community. There were 5 deaths in children of this age group (1 - 5) in West Ham, 3 of which were due to malignant and lymphatic neoplasms, 1 to heart disease, and 1 to a road acc ident. The importance of malignant and lymphatic disease as a cause of death in children has recently become prominent throughout the country, and research into its origin is now being planned. Maternal Deaths. The maternal mortality rate for West Ham is lower than the national rate. There was one maternal death. The cause was certified as Acute Eclampsia. The patient booked a General Practitioner Obstetrician and a midwife to attend her confinement, but she did not attend a municipal ante-natal clinic. Later she was referred to hospital and was advised immediate admission, but she refused. She was subsequently admitted to hospital in a very serious condition. 56 57 SHOWS TOTAL INFANT LIFE WASTAGE - 1933 — 1955 SECTION 23: DOMICILIARY MIDWIFERY. General Arrangements. There have been two changes in the general arrangements. 1. In accordance with the agreement reached in 1954 between the County Borough of West Ham and Group 9 Hospital Management Committee, the agency arrangements with Plaistow Maternity Hospital came to an end on February 14th, 1955. Four midwives who had been engaged in domiciliary work for the hospital joined the staff of the local health authority bringing the number of municipal midwives up to eight. The transfer was completed in two weeks and 163 mothers came over to the care of the Borough domiciliary midwifery service. The department wishes to place on record its deep gratitude to the staff of Plaistow Maternity Hospital for the devoted service which they have given over many years to the mothers in West Ham whom they nursed in their own homes and also for their very great co-operation at the time of transfer. As a result of this the arrangements, which had been carefully planned, worked very smoothly; nothing untoward came to light and it is hoped that no mothers were inconvenienced. We were happy to welcome the four hospital midwives into the local health authority team and wish to thank them for their loyal co-operation with their new colleagues. Before the end of the year one of these four midwives had left the Council's service in order to take up a vacant post on the hospital staff, and on December 31st there were seven domiciliary midwives in the Council's service. 2. The second change occurred when Miss Booth retired from the post of senior nurse midwife to the Silvertown and North Woolwich District Nursing Association on October 31st. West Ham then took over responsibility for the domiciliary midwifery service for that part of the Borough which lies south of the Victoria and Albert Docks, and the association, which had sponsored splendid work for many years closed down. Following consultation between the organisations and authorities concerned, West Ham Council also agreed to undertake the domiciliary midwifery service for that part of the area which is the responsibility of the London County Council, because geographical and transport factors make it very difficult indeed for the London County Council to give an efficient service to the mothers in this area. Distance and difficulty of access presents some problems also to the West Ham domiciliary midwives but the number of cases involved is small. The midwife who serves this area sees her patients at the L.C.C. clinic premises which are situated at Fernhill Street Baths, North Woolwich, E.16, where she has excellent and friendly co-operation from the London County Council Staff. Everyone was sorry to lose Miss Booth; her capable and colourful personality will long be remembered in the district. The West Ham Borough Council now provides the only domiciliary midwifery service to the whole of the Borough with the exception of that part which lies north of the district railway. In this area some of the mothers book midwives from the Lady Rayleigh Training Home which is about half-a-mile outside the Borough and is administered by the Essex County Council. 58 Maternity Outfits, each with an 8 ounce bottle of dettol, are supplied at the appropriate time through the Domiciliary Midwives to all expectant mothers who are to be confined at home. Supervision of Midwives. The Senior Assistant Medical Officer for Maternity and Child Welfare has continued to act as medical supervisor of midwives. The Non-Medical Supervisor of Midwives, who is also the Supervisor of Home Nurses, is in almost daily contact with the municipal midwives. Informal meetings of the midwives with both their supervisors are held as often as circumstances permit, and many interesting matters have been discussed with profit. The duties of the Non-Medical Supervisor have included:- (a) Periodic visits to the domiciliary midwives, both in their own homes and when they are attending to their patients, for the purpose of statutory supervision and to give advice and guidance. (b) Visits to the ante-natal clinic at which the midwives carry out the examination of their patients. (c) Relief work at the clinics and on the district, when necessary. (d) Investigation of notifications received from the midwives tinder the rules of the Central Midwives Board. (e) Consultation with other senior officers on matters affecting the midwifery service. Administration of Analgesia by Midwives. All the domiciliary midwives at present employed are qualified to administer gas and air and have been trained in the administration of Pethidine. The apparatus for the administration of gas and air analgesia are sufficient to meet the need and the arrangements for the transport of this apparatus by the Ambulance Service have proved very satisfactory. In addition, the apparatus is now available at all clinic sessions so that the mothers can be instructed in its use before labour commences. This early introduction helps to allay fear and enables the mother to take more advantage of the available analgesia. Following the publication of the new rules of the Central Midwives Board, which permits midwives to administer Trilene to their patients, under certain conditions, the Council agreed to the purchase of the necessary machines. By the end of the year one machine had been received and two midwives had attended a course on the administration of Trilene which was held at Forest Gate Hospital. Once again we are such indebted to this hospital for making their facilities available to our staff. It is not anticipated that every mother will need or will benefit from Trilene, but with increasing experience of its use the administration to selected patients should give them much help. Out of 388 domiciliary confinements gas and air was given to 201 mothers (approximately 50 per cent) and Pethidine to 113 mothers, (approximately 30 per cent). We had not yet started to use Trilene by the end of the year. 59 Refresher Courses for Midwives. Two midwives attended and derived much benefit from a residential course held in Leeds during August. On their return they discussed with the rest of the staff the new knowledge and different points of view which they had been given. Under the rules of the Gentral Midwives Board, after 31st December, 1957, it will be necessary for every midwife who has not qualified within the last five years, to attend a course of instruction approved by the Board, unless she has attended such a course during the preceding five years. In order to avoid having to send several midwives to courses during 1958 it is hoped to space their attendance at courses in such a way that the service will not be unduly depleted during any one year. Relaxation Classes. On account of the reorganisation of the midwifery service, we have not yet been able to resume the relaxation and mothercraft classes which had been organised so successfully at West Ham Lane clinic, during the past two years. However, we were fortunate in being able to make arrangements whereby one of the Medical Officers in charge of ante-natal clinics, the Non-Medical Supervisor of Midwives, and two midwives attended a series of sessions on "Relaxation and Mothercraft" at University College Hospital. When circumstances permit it is hoped that the remaining midwives will attend and that we shall before long be able to organise similar classes in each of our own clinics, so that the West Ham mothers may have the benefit of this new approach to childbirth, which takes into account the mental and emotional factors as well as the physical. Training of Pupil Midwives. All the municipal midwives have co-operated in the district training of pupil midwives. These pupils, who have already completed six months training in hospital, are resident in a hostel at Plaistow Maternity hospital, and their tutor is a member of the hospital staff. Each is allocated to one of the domiciliary midwives for six months, and accompanies her throughout her daily work. All the first group of pupils, who had been with the municipal midwives for three months of their training, were successful in their examination in June. And of the second group who took their examination in December five out of six were successful. This reflects much credit on all the midwives, but in particular on the four municipal midwives who, although very experienced in midwifery, had had no recent experience of teaching pupils. Co-ordination of Maternity Services. Now that we have achieved close working arrangements between the municipal midwives and the doctors and health visitors working in the Council's ante-natal clinics, we are seeking to achieve an equally close co-operation between the midwives and the doctors giving maternity medical services. In West Earn this co-operation has always been friendly, but we hope to make it closer by providing an opportunity for doctor and midwife to see the patients together on at least two occasions. These consultations are to be arranged by mutual agreement, either at the doctor's surgery or at the sessions of the municipal clinic at which the midwife normally carries out her examinations. The responsibility for initiating these consultations is to be placed on the midwife. 60 Maternity Services. Total live births notified as West Ham births during the year 1955 was 2,577 and of these 15% were born at home and 85% born in hospital. Domiciliary births within the Borough 383 15% Domiciliary births outside the Borough 4 Hospital births within the Borough 2,012 85% Hospital births outside the Borough 178 2,577 Number of Live Births in Maternity Units in the Borough. Hospital West Ham Residents Total Live Births Forest Gate 856 1,558 Plaistow Maternity 803 1,051 Queen Mary's 353 664 TOTAL: 2,012 3,273 Midwives attending at Domiciliary Confinements Source Number (or equivalent number) of midwives on 31.12.55. Number of Live Births Municipal 7 * 305 Plaistow Maternity Hospital Nil 30 (to 13.2.55) Essex County Nurses Training Home 2 x 42 Silvertown & N.W.D N.A. Nil 5 (to 31.lO.55) TOTAL: 9 382 x These midwives undertake the training of pupils. In 1 of the 383 live births in their own homes the midwife acted as maternity nurse. One case was attended by the family doctor only, no midwife being present at this birth. Medical Aid was summoned in 152 cases. In 106 of these help was required for the mother only, in 40 help was required for the baby only, and in the remaining 6 cases help was summoned on account of both mother and baby. 6l SECTION 24: HEALTH VISITING. Staffing - The Joint establishment of 40 health visitors and school nurses (apportioned as 22 to the Health Committee and l8 to the Education Committee) has never yet been filled. All trained health visitors undertake duties in the School Health Service, as well as in maternity and child welfare and more general public health work. There is still a small number of school nurses who are not trained health visitors and are too near retirement to take additional training. They work mainly in the School Health Service, but sometimes take clinic duties at the Maternity and Child Welfare centres. At the end of the year the health visiting and school nursing staff was as follows: (a) Superintendent Nursing Officer and Deputy Superintendent Nursing Officer. (b) 23 health visitors employed on Joint Health Visiting/School Nursing duties. 32 (c) 9 school nurses employed solely on. School Nursing duties. (d) 1 health visitor employed by the South West Ham Health Society. Not included in the (e) 3 health visitors (out of an establishment of 4) employed establishment of 40 on Tuberculosis work. health visitors/sohool nurses. Three student health visitors completed their training under the Council's scheme, and were appointed to vacancies on the establishment. They are under contract to give the Council two years' service. At the end of the year there were six students in training, but the department is finding it increasingly difficult to recruit suitable students. This is in accordance with the experience in other areas, but as there is a continuing drain on the service through resignations, a review of the whole position is indicated. It is hoped that the publication of the report of the working party on "The Field of Work, Training, and Recruitment of Health Visitors" will afford a suitable opportunity for a review of the whole organisation and structure of the health visiting service. It is greatly to the advantage of the work if health visitors of some maturity and experience can be retained long enough to become thoroughly familiar with the families in their districts, and with their colleagues in the other social services. Eight health visitors resigned during the year. They had been in the department for:- 1 less than 1 year 3 for 2 years each 2 for 3 years each 2 for 5 years each and the more senior ones in particular have done very valuable work in building up the service during the post-war period, and in setting a high standard for their colleagues to follow. The Health Visitor who had been with us for less than 1 year was released from her contract for urgent domestic reasons, of the remaining seven who left during the year two had married and the others wished to widen their experience or to work in areas which they preferred for personal reasons. With one exception, all of our present 23 health visitors have been trained under the Council's scheme. 15 have been with us less than 2 years and are still under contract. 3 " " " " 2 years 3 " " " " 3 years 1 has been with us 4 years 1 " " " " 5 years 62 Home Visits. First Visits Total Visits To expectant mothers 1,065 2,184 To children under 1 year 2,495 16,298 To children 1-2 years - 7,441 To children 2-5 years - 16,282 Special visits - 5,035 The number of "special visits" has doubled since last year, the increase being mainly of visits to old people. Refresher Courses . No health visitor was recommended for a general refresher course this year, but 2 of the more senior health visitors attended a two weeks course run by the Department of Education of the Deaf at Manchester University. They both enjoyed and benefited greatly from this course and received certificates stating (a) that they are now capable of satisfactorily carrying out screening tests for the ascertainment of hearing defects in young children and (b) that they had satisfactorily completed attendance at a course of instruction in diagnostic tests of the hearing of young children, and principles and methods of guiding parents of deaf children of pre-school age in order to give them home training. Their work was commented on very favourably by the organisers of the course and, indeed, it has proved invaluable in the new Audiology Unit. Extension of Health Visitors Duties. In spite of temporary shortages of staff and the necessary maintenance of established duties, steady progress has been made in the extension of the health visitor's field of work, particularly in relation to old people and in mental health. In January, one of the senior health visitors, who had shown a special interest in the aged, commenced regular visits twice weekly to the Geriatric Unit of Langthorne Hospital, where the senior medical officer was able to discuss with her the home conditions of patients who were ready for discharge. It is this health visitor's responsibility to contact the general practitioner and to see that all necessary services are laid on when the patient comes home. When she is satisfied that these services are functioning efficiently, she is able to hand over the supervision of the old person to her colleague, the district health visitor. The geriatric liaison health visitor, as she is called, remains available for consultation by her colleagues and has free access to the hospital consultant should his advice be needed. She is also able, on some occasions, to accompany the consultant on his domiciliary visits to old people who are awaiting admission to hospital, who have spent some time in hospital. This work is increasing and unless the geriatric health visitor is to become a specialist and give up her district, it will probably be necessary for her to share her work with one or more of her colleagues. The district health visitors are gradually building up a case load of old people whom they visit as frequently as circumstances indicate. In the field of mental health, there has been increasing co-operation between the Psychiatric social worker and the individual health visitors, and a number of case conferences have been held, on families in which the emotional factor, or mental illness has had serious effects on the children, or threatened the stability of the family. This is a good beginning, but there is great scope for future developments in this field, and for in-service training. 63 Ministry of Health Circular on the Prevention of Break-Up of Families. This was received with much interest and discussed at many different levels. At a meeting of the Council's senior officers from appropriate departments, held under the chairmanship of the Town Clerk, it was agreed that the health department should initiate administrative proposals arising from the Circular and that the health visitor would probably be the first person to realise that a dangerous situation was developing in a particular family. The local medical liaison committee (composed of doctors representing the hospital service, general practitioners, and the public health department) recommend that the general practitioner should be invited to attend individual case conferences or meetings of the Council's sponsored standing conferences on children neglected or ill treated in their own homes, when any of his patients were under consideration this suggestion was accepted. The health visitors-consultative committee (referred to in the last report) discussed the circular at some length, and made a number of suggestions which were helpful in framing recommendations to the health committee. They agreed that the district health visitors could undertake a great deal of preventive work in relation to problem families, but needed various kinds of support and assistance on which they could draw. When the family had already broken down, case workers with fewer routine responsibilities might be required to undertake the intensive work of rehabilitation. It is hoped to place recommendations before the health committee early in 1956. Diabetic and paedlatric liaison health visitors schemes previously discussed have continued on a full scale and are much appreciated. Progress has been made in establishing closer relationship between health visitors and the general practitioners in the area. Each health visitor has called on the doctors whose surgeries are in her district, and the health visitors have from time to time consulted the family doctors on problems relating to their patients. One general practitioner holds a regular weekly consultation with a health visitor at his surgery, and has expressed his appreciation of her help. Other general practitioners have phoned the superintendent nursing officer from time to time to discuss problems or have asked the health visitor to visit a particular family. Here, too, a good beginning is being made which it is hoped will grow as mutual confidence is established, Health Education. The Maternity and Child Welfare Centres are supplied with leaflets and posters, some of which are basic and in regular use, while others are of a more temporary interest and may be used in conjunction with a topical demonstration. Very good use is made of the blackboards, particularly by those health visitors who have artistic ability. Each Centre has the articles necessary for demonstrating baby bathing, a flannelgraph on the "stages of labour", a birth atlas for the instruction of expectant mothers, and other visual aids such as types of children's shoes and several items for illustrating the causes of accidents. More elaborate aids are obtainable from the Health Department, these include a magnetic blackboard, a selection of flannelgraphs, films, film strips and projectors. Other films may be hired as required. 64 Health education is given regularly in personal interviews with mothers at home and at the welfare centres, and this remains a most acceptable and effective means of offering guidance. Other techniques, however, have their uses, though they are not so easy to acquire or to apply. Many of the talks to groups of mothers have been outside the clinic sessions to "ready-made" audiences such as the Nursery School Association, Parent-Teacher Association, Church Groups and the Mothers Club at Plaistow Maternity Hospital at the invitation of the matron. This is a club to which the mothers who have been confined in Plaistow Maternity Hospital may go with their children. Meetings are held weekly, and about 20 mothers usually attend with children of various ages. In co-operation with a committee of mothers, the health visitors from Balaam Street Clinic have organised a series of talks, demonstrations and films. The minding of the children in a way which will allow the mothers to pay full attention to the group is presenting a problem which has already arisen in connection with similar activities at our own centres. It is not easy for the recently qualified health visitor, intent on getting to know the families in her district and absorbed in the daily round of her new profession with its ever widening field, to give talks or lead discussions. The more senior health visitor, particularly if she has had the advantage of attending one of the parentcraft courses organised by the Nursing Associations, or one of the special courses organised by the Central Council for Health Education, is able to undertake this work with greater confidence. It is this side of the work, therefore, which is one of the first to suffer through lack of experienced Health Visitors. There is no doubt that the health education undertaken by the health visitors would be more effective if it were part of a general programme planned from year to year by the Health Department for application throughout the borough. It would be particularly helpful if they could be fed at regular intervals with information on local circumstances and statistics (such as the causes of local accidents occurring in the borough) or of demonstration material prepared to meet local needs. None of the existing staff can spare the time to do this consistently, though many noble efforts have been made from time to time. 65 SECTION 25: HOME NURSING Staffing. Municipal Home Nursing Staff on 31st December, 1955. 1 S.R.N. 2 S.E.A.N. 1 S.C.M. employed full-time. 8 S.R.N. 7 S.E.A.N. employed part-time, average 24 hours weekly. General Arrangements. Summary of work carried out by all Home Nurses within the Borough. Total Cases attended Total number of visits paid Average number of visits per case 3,270 92,492 28.3 Types and proportions of cases treated are set out below:- Total Cases New Cases Total Visits Medical 2,228 1,821 70,151 Surgical 340 286 11,806 Tuberculosis 70 51 2,255 Infectious Diseases 19 19 107 Maternity 9 9 42 Miscarriages 15 15 97 Other Conditions 589 553 8,034 TOTAL: 3,270 2,754 92,492 There has again teen a slight decline in the number of patients attended, but the total number of visits has risen because of an increase in the number of visits paid to each patient from 25.4 to 28.3. Age groups of patients treated are as follows:- Total Cases New Cases Total Visits Under 5 years 104 102 574 5-64 years 1,610 1,452 32,321 65 years and over 1,556 1,200 59,597 TOTAL: 3,270 2,754 92,492 There has been no change in the arrangements by which the staff of the Lady Rayleigh Training Home give the Home Nursing service for the part of the Borough north of the District Railway Line (under agency arrangements with the Essex County Council). 66 On the 31st October, the Silvertown and North Woolwich District Nursing Association, for many years associated with the area south of the Docks, wound up its work on the retirement of the sister in charge - Miss Booth. Miss Booth left after many years of loyal and devoted service to the sick of Silvertown and will be much missed by patients, friends, and colleagues. The municipal home nursing staff now cover the whole of that part of West Ham which lies south of the District Railway Line. Home Nursing Centre. This has remained at Liverpool Road (in the premises previously used as a Day Nursery). While the building has been found quite suitable for Its new purpose, its situation, which is not sufficiently central, has certain disadvantages. It had been hoped to encourage able-bodied patients to attend the centre for routine treatment (mainly injections) thus freeing the staff to give more time to visits to patients confined to their homes. The inconvenience and cost of the Journey to the centre has prevented much progress being made in this direction. Male Nurse. We have appointed our first male nurse, and his work with elderly male patients has been much appreciated. Loan Scheme. The scheme for lending nursing equipment has been much used and the number of articles lent is rising every year. Laundry Service. Frequent changes of linen are essential to the comfort of the senile and chronic sick, and the need, therefore, arises for a laundry service for the washing of articles not suitable for a commercial laundry. The possibility of providing special laundry services is being explored. Future of the Service. Contemplation of the future of the Home Nursing Service gives cause for some anxiety on account of the failure to recruit full-time staff. Attractive and convenient modern flatlets are available for the staff in the new Guinness Trust building, and with the problem of recruitment in mind, the hours of work have been fixed slightly below the generally accepted level. The supervisor, who is a Queen's Nurse, has done much to introduce modern nursing techniques and to organise the service on up to date lines, and to give the staff every encouragement and guidance. Nevertheless, it is not proving possible to recruit even a nucleus of full-time nurses. The part-time staff are the mainstay of the service and always give of their best but with their own homes and families to care for, the times at which they are available are necessarily limited. In these circumstances it is becoming increasingly difficult to meet present commitments and no extensions can be contemplated, though many are desirable. 67 The problem is not peculiar to the locality, but does seem to be intensified in West Ham. This perhaps is partly because of the character of the district, and partly because the borough did not have a Queen's Nurses home with trained staff on which to build the service. There is an increasing demand for trained nurses which cannot be met from the supply available. With the advances in medical treatment, the type of domiciliary nursing required has changed and is now largely confined to the care of the chronic sick and elderly. This may not appeal to the highly trained nurse, and it may be that in the immediate future we should consider the employment of attendants to cater for the simpler needs of the elderly and chronic sick, thus freeing the trained personnel for the more specialised nursing tasks. The nursing organisations are fully alive to the need for a comprehensive nursing service and much thought and discussion is being given to this subject on a national level. Various ways of combining the nurse's responsibilities in the promotion of health with her duties in the care of the sick are being tried in many areas, both urban and rural. The object is to achieve a service which meets the needs of the community and, at the same time, provides the nurse with a satisfying career. We are paying close attention to these discussions and experiments in the hope that we may learn something which will benefit our own nursing service. 68 SECTION 26: - VACCINATION AND IMMUNISATION. There were no significant developments in this service during the year. Vaccination. The following table shows the number of vaccinations carried out during the year. Number of Persons Vaccinated (or re-vaccinated). Age at date of vaccination Under 1 1 2-4 5 - 14 15 or over Total Number vaccinated (primary) 401 16 15 11 28 471 Number revaccinated 1 10 46 57 Of these vaccinations, 146 were performed by general practitioners and 382 by the medical staff of the local authority. No complications from vaccination were reported during the year, IMMUNISATION. The number of children immunised during the year by medical officers of the authority or reported as having been immunised by general practitioners in the area are given in the following table TABLE B. AGE at date of final injection Undefr 1 1-4 5 - 14 TOTAL A. Children who completed a full course of immunisation. 952 400 1,156 2,508 B. Children who received a secondary reinforcing injection. 4 458 3,728 4,190 69 The following table gives, as nearly as can be estimated, the proportion of children in any age group who have received a course of immunisation since 1st January, 1941j- Number of children who had completed a course of immunisation at any time between 1st January 1941 and 31st December 1955. TABLE C. Age at 31.12.55 i.e., Born in Year Under 1 1955 1-4 1954-1951 5-9 1950-1946 10 - 14 1945-1941 Under 15 Total Last complete course of injections (whether primary or booster) A. 1951-1945 30 5,6l8 9,413 4,576 19,637 6. 1950 or earlier - - 2,885 3,271 6,156 C. Estimated mid-year child population 2,630 10,070 ^ v J 26,700 39,400 Immunity index 100A/C l',06 55.79 52.02 49.84 It will be seen from this table that little more than one per cent of the children born in 1953 were fully immunised during the year. This finding, among other things, has given rise to doubts about the policy of regular suspension of diphtheria immunisation during the poliomyelitis season. It was first introduced to avoid public alarm and administrative dislocation caused by the sudden stoppage of immunisation as an emergency measure. In the light of experience, however, it does seem to have resulted in the loss of many valuable weeks of immunising time and to have had as discouraging an effect in its own way as ever arose from the association in the public mind of immunisation with poliomyelitis. This association now appears to be generally understood and accepted, and the way lies open for the application of a more adaptable policy adjusted to the epidemiological circumstances prevailing in any particular year. Before this report went to press a change of policy along these lines had been adopted by the Council. Accompanying this decline in the protection of children under one year there was a small increase in the Immunity Index for the total child population. This can be attributed to the 2,364 injections (mainly boosters) which were given in the last four days of the year. 70 SECTION 27: AMBULANCE SERVICE. The organisation of the service remained unchanged during the year with responsibility divided as follows:- Medical Officer of Health - Organisation and administration Borough Engineer - Provision, maintenance and manning of vehicles Chief Officer, Fire Brigade - Operational control of ambulances. The Acting Ambulance Officer and his assistant, who are on the staff of the Health Department, are responsible to the Medical Officer of Health for the day to day administration of the service, advance booking for ambulances and ambulance cars, and act as liaison officers with the other two heads of services involved. Operational vehicles are deployed as follows:- Ambulances: Stratford Fire Station: 1 Plaistow Fire Stations 1 Sllvertown Fire Station: 1 Transport Depots 4+1 reserve vehicle. I Ambulance Cars: Transport Depot: 11 The latter are provided by the Borough Engineer from the Council's passenger car fleet, and include one 8-seater vehicle designed specifically for sitting case work. Transport is provided only upon the request of doctors or hospitals, except in cases of accident or emergency. In addition to conveying patients to and from hospital, the service provided transport for the "gas and air" analgesia outfits used in connection with the Council's Domiciliary Midwifery Service. Arrangements are made for patients undertaking lengthy Journeys to travel by rail, in those cases where this is in the patient's interests; It is also more economical and convenient than providing an ambulance for the whole Journey. A special stretcher is used, which fits above the seats in the compartment; British Railways offer special facilities for ambulance patients, including free reservation of seats or compartments, and assistance for patients who have to change from one train to another en route. As in previous years, a close and friendly liaison has been maintained with hospital authorities, the ambulance services of neighbouring authorities and with other departments of the Corporation. The charts below provide a diagrammatic representation of the work done by the service since 1949 (its first full year of operation); it will be seen that the demand on the service (in terms of the number of patients carried) has increased very slightly - by little more than 1%, while the mileage travelled has decreased slightly. It seems likely that the demand, which had increased steadily until 1954, has now reached its maximum, and "ill continue at its present level in future years. 71 72 SECTION 28: PREVENTION OF ILLNESS, CARE AND AFTER-CARE TUBERCULOSIS. The statistics relating to notified cases of tuberculosis are given in an earlier section. Although there has been some further decrease in the incidence of this disease there still remains much scope for improvement. Much has been achieved through the earlier diagnosis of tuberculosis by means of mass radiography and improved contact tracing. The majority of the early and some of the more advanced cases now have a greatly improved chance of ^recovery with the new drugs that are available and the improved surgical techniques which are being developed. In spite of all this there remain problems which are pressing - the question of the elderly undiagnosed and infective cases of so-called "bronchitis" or the open chronic tuberculous patient who has failed to respond to medical and surgical treatment. The latter is not of such danger, as his disability is known and he has been advised as to how he should conduct himself. The former, on the other hand, is a menace and increasing detection of this class can be brought about by the continued efforts of the general practitioner, the Mass Radiography service, by Health Education of the community and by thorough contact tracing until every avenue has been explored. A further weapon Is B.C.G. vaccination among the school leaving population in an effort to prevent the disaster of a young and promising career being ruined by some chance infection of the teenager or young adult from a fellow employee, or at the dance hall or Community Centre. Not only will it be possible to give these young people some protection against the disease but by means of the preliminary tests and x-ray of tuberculin positive children, early cases would be brought to light. Another factor which requires urgent consideration in regard to the prevention of tuberculosis or the deterioration of the tuberculous case is the question of housing. It is realised that this is an extremely difficult problem especially as local authorities are beset by the difficulty of rehousing people from clearance areas and overcrowded accommodation, of old people, handicapped persons and so on. Nevertheless, unsatisfactory housing conditions and especially overcrowding are an important factor and everything possible needs to be done to avoid the deterioration of the case who has been discharged from hospital, who has perhaps spent months in hospital or sanatorium and upon whom much time and trouble in addition to money have been expended. In the long run it would probably be more profitable to the country as a whole to provide new homes for these cases wherever necessary. The close co-operation between the Chest Clinic and Health Department has continued. The Senior members of the Health Department and the Chest Physician meet for monthly conferences and close working liaison has been maintained. The library service for tuberculous cases has continued to serve a most useful purpose and regular additions have been made to the stock of books. The Tuberculosis Voluntary Aftercare Committee has continued its good work in providing for the needs of patients and their relatives which cannot be met from public funds. In addition, an Occupational Therapist was appointed and started a domiciliary service which included tuberculous patients, and also held weekly classes for such eases at the Chest Clinic. Although this service has had small beginnings it is hoped that in due course it will be expanded to a larger centre where group therapy for tuberculous eases can be reinforced by social activities and where Productive work can be carried out under sheltered conditions. 73 (a) Work of the Tuberculosis Health Visitors. Three Tuberculosis Health Visitors have continued their work in regular home visiting of the tuberculosis patients. It is regretted that the resignation of one member of the staff of four occurred In May and it was not possible to fill the vacancy during the year. This, and the unfortunate absence from duty for two months of another member of the staff, Is reflected by the fall in the number of home visits, and was a serious handicap to the work. Home Visits 1954 4,076 1955 2,595 Clinic Sessions 1954 555 1955 468 The Health Visitor continues to deal with the many social and domestic problems which arise in practically all cases of tuberculosis. The integration of her functions as health adviser and social worker has been of great benefit to the families concerned and has done much to encourage and sustain the patient's co-operation in the treatment and after care advised for his special needs. The Health Visitors have continued their work with the Tuberculosis Voluntary AfterCare Committee and investigate all applications for assistance on their behalf. Their previous contact and knowledge of the family makes for a simple and friendly assessment of their particular needs. Social Work done by Tuberculosis Health Visitors; Number of cases dealt with: 326 Preventive measures: Child Convalescence 26 Referred to Children's Officer 7 Referred to Housing Officer 48 Referred to Sanitary Inspector 12 Miscellaneous 26 After-care and Rehabilitation: Referred to Disablement Resettlement Officer for work or training 48 Referred to Home Help Service 4 Referred to Occupational Therapist 29 Provision of clothing or bedding 65 Miscellaneous 63 Financial Aid: National Assistance Board 62 Voluntary Funds (including After Care Committee) 126 74 (b) Contact Tracing and B.C.G. Vaccination. As soon as a case of tuberculosis comes to the notice of the Chest Physician, the Tuberculosis Health Visitor calls at the home address and ascertains as far as possible the members of the family and any other people who have been in contact. Discreet and tactful enquiries are also made about contacts outside the Immediate family circle. Adult contacts have a chest x-ray examination at periodic intervals. Child contacts are tuberculin tested and those found to be tubereulin positive are x-rayed while tuberculin negative cases may be given B.C.G. vaccination. Surveillance of each case is continued for as long as Is necessary depending upon the circumstances. The following table shows the numbers of contacts given B.C.G. vaccination during the past five years:- Age 1951 1952 1953 1954 1955 0-1 28 46 59 70 51 1-2 8 12 5 12 12 2-3 8 6 9 13 11 3-4 8 7 17 13 9 4 - 5 7 5 10 16 Over 5 32 49 73 111 45 TOTAL 91 125 173 235 132 In addition, 8 nurses employed at hospitals In the Borough were given B.C.G. vaccination. bpeelal clinic sessions are held for contact cases and during the past year 6O5 contacts were examined as a result of 157 new cases, giving an average number of 3.85 contacts per notified case. Tha figures for this work in relation to those of previous years are:- Year New contacts examined New notified cases on Clinic Register Average number of contacts examined per notified case 1950 421 186 2.26 1951 643 196 3.28 1952 79* 202 3.93 1953 916 226 4.05 1954 996 194 5.13 1955 605 157 3.85 As a further step in the campaign of prevention, the Tuberculosis Health Visitors are informed of all deaths from tuberculosis and In those Instances where the case has not been notified during life, a tactful home visit is paid as in the ordinary notified case to ascertain the contacts. The routine procedure of examination is subsequently followed. (c) Rehabilitation and Employment of Known Cases of Tuberculosis. Rehabilitation is a continuous process from the time of diagnosis of the disease until the patient is finally placed in his own or in alternative employment or is made as fit as is Possible to lead a reasonably useful life in the community. To this end the Local Authority Provides help in a number of ways - through the Home Help service to give the housewife the 75 requisite rest to speed her recovery; the district nurse; the occupational therapist to maintain interest anC at the same time provide patients with work which will encourage them to remain at rest or use their limbs and lungs at the appropriate stage; the convalescent holiday scheme which will give a change of environment as a relief from the home worries which are bound to beset the patient. Every effort Is made in co-operation with the Disablement Resettlement Officer to place quiescent and suitable chronic sputum-positive cases in appropriate employment to ensure that both the work and the conditions will be compatible with their own health and that of their fellow employees. The risk to others is minimised as far as possible by training in precautionary measures, especially in the chronic sputum-positive cases. At the beginning of the year, 1 patient for whom the Council had previously accepted financial responsibility was still undergoing rehabilitation and training at Papworth Village Settlement. She was discharged later in the year. Financial responsibility was also accepted for two male tuberculosis patients to receive rehabilitation and training at Papworth Village Settlement. Workshop Facilities for the Tuberculous. The importance of sheltered employment in the rehabilitation of tuberculous patients has long been recognised; and informal exploratory discussions continued with neighbouring authorities to determine the feasibility of adopting a suitable scheme on a regional basis. Arrangements for Convalescence. Cases referred by Chest Physicians were sent for convalescence before returning to work or following the completion of immediate treatment. Arrangements were made in respect of 10 adults and 26 children. Mass Radiography Unit. The Mass Radiography Unit of the Regional Hospital Board was stationed at the Public Hall, Canning Town, for a period of one month commencing 12th October, 1955. The results of this survey are summarised below:- Male Female Total No. of attendances for miniature x-ray 3,526 3,613 6,939 No. recalled for Large Film examination 153 122 275 No. showing some abnormality 159 105 264 Percentage showing some abnormality 4.78 2.90 3.80 Palled to attend for Large Film examination 5 7 12 Tuberculous Lesions. Active tuberculosis 9 6 15 Inactive tuberculosis 29 25 54 Other abnormalities revealed. Abnormalities of bony thorax 16 18 34 Bacterial virus Infection of lungs 6 1 7 Bronchiectasis 3 2 5 Emphysema 9 2 11 Pulmonary fibrosis (non T.B.) 25 9 34 Spontaneous pneumothorax 1 - 1 Benign tumour of langs 1 - 1 Bronchial carcinomata 1 1 2 Pleural thickening 39 20 59 Abnormalities of the diaphragm - 3 3 Congenital cardio-vascular lesions 2 - 2 Acquired cardio-vascular lesions 14 18 32 Miscellaneous 4 - 4 Totals 159 105 264 76 From the above tables it will be seen that of the total of 6,939 persons examined, 69 showed evidence of pulmonary tuberculosis; 15 of this number wore found to have active disease at the time of examination, i.e., 9 males and 6 females. The combined rate for active tuberculosis discovered was 2.16 per 1,000 examinees. The rate for males was 2.70 and for females 1.66. The combined rate per 1,000 for active tuberculosis is in keeping with the findings of the previous year (2.17). There was, however, a marked drop in the number of cases of bronchial carcinomata discovered (2 in 1955, 15 in 1954). The rate per 1,000 for Inactive tuberculosis was 7.78. In this survey attendances by the public, from firms, of scholars and of patients referred by private practitioner were as follows Group Male Female Total Public 1,216 1,753 l2,969 Firms 1,160 979 2,139 Scholars 796 746 1,542 Referred by Doctors 154 135 289 Totals 3,326 3,613 6,939 As a result of this survey, 13 school children were asked to attend the Chest Clinic for further examination. Among these were found 4 active cases and one case which was still under observation at the end of the year and which was subsequently confirmed as tuberculosis. In addition, a survey was carried out in July at a secondary school for boys when 275 scholars and 7 members of the staff were examined. One member of the staff and 1 child were recalled with negative results. A further survey was arranged at a primary school as a result of a school teacher being found to have tuberculosis. One-hundred-and-sixty-two boys, 201 girls and 3 members of the staff were examined and of these 4 boys and 2 girls were recalled again with negative results. The following statistics have also been supplied by Dr,Lawless, Medical Director of the Mass Radiography Unit, 6b., to whom i am greatly indebted for his ready co-operation. A total of 15,069 miniature X-ray examinations were carried out in the Borough of West Ham during the year 1955; of this number 8,302 were males and 6,767 were females. Of the total examined, 288 males and 207 females were recalled for further large film examination. The numbers falling into the various age groups were as follows:— Under 14 14 15-19 20-24 25-34 35-44 45-54 55-59 60-64 65 + Males 367 593 696 601 1,925 1,694 1,442 542 325 157 Females 207 540 948 1,021 1,693 l,l4l 776 225 113 103 Totals 574 1,133 1,644 1,622 3,618 2,795 2,218 767 438 260 77 Totals under groups Males Females Total (a) Factories and Schools visited by Unit 4,976 2,187 7,163 (b) Public Survey (Canning Town) 3,326 3,613 6,939 (c) Ante-Natal Clinics - 967 967 8,302 6,767 15,069 Abnormal findings:— Males Females Total Active Tuberculosis 14 9 25 Inactive tuberculosis 76 54 130 Carcinoma of bronchus 1 1 2 Other conditions 250 107 357 Active tuberculosis discovered among Expectant Mothers (included in general Total):- Number examined 967 " active tuberculosis 2 It will be seen from the figures quoted that out of the total number examined (15,069), there were 25 cases of active tuberculosis disclosed, a rate of 1.55 per 1,000 examined. Rate for males 1.69 per 1,000; rate for females 1.55 per 1,000. This compares favourably with findings in other areas covered by the Unit. The rate per 1,000 for inactive tuberculosis was 8.65. Staff X-Ray. The above Survey included the staff of the Health Department. One-hundred-andt twenty-five attended out of a total of 543 who were given invitations all of whom had satisfactory results. In addition, 17 members of the Children's Department were x-rayed, again with satisfactory results. Other members of the Health Department, such as Occupation Centre staff, Tuberculosis Health Visitors and Home Helps also attended other sessions held by the Mass Radiography Unit and all x-rays were clear. West Ham Tuberculosis Voluntary After-Care Committee. The Committee met monthly and established quite clearly the need for assistance being given to families of patients in hospital and for extra nourishment, clothing and bedding for patients living at home. Assistance was given in l4l cases which included 80 new cases while 6l had been carried over from the previous year following re-consideration of their need. 78 Expenditure Included the following forms of assistance:— Fares to hospital Clothing Holiday grant Extra Nourishment Furniture and bedding Removal expenses Christmas gifts to patients It is evident that the amount expended on extra nourishment for patients is comparatively small and it would appear that this problem could be more thoroughly dealt with if the Committee had sufficient funds or if the local health authority Itself provided extra nourishment, especially milk, on the special recommendation of the Chest Physician. The income of the Committee is not very large at present and it would appear desirable that whatever funds it is able to collect should be used to provide assistance that is not covered by the National Assistance Act or the National Health Service Act, OCCUPATIONAL THERAPY. Miss Stephens was appointed to the new post of Occupational Therapist in September, 1955. In the three months to the end of the year occupational therapy materials and equipment were ordered and seventeen patients had been registered for treatment. These patients suffered from a variety of conditions and were referred by the Chest Physician and general practitioners. For patients attending the Chest Clinic a small occupational therapy class was commenced in the Health Visitors Office in Balaam Street Baths on the 7th December, 1955. The Occupational Therapist was accommodated in an office Jointly with the Non-medical Supervisor of Midwlves. It is hoped that as the service develops a suitable occupational therapy centre will become available where there is adequate accommodation for equipment and materials and where group therapy reinforced by social activities can be carried out. Convalescence. The arrangements for the provision of convalescence in cases where no active medical or nursing care is necessary, were again fully used during the year, 132 adult persons being recommended for recuperative holidays, a decrease of 11 over the previous year. The sources of reference were:- General Practitioners 90 Hospitals 26 Chest Clinic 10 Other 6 Of the initial recommendations, 24 were withdrawn, either by the patient or the referring agency, before consideration by the Council's medical officer; and of the 108 thus reviewed, 98 applications were approved, 3 were not approved, 3 were referred to the Regional Hospital Board, 3 referred to the Chief Welfare Officer, and 1 was deferred and subsequently cancelled. Of the 98 approved, 14 were withdrawn, for various reasons leaving 8^ for whom convalescence was arranged. 79 The procedure for assessment of the financial circumstances of each applicant in accordance with the Council's scale, continued as in previous years. Apart from the summer holiday period, no difficulty was experienced in placing the applicants, 22 convalescent homes being used by the Department. The age and sex incidence of the cases placed in convalescent homes was:- SEX Under 25 25 - 45 - 65 - 75 - Total Male - 3 14 6 - 23 Female 2 12 23 18 6 61 Total 2 15 37 24 6 84 In addition to the above, 26 children under the age of 15 years were sent to convalescent homes following reoommendation by the Chest Physician as part of the preventive care and after care of tuberculosis patients. Details of the convalescence provided for mothers and young children and for school children will be found on pages 53 and 152 respectively. Health Education. Talks, supplemented by film strips, sound films, posters, models, etc., were given on a variety of health subjects to parents and others at the various clinics and centres during the year. Request for lectures were also received from interested organisations in the Borough. Senior members of the department have taken part in the instruction of D.P.H. students, student health visitors, student sanitary inspectors and nursery students. Lectures were given to student nurses in the block training schemes run by the West Ham Group Hospital Management Committee and Whipps Cross Hospital. Their syllabus, which now includes instruction in the social aspects of disease, involves both lectures on and practical demonstrations of the Local Authority Services. It is a most valuable development in the training of the nursing profession and helps the students to understand the linking up of the medical care of the patient before and after his stay in hospital. For the furtherance of health education measures in the prevention of food poisoning, the West Ham Clean Food Advisory Association, which is sponsored by the Council, continued its steady campaign during the year. In its various activities in the field of clean food hygiene special mention should be made of the enthusiastic response to the competitions held for the school children of the Borough - the future food handlers and housewives. The standard of entry was very high, and it is clear that a valuable opportunity was taken and fully utilised to impress the practical application of food hygiene, not only upon the children but also upon their parents. 80 CANCER EDUCATION By C.H.Phillips, M.R.C.S., L.R.C.P., D.P.H. Deputy Medical Officer of Health Although there is some decrease in the total number of deaths from cancer in West Ham it should not be concluded that the tide is turning. National figures continue to show an increasing trend. The high proportion of deaths from malignant disease of the lung and bronchus as compared with the total deaths from cancer continues to give cause for concern. Compare the deaths from malignant disease of the lung and bronchus (page 21 ) with those from respiratory tuberculosis (page 19 ) and consider the attitude of the community as a whole to the two problems. People are generally well aware of the cause and course of tuberculosis, the advantages of early treatment, are co-operative in contact tracing, are ready to attend for Mass radiography or are willing to have their children given B.C.G. The attitude to cancer, on the other hand, is quite different. They are not yet willing to face the issue. However, new knots are being unravelled each year on the cancer problem as a whole and the public must continually be reminded of the known facts until such time as their prejudices, fears and hoodoos regarding cancer have been dispelled, as they have been to a very great extent in the case of tuberculosis. Cancer arises from body cells which have for some reason started to multiply rapidly until they form a lump or may invade the surrounding tissues, destroying them in the process or breaking off in pieces and being carried to glands or more distant parts of the body where they continue to multiply and destroy. There is still much to be learnt about the cause of cancer, but we do at least know that certain substances called carcinogens present in a great many things can cause the disease. It is mainly a question of the type of carcinogen and the strength and duration of its application. Just as carcinogens in soot were responsible for cancer of the scrotum in chimney sweeps, so also may cancer of the lung be caused by the filth we breath in from the air of our cities and towns and in tobacco smoke. There is now a great deal of evidence to show that cancer is more prevalent among town and city dwellers than in the country and in cigarette smokers as compared with non-smokers. What is to be done about the problem while research continues to probe into the causes obviously one step is the clearing of the air we breath. Another is the earliest possible detection and treatment of the disease. The solution here surely lies with the public, the general practitioners, the hospitals and the mass radiography services. But to obtain the greatest possible response the public must know what to look for - the skin ulcer that does not heal; the small lump in the breast which is best felt with the flat hand (not with the fingers); bleeding or disturbance of menstruation in cancer of the cervix or uterus; loss of weight, indigestion and abdominal pain, loss of appetite and anaemia in cancer of the stomach and blood in the urine which may result from cancer of the bladder. 81 Cancer of the lung or bronchus presents a rather more difficult problem as the symptoms may pass unnoticed until the disease is too advanced. However, cough lasting more than a few weeks, blood in the sputum, pain in the chest or shortness of breath all call for the advice of a general practitioner without delay and further investigation if necessary. The case of so-called bronchitis may indeed prove to be cancer of the lung or tuberculosis, and with the ready availability of the mass radiography service there seems to be no reason why every case of prolonged bronchitis should not be x-rayed. A fair amount of attention has been given by the press and radio to the possible association of atmospheric pollution and tobacco smoke with cancer of the lung and bronchus. There appears to be little reduction in tobacco consumption but surely it is too early to expect any result. The heavy smoker is unlikely to change his habits on the off-chance of developing cancer of the lung at some time in the future. He tends to measure the risk against the possibility of being run down by a car or falling down the stairs or getting some other disease, decides it is hardly worth the effort, and goes on smoking. If health education is to play a successful part it seems that it must be directed more at the younger generation before they have started smoking. Parents, school teachers, health visitors and other social workers all have an important part to play. The Forces, too:, are probably heavily involved for is it not likely that many young men first acquire the habit during their National Service? Incidentally, it is interesting to note the great preponderance in deaths from malignant disease of the lung and bronchus among men as compared with women in the table on page 21. The Government and Local Authorities are becoming increasingly concerned about the problem of atmospheric pollution - not only on account of its possible relationship with cancer of the lung, but also on account of the needless chronic incapacity, or, indeed, loss of life, resulting from bronchitis. Furthermore the damage to buildings and goods is an equally good reason for trying to do something about the matter. The public ignorance about cancer is quite surprising. I am reminded of the Storeman on whose face I noticed an obvious rodent ulcer. He told me that he had had it for about a year, that a friend, a member of one of our great first aid organisations, had told him that it was a cancer and nothing could be done about it, and consequently he had not bothered his doctor1 Fortunately the condition still appeared to be localised. After referral to his doctor and treatment at hospital, I saw him again in a few weeks when he was very pleased with the result. The obvious answer seems to be to see oneJs doctor without delay. 82 Provision of Nursing Requisites. The arrangements for the loan of nursing equipment to domiciliary patients continued as in previous years, issues in respect of tuberculous cases being made from the Chest Clinic whilst those for other cases of illness are supplied from the Health Office and the Home Nurses Headquarters at Liverpool Road. Details of the equipment lent are given in the following table Nursing Equipment Loaned during the year 1955. Article Number loaned to TOTAL Tuberculosis Patients Other Patients Air-rings 4 112 116 Back-rests 5 95 100 Bed cradles - 5 5 Bed pans 1 136 137 Rubber sheets - 117 117 Urinals 3 59 6l Sorbo pillows - 8 8 Lifting Apparatus - 2 2 Bed Tables - - - Wheel Chairs - 20 20 Sputum Pots 1 - 1 TOTAL: 14 554 567 83 SECTION 29: DOMESTIC HELP. While there was a small increase in the new cases accepted during 1955, the number of cases remaining on the books at the end of the year has risen considerably and indicates that the demand for this service has maintained an upward trend. The increase in demand has again been in the older age groups more especially from 60 - 80. As has been stated before, this trend is likely to become more pronounced in a few years owing to the steadily ageing population and the tendency for young people to move outside the Borough. Corresponding with the increase in the proportion of old people receiving the service the number of free cases has also risen. On the other hand, applications for tuberculous and maternity cases have fallen considerably, probably the result of the decline in the notifications of tuberculosis, the more ready availability of T.B. beds and the increasing tendency for maternity cases to be admitted to hospital. An important development in the service arose out of discussions aiming at the coordination of the efforts of this department and Langthorne Hospital to provide a more efficient service for the aged sick. The Home Help Organiser and Geriatric Liaison Health Visitor work in close co-operation with the Senior Medical Officer and Social Workers of Langthorne Hospital to meet the social needs, including domestic help, of patients awaiting admission to or discharged from hospital. A difficulty experienced in the past has been the matter of cleansing male verminous cases. A male Home Help took over this work, treating the cases at Stock Street Clinic. This arrangement has proved most successful. Home Helps gave 1,018 hours service to maternity cases during the year, which was equivalent to 0.44 full-time home help continuously employed. New Cases. Maternity cases - all cases were covered for a period of 14 days. The duration of service provided in respect of other new cases during the year was as follows:— Duration of Case Tuberculosis Cases General Sickness, Aged and Infirm Cases 4 weeks & under 3 74 5-8 weeks 1 18 9-12 " - 16 13 - 16 " - 5 17-20 " - 5 21-24 " - 6 25-28 " - 2 29 - 32 " - 4 33 - 36 " - 2 37 - 40 " - 1 4l - 44 " 2 5 45-48 " - 1 TOTALS: 6 139 Continuing over, into 1956 7 275 84 These oases first received the home help service in the months detailed below and were still having it at the end of the year. Tuberculosis Cases General Sickness, Aged and Infirm January - 22 February - 28 March 2 18 April - 22 May 2 20 June - 21 July - 25 August - 27 September 1 28 October 2 23 November - 19 December - 22 TOTALS: 7 275 General Sickness, Aged and Infirm Cases. Number of applications received 455 Number withdrawn or refused 47 New Cases accepted during 1955 408 - Males 77 Females 331 408 Number of cases on books at tend of 1954 555 Total number of persons receiving home help during 1955 963 Number of cases on books at end of 1955 767 Ages of Applicants to whom home help was supplied for the first time:- % Under 50 42 10.3 Between 50/59 19 4.6 Between 60/69 88 21.7 Between 70/79 187 45.9 Between 80/89 68 16.5 Between 90/99 4 1.0 Total 408 100% Cases assessed to pay 67 Cases free 341 Average number of hours of service per case per week 4.1 Tuberculosis Cases. New applicants accepted during 1955 13 - Males 3, Females 10 Number transferred from 1954 25 Total number of persons receiving home help during 1955 38 Number of cases on books at end of 1955 17 85 Ages of Applicants to whom home help was supplied for the first time:- Under 50 8 Between 50/59 2 Between 60/69 1 Between 70/79 1 Aged 91 (Tuberculous ankle) 1 Cases assessed to pay 5 Cases free 8 Maternity Cases. Number of applications received 24 Number withdrawn 8 Number received service 16 Staffing. Permanent full-time Home Helps employed at 31st December, 1955 10 Part-time Home Helps employed at 31st December, 1955 93 Average hours worked per week per part-time Home Help (includes Tuberculosis cases) 32.4 Total number of hours worked by Home Helps (approx.) 145, 951 (on the basis of a 44-hour week, this is equivalent to 63.8 full-time Home Helps throughout the year, making no allowance for sickness, statutory holidays, annual leave and travelling time). Work of the Male Home Helps. Male home helps undertake routine duties, but are especially useful in assisting in difficult circumstances. As an example they were sent to clean 11 homes which were found in an extremely filthy condition. After many hours of hard and unpleasant work these homes were transformed and made fit for the female home helps to take over. Home Visits of Home Help Organiser and her Assistants. General Cases:- Visits to Applicants and Recipients 2,353 Visits to Home Helps 230 Tuberculosis Cases Visits to Applicants 276 Maternity Cases:– Visits to Applicants 65 Total number of visits: 2,924 Office consultations - Applicants and Home Helps 5,000 approx. 86 SECTION 51 - MENTAL HEALTH SERVICE. The Medical Officer of Health is responsible to the Health Committee for the general administration and organisation of the Mental Health Service. There is no Mental Health Subcommittee. No new legislation or alteration of existing legislation in relation to Mental Health was introduced during the year. Staffing of the Service. 1. Medical. The Deputy Medical Officer of Health is responsible for the day to day medical supervision of the service. This officer and the Chief Assistant School Medical Officer are approved by the local health authority for the purposes of the Mental Deficiency Acts (1913-1938): they carried out medical examinations and where necessary certification of mental defectives. Three local general practitioners, in addition to the Deputy Medical Officer of Health, have also been approved by the Minister of Health for the purpose of making recommendations under Section 1(3) and 5(3) of the Mental Treatment Act, 1930, and were available when required. 2. Lay Staffs. The establishment consists of one Senior Duly Authorised Officer largely responsible for the administration of the Mental Deficiency, Lunacy and Mental Treatment Acts; two full-time Duly Authorised Officers carrying out visiting and other personal duties under these Acts; one relief Duly Authorised Officer who takes a regular turn on the duty rota for emergency calls outside office hours, and one Psychiatric Social Worker. The establishment of the Occupation Centre comprised a Supervisor, three Assistant Supervisors, and a Male Handicraft Instructor. Co-crdination with Regional Hospital Boards and Hospital Management Committees. I would like to express my appreciation of the ready help and co-operation this Department has received from the medical staff of Goodmayes and South Ockendon Hospitals. The Council's Duly Authorised Officers continued to supervise defectives on licence from institutions and to prepare progress reports. They also paid home visits and prepared reports for any defectives in institutions whose orders were due for review, or who were under consideration for holiday leave, licence, or discharge. 87 Prevention of Illness, Care and After-Care work in relation to Mental Health. The Work of the Psychiatric Social Worker (P.S.W.) The P,S.W. commenced with a load of 15 cases in March 1955- During the first months the main work consisted of establishing and renewing contacts with mental hospitals and general hospitals of the area; also with health visitors, social and welfare workers. These efforts led to many new referrals, and the case load showed a steady increase. By December 1955. 150 cases were on the register. After Care Service. At a conference held at Goodmayes Hospital in May 1955, between the psychiatrists, the Deputy Medical Officer of Health, and the Psychiatric Social Workers of Goodmayes Hospital and West Ham, it was decided that the after care service to be carried out by the West Ham P.S.W. should be a selective one. Not all patients discharged from hospital are in need of after care by a P.S.W. However, where after care has been recommended, she often sees a patient for a fairly long period ranging from one month to one year or more. Reports of the P.S.W's interviews with former Goodmayes patients are sent to her colleagues at Goodmayes Hospital, Further she attends case conferences at Goodmayes Hospital twice monthly, when an opportunity is given to her to discuss cases of patients now in her care, and also to inform herself of the progress of patients for whom she has been responsible and who are at present undergoing treatment at the hospital. In addition to this work, she meets the psychiatrists from Goodmayes Hospital at their out-patient clinics held at St.Mary's Hospital. At these clinics she may introduce to the psychiatrists, on behalf of general practitioners, patients who have been referred to her in order to obtain an expert opinion and also to obtain recommendations as to further action. She is also able to ask the psychiatrists to review the case of an after care patient who shows signs of deterioration or she may meet out-patients prior to their admission to Goodmayes Hospital, to obtain a social history, and also to discuss vital problems such as care of children and financial problems arising from the patient's hospitalisation. In reviewing the work done during the period of 10 months, the best results obtained were those of patients seen over a fairly long period prior to, during and after hospitalisation. Many of these cases are known to other workers of the Department, especially Health Visitors, Duly Authorised Officers, the Home Help Organiser, and outside workers such as Probation Officers, Children's Officers, and the N.S.P.C.C., and it has been found to be of the greatest importance to keep in touch with these workers while the patient is In the care of the Psychiatric Social Worker. 88 Preventive Psychiatric Social Work. The Psychiatric Social Worker has been encouraged to devote an ever increasing part of her work to mental health problems arising out of social and relationship difficulties in the family circle. If problems of this kind are brought to her notice at an early stage, breakdowns of a more serious nature needing psychiatric treatment, might be prevented. In 1955, the Psychiatric Social Worker gave an outline of this side of her work to the Health Visitors which enabled them to refer suitable cases earlier than they would otherwise have done. Cases referred by Health Visitors. In most of these cases satisfactory relationships have already been established between the Health Visitors and the families. The Psychiatric Social Worker assists by discussing with the Health Visitors the handling of difficult emotional problems between, for instance, husband and wife, mother and child, family and in-laws. Cases referred by School Medical Officers. Most of these cases are dealt with by the Psychiatric Social Worker who, in trying to help a mother with her difficulty in handling her child may render the referral of the child to a Child Guidance Clinic unnecessary, or by supplying a full history of the disturbed relationship, bring the problem to the early notice of a child psychiatrist. Case conferences between the referring agencies and the Psychiatric Social Worker were held when necessary, and where there were medical problems, the cases were referred to the medical officer concerned. Referrals from General Practitioners. Very few cases of the above type have as yet been referred to the Psychiatric Social Worker by the general practitioners. The Psychiatric Social Worker, as well as the Health Visitors, have made it their duty to report to the family doctor about most of these cases. It is hoped that a closer link between the General Practitioners and this service will be established in course of time. The following details relate to the work of the Psychiatric Social Worker:- Referrals Pre-care 65 After-care 89 154 Sources of Referral Hospitals: Goodmayes Hospital 86 Whipps Cross Hospital 3 Queen Mary's Hospital 11 St.Mary's Hospital 1 London Hospital 1 Belmont Hospital 1 St.George's Hospital 1 104 89 Public Health Department: Medical Officer of Health 3 Maternity & Child Welfare Service 14 School Medical Officers 2 Child Guidance Clinic 3 Duly Authorised Officers 1 Home Help Organiser 1 24 Probation Officers 5 Disablement Resettlement Officer 1 National Assistance Board 2 Citizens' Advice Bureau 4 Blind Welfare Officer 1 General Practitioners 4 Others 10 27 No. of Hcroe visits 117 * No. of Office interviews 425 Visits to Social Agencies, Hospitals, etc. 147 * This figure Includes case conferences and Individual conferences with Health. Visitors. Psychiatric Club, Owing to the lack of suitable patients the Psychiatric Cltib was suspended in August. It is hoped that in the future, given sufficient suitable patients, the Psychiatric Club can be re-started in brighter and more suitable permanent premises, or that arrangements can be made with one or more neighbouring authorities for patients In this authority to attend a joint Psychiatric Club. With the appointment of an Occupational Therapist there is still greater scope for organising a social club under her charge, rather than that the club should be run by a Psychiatric Social Worker or Duly Authorised Officers who are concerned more with the care of the patient or his removal to hospital at a time when he is in greater need of actual psychiatric treatment. Short-Term Care of the Mentally Defective. During the year arrangements were made for 10 mentally defective persons to receive temporary accommodation and care as a result of urgent medico-social circumstances. In most of these cases the period of care varied from about four to six weeks. Details of these are given on page 93. Severely defective children may prove unsuitable for admission to the Occupation Centre, and their parents may not wish them to be admitted to a mental deficiency hospital. Such cases often have added physical disabilities or suffer from epilepsy which add considerably to the difficulties of caring for them. They require attention frequently, day and night, and the devoted parents, especially the mothers, have the task of washing, cleaning, feeding and carrying the child (or adult) in addition to trying to cope with the daily routine of work. There is never any let-up for them and they are denied relaxation or entertainment or the annual holiday unless there are willing relatives to relieve them. 90 A day centre for such children would help to relieve the mothers considerably, enabling them to do their housework or shopping unhindered. Whether such a project would be feasible would depend largely upon the number of parents who would wish to use the day centre for the care of their children. Convalescence from Mental Illness. One patient, a woman of 49 years, attending a Psychiatric Out-patient Clinic had a period of convalescence under the Council's recuperative holiday scheme. Lunacy and Mental Treatment Acts,l890-1930. Work undertaken by the Duly Authorised Officers. The arrangements for obtaining the services of the Duly Authorised Officers remained unchanged during the year. A twenty-four hour rota system was in operation and calls for their services after office hours continued to be made through Ambulance Control. During the year, the Duly Authorised Officers carried out the following work and visits in connection with these Acts:- 1. Calls received in connection with mental illness numbered 272 and were from:- (a) General Practitioners 149 (b) (i) Goodmayes Mental Hospital 42 (ii) General Hospitals 21 (e) Other Agencies (police, relatives, etc.) 60 212 The total number of visits made to these cases was 554. Disposal of cases. Two-hundred-and-three were admitted to hospital:- M. F. Total (a) As voluntary patients 47 75 122 (b) As temporary patients 5 16 21 (c) Under Urgency Orders 14 16 30 (d) Under Summary Reception Orders 6 5 11 (e) For observation 14 5 19 86 11 203 These were admitted to the following hospitals:- Goodmayes 174 St.Clement's (observation ward) 18 11 91 The age incidence of these admissions was as follows:- Sex 0 - 15 - 25 - 35 - 45 - 55 - 65 - 75 & over TOTAL Male - 10 17 18 12 18 11 5 89 Female - 5 17 20 15 21 22 14 114 Total - 15 34 38 27 39 35 17 205 It will be noted that 17 of these admissions were of persons aged 75 years or over, with a total of 50 for persons aged 65 and over. This is an increase of 14 in the group of persons aged 65 and over and is perhaps an indication of the problem which is likely to increase from year to year owing to the ageing population and to the continued difficulties in the housing and economic situation which are resulting to some extent from the break up of the family system. More and more old people are being left to their own resources by their children who are married and who have been rehoused elsewhere. Many of them continue to live lonely lives and have an inadequate diet, both of which factors may contribute to their general enfeeblement and mental deterioration, Of the 203 cases admitted to hospital through the Council's service, 122 (60%) were voluntary patients which is again an upward trend. Of those initially admitted under Urgency Orders and for observation, 23 (47%) subsequently consented to remain for voluntary treatment and the question of certification did not arise. In addition, 101 patients were admitted direct to hospital as voluntary patients either through the psychiatric clinics or by their private doctors. It can thus be seen that of the 304 patients admitted to mental hospitals from West Ham, 246 (81%) were voluntary patients. Much of the prejudice against admission to mental hospitals has now been overcome but considerable harm cam be done by sensational articles in the press. There can never be any objection to factual comment on any shortcomings in mental hospitals, but the manner of presentation may increase the resistance of would-be voluntary patients to admission to hospital for treatment which they urgently need, even in those areas where the hospital facilities are excellent. In 45 cases (22 males and 23 females) to which the Duly Authorised Officers were called no statutory action was taken as alternative means could be found of helping the patient in co-operation with the general practitioner either by reference to a Psychiatric Clinic, by sending the patient away for recuperative holiday, or by enlisting the aid of other persons who could help in one way or another, (c) Mental Deficiency Acts, 1915-1938. Ascertainment. Thirty-two defectives (16 males and 16 females) were ascertained during the year. Of these, 24 (13 males and 11 females) were reported by the Local Education Authority (14 as being ineducable children and 10 as needing supervision after leaving school); 2 cases (l male and 1 female) came from the Courts and 6 (2 males and 4 females) from other sources. Twenty-seven of these cases (14 males and 13 females) were placed under Statutory Supervision and the remaining 5 (2 males and 3 females) admitted for institutional care. In addition to the ascertained defectives, 4 other cases came to the notice of the department. Two were placed under friendly supervision and two were still under investigation at the end of the year. 92 Supervision. At the end of the year 322 mental defectives (170 males and 152 females) were under statutory supervision, 5 under friendly supervision, and 8 on licence from Institutions. These cases were visited by the Duly Authorised Officers at approximately quarterly Intervals or more frequently if need be. In addition, informal contacts were maintained with other cases who it was felt might be in need of friendly help or guidance from time to time. They included individuals on the border-line of mental deficiency, barely able to hold their own alone and defectives discharged from statutory Orders. The majority of the defectives under statutory supervision are in fairly regular employment and self-supporting. Those defectives considered capable of working but finding difficulty in obtaining employment of a suitable nature are referred to the Disablement Resettlement Officer and consultation takes place to decide the most suitable occupational placing. Guardianship. There were three defectives under guardianship at the end of the year. They were all females aged 6l, 48 and 20 years respectively and have been with their present guardians for 20, 18, and years, two being in convents as domestic workers and one in a private household. As all the places of guardianship are outside the Borough the cases were supervised by the local health authority of the area in which they reside and were, in addition, visited at six-monthly intervals by a member of the Health Committee and the Deputy Medical Officer of Health. During the year two children were referred to the local education authority under Section 8 of the Education (Miscellaneous Provisions) Act, 1948. In both cases the reports of ineducability were withdrawn and the children are now attending a special school for the educationally sub-normal. One of the children, a boy aged 8£ years, was reported under Section 57(3) of the Education Act, 1944, in December, 1952. His case was kept under constant review and he attended the Occupation Centre. He was referred back to the local education authority in March, 1955. The second case, a girl of 8 years, came to this area from Essex County Council in January, 1953, having been reported to that authority under Section 57(3) of the Education Act, 1944, in October, 1951. She also attended the Occupation Centre and was referred to the local education authority in July, 1955. Temporary Accommodation for Defectives. During the year arrangements were made for 10 defectives to receive temporary care. Six were females aged 39, 32, 17, 8, and 5 years and four were males aged 16, 13, 10 and 5 years. Eight were accommodated at South Ockendon institution by the kind permission of the Physician Superintendent; one by arrangement with -he Guardianship Society, Brighton, and one was sent to a children's home. Visits in connection with the Mental Deficiency Acts during the year were as follows:- Cases under statutory supervision 1,525 Cases on licence from institutions 50 Reports for licence, holidays, etc., from the institutions 47 Reports for Statutory Visitors 128 Other visits 331 2,081 93 Institutional Accommodation. Eleven defectives were admitted to South Ockendon Institution, The age and sex incidence was:- Male Female Children 0-5 1 - Children 5 - 15 2 3 Adults 2 3 At the end of the year, there were 5 defectives in the area awaiting institutional accommodation. Three of these, adult males and former poor law patients, are In Forest Gate Hospital not under Order and are on the waiting list for admission to South Ockendon Institution. Home Training. No special arrangements existed for the home training of defectives. Though likely to be limited In extent, there may well be a potential need for this type of provision which may require consideration in future years. Occupation Centre. Eighteen new cases were admitted to the children's Occupation Centre. Discharges from the Centre were as follows 3 children were admitted to South Ockendon Hospital 1 child, who was on licence, was returned to South Ockendon Hospital 2 children were transferred to an E.S.N, special school 1 child proved unsuitable 1 child left the centre 1 child spent one day only at the Centre: this was an adopted child and the parents would not accept the fact that he was a mentally defeotive person 1 boy was found work 1 girl went home to help her widower father with domestic work. Thus, at the end of the year there was a total of 57 children on the register as compared with 50 at the end of 1954. It is very likely that soon the number of children attending the Occupation Centre will increase to such an extent that the existing accommodation will not be sufficient for them. Furthermore, the present accommodation cannot really be considered as anything but temporary. In March, one of the Assistant Supervisors who had formerly worked at the Centre was reappointed to the staff and took over the Intermediate group and seven senior girls. These two groups have progressed particularly well, especially those who have been trained in domestic work. In March, in order to provide adequate transport,temporary arrangements were made for a private car to be hired In addition to the coach. The car was discontinued in July and when the Centre re-opened in September a further coach started operating under contract arrangements and has proved a great help to the staff in enabling them to cope with the children while on coach duty. Previously the overcrowding had made this difficulty a nightmare for the Supervisor concerned. In the same month the Handicraft Instructor commenced the two-year in-service course for the Diploma for Teachers of Mentally Handicapped Children. While he is away from the Centre some reorganisation will be necessary. 94 In May, a Trainee Supervisor was appointed and has settled down well. In the same month an outing was arranged to Maidstone Zoo which was thoroughly enjoyed by all the children. In July, an Open Afternoon was arranged which was attended by about 50 visitors consisting of parents, officials and friends. They were given an opportunity of seeing the children at work and the variety of activities and occupations which are included In their curriculum. In November, there was a display and sale of hand-work and the staff were very grateful for a visit from His Worship the Mayor and the Mayoress (Alderman D.Thorogood, J.P. and Mrs. Thorogood. There were many interested visitors and parents who purchased most of the work done by the children. At Christmas, the children gave a play which was a great success. All the properties needed were made by the senior boys' group and parents and friends helped with dresses for the performers. Santa Claus paid his usual visit and delighted the children who thoroughly enjoyed their festivities. 95 SUMMARY The following are the statistical returns relating to mental defectives. 1. Particulars of Mental Defectives on Register as at 31st December, 1955. Under age 16 Aged 16 and over Total M. F. M. F. (a) Cases ascertained to be defective found "subject to be dealt with" (i) Under Statutory Supervision (excluding patients on licence) 39 23 131 129 322 (ii) Under Guardianship - - - 3 3 (iii) In places of safety - - - - - (iv) In hospital (Including eases on licence therefrom) 29 11 *191 192 423 Total: 68 34 322 327 748 (b) Cases not ascertained to be defective found "subject to be dealt with" Under Voluntary Supervision - - 2 3 5 Grand Total: 68 34 324 327 753 (e) Number of cases in above receiving training In Occupation Centre 31 18 5 3 56 x Includes 3 cases In Forest Gate Hospital not under Order awaiting admission to South Ockendon Hospital. 2. Particulars of cases reported during 1955. Under age 16 Aged 16 and over Total M. F. M. F. (a) Cases at 31st December ascertained to be defectives "subject to be dealt with" Action taken on reports by:- (1) Local Education Authorities on children (1) While at school or liable to attend school 10 4 - - 14 (2) On leaving special schools - - 3 7 10 (3) On leaving ordinary schools - - - - - (ii) Police or by Courts - 1 1 - 2 (iii) Other sources 1 - 1 4 6 (b) Cases reported but not regarded at 31st December, 1955, as defectives "subject to be dealt with" - - - 2 2 (c) Cases reported but not confirmed as defectives by 31st December - - 1 1 2 Total number reported; 11 5 6 14 36 96 LIAISON By Dr.C.H.Phillips, M.R.C.S., L.R.C.P., D.P.H. Deputy Medical Officer of Health. Public Health is a combined operation which depends for its success on the co-operation of the public and social services, both statutory and voluntary. It is an ever-changing field in which adaptations have to be made as medico-social circumstances alter. A department cannot possibly 'go it alone' if it is to provide the maximum benefit and keep abreast of new developments. Liaison with Local Authorities. This relates mainly to the prevention of infectious disease but also to some extent in the maternity and child welfare, school health, and after-care services. It is particularly important that epidemiological information should be readily exchanged between local authorities, more especially adjacent authorities. For example, the Health Department compiles a weekly return, prepared from information received from neighbouring local authorities, of the incidence of poliomyelitis over the whole area, and this Information is circulated to the Medical Officers of Health concerned so that they are aware of the poliomyelitis picture week by week. Close co-operation is,also maintained with other Medical Officers of Health regarding the movement of contacts of Infectious disease and of outbreaks, such as food poisoning, to enable suitable action to be taken towards the prevention of further cases. Dossiers of young children attending local authority clinics and school children are freely interchangeable between local authorities when people move from one place to another. Likewise, information regarding mentally defective persons moving into or out of the Borough is made available to the local authority into which the person has moved. Vaccination and immunisation cards are also forwarded to othajviocal authorities when a child moves, so that the new authority will know exactly what is the immunisation state of the child. Liaison with the Hospital Services. A close and friendly relationship has been maintained at all levels with the hospitals in the area and also with Goodmayes and South Ockendon Hospitals. Consultants of the Regional Hospital Board are employed for part of their time in local health authority services which ensures easy referral by medical officers to the consultants of oases about whom they are concerned. This close working relationship is particularly evident in the child welfare and school health services where children are readily seen by the paediatrician, Orthopaedic specialist, ear, nose and throat, or eye specialist, or by a psychiatrist at the child guidance centre as the occasion arises. Except in certain agreed conditions a child is not referred to a consultant without the general practitioner's agreement. A copy of the consultant report is later sent to the general practitioner. A number of hospitals send to the Medical Officer of Health copies of reports to the general practitioner on children who have been in-patients. Hospital almoners and the staff of the maternity units give much helpful co-operation in relation to out-patients as well as in-patients and in making arrangements for the training of Part II pupil midwlves taking their domiciliary training. The resent arrangements by which hospital student nurses are given some insigjit into the local health authority service and some teaching by local health authority officers augurs well for future understanding and good will 97 at this level. Close co-operation also exists between the chest physician and the officers of the Health Department, and to foster this the chest physician has working with him a staff of tuberculosis health visitors who are responsible for the follow-up of contacts and for arranging for the provision of after-care services. In general, experience has shown that membership of hospital committees can do much to facilitate liaison with the hospital services. Paediatrlc Liaison. This was first established on a formal basis in June, 1950 when a paediatric health visitor was allocated to work with the Borough's consultant paediatrician who is consultant to Whipps Cross Hospital, Certain modifications and extensions of the scheme have been made since its inception. At present there is one paediatric health visitor who accompanies the paediatrician on his twice weekly round at Whipps Cross Hospital and also attends the consultant clinics which he holds on local health authority premises. Another paediatric health visitor has similar functions at Queen Mary's Hospital. These paediatric health visitors are changed every six months. The privilege is eagerly looked forward to by the health visitor and keeps her up to date in modern methods of nursing and treating children's diseases. It is helpful to the paediatrician in keeping him in closer touch with the social conditions under which his patients live. Geriatric Liaison. To obtain the greatest benefit in the treatment and care of the elderly sick it is necessary that there should be close co-operation between the geriatric unit at Langthorne Hospital and the Health Department. This co-operation has been assisted greatly by the nomination of two geriatric liaison health visitors who attend at Langthorne Hospital twice weekly for advice regarding the care of old people to be discharged, and who arrange whatever facilities are desirable and available prior to the discharge of the patient. Such arrangements may include the provision of a home help, the loan of nursing requisites, "meals on wheels", and so on. She is also in a position to advise the senior medical officer of the hospital regarding the social circumstances of cases awaiting admission to hospital. Diabetic Liaison. Health visitors nominated as diabetic liaison health visitors attend the diabetic clinic at Queen Mary's Hospital where they receive consultant's advice regarding the care of the patients. They teach the patients or their relatives how to work out and prepare the menus prescribed for the patients, and discuss with general practitioners any problems which may arise. Liaison with General Practitioners. Co-operation with general practitioners in the Borough has improved most noticeably during the past few years. The local authority medical officers, health visitors, midwives and home nurses, psychiatric social worker, occupational therapist, and other officers have all been encouraged to work in close touch with the practitioners in the interests of their patients. 98 Consultation with the general practitioner prior to referring a patient to a consultant has already been referred to. Senior medical officers find general practitioners very helpful when they approach them to discuss such things as arrangements for the care of handicapped children, the suitability of persons wishing to adopt children, children excluded from day nurseries on account of Illness and many other similar matters. The steady development of the after-care services, especially the provision of recuperative holidays, has done much to foster this relationship and it is hoped that this will grow with the further development of the service, particularly in the field of mental health. Consultation with the representatives of the general practitioners takes place through the medium of the statutory Local Medical Committee and more Informally through a medical liaison committee which also includes hospital medical representatives. Liaison with other departments of the Local Authority and with Central Government Departments. Needless to say the closest co-operation exists between the officers of the Health Department and the other departments of the Local Authority. Without this co-operation the public health inspectorate would be in a difficult position in dealing with problems arising out of defective houses and drainage; many medico-social cases might not come to the notice of the Housing Officer; and many of the problems relating to old people, epileptics and otherwise handicapped people, would remain unsolved without the assistance of the Chief Welfare Officer. Officers of the Health & Children's Departments are in almost daily consultation regarding children whose home circumstances are unsatisfactory or whose parents are not in a position to give them adequate care. The officers of the National Assistance Board are frequently consulted and always very helpful. Liaison within the Health Department. The practice has gradually been increasing during recent years of holding regular consultations with various groups of staff on departmental matters affecting their own particular functions. It has been found preferable, in the rather complicated structure of the health services, to keep such subjects separate from staffing questions related to conditions of service which are more appropriately the concern of the general staff advisory committee. The machinery for consultation along these lines is not yet complete and must obviously be limited both by the amount of time which can reasonably be devoted to it and by the number of occasions on which it Is possible to gather the particular group of staff together - it is distinctly difficult, for instance, to muster staff providing a 24-hour service such as the midwives - but opportunities for developing this kind of liaison are considered as they arise, Liaison with Voluntary Organisations, The Health Department is represented on the West Ham Clean Pood Advisory Association, the West Ham County Borough Old People's Welfare Committee, and the West Ham Tuberculosis After-care Committee. The former has done most useful work in the promotion of clean food handling practise while the latter has provided, to the extent of its resources, those services at present not available under any local authority scheme. The tuberculosis health visitors bring to the notice of the Committee the needs of patients and their families and these have been largely met by the Committee. The Conferences on Children Neglected or Ill-treated in their Own Homes have served a most useful purpose by outlining the action which is needed in individual cases. This has avoided the considerable overlapping of effort which existed prior to the holding of the discussions. This department is also greatly indebted to the Invalid Children's Aid Association, the oraen s Voluntary Services, the National Association for Mental Health, the South West Ham Health Society, the National Society for the Prevention of Cruelty to Children, the Canning Town Women's Settlement, the Chelmsford Diocesan Moral Welfare Association, the Committee of St.Agatha's Hostel, the Central Council for Health Education, and many other voluntary organisations. 99 GENERAL HEALTH AND WELFARE SERVICES, National Assistance Act, 1948 National Assistance (Amendment) Act, 1951 Removal to suitable Premises of Persons in need of Care & Attention A number of cases, mainly aged, were brought to the notice of the department by general practitioners, welfare officers, and voluntary organisations with a view to possible action under these Acts. Special visits were made and in most cases it was possible to either persuade the person to enter am institution voluntarily Or to provide services such as domestic help, home nursing, etc. In three cases, however, it was necessary to take action under the Act, Details of these cases are as follows:- Case 1, Female Aged 80 years- This case living alone, was brought to the notice of the department by her doctor. When visited she was found to be inadequately clothed, her person and home were in an extreme state of filth, she was aged and Infirm and was unable to look after herself, and was not receiving proper care and attention. All efforts to help her were unavailing and an order was obtained under the National Assistance (Amendment) Act and she was removed to Part III accommodation at Langthorne Hospital. After admission she settled down well and was quite content to remain in the hospital. No extension of the order was necessary. Case 2, Female aged 79 years. This case was reported to the department by her doctor. When visited she was found to be living with her daughter who was very eccentric and incapable of looking after her mother. The patient was ill, emaciated and very weak, she was lying on a filthy old bed without any proper coverings apart from some dirty blankets. The room was indescribably filthy. She refused to go to hospital. Action was taken under the National Assistance (Amendment) Act in co-operation with her private doctor and admission to hospital was arranged. She settled down in hospital but in view of the circumstances of the case an extension of the order was obtained. Unfortunately her condition deteriorated and she died. Assistance and guidance was given to the daughter by officers of the department and after a time she began to take an Interest in her home and person and obtained employment. Case No.3. Female aged 80 years. This case living alone, had been under surveillance by the department for some time. Daily visits were made by a home help, she was supervised periodically by health visitors; new bedding etc., was provided through the National Assistance Board in an effort to maintain her and her home in a satisfactory condition. The patient, however, would not co-operate and she refused to be washed or have her clothing changed. Despite the efforts of all concerned her condition deteriorated. She refused to go to hospital and it became necessary to take action under the National Assistance (Amendment) Act, She was admitted to Langthorne Hospital where she settled down quite happily, and at the end of the year was still there. No extension of the Order was necessary. 100 Incidence of Blindness. The Local Authority's duties under the National Assistance Acts are administered by the Welfare Committee of the Council through its Chief Welfare Officer and Blind Welfare Officer. Arrangements are made for,the examination of adults suspected of being blind or partially sighted and the requisite form B.D.8 is completed as necessary for such cases by the examining ophthalmic surgeon. In the case of pre-school children, such examinations are arranged through the School Health Service and the relevant forms are passed to the Chief Welfare Officer. In both categories, admission to the Registers of Blind and Partial Sighted Persor are effected as necessary in order that appropriate arrangements for their supervision, ca and training may be made. The Information given below has been made available through the courtesy of the Chief and Blind Welfare Officers from the statistical returns normally submitted to the Ministry. A. Blind Persons. Classification of Registered Blind Persons by Age Groups, Table I. Total cases on Register (Age at Dec. 31st., 1955.) New Cases Registered Jan. 1st. 1955 to Dec. 31st. 1955. (Age at Redstrati on) M F Total M F Total 0 _ - - - - - 1 _ - - - - - 2 - 1 1 - - - 3 - - - - - - 4 1 - 1 - - - 5-10 2 3 5 - - - 11 - 15 _ 1 l - - - 16 - 20 - 1 1 - - - 21 - 30 8 5 13 - - - 31 - 39 15 2 17 1 1 2 40 - 49 22 23 45 - - - 50 - 59 21 27 48 1 1 2 60 - 64 18 22 40 1 - 1 65 - 69 19 17 36 2 2 - 70 and over 72 140 212 6 24 30 Unknown - - - - - - Totals: 178 242 420 11 28 39 101 TABLE II. Age at which onset of Blindness occurred. Total cases on Register New Cases Registered Jan. 1st to Dec. 31st. 1955. M. F. Total M F Total 0 27 17 44 - - - 1 - 3 3 - - - 2 1 - 1 - - - 3 - 1 1 - - - 4 - - - - - - 5 7 12 19 - 1 1 11 - 15 6 5 11 - - - 16 - 20 9 5 14 - - - 21 - 30 19 12 31 1 - 1 31 - 39 14 13 27 - - - 40 - 49 22 33 55 - 2 2 50 - 59 26 30 56 1 2 3 60 - 64 14 15 29 2 1 3 65 - 69 6 18 24 2 3 5 70 and over 19 66 85 5 17 22 Unknown 8 12 20 - 2 2 TOTALS: 178 242 420 11 28 39 TABLE III. Distribution of Local Blind Persons. I. Children, age under 16. M. F. TOTAL M F TOTAL Under 2 at home - - - - - - Age 2-4 Educable, At home 1 1 2 1 1 2 Age 5-15 Educable Attending school - 2 2 Not at school 1 1 2 Ineducable In Mental Deficiency Inst. 1 1 2 At home - - - 2 4 6 3 5 8 102 II. Age Period l6 years and upwards. Employed. (a) In Workshops for the Blind. M. F. TOTAL M. F. TOTAL 16-20 - - - 21 - 39 9 - 9 4-0 - 4-9 7 1 8 50-59 5 - 5 60-64 3 - 3 65 and over 3 - 3 27 1 28 (b) As Approved Home Workers. 21-39 40 - 49 2 2 - 2 2 (c) All Others (than in (a) or (b)) 21 - 39 11 11 40-49 5 1 6 50 - 59 3 1 4 60 - 64 - - 65 and over 1 - 1 20 2 22 47 5 52 Undergoing Training. (a) For Sheltered Employment 2 2 (b) For Open Employment - - - (c) Professional or University - - - 2 - 2 Not Employed 126 232 358 Grand Total 175 237 412 Number of Persons registered under the Disabled Persons (Employment Act, 1944) included in the Grand Total. 48 5 53 103 TABLE IV. Nature of Employment. Within Workshops for the Blind, Basket Makers 5 Mattress Makers 4 Brush Makers 13 Machine Knitters 1 Labourers 1 Mat Makers 4 28 As Approved Home Workers. 2 All Others, not Part-time Workers 2 Clerks and Typists 1 Dealers, tea agents, newsagents, shopkeepers 2 Factory Operatives (Open Sheltered) Employment 4 Home Teachers 1 Office Executive 1 Piano Tuners 1 Porters, packers and cleaners 7 Telephone operators 4 Open Employment, other than already catalogued 1 22 Grand Total: 52 104 TABLE VI. Nature of Disability of New Cases Registered as Blind During the year. Cause of Disability Total No Treatment Recommended Recommended for Medical Treatment Surgical Treatment Cataract (both eyes) 17 13 - 4 Glauocma (both eyes) 4 - 3 1 Cataract (both eyes) and Glaucoma (one eye) 1 1 - - Cataract (one eye) and Glaucoma (one eye) 1 1 - - Cataract (one eye) and other cause (one eye) 6 5 - 1 Glaucoma (one eye) and other cause (pne eye) l - 1 - Other and unknown causes both eyes 9 5 4 - TOTAL: 39 25 8 6 (B) PARTIALLY SIGHTED PERSONS. TABLE I. Register of Partially-Sighted Persons. Year ended 31st Dec. 1955. Total No. on Register - Age Groups and Sexes. Age Group 0-1 2-4 5-15 16 - 20 21 49 50 - 64 65 & over Total & Sex. M. F. M. P. M. F. M. P. M. F. M. P. M. P. M. P. - - - 1 3 6 4 2 4 9 5 5 13 34 29 57 8 6 TABLE II Cases newly Registered: Age at Date of Registration. Age Group 0-1 2-4 5-15 16 - 20 21 - 49 50 - 64' 65 & over Total & Sex M. P. M. P. M. F. M. P. M. F. M. F. M. F. M. P. - - - 1 1 1 - - 1 2 1 4 5 10 8 18 26 TABLE III Removals from Register. (a) On admission to Blind Register M. P. Total 1 1 2 (b) On Decertification due to Improved Visual Acuity TABLE IV. Persons Requiring Observation Only (Age 16 and Over) 16 - 20 21 - 49 50 - 64 65 and over Total M. 3 4 5 13 25 F. - 9 5 34 48 Totals 3 13 10 47 73 105 TABLE V. Details of Children: (a) age 5 under 16. Educable Ineducable Total Attending Special Schools Attending Other Schools Not at School M. 3 M. - M. - M. 3 F. 5 F. 1 F. - F. - 6 Total 8 Total 1 Total - Total - 9 Details of Children; (b) Age 16 and over still at School. M. 1 F . 2 Total 3 TABLE VI. No. of Persons Registered under the Disabled Persons (Employment) Act, 1944. M. 4 F. 3 Total 7 TABLE VII. Nature of Disability of New Cases Registered as Partially-Sighted during the Year Cause of Disability Total No Treatment Recommended Recommended for Optical Treatment Medical Treatment Educational & Optical Treatment Cataract (both eyes) 5 1 1 2 1 Cataract (one eye) and Glaucoma and Cataract (other eye) 1 1 - - - Cataract and Glaucoma (one eye) and other cause (one eye) 1 - - 1 - Cataract (one eye) and other cause( one eye) 5 2 1 - 2 Other and unknown causes 14 11 2 1 - TOTALS 26 15 4 4 3 106 Epilepsy and Cerebral Palsy. A. Epilepsy. 1. Children. The arrangements whereby all children between the ages of 2 years and 16 years found to be suffering from epilepsy are referred to the School Health Service for examination and any necessary action remained unchanged. When the need for special educational treatment arises, arrangements are made for the child's admission to either a special day or residential school if the recommendations cannot be met in the ordinary day school. One such case was dealt with during the year. The number of children known to be suffering from the defect and their placing is as followsj- 1. In attendance at ordinary schools 53 2. In attendance at day special schools 1 3. In attendance at residential special schools 3 Total: 57 2. Adults. It is impossible at present to ascertain the true Incidence of epilepsy in the community, since there are no adequate means of effecting a complete registration. In the majority of such cases, the epilepsy is of a minor degree, adequately controlled by medication and the individual concerned is following normal employment with little, if any, limitation in his activities. The more severe eases usually come to notice because they are in need of special care, and admission to an epileptic colony or other form of residential accommodation is arranged by the Welfare Department under Part III of the National Assistance Act, 1948. During the year, I such case was admitted to Chalfont Epileptic Colony. The number of West Ham cases of epilepsy in residential care at the end of the year was 14, these cases being accommodated as followss- Porest House 5 Chalfont Epileptic Colony 4 StoElizabeth's Home for Epileptics, Much Hadham 1 Llngfield Epileptic Colony 1 Langho Epileptic Colony 1 Wessex House 2 In some further cases known to this department the epilepsy is associated with a degree of mental deficiency. If institutional care is not required such cases may be Placed under supervision in accordance with the provisions of the Mental Deficiency Acts. 107 B. Cerebral Palsy. In the report for 1954 a full account was given of the opening and development of the Spastic Unit attached to the Elizabeth Fry Special School for Physically Handicapped Pupils. The Unit has continued to serve a most useful purpose in providing for the treatment and training of cerebral palsied children. Not only did it cater for children from this Borough but a number of requests were received from other authorities and arrangements were made, in conjunction with the Education Authority, for the attendance of some of the cases after suitable medical assessment. The admissions and discharges of cerebral palsied children aged 2-16 years were as followss- Total carried over Admissions Transfer to Day Special School Discharges Total on Roll at end of 1955 Nursery Class of Spastic Unit. West Ham Extra 7 9 2 Nil 7 District 1 6 2 Nil 5 Day Special School for West Ham 13 5 - 1 17 Physically Handicapped Children Extra District 7 3 - _ 10 Totals 28 23 4 1 39 Adults. As with epilepsy, this condition is not notifiable and, therefore, its true incidence in the community cannot be determined, but, in the cases registered as disabled persons, suitable employment is arranged so far as is possible in conjunction with the various welfare and other organisations concerned. In addition, any adult spastic brought to notice as in need of residential accommodation or specialised treatment or training is referred to the Chief Welfare Officer. The provision of Welfare Services for Handicapped Persons under Section 29 of the National Assistance Act, 1948, is the responsibility of the Welfare Committee. Medical Examinations. During the year, the medical officers of the department carried out examinations of new entrants to the Council's service or under the Protracted Sickness scheme as follows:- Department Medical Examinations.Protracted Sickness Examinations. Health 48 48 Education 109 45 Borough Engineer's 49 195 Children's Department 21 5 Welfare 3 8 Libraries 3 2 Borough Architect's 11 2 Borough Treasurer's 17 3 Fire Brigade 21 5 Town Clerk's 9 - Housing 5 - Baths 1 - Weights & Measures 1 - Canning Town Women's Settlement 1 - For other Authorities 3 302 313 * Includes 26 entrants to training colleges. Annual examination of Sewermen 35 Medical examinations carried out by other Authorities for the Education Department 21 Chest X-rays arranged for New Entrants. By M.R.U. Local Hospitals Education 13 75 Children's Department 1 19 Health 7 37 Canning Town Women's Settlement - 1 Annual Chest x-rays (present staff). Health 137 - Educ at ion 19 - Children's Department 17 - Borough Engineer's - 1 109 SCHOOL HEALTH SERVICE SCHOOL POPULATION There was a small decrease in the school population during the year. On the 31st December, 1955, there were 29,487 children on the school rolls, as compared with 29,707 on the corresponding day of 1954. The number for 1954 showed a small increase on the previous year when the school population was 29,653, so it will be seen that the variation during the past three years has been only slight. MEDICAL INSPECTION The School Health Service and Handicapped Pupils Regulations 1953, require that general medical inspection shall be carried out at least three times during the school life of the child, but it is left to the discretion of the local education authority to fix the ages at which these, and any other medical inspections which may be necessary, are carried out. In West Ham the practice for many years has been to carry out as a routine three general (or "periodic") medical inspections; at the beginning of school life (Entrants); at the end of school life (Third Age Group); and at the age of ten years plus shortly before the child enters the secondary school or department (Second Age Group). This arrangement was continued during the year. In addition, special inspections or inspections are undertaken as required. There was a decrease of over 1,000 in the number of periodic inspections and a decrease of over 2,000 in the number of special inspections and inspections, The fall in the number of entrants examined (1,083) was due, in part, to a much reduced intake of new entrants (797). Another reason for the fall in the number of children examined in the three age groups was due to the Ministry of Education altering certain definitions used in their returns. Thus children were regarded as falling into one of the three prescribed age groups (Entrant, Second Age Group or Third Age Group) only if inspected at the normal time at a periodic inspection. If they missed the usual periodic inspection and were inspected later, they were to be classed under a new heading "Additional Periodic Inspection". Inspections at grammar and technical schools after the normal school leaving age are classed as "Additional Periodic Inspections"; also the annual inspections at the day special schools come under this heading. The first inspection of nursery school children in any calendar year other than in their first year is classed as "Additional Periodic Inspection", Consequently, the number of children examined under the old title of "Other Periodic Inspections", 595 in 1954, rose to 1,204 in 1955 under the new title of "Additional Periodic Inspections"„ Tables setting out the work done under the heading of medical inspection and treatment will be found in Appendix IV on page 159. 110 General Condition. The medical officer's survey at the periodic medical inspections includes an estimate of the child's general condition. This is classified into three grades; "Good", "Fair" and "Poor". The proportions recorded during 1955 are set out in detail belowi- Classification of the General Condition of Children assessed at Periodic Inspections No. of children inspected A (Good) B (Fair) c (Poor) No. No. % No. Entrants 2,668 992 37.18 1,641 61.51 35 1.31 2nd age group 2,329 868 37.27 l,44l 61.87 20 0.86 3rd age group 1,871 870 46.50 978 52.27 23 1.23 Additional periodic 1,204 585 48.59 598 49.67 21 1.74 Total 8,072 3,315 41.07 4,658 57.70 99 1.23 A child to be placed in the "Good" category has to be really good. He is a child who is well developed, has plenty of vitality and vigour and shows a keen Interest in life; a "Fair" child is a normal, average or satisfactory child} and a child in the "Poor" category appears tired, listless, dull and perhaps stands badly - he is under suspicion at once and his condition is unsatisfactory - he needs a full investigation. The following table shows a comparison of the findings for the past ten yearsi- Year Excellent Normal Sub-normal and bad 1946 23.76 61.97 14.27 Good Fair Poor 1947 79.43 20.19 0.38 1948 35.67 54.46 7.87 1949 35.06 56.16 8.78 1950 38.07 55.44 6.49 1951 39.03 53.44 7.53 1952 48.94 47.71 3.35 1953 44.69 53.97 1.34 1954 42.90 55.80 1.30 1955 41.07 57.70 1.23 This period covers the change which took place in 1947 from the Ministry's previous four point classification. For a period the figures showed instability, due largely to uncertainty of interpretation of the new categories. There are many factors which can influence this essentially subjective assessment, so that there still remains some doubt how far even the more recent figures can be regarded as giving a valid comparison. We can, however, say without any hesitation that the health of the children is satisfactory. Welfare of School Children. It is perhaps not well-known that the School Health Service Is the oldest statutory personal health service in the country, owing its formation largely to the report of the Inter-departmental Committee on Physical Deterioration. This Committee was set up as a result of national apprehension at the physical state of the recruits during the Boer war and it identified the appalling defects in conditions bearing on the physical and moral welfare of children and young persons and decided that these were the most important factors in the alleged physical deterioration of the nation, and that long-term policy of child welfare was urgently required. The School Medical Service, as it was originally called, came into being with the passing of the Education (Administrative Provisions) Act of 1907. Since then it has gradually developed, with West Ham to the fore in certain fields. A strange position existed in the early days of the Service; altho'ugh inspection revealed the need for treatment, local education authorities had no power to spend money on this. The School Health Service has been fashioned by a process of evolution to meet the special circumstances attending the life of the school child and from the earliest days the attitude of the school doctor has been essentially that of a practitioner of social medicine. We have now come to a new concept, "that of discovering the first signs of failure of physiological adaptation which precedes the stage of pathological lesion, and this pre-supposes a greater familiarity with what constitutes normality, which is recognised not as a point in a scale but as a range." This point has been stressed by Dr.Hinden in one of his reports . All school children are inspected by a medical officer three times during their school life - on entrance to school; at the age of ten years plus; and at fourteen years plus; this final medical inspection enables the medical officer to give an opinion about the type of work for which the boy or girl is physically suited. These inspections bring together child, parent, medical officer and often the teacher, and provides an opportunity for stimulating an interest in health matters as well as in allaying unnecessary anxiety. Besides health education they also have the function of health assessment and detection of faults. Special inspections are also carried out at any time if for any reason a parent, teacher, school nurse or health visitor wishes to have the doctor's opinion. In addition to this work, children who have been referred for treatment or observation are re-examined at intervals. It is interesting to note that now only 7.8 per cent of our children have a defect found to require treatment when seen at periodic medical inspection. In 1954, the number was 9.3 per cent. Apart from defects of vision and squint the percentage found to require treatment was only 4.1. School doctors are assisted in their work by school nurses and health visitors, who inspect all children in school every term for personal hygiene. The nurses inspections of personal hygiene are the basis of the "cleansing scheme". There has been great progress since the early days of this work, but even to-day a small percentage of children are found to be "dirty" and the work of inspection must therefore go on. Schools have played an important part in the raising of general standards of hygiene. Health education in schools is properly a responsibility of the teachers, though at times the medical officers and nurses can help. This aspect of education is most important, not only in the interests of the children themselves, but also because of their future influence as parents of the next generation. The school nurse has many other important functions to perform. By regular visiting of her area she can detect abnormal environmental conditions long before they have resulted in departures from health which are Likely to be detected at periodic medical inspections. The mental health of the child is receiving more and more attention in the 112 School Health Service and both the school doctor and the school nurse can often detect psychological aberrations in their earliest stages. There is a great future for this kind of work in the Education and School Health services, as also in the Infant Welfare Service. In dealing with handicapped children the Service now shows a greater preoccupation with ensuring that handicap does not prevent the child from receiving an education appropriate to his age, ability and aptitude. The principle of special educational treatment for certain children constituted a major advance. Later it will be shown what is done for the ten categories of handicapped pupil. The Local Education Authority has the duty of ascertaining these children and one great advantage is that the Authority may examine a child at the age of two years so that at least three years are available to make arrangements for its suitable placement. Turning to recent years the passing of the National Health Service Act of 1946 might well have foreseen the disappearance of the School Health Service; but instead, it is more firmly established than ever. The reason for this is that the School Health Service, as its name Implies, is much more than a medical service, and Is closely linked up with the educational life of the child. The first effects of the National Health Service were, however, unfortunate because the demands of other sections of the community for free treatment caused a loss of certain facilities to school children. Difficulties in the supply of glasses have now been overcome but there still remains a shortage of school dental officers. Continuous consultation and co-operation between the Authority and the various bodies administering the National Health Service is required to ensure that the scheme for the treatment of school children is comprehensive and efficient. Close liaison Is obtained by having hospital specialists - ophthalmological, ear nose and throat, paedlatric and psychiatric - working In our premises. The school medical officers refer large numbers of children requiring specialist attention to these consultants, subject to the consent of the general practitioners. Copies of reports are sent to the practitioners. Likewise, when children are sent direct to the hospitals in which these consultants work, copies of the reports to the general practitioners are sent to the School Medical Officer. This account can suitably be closed by quoting from a well-known health education expert, "The contribution of the School Health Service to social medicine is considerable. It Is both an executive and a research instrument, and its sphere of influence spreads far beyond the school into the community. It has helped to reduce the illness of childhood, raised the standard of positive health, compensated for the handicaps of the crippled and now can Point the way to an understanding of the causes of health." Medical Inspection Rooms, The Standards for School Premises Regulations do not specify separate accommodation for medical inspection purposes, merely requiring that suitable accommodation shall always be available at any time during school horn's for the inspection of pupils by medical officers, dental officers and nurses. The accommodation for such inspection shall be well arid suitably lighted and heated, and should be conveniently accessible to a closet, and every room provided for such purposes shall include a wash basin with a supply of hot and cold water. In a number of the older schools »edical rooms are not available, and consequently inspections have to be carried out in classrooms, school libraries, or other rooms. Every effort is made to make the parents children and medical staff comfortable. However, in the newer schools a medical suite Is included. 113 HYGIENE OP SCHOOL PREMISES The Standards for School Premises Regulations, 1954, lay down scales of provisions for cloakrooms, washbasins, water closets and urinal stalls and, in the case of county and voluntary secondary schools, changing rooms and showers. In all county and voluntary schools suitable accommodation should be available for dining and every school should have sufficient and suitable kitchen accommodation. Sufficient and suitable cloakroom, washing and sanitary accommodation other than that provided for the pupils, should be provided in every school for the use of the teaching staff and the staff employed in the School Meals Service. At a number of old schools these modern sanitary standards are not attained. A few schools are still equipped with trough closets and although these, are outmoded every effort is made to keep them in a sanitary condition, and it is likely by nest year they will be replaced by modern sanitary fitments. Medical officers when visiting schools for medical inspection do not confine themselves to seeing the children but interest themselves in general hygienic arrangements and the condition of the sanitary accommodation in so far as these may affect the health of pupils and staff. For a number of years now the medical officers have conducted a review of the hygiene of each school at the completion of their periodic medical inspection. Although the detailed reports for each school are kept in the school health office any observations made by the medical officer are sent to the Chief Education Officer whenever necessary so that he can consider how far and at what stage it may be practicable to implement any recommendations. Minor matters may be remedied as they arise but certain improvements can only be implemented by inclusion in long-term plans. Liaison between the Education Department and the Borough Engineer enables the medical officers' recommendations to be interpreted into practical improvements to the school buildings or to the various services accommodated In them. During the year 63 reports were made and dealt with in this way. It can appropriately be mentioned at this stage that In January the Primary Education Sub-Committee recommended agreement in principle to the closing of spray baths in all schools with the exception of Elizabeth Fry and Gurney special schools. It is gratifying to believe that the cleanliness of the children has improved sufficiently to make this possible. THE WORK OF THE SCHOOL NURSES NUTRITION In connection with nutritional surveys I reported in 1949 that "The ideal was a terminal Inspection although a six-monthly inspection would be considered very satisfactory." At this time inspections were carried out at approximately once a year for most of the pupils and this was continued in the years 1950, 1951 and 1952. In 1953 it was decided to abandon the idea of aiming at a terminal of six monthly inspection and to continue the annual survey as in previous years and this was continued in 1954. At this time it was felt that with the maintenance of a good standard of general condition among the children it might be possible that a still further lengthening of this interval or even abandonment of the surveys could become acceptable with corresponding release of school nurses' time for other purposes. Following a further review during the course of the year the Committee approved the termination of regular weighing and measuring of the children as from the end of October, with the exception of those due for periodic medical inspection and certain special cases. 114 During the year under review 20,629 inspections were made in these surveys. Nine cases were referred to the medical officers for further consideration of their nutritional state but none were found to be suffering from malnutrition. This is the sixth year in succession in which this gratifying result has obtained, and fits in with the general pattern of Improved general condition. NUTRITION SURVEYS Number of inspections 20,629 Referred to school doctors (nutritional grounds) 9 Referred to school doctors (other conditions) Obesity 8 Ear defects 2 Orthopaedic conditions 2 Defective vision and squint 2 Other c and it ions 19 Totals 42 CLEANLINESS. Routine cleanliness surveys are carried out each term. The numbers found to be infested at these surveys are augmented by others who are discovered at periodic or special medical inspections. The numbers found at periodic medical inspection are very few, the main reason being that parents receive notice of this examination and therefore have time to see that their children are presented In a satisfactory condition. In the case of cleanliness or hygiene inspections carried out by the school nurses neither the parents nor the children receive notice of the inspection, and the scholars are found in the condition In which they habitually attend school. While the responsibility of cleansing is upon the parents, children found to be Infested are followed up until the school nurse is satisfied that they are clean. During the year 68,974 inspections were made at these cleanliness surveys and 765 instances of infestation found. On the basis of a school population of 29,487 this gives a proportion of uncleanllness of 2,59 Per cent which compares with 2.95 per cent in 1954 calculated in the same way on a school population of 29,707. This number refers to Individual children, because however many times a child is found dirty in the year, it is only recorded as one case. There are many instances of recurrent infestations in the same children, and these persistent offenders provide the School Health Service with one of its most pressing problems. Infestation in such children can never be eradicated until the whole family is freed from it. The revised procedure for dealing with Infestation in school children adopted by the Education Committee in 1953 and described in the annual report for that year, was continued throughout 1955. The following figures relate to the work done during this period:- Total number of Individual pupils found to be infested 765 Total of individual pupils In respect of whom cleansing Notices were issued (Section 54(2) Education Act, 1944) 275 Total of Individual pupils in respect of whom cleansing Orders were issued (Section 54(3) Education Act, 1944) 48 115 It is interesting to record that, although 48 cleansing Orders were issued, only 17 children were compulsory cleansed at the Treatment Centre. Experience shows that the force of the cleansing Notice has the effect in many cases of making the parents realise their responsibilities so that, even although it was necessary to issue a cleansing Order, by the time it is in the parents hands many of the children have been satisfactorily cleansed. Comparative statistics cannot be expected to give a wholly reliable assessment of the results of these new methods after three years' working, but the results for 1955 can be said to be heartening. During the three years under review the percentage of cleanliness has dropped from 4.6 in 1953 to 2.59 in the present year. Although 135 more inspections were carried out in 1955 than in the previous year, there were 113 fewer instances of infestation. There was also a reduction of 47 cleansing Notices and 22 cleansing Orders issued during the year compared with the previous year. There have been many indications of the salutary effect of the cleanliness campaign upon the parents, and fathers in particular have realised, often for the first time, the condition into which their children have been allowed to fall and have taken active steps to remedy the situation. The main burden of the attack on this social evil is borne by the School Nursing Service. The real propaganda work the school nurses and health visitors have done in educating the children and their parents in the need for cleanliness deserves recognition. It is a thankless task, but any relaxation of vigilance would gradually give rise to the former bad state of affairs. FOLLOWING UP. This continues to be a most important function of the School Health Service, and is carried out by the school nurses and health visitors. This work is essential if the full value is to be obtained from the medical inspections and the cases referred for observation or treatment. Many children would become tired of carrying out the medical officers recommendations and parents fail to co-operate without the friendly encouragement and advice of the school nurse. The School Health Service frequently requires the nurse to visit the children's homes to obtain reports of various kinds and this is welcomed as an excellent opportunity of getting to know really intimately the families for whose welfare they are responsible. Valuable social work is carried out by the nurses by giving help and guidance in a variety of ways to families needing it. Reports on home conditions of a variety of cases - chiefly asthma and rheumatism required by hospital specialists, are often prepared by the school nurses following home visits. During the year the school nurses paid 5,134 home visits in this way. This number includes 1,300 visits in connection with the Medical Research Council's controlled B.C.G. trial with school leavers mentioned on page 132. RESEARCH AND INVESTIGATION A joint committee of the Institute of Child Health (University of London), the Society of Medical Officers of Health and the Population Investigation Committee at the London School of Economics has been following the health, growth and development of 6,000 children born in the first week of March 1946, who are drawn from all social classes and from all parts of England and Wales. The first part of the survey is over and a pamphlet entitled "The Health and Growth of the Under-Fives" was published by the joint committee for the information of school nurses, health visitors and others who helped In the field work. 116 It was found that among the short and underweight children there were nearly twice as many girls as boys. It was significant that a comparatively high proportion of the underweight (19 per cent) were the later-born children of large families, whereas these families only provided 8 per cent of the heavy ones. The lowest social groups provided more than their fair share of stunted and underweight children and proportionately less than their share of physically superior children. It was not possible, at this stage of the survey, to do more than take note of these differences, since any interpretation of them would be incomplete without relating the heights and weights of the children to those of their parents, and this is now being done. A comparison of the growth of premature children with a similar, control group born at term showed that the premature children were lighter and shorter at all ages than their controls. It was interesting to note that as many as 40 per cent had eliminated their Initial handicap by four years. Those who had caught up In this way were found to have mothers whose heights and weights were similar to those of their controls, whereas the mothers of those who did not catch up were shorter and lighter. It is hoped to keep the children in the survey for another three years - until the end of the Primary School period. The joint committee concluded their report thus "Such an opportunity to study growth Is unique, and we are confident that the importance of the results for child health will fully justify the amount of work involved In carrying out the surveys." The joint committee recorded their gratitude to the health visitors and school nurses for the work which they had done. During 1952 and 1953 the medical officers carried out 25 and 21 survey examinations respectively, but none were carried out in 1954 or 1955• The number of reports completed by the school nurses during 1952, 1953, 1954 and 1955 were 25, 68, 24 and 23 respectively. TREATMENT RINGWORM, One case of ringworm of the scalp was treated during the year. It was a single lesion treated at hospital by fungicidal ointment. Last year only one case was treated and in 1953 no case was recorded, this being the only occasion in the history of the Service when no case was found. The reduction in the number of children with ringworm is general and there is a good deal of evidence to show that scalp ringworm is a declining disease. The figures for previous years are given for comparisoni- Year Total number treated Received X-ray treatment 1946 24 16 1947 15 9 1948 7 6 1949 2 1 1950 4 1 1951 5 2 1952 3 - 1953 - - 1954 1 - 117 The incidence in 1955 was 0.0033 per cent. It is interesting to compare this very low incidence with that of twenty-seven to twenty-nine years ago. Year Number of cases School Population Incidence 1926 117 50,279 0.23 1927 84 49,660 0.17 1928 78 48,939 0.20 THE WORK OF THE MINOR AILMENT CLINICS. There are three minor ailment clinics in the Borough, their location being as follows5- Balaam Street School Clinic, Balaam Street, Plaistow, E.13. Rosetta School Clinic, Sophia Road, Custom House, E.l6. Stratford School Clinic, 84 West Ham Lane, Stratford, E.15„ Open 9 a.m. to 12.30 p.m. Monday to Saturday ditto. ditto. A medical officer is In attendance at Stratford School Clinic and Rosetta School Clinic on Monday and Thursday mornings from 9 a.m. to 12.30 p.m. and at Balaam Street School Clinic on Tuesday and Friday mornings from 9 a.m. to 12.30 p.m. One of the difficulties to be faced by the assistant medical officer is that In the school he frequently has neither sufficient time nor suitable accommodation to examine some children as thoroughly as he would wish. The minor ailment clinic, serving as it does a group of schools, becomes the centre of school health work in the area. The minor ailment clinics are used for the examination of many different kinds of cases. These clinics have always been well-used for the treatment of minor ailments and although attendances are steadily falling a large number of children still come to them, referred mainly by head teachers. The cases are seen by the medical officers on their clinic sessions, and the bulk of the treatment is carried out by the school nurses. Although many of the conditions seen may be regarded as trivial their prompt treatment saves a good deal of minor disability and in some cases prevents a simple lesion becoming a major one. These clinics enable children with all kinds of minor ailments to be treated at a time and place which reduces to a minimum the loss of school time. The School Health Service is well placed for dealing with such conditions, as continuity of treatment is ensured through close association with the schools. Many troublesome conditions are treated expeditiously and often prevent further impairment of health. The chief conditions treated fall under three main heaaings:- Mlnor skin troubles of various kinds. These include the triad of ringworm, scabies and impetigo, together with a variety of other skin conditions. In the case of ringworm of the scalp and scabies there has been a spectacular lessening in numbers, but not so in the case of impetigo. Many children are affected each year with plantar warts. The incidence is three or four times greater among girls than among boys, and it is at its maximum between 11 and 14 years,, Similarly many children attend the minor ailment clinics in the summer with ringworm of the feet. This Is very troublesome and treatment is prolonged. Stress is laid on preventive measures. The few cases of scabies seen are referred to the special clinic for treatment. 118 Minor ailments of the eyes. These are mainly external diseases such as slight inflammatory conditions, sore eyelids, minor injuries and foreign bodies. In certain cases external eye diseases indicate eyestrain or debility, or unhygienic surroundings. Eyestrain can cause tired eyes, and these are rubbed more than usual, hence Inflammation results. With a general improvement in living conditions, in hygiene generally, and in the health of the children these diseases of the external eye are seen much less frequently than formerly. Some of these diseases are, however, according to their nature and severity, sen to the ophthalmic clinic for specialist attention. Minor ailments of the ears. These consist of small boils In the outer passage of the ear and which can be very painful, wax, foreign bodies (chiefly met with in the younger children) and the slighter degrees of earache and discharging ears. As with minor eye diseases these ear conditions are much less common than formerly. The more serious conditions, considered to require specialist attention are referred, subject to agreement with the child's family doctor, to the ear, nose and throat specialist. These serious cases are seen much less frequently than formerly and the aural specialist in his report notes a marked redaction In the number of chronic ear diseases In the Borough. Miscellaneous conditions . These form the bulk of the cases treated and consist of a very mixed collection such as bruises, sores, chilblains, boils, whitlows and minor injuries of various kinds, namely, cuts, abrasions and small lacerations. The above cases form the main mass of work at minor ailment clinics and the following figures give the number of cases of these kinds which were seen at the clinics during the year:- Skin Diseases 913 External Eye Diseases 192 Minor Ear Defects 156 Miscellaneous Defects 1,06l Total: 2,342 The total number of children who attended the three individual clinics for all purposes was as follows:- Clinic New Cases Stratford 1,126 Balaam Street 1,360 Rosetta 1,473 It is, of course, necessary for many of the children co attend on more than one occasion, and medical officers differ in the number of times they wish their cases to attend the clinic. Some indication of the volume of work carried out at these clinics will be obtained from the following tables- Clinic No. of Attendances Stratford 3,725 Balaam Street 6,839 Rosette 7,187 Total 17,751 119 This is a decrease over last year's figures. During the post-war years there has been a steady decrease in attendances, with the exception of 1951, as the following figures shows- 1946 41,746 1947 38,443 1948 36,165 1949 33,221 1950 28,605 1951 32,248 1952 26,160 1953 22,011 1954 18,760 1955 17,751 These welcome reductions may be attributed to a decline in the incidence of many of the conditions commonly treated at minor ailment clinics, as mentioned when dealing with ringworm, scabies, minor eye and ear diseases, and perhaps also to an increasing tendency to use the services of the private practitioner and the hospitals which are available { through the National Health Service, SCABIES. The incidence of scabies remains low. In recent years there has been a general reduction in the number of children with this disease. Six cases were discovered this year as compared with one case in 1954, This gives rates of 0.02 and 0.003 per cent of the school population. The incidence in 1954 was the lowest ever recorded. Previous annual reports have shown the steady decline of this infestation from the wartime peak of 2,750 cases in 1942; it is interesting to compare the present incidence with that of the middle years between the wars when the rates were also low. To this end the following table has been compiled:- Year No, of cases School Population Incidence 1926 66 50,279 0.13 1927 82 49,660 0.16 1928 100 48,939 0.22 1951 25 28,178 0.09 1952 35 29,139 0.12 1953 3 29,653 0.01 1954 1 29,707 0.003 1955 6 29,487 0;02 REPORT ON THE WORK OF THE OPHTHALMIC CLINIC by Miss A.A.S.Russell, M.B., Ch.B., D.P.H., D.O.M.S. The work of the ophthalmic clinic continued as in previous years. As usual a large number of refractions were carried out and 1,475 pairs of glasses were ordered, but many more children were examined who either had suitable glasses or did not require them. In addition to the children having a full eye examination, many others are reinspected and many children make several attendances. The total number of attendances during the year was 6,336 and of these 5,303 were made by school children and 1,033 by children under school age. Children were admitted to whipps Cross Hospital for operative treatment where such was necessary and during the year 57 squint operations were performed on children from the West Ham clinic; 17 of these were on children under school age. The results of operation combined with treatment in the Orthoptic department were very satisfactory. 120 The work of the Orthoptic department has been carried out by Mrs. palfreman and she had 2,547 attendances including 387 from children under school age. Of these there were 63 new patients under school age and 122 new patients among school children. Mr.Lauder continued with his duties as full time optician and he dispensed 1,094 prescriptions for new glasses; while 381 prescriptions were taken to outside opticians. In addition to measuring and fitting new glasses Mr. Lauder deals with a large number of repairs for broken glasses and many of the minor repairs or adjustments he carries out in the clinic. The number of attendances in Mr. Lauder's department amounted to 4,777. DEFECTIVE COLOUR VISION. The Confusion Chart Test designed by Professor Shinobu Ishihara of Tokyo University and known as the Ishihara Test, Is considered a satisfactory test for general use in the School Health Service, and all our school medical officers are provided with an album of plates. This test has been used in West Ham for many years for children attending grammar schools and other higher schools; for boys who have entered for Sea Training Scholarships, and for those children who propose entering services where correct colour discrimination is necessary. Defective colour vision Is of fairly frequent occurrence in boys - about one in ever twenty being affected, but in girls it is much less common. Since it is a severe handicap in certain occupations it is clearly in the child's interest that it should be discovered before his career is decided. The test, which is given quickly, easily explained and understood, is given at the age of 14 years and can be carried out in an ordinary room in good daylight. In many cases, the boy and parent, when informed of the defect state that they are aware of It and they often explain in various ways how they became aware of it. When a defect is found the parent is advised and the hea teacher informed , The colour defective boy may be at a serious disadvantage in any profession or trade which demands accurate colour discrimination and because of this the test is given In good time to prevent boys from preparing for occupations for which a colour vision defect might render them unsuitable. Among the various industries in which colour discrimination is Important are the following - textile manufactures, electrical trades, paper making, photographic industries, printing, printing ink manufacture, the paint industry, painting, build and allied trades, the chemical industry and in various industrial laboratories. In certai: occupations the defect might endanger the safety of others. In some grades of the Royal Na' Royal Air Force apd the Railways normal colour vision Is required. At the examinations held at the grammar and technical schools during the year the following results were obtained:- Number examined Colour Defective Percentage Colour Defective Boys 507 27 5.32 Girls 644 Nil Mil The following figures relate to the findings during the last ten years;- Number examined Colour Defective Percentage Colour Defective Boys 8,309 449 5.40 Girls 8,429 10 0.11 121 During this period the boys were examined by the same medical officer, and the girls by the same medical officer except during the last two years. Some years ago the Ministry of Education sought the advice of the Faculty of Ophthalmologists on this subject and the following are some extracts from their recommendationss- (a) It is desirable that all children should be tested for colour vision some time during their school career. (b) Primarily, all children should be tested by the Ishihara method in good daylight, and all failures should be re-tested by a lantern test. (c) Ahy child who is colour blind should not be regarded as a disabled person." The standard School Medical Record Card (10M) has a space for the recording of "colour vision" and the school-leaving medical report to the Youth Employment Service also notes this subject and if the child is defective the medical officer indicates that the pupil should not enter any occupation involving normal colour vision. Defective colour vision does not render a child disabled under the Disabled Persons (Employment) Act, VISUAL SURVEY, A special visual survey was carried out under the auspices of the Royal College of Surgeons by Professor Arnold Sorsby and his co-workers at the Public Hall, Canning Town, during the years 1948 ana 1949. The work of this survey was referred to in the Annual Reports of those years and an evaluation of the findings was recorded in the Report for the year 1951. Further information resulting from the survey has been reported by Professor Sorsby in an article entitled "Incidence of Defects in Visual Function in Children and Adults" in the British Journal of Preventive and Social Medicine, January 1955• The conclusions to be drawn from this report so far as they affect the School Health Service are that the present systems of visual testing does succeed in detecting and bringing under control virtually all the defects which, in our present state of knowledge, are of practical importance} but that further advances may be possible, after investigation, in the detailed assessment of visual function for special occupational tasks and in the amelioration of other visual disabilities which are not at present usually assessed. If developments of these kinds become possible they might ultimately require some extensions of the school eye services, but for the present the arrangements seem well adapted to their purpose. REPORT ON THE WORK OF THE AURAL CLINICS by C.J.Scott, M.B., Ch.B., D.L.O. During the year, attendances were up to average at West Ham Lane clinic and below average at Rosetta Clinic. Children requiring operation were admitted to Whipps Cross Hospital, and the follow-up after operation continued at the clinics in the Borough. This arrangement is most satisfactory for the parents and allows for a close study of the result of operation. I am happy to report marked reduction in the number of chronic ears in the Borough. Perhaps the greatest value of these clinics is in the early recognition and treatment of deafness in children and it is only in clinics of this type that this important work can be carried out. Close study and follow up £s essential. An Audiology Wiit was inaugurated in May at Maybury Road Clinic, Plaistow. This unit meets once a month and is now working smoothly. It is hoped in this way to detect deafness in very young children and to institute early treatment and supervision. In all, I would say that 1955 has been a good year. 122 The Ear, Nose and Throat clinics are administered by the West Ham Group of the Hospital Management Committee but are held on the West Ham Education Committee premises as follows:- HEARING OF SCHOOL CHILDREN. The methodical testing of school children by the gramophone audiometer ceased in November 1952 when the audiometrician resigned her appointment, but in the autumn of 1954 a school nurse was sent to one of the Divisions of the London County Council for training, and for the last two months of 1954 and the whole of this year has been engaged for four sessions a week in audiometric work in the schools. Her work is being efficiently carried out and it has been found that gramophone audiometry is well within the competence of a good school nurse. In the early part of the year Miss A.Smart, an audiometrician, was appointed and commenced duty on 21st February. Her work is divided between the School Health Service and the Regional Hospital Board, giving approximately half her time to each Service. Besides testing the children in the schools with the gramophone audiometer, the audiometrician also attends the ear, nose and throat clinics with the audiologist, the deaf school, the spastic unit and the audiology unit after its opening in May. Her specialist knowledge of pure-tone testing is taken advantage of in certain of these centres. As mentioned in previous reports the value of the gramophone (group) test is to ascertain the less obvious degrees of deafness which may in many cases be relieved by simple forms of treatment, rather than for the ascertainment of children whose hearing loss is such as to cause them to suffer educationally. In fact the audiometric surveys in the schools very rarely bring to light children whose hearing is so defective that they require education in a special school. The school medical officers, as for many years past, refer any cases of suspected deafness to the aural specialist and if he considers that there is any degree of deafness present a pure-tone audiogram is taken. Should the audiogram confirm a loss of hearing sufficient to justify special educational treatment the necessary steps are taken to ascertain the child as deaf or partially deaf and appropriate action is taken. Gramophone audiometry cannot be used for children much below eight years of age and in my report for 1952 I mentioned that some new technical advance would be needed. Since that time the trend has been away from gramophone audiometry to pure-tone audiometry. The Medical Research Council's Committee on the Educational Treatment of Deafness has recommended the adoption of the sweep-frequency method. I hope that in my next Report I shall be able to mention, that a s'lart has been made with pure-tone screening. Stratford School Clinic, 84, West Ham Lane, E.15. Rosetta School Clinic, Sophia Road, Custom House, E„l6. Friday mornings 9 a.m. to 12 noon Monday and Tuesday mornings 9 a.m. to 12 noon 123 The following figures relate to the findings during the year - No. of children tested No. of children retested No. referred to School Medical Officers 4,887 1,649 447 1955 AUDIOMETRIC SURVEYS - COMPLETED INVESTIGATIONS For treatment For observation Refused investigation Removed from area before inv e stlga tlons completed No action Required Totals Defect Minor Aliment Clinic E.N.T. Clinic Hospital General Practitioner Assistant Medical Officer E.N.T. Clinic Recommended to sit In favourable position Cerumen 12 5 - 3 1 - - - - 1 22 No Hearing Loss - 2 - - 2 5 - - - 39 48 For Tonsil and Adenoid Dissection - 4 - - - - - - - - 4 Conductive Deafness - 1 - 3 2 7 2 - - - 15 Eustachian Tube Blockage - - 1 2 3 - - 1 - - 7 Mixed Deafness - - - - - 1 - - - - 1 Deafness due to mechanical obstruction - 1 - - - - - - - - 1 Familial Deafness - - - - - - 1 - - - 1 Deafness: Cause not known - 4 1 1 - - - - 1 - 7 Total Deafness one ear - 1 - - - - - - - - l Catarrhal Deafness 2 1 - 2 1 - - - - - 6 Deafness due to Perforated ear drum - 1 - - 2 1 - - - - 4 High Frequency Deafness - - - 1 - - - - - - 1 Otorrhoea - - 1 1 1 - - - - - 3 Rhinitis - 1 - - - - - - - - 1 Doubtful Defect - - - - - - - 3 1 - 4 Grand Totals: 14 21 3 13 12 14 3 4 2 40 126 ORTHPAEDIC AND POSTURAL DEFECTS. Children with more severe degrees of these defects were referred, as in previous years, to the orthopaedic surgeons at the Children's Hospital, Plaistow, Queen Mary's Hospital, Stratford, and various other special hospitals. In many cases insoles or wedging of the shoes were prescribed, while in a few cases orthopaedic operations were carried out. In certain cases, when specialist opinion is helpful, as in some handicapped children, it is willingly given by the specialists. Following the establishment of the Council's own physiotherapy service at the beginning of 1952, 111 children were treated at Forest Street, Grange Road, Maybury Road, and at the Elizabeth Fry Special school during the year. Cases known to have been treated outside the Council's scheme numbered 122. Cases so treated have progressively fallen from 311 in 1952 to 122 at the end of 1955. Four of these children were known to be in-patients in various hospitals. In accordance with the National Health Service arrangements surgical boots and orthopaedic appliances are provided by the hospitals when needed. PHYSIOTHERAPY. Mrs.A.M.Tootell, the superintendent physiotherapist, continued her work on a part-time basis. She attended three full days a week, approximately 89 per cent of the time being devoted to the School Health Service, The local authority clinic premises are equipped for artificial light therapy and treatment is given in Forest Street Child Welfare Clinic and Grange Road Child Welfare Clinic. Two clinics were held weekly at each of these clinics and at each of them both school children and pre-school children were treated. For a short period in the early part of the year three physiotherapists were working, Miss Murphy having commenced duty on 3rd February, and Mr.Boulton on 7th March, and in March the physiotherapy services were extended, two exercise clinics being put into operation, one at Forest Street Clinic and one at Maybury Road Clinic. The superintendent physiotherapist referred children to these classes from the children recommended for physiotherapy. The third physiotherapist. Miss Murphy, resigned on 28th April and from this date until 3rd October, when Miss Forrest commenced duty the following programme was In operations- Super int. endent Physiotherapist Physiotherapist Monday Grange Road Clinic Spastic Unit P.M. Spastic Unit Forest Street Clinic A.M. - Spastic Unit Tuesday P.M. - Spastic Unit A.M. Spastic Unit Spastic Unit Wednesday P.M. Spastic Unit Maybury Road Clinic Thursday A.M - Spastic Unit P.M. - Spastic Unit _ A.M. Spastic Unit Grange Road Clinic Friday P.M. Forest Street Clinic Spastic Unit 125 From the 3rd October there was again a full staff of three physiotherapists and at the beginning of December the physiotherapy services were again extended, Maybury Road Clinic coming into operation as an artificial light clinic, two sessions a week being devoted to this form of physiotherapy on Monday morning and Thursday afternoon. At the end of the year the following amended programme was in operation:- Superintendent Physiotherapist Physiotherapist Phys iotherapist (Mr.Boulton) (Miss Forrest) Monday A.M. Grange Road Clinic Maybury Road Clinic Spastic Unit P.M. Spastic Unit Spastic Unit Forest Street Clinic A.M. - Spastic Unit Spastic Unit Tuesday P.M. - Spastic Unit Spastic Unit A.M. Spastic Unit Spastic Unit Forest Street Clinic Wednesday P.M. Spastic Unit Maybury Road Clinic Spastic Unit A.M. - Spastic Unit Spastic Unit Thursday P.M. - Maybury Road Clinic Spastic Unit A.M. Grange Road Clinic Spastic Unit Spastic Unit Friday P.M. Spastic Unit Spastic Unit Forest Street Clinic Children are usually referred to the physiotherapist by the local authority medical officers. An increasing number of general practitioners refer cases. Specialists at a number of London hospitals also wish cases, chiefly asthma and bronchitis, to be treated at the local clinics to save the parents and children the trouble and time of travelling long distances. The consultant paediatrician and the ear, nose and throat specialist refer cases from time to time. Children with the slighter degrees of flat foot, valgus ankles, knock knees and poor posture are treated by remedial exercises, mainly in the form of exercise classes, massage is given when necessary. The classes for foot defects yield satisfactory results, and this lends support to the view that -these conditions, if dealt with in the early stages, can be more easily remedied and probably spared the need for later treatment at an orthopaedic clinic. Usually only the more severe cases are referred to an orthopaedic surgeon and for the past four years there has been a marked fall in the number of children so referred. Many cases of asthma, bronchitis and recurrent upper respiratory infection are given breathing exercises, modified according to the particular type of chest condition. A number of these cases, as also cases of general debility from many and varied causes are also given general ultra-violet irradiation. Artificial sunlight or ultra-violet irradiation as it is termed is given by a special type of mercury vapour lamp - "Centrosol" - which enables a number of children to be treated simultaneously in a group. All the above facilities, provided on premises which are easily accessible and well known to the parents and children, encourage acceptance of treatment at a stage when it will be really preventive. Much valuable work was carried out for many of the children at the Elizabeth Fry Special School, and these, together with the children in attendance at the Spastic Unit, and those attending the Unit as out-patients, were treated in the well-equipped Unit. As 126 will be seen from the amended programme two physiotherapists were in attendance at the Unit on every session except Monday morning and Thursday afternoon when only one wae in attendance. The physiotherapeutic services carried out consist of massage, manipulation and special exercises, and most of the children require individual treatment. In fact so much attention is given by the physiotherapists that they become familiar with the characteristic needs and responses of each individual child. Any of these children found to require ultra-violet irradiation are treated at the nearby Grange Road Clinic. Location of physiotherapy clinics and times of attendance. Forest Street Maternity and Monday and Friday 1.30 to 5«15 p.m. Child Welfare Clinic, Wednesday 9 a.m. to 12 noon. Forest Street, E.7„ Grange Road Maternity and Child Welfare Clinic, Monday and Friday 9 a.m. to 12 noon. Grange Road, Plalstow, E.13. Maybury Road Maternity and Child Welfare Clinic, • Monday 9 a.m. to 12 noon. Maybury Road, Flaistow, E.13. Wednesday and Thursday 1.30 to 5.15 p.m. The following figures relate to treatment given to school children during the years- Number treated Total number of treatments given Forest Street Clinic Sunlight 90 2,074 Massage and Exercises 55 659 Grange Road Clinic Sunlight 85 2,272 Massage and Exercises 50 689 Maybury Road Clinic ' Sunlight 10 54 Massage and Exercises 16 26 Elizabeth Fry Special School Massage and Exercises 41 6,414 At the West Ham Residential Open-Air School, Fyfield, Essex, a number of children with various chest complaints (asthma, bronchitis and recurrent upper respiratory infection) received special attention. The physiotherapist made occasional visits to the school during the year to mark progress. The guidance which she gave to the nursing staff so that they could continue the relatively simple treatment in between her visits proved satisfactory. Twenty-four children were treated at the school during the year. HEART DISEASE AMD RHEUMATISM. At the present time all conditions of the heart and circulation are grouped together under one heading on the child's medical schedule. During the year under review 43 cases were referred at periodic and special inspections for treatment and 64 for observation, these being 20 and 10 less respectively than -ast year and much less than the figures recorded only a few years ago. Separate statistics are available for the individual conditions making up the total, and it can be said that most of the defects consist of anaemia, chilblains and functional disturbances 127 of the heart of no serious import, and very few are organic lesions due to the effects of rheumatism. An analysis of cases seen by the paediatrician for the first time during the year showsthat only three children were found to have a heart condition, 1 was of congenital origin, 2 were found to have slight murmurs, the lesions being regarded as of no real significance, and could not be classed as cases of heart disease. This number is only half the number found last year. The statement can again be repeated that rheumatic fever, with its serious heart complications, is much less frequent than it was even a few years ago. Restrictions in activity are no longer being imposed because of heart murmurs of doubtful significance. No case of organic heart disease was recommended for heart hospital school but one boy with this condition was admitted to the Elizabeth Fry Special School during the year. REPORT ON THE WORK OF THE PAEDIATRIC CLINIC by E.Hinden, M.D., M.R.C.P. The work in the school health consultative clinics has followed the same pattern as in previous years. There is however a striking falling-off in the number of children referred to the clinics. I think this is due to a real improvement in the health of the young community. The patient work of clinic doctors and health visitors is now bearing fruit in healthier children, who are generally bigger and heavier than they were 20 years ago, and more resistant to infection. There is no doubt that the killing infections of infancy and childhood, diphtheria, tuberculosis, rheumatic fever are declining rapidly! but unfortunately the non-specific respiratory diseases such as the common cold, tonsillitis and bronchitis, are as active as ever and cause a good deal of invalidism and loss of school time. There are some unlucky children, who seem to recover from one cough only to start anotherj this is particularly true during their first year at school. This is because the child exchanges the closed family circle for free mixing with hundreds of other children, with consequent exposure to a very wide range of disease-producing agents. This cycle of head-colds tends to weaken during the second year of school life, and rarely persists after the age of There is some evidence that repeated bronchitis may have more serious effects. Some children develop a persistent low-grade infection of their lung bases, resistant to treatment, which produces an intractable cough and impairment of general health. These children also lose much time from school, and lack the wind to run about as vigorously as other children even when they are well} and they are very prone to acute exacerbations of their smouldering infection. But even these patients improve very much on a couple of weeks hospital treatment followed by convalescence, and generally recover completely at adolescence. We do not yet know the connection between this "ehronlc chest" in childhood and the chronic bronchitis of later life. I should like to express my gratitude to my colleagues, the assistant school medical officers for consulting me about their charges, and to the family doctors for their courtesy in permitting the referrals. I should also like to thank the pathologist at Whipps Cross Hospital and the radiologist at St.Mary's Hospital, Plaistow, for continuing to extend to me the facilities of their departments. The paediatric clinics are administered by the West Ham Group of the Hospital Management Committee but are held on the West Ham Education Committee premises as followss- Rosetta School Clinic, Wednesdays from I.30 to 5.15 p.m. Sophia Road, Custom House, E,l6. Stratford School Clinic, Thursdays from 1.30 to 5.15 p.m. 84 West Ham Lane, E.15. 128 It is not yet certain exactly how much benefit in the way of protection from tuberculosis can be expected from B.C.G. vaccination of school children. The object of the vaccination of the non-reactors to the tuberculin skin test is to produce in them a controlled primary focus of attenuated infection, with consequent development of acquired resistance, instead of allowing them to risk the dangers which are inseparable from natural, uncontrolled exposure to Infection by virulent tubercle bacilli in large numbers. The evidence suggests that B.C.G. vaccination probably affords a useful degree of protection to supplement all the other measures employed in the prevention and control of tuberculosis. The Medical Research Council has extended its thanks to all who helped and co-operated in the scheme. REPORT ON THE WORK OP THE SCHOOL DENTAL SERVICE by S.Maxwell Young, L.D.S., R ,C .S . During 1955, the main obstacle in the road to a thoroughly efficient and comprehensive dental service has been the shortage of staff. There has not been at any time more than three full-time dental officers, including the Senior Dental Officer, and very strenuous efforts have had to be made to keep open as many clinics as possible with temporary part-time officers. This arrangement, apart from making any long-term planning impossible, has created much administrative difficulty, such as the engagement of dental attendants, the curtailing of orthodontic work, transferring of patients and the opening and closing of clinics. Nevertheless, all the clinics, with the exception of Maybury Road, have been functioning during the year (Table A), and there has been a remarkable spreadover of service for the whole of the Borough. Hitherto, the Maternity and Child Welfare Service has been on what one might call a "chance passer-by" basis,, that is to say, the onus of requesting dental treatment was left to the mother-to-be or the toddler's parent; this was obviously unsatisfactory, as in the former patient's case, the request, when it did come, often came too late in pregnancy to be of any real good, and in the latter case, treatment was more often sought only as a relief from pain. In March, therefore, a pilot scheme was instituted at West Ham Lane (and later at Grange Road and Forest Street), whereby all expectant and nursing mothers and all toddlers who attended for routine medical examinations were given appointments to the dental clinic, where they were inspected and offered treatment if this was found to be necessary (Table B). In this way, much pain and sepsis was avoided by early treatment and the frightening effects of emergency treatment of toddlers was obviated. Most of the dental treatment of the expectant and nursing mothers was done during the evening sessions at West Ham Lane, of which there were five or six each week. It may not be out of place here to outline the basic policy of the Borough's dental service, so that the results achieved may be seen in their correct perspective. Were there a full complement of staff (i.e., 10 full-time officers, as recommended by the Ministries), then a comprehensive service could be offered to all the patients for whom "he Authority is responsible, but as there has not been even half this number at any one "ime, it is obvious that some form of selective service has to be substituted. How then to deploy the available forces, so that they will do the most good? It was decided, therefore, to offer comprehensive treatment to primary school pupils only, after routine inspections had shown that they were in need of it. No school child was to be refused treatment for the relief of pain and where a secondary modern, technical or grammar school pupil requested comprehensive treatment at a clinic, this was, as far as possible, to be given. 129 It was considered that this scheme had sufficient flexibility to meet fluctuating staffing and yet sufficient rigidity to permit a limited amount of planning. So far it has worked reasonably well, and it is very gratifying to see the large increase in the number of teeth saved and the corresponding fall in the number of teeth extracted. Incidentally, it may be mentioned here that a large number of the permanent teeth extracted have been removed for orthodontic purposes and as a part of a planned course of treatment. In June, a visit was paid by Dr.A.T.Wynne, Chief Dental Officer to the Ministry of Education. He was pleased to note the increased sessional output of work and the balance between the various types of treatment, but was disappointed to find that the West Ham Lane Clinic was still housed in the same building he had visited in 194-6 and had adversely criticised then. Early in the year a rationalisation of the supply and equipment position was undertaken under three main head trigs s- (a) Existing stocks of instruments, medicaments and materials were examined and any that were surplus to requirements or which were unlikely to be used were returned to the suppliers and credited. (b) An investigation into sources of supply was undertaken and a considerable saving was effected by ordering some goods which are in constant demand from different firms than previously. It must be emphasised that this was not done at the expense of quality. (c) An inspection of the major items of equipment revealed that it would be advisable to replace a number of obsolescent items by new ones? this to be done as finances permit. All dental officers have been encouraged to undertake as many orthodontic cases as they have felt they were able to manage without detriment to their routine conservative work, but it has always been emphasised to the parents that most pf these cases require, for their success, the whole-hearted co-operation of the child and parent; where this has not been forthcoming, the case has been dropped, as an unco-operative orthodontic patient can entail a considerable waste of time and money. The Principal School Dental Officer has supervised the majority of the orthodontia and has always been ready to advise on diagnosis and treatment. A number of more complex cases were referred for specialist advice to the London Hospital. Several cases required team-work of the dental officer, physiotherapist, speech therapist and ear, nose and throat surgeon, and through the Chief Assistant School Medical Officer, this liaison has been found to work very smoothly. Little has been done during the year in the field of dental health education on a large scale and this omission has been, in the main, deliberate; as the service cannot meet the demands already made upon it, how much less would it be able to manage, were there suddenly to be thrust upon it a large number of potential patients who had seen the light! In conclusion, I would like to record my appreciation of the unstinting efforts of the dental and clerical staff during the year to cope with the demands made upon them and also of the never-failing co-operation of the medical officers, nurses and teachers. 130 TABLE A Daytime Clinical Sessions West Ham Lane Dental Clinic (Surgery A) 442 (Surgery B) 342 (Surgery C) 480 Forest Street Dental Clinic 473 Rosetta Dental Clinic 384 Grange Road Dental Clinic 107 Total: 2,228 TABLE B Routine Dental Inspections of Expectant and Nursing Mothers and Pre-School Children Mothers Children West Ham Lane (Commenced in March) Inspected 73 298 Offered treatment 67 83 Grange Road (Commenced in October) Inspected 34 49 Offered treatment 32 12 Forest Street (Commenced in November) Inspected 16 70 Offered treatment 11 23 Location of Dental Clinics and times of attendance. Forest Street Maternity and Monday to Friday 9 a.m. to 5.15 p.m. Child Welfare Clinic, Saturday 9 a.m. to 12.30 p.m. Forest Street, E.7. (alternate weeks) Grange Road Maternity and Monday and Tuesday 9 a.m. to 5.15 p.m. Child Welfare Clinic, Wednesday 9 a.m. to 12.30 p.m. Grange Road, Plaistow, E.13. Closed 5th May 1955, Reopened 2nd November 1955. Wednesday 1.30 to 5-15 p.m. Thursday 9 a.m. to 12.30 p.m. Rosetta School Clinic, Monday, Tuesday and Wednesday Sophia Road, Custom House, E.l6. 1.30 to 4 p.m. Thursday and Friday 9.30 a.m. to 4 p.m. Stratford School Clinic, Monday to Friday 9 a.m. to 5.15 P.m. 84 West Ham Lane, E.15-. Saturday 9 a.m. to 12.30 p.m. 131 TUBERCULOSIS IN CHIIDHOOD. The number of children in whom active tuberculosis is found remains comparatively small but has shown no marked trend of recent years. The number of children found to be suffering from tuberculosis was 14 in 1952 and the same number was found in 1953; while in 1954 and this year the number was 13 in each year. A summary of the work of the West Ham Chest Clinic in this respect has kindly been contributed by Dr„D,J.Lawless, the Consultant Chest Physician;- Number of school children referred by assistant school medical officers 1 Number of school children referred by general practitioners 96 Number of school children examined as contacts l8l Number of school children found to be suffering from tuberculosis 13 The classification and disposal of the definite cases is set out below:- Resplrat-ory Npn-respiratory Active primary pulmonary tuberculosis 8 Symphysis pubis 1 Primary tuberculous pleural effusion 1 Peritonitis 1 Post primary active pulmonary Cervical glands 1 tuberculosis 1 These 10 respiratory and 3 non-respiratory cases were admitted to hospital. B.G.G.YACCINATION. In September 1950, the Medical Research Council began a controlled clinical trial with school leavers. The main object of the research was "to determine with precision tuberculosis mortality arising in each of the groups of the trial in the years following their first examination for the trial." West Ham children in their final year at secondary modern schools and nearly all of whom were aged between l4i and 15 years, took part in this investigation, and the procedure was described in some detail in my report for the year 1953. All children taking part in the trials, both positive and negative reactors to the intracutaneous skin test, are being followed up for some years, and are being offered an annual x-ray examination and a repeat tuberculin test. The Medical Research Council Team visited West Ham in June 195^ for the second annual x-ray and tests of the school leavers (Christmas 1951 and Easter and Summer 1952), and again in February and October 1955 for the third annual x-ray and tests of the school leavers (Easter, Summer and Christmas I95I and Easter and Summer 1952) Approximately 1,300 home visits were made by the school nurses during 1955. So far, a satisfactory proportion of the boys and girls have remained in the trials and much of the credit for this is due to the keenness and good work of the health visitors and school nurses who visit the children once a year in an attempt to sustain their interest and to enquire about their health at the time of the visit and during the previous interval. This work, which has often involved making repeated visits, has been painstakingly carried out, and the interest of the volunteers and their parents in the trial and their response to the invitation for x-ray, are a reflection of the effort made. The trial is still in progress and the first progress report presenting preliminary results after each participant had been in the trial for two and a half years, with supplementary Incomplete information up to four years, was issued in the early part of 1956. The results can be said to be most encouraging, and the investigation has provided evidence of the efficiency of B.C.G. in preventing tuberculosis in adolescents. It is hoped to give in next year's report a resume of the progress. 132 SPEECH DEFECTS. Miss R.Clarke, the senior speech therapist, continued her work at the main speech clinic; in addition two visits a week were made to the Spastic Unit. Miss A. Clarke, the assistant speech therapist, who commenced duty in November 1954-, was occupied mainly with the work at the Spastic Unit at the Elizabeth Fry Special School. The Spastic Dnit provides treatment for spastic children of all ages, particularly for those under seven years of age who are in the nursery class in the Unit. Physically handicapped pupils, .including those with cerebral palsy, who need treatment for speech defects are also treated at the Unit. The assistant speech therapist attends the Unit every morning and in the afternoons spends two sessions at the main clinic, two at the branch clinic at the Grange Road Maternity and Child Welfare Clinic, and one at the Gurney Special School where, in the past, it has not been possible to arrange for treatment. It is important that these educationally sub-normal children with speech defects should receive every help we can give them: on the whole they make slow but steady progress. Students from the West End Hospital for Nervous Diseases attend both the main clinic and the Spastic Unit. Speech therapy tape-recording machines have been in constant use during the year at both the main clinic and the Spastic Unit and are proving a great help in treatment. A record of the children's progress is kept while attending the speech clinic; as a means of demonstrating to the child his own speech pattern, and its gradual improvement during treatment, it provides great encouragement and an incentive to steady perseverance. A permanent record is made at the Spastic Unit of the progress of each child, by regular recordings every half-term. The special tape-recorder is most useful in demonstrating to parents in a most convincing fashion, exactly how much has been achieved by the patient work of the speech therapists. The close liaison between the speech clinics and other parts of the service, child guidance, nose and throat, paediatric and dental, which is so essential to its success, has continued to work smoothly under the guidance of the Chief Assistant School Medical Officer who attends the clinics and Spastic Unit from time to time. The number of children found suitable for speech therapy during the year was 78, and 62 were considered as no longer in need of treatment. Speech defects of a degree sufficient to warrant speech therapy do not commonly show themselves in very young children; and as was to be expected the number of referrals from the maternity and child welfare department remained low, but was higher than in the previous year. However, this year an experiment was started of dealing with these pre-school children in a group and so far it has proved successful. 133 The following programme was in operation during the year:- Senior Speech Therapist Assistant Speech Therapist Monday A.M. Spastic Unit Spastic Unit P.M. Main Speech Clinic Main Speech Clinic Tuesday A.M. Main Speech Clinic Spastic Unit P.M. Main Speech Clinic Branch Speech Clinic Wednesday A.M. Main Speech Clinic Spastic Unit P.M. Main Speech Clinic Gurney Special School Thursday A.M. Spastic Unit Spastic Unit P.M. Visiting Main Speech Clinic Frid ay A.M. Main Speech Clinic Spastic Unit P.M. Main Speech Clinic Branch Speech Clinic Saturday A.M. Clinical work and Visiting (alternate mornings) Clerical work and Visiting (alternate mornings) Location of Speech Clinics and times of attendance. Main Speech Clinic, Monday and Thursday 1.30 to 5.15 p.m. Greengate School, Tuesday, Wednesday 9 a.m. to 5.15 p.m. Cave Road, Plaistow, E.13. and Friday Branch Speech Clinic, Grange Road Maternity and Tuesday and Friday 1.30 to 5.15 p.m. Child Welfare Clinic, Grange Road, Plaistow, E.13, REPORT ON THE WORK OF THE SPEECH CLINICS by Miss R.Clarice, L.C ,S .T . The year 1955 has been a busy one at the speech clinic. Since the appointment of Miss A.C.Clarke in November 195^, it has been possible to give a better service to the Borough, by extending the number of clinics available to school children, and also to the handicapped child. There have been clinics for 9 sessions a week at the Greengate Speech Clinic, and 2 weekly sessions at the Grange Road Maternity and Child Welfare Clinic in Grange Road. There has also been daily treatment for the spastic children at the Elizabeth Fry Special School, and 1 weekly session for the children of Gurney Special School. Statistics: Number of children who attended Boys 130 Girls 29 Total: 179 134 Types of Defect Dyslalia 87 Stammer 38 Stammer with dyslalia 12 Stigmatism 12 Cleft palate 6 Hyperrhinolalla 5 Hyporhinolalia 1 Cerebral palsy 13 Deafness 1 Dysphonia 1 Miscellaneous 3 Discharged Improved 62 There has been an increased number of cerebral palsy cases at the Elizabeth Fry Special School, but so far it has been possible to arrange for them all to have regular treatment, with dally treatment for the more severe cases. Eighteen children received treatment at the school, 11 of whom were spastlcs in the Unit, It is often to be noted that some children with speech defects are very retarded in reading. Wherever possible these children are given individual reading lessons at the speech clinics as well as speech therapy so that they may have a chance to attain the standard required of their age at school. The children who receive this help are usually between the ages of 7 and 12 years, and are in big classes where it is quite often impossible for them to receive individual help from their teachers. The Increased ability to speak and read well, naturally gives the child Increased confidence at school, and often leads to a marked improvement in all school work. In the last year or two more very young children, between three and five years of age, have been referred for treatment. This year a small group for pre-school children was started. This is in the nature of an experiment but has so far proved successful. The children are given a little individual therapy, but they are also encouraged to learn, play and talk together, As well as improving speech, it is hoped that this treatment will prepare the child for school. Our thanks are due to all those who have co-operated in our work, and have helped us to bring relief to the speech defective child, CHILD GUIDANCE. This clinic is held at the Credon Road School, Plaistow, E.13. and is open daily (Monday to Friday) from 9.0 a.m. to 5^15 p.m. Dr.T,P.Riordan, the Medical Director of the clinic has kindly sent the following report on the year's work. 135 REPORT ON THE WORK OF THE WEST HAM CHILD GUIDANCE CLINIC by T.P.Riordan, MD., B.Ch., D.P.M. During the year 1955 the work of the Child Guidance Clinic for the most part followed the pattern of previous years. The bulk of the staff time and effort was again deployed on the provision of a diagnostic and treatment service, and no new ground was broken in the field of prophylaxis. Special features of the years activities were, an emphasis on individual therapy with children and sustained work with parents in cases needing long term treatment, the extension of remedial coaching facilities on the clinic premises, and a more effective link with the educational service. The table of statistics does not vary significantly from that of the preceding year and calls for little comment. The reduction in the number of children who attended for psychiatric interviews reflects the increase in individual therapy at the expense of group therapy. The current practice here is to use group therapy for most of the preschool and infant school children and for some of the adolescents. Individual therapy is reserved for the more difficult problems of maladjustment irrespective of age group. One such problem that received considerable attention during the year was encopresis. A small number of children with soiling as the presenting symptom was studied in some detail in an endeavour to indentify causative factors. The problem was found to arise in a different way in each case and no suggestion of a common causative factor emerged. The mother-child relationship was always disturbed and often the symptom appeared to be a vicarious means of satisfying an individual need denied a more direct and natural expression. In one instance in which maternal inconsistency and partial rejection was clearly a major stress, advice to the parents leading to a reduction in maternal anxiety and to father taking a greater share in the management of the child was followed by steady improvement. In another case in which maternal rejection appeared to be the important factor, the girl's incontinence was clearly linked with frustrated aggression. She described the feeling of a "quiet rage" as she soiled herself. The majority of the children with encopresis were boys and in general the mothers were intelligent, anxious and not consciously rejecting in their attitude. Usually, they were highly critical of themselves and often unaware of the critically expectant and over-close relationship they had with their sons„ Progress in the treatment of such situations was slow with periods of improvement and relapse succeeding each other often to the great distress of the parents. As the treatment relationship developed between child and therapist, visits to the clinic often evoked recurrences of soiling. More than one boy asked whether clinic attendance would finish if soiling ceased and more than one boy experienced satisfaction from his behaviour lapse. At this stage in the treatment it was often very difficult to dissuade parents from assuming that such attitudes on the part of the children called for immediate and severe corrective measures. More often than not untimely correction was meted out. This usually induced an immediate, but unsustained improvement in the child and brought about a setback in the progress of treatment. The decline in the figures for home visiting by the psychiatric social worker during 1955 caused concern, particularly to the psychiatrists who felt that the time and effort involved in doing this work was amply repaid by the insight such visits gave into the atmosphere of the home. However, as much home visiting could only be done in the evenings and out of the usual office hours, it was found more convenient and time saving to arrange for most of the social histories to be taken at the clinic by the psychiatric social worker. She then, was able to plan her work with the confidence that she could^fulfill a planned programme of interviews - psychotherapeutic,, social and educative - during her working hours. 136 As Mrs.Nathan, the Educational Psychologist has been attached to the clinic for five years now, and has had time to consider the ways in which her special skills can be utilised in this area, and with the time at her disposal, most of the rest of this report will be directed to her account of her work. The Educational Psychologist continued working six sessions per week. Her time is taken up by routine testing at the clinic of all children referred as well as by testing at schools of special cases where there is lack of parental co-operation or where mother is unable to bring the child to the clinic because she has to go to work. She also visits maternity and child welfare clinics to test some of the under school age children. With the introduction of the Griffith's Scale tests, she is now able to test very young babies, and this is helpful not only with those very young, but with older children who have the mentality of young babies. Apart from the value generally of an early prognosis, an assessment of the mental potential is very helpful in cases of proposed adoption. When testing school children, it is important not only to find out the child's innate ability, but also his achievement. Where achievement, as shown on standardized Scales is very much below ability, it is important to find the cause for this. The causes may be manifold - it may be emotional disturbance or difficult home background or some specific disability such as poor visual or oral perception or just simply missing a long period of schooling through some childish illness whilst in the infant school, and then being moved up to Junior department before the child is able to cope with the work there. Full investigation would decide whether the child needs psychiatric treatment or whether the treatment may have to be carried out by the psychiatric social worker through the parents or whether it is purely educational and has to be dealt with by the Educational Psychologist. Sometimes the treatment has to be carried out Jointly by two or even all three members of the Child Guidance team, according to the needs of the child. In cases of severe retardation, the Educational Psychologist may take the child on for remedial coaching. In these cases she has not only to find the right method for each child to make quick progress, but has to direct her coaching towards changing the child's attitude to learning and giving him confidence in his own ability. In this way she has managed often with only half-an-hour weekly coaching to get the child to cover a year's work or more in very few months. In one case of severe perceptual difficulty, a boy of ten at the time of referral has attended for two years, but he is now beginning to read and write. He is one of those cases who would, years ago, have been described as "word blind" and probably never learned to read and write. By arrangement with the Education Department, Miss Walker attends the Child Guidance Clinic for two days a week to help with remedial coaching under the Educational Psychologist's supervision. This has been of great help and made it possible to increase the number of children taken on for coaching. The Educational Psychologist also takes special interest in the remedial coaching classes now being established by the Education Department, in order to get the most value out of these classes the right selection of children is most important. Obviously, the very dull ones (below I.Q.85) who are very slow learners and usually immature should be dealt with at school in the lowest streams, and in small classes. Those above I.Q.85 whose achievement is below 15# of ability in reading, spelling or arithmetic would benefit most from the remedial classes, However, 137 the achievement of the children in our classes at present is below 25# of ability. In fact, most of the remedial work is at present carried out with children from 8 to 11 years whose achievement in reading and writing is practically nil. In order to select the children in most urgent need of remedial classes the Educational Psychologist started group testing of children in the backward classes of schools within easy access of the remedial classes centres. So far, this has been carried out in two schools only, but the results of the tests have been significant in-as-much as it showed that out of 46 children tested 15 were of probably E.S.N, level and 5 well above average, one of these of very superior ability (I.Q.IJO), One has to remember, however, that group testing cannot be considered strictly accurate, and that the 20 children at both extremes will have to be given individual tests on both Verbal and Performance Scales to get a more accurate assessment in order to place them in schools and classes that would be most conducive to their fullest development. This obviously, would entail time completely out of proportion to the six sessions available for all the Educational Psychologist's different activities as enumerated above. The growing confidence in the value of the Educational Psychologist's work by the different referring agencies can be seen from the fact that apart from the number of general referrals to the clinic, the number fbr psychological testing only is 88 this year as against 29 last year. The importance of mere Educational Psychologist's time to meet the demands of the Borough can therefore not be overstressed. The minimum needs are at least one fulltime and one part-time appointments. The shortage of staff not only of psychologists, but of child therapists and psychiatric social workers hampers the further development of the prophylactic function of the clinic. The enforced neglect of this aspect of the work detracts greatly from the total effectiveness of the organization. Where the principles of mental hygiene and the factors that contribute to maladjustment are understood by school teachers and parents, mental ill-health is discouraged, incipient difficulties noticed and dealt with early, and the general quality of co-operation from school and home improved. Experience at this clinic continues to support the view, now generally agreed, that the Child Guidance Clinic should do as much for the prevention of maladjustment as for its recognition and treatment. STATISTICAL SUMMARY OP ACTIVITY OF CHILD GUIDANCE CLINIC STAFF: Consultant Psychiatrists T.P.Riordan, M.D., D.P.M. {Medical Director) 4 sessions weekly Geo.Somerville, M.D., D.P.M. 1 session weekly J.E.Glancy, M.D., M.R.C.P., D.P.M. 1 " " Educational Psychologist Mrs.Nathan, Dip.Psych., A.B.Ps.S. 6 sessions weekly Psychiatric Social Worker Miss Mayne, B.A, (Full-time) Secretary Mrs .Peters (Full-time) 138 Psychiatrist's interviews at clinic 684 Psychologist's interviews at clinic 248 " testing interviews at school 60 " school visits 7 " tests for ascertainment of E.S.N, children 25 Psychiatric Social Worker's interviews at clinic 421 " " " home visits 47 " " " school visits 40 " " " other visits 9 Remedial coaching interviews (with Miss Walker) 126 Number of cases newly referred 204 " " " re-opened 37 " " " carried over from previous year 122 Waiting List 32 Total number of cases dealt with 331 AGE INCIDENCE Under 5 years 5 to 11 years 11 years + Cases carried over 7 83 32 New referrals 29 115 60 Re-opened 1 20 16 SEX Male Female Cases carried over 85 37 New referrals 135 69 Re-opened 28 9 SOURCES OF REFERRAL Cases carried over School Medical Officers 48 Head Teachers 27 Maternity & Child Welfare Department 6 General Practitioners 6 Children's Department 6 Education Department 4 Parents 9 Probation Officers 3 Hospitals 6 Others 9 139 New referrals and re-opened cases School Medical Officers 113 Head Teachers 37 Maternity and Child Welfare Department 24 General Practitioners 11 Children's Department 14 Education Department 14 Parents 8 Probation Officers 5 Hospitals 7 Others 6 INTELLECTUAL LEVEL OF CASES TESTED OTHER THAN THOSE REFERRED FOR ASCERTAINMENT ONLY Cases carried over New referrals and re-opened cases Above average 18 Above average 30 Average 58 Average 54 Below ayerage 27 Below average 50 E.S.N. 4 E.S.N. 25 TREATMENT Cases carried over New referrals and re-opened cases Individual 33 Individual 26 Group 16 Group 5 Both 9 Both Nil Remedial coaching 9 Remedial coaching 8 DISPOSAL Cases carried over from previous year Still under treatment 25 Closed 97 Improved 32 Not improved 3 Before end of treatment (improved) 2 " " " " (not Improved) 7 Never attended 10 Diagnosis only 29 Psychological test only 12 P.S.W. advice only 2 Covrt reports 2 Placement recommended 9 (West Ham Open Air School ) Fyfield 3) (Special School for ) E.S.N, children 2) (School for maladjusted 4) 140 Cases newly referred Still open 84 Under treatment 23 Partially Investigated 13 Awaiting treatment 16 Waiting List 32 Closed 120 Improved 6 Before end of treatment (improved) 1 " " " " (not improved) 3. Never attended 5 Diagnosis only 14 Psychological test only 88 P.S.W. advice only 3 Court reports 8 Placement recommended 9 (West Ham Open Air School Fyfield 1) (Special School for E.S.N. ) children 5) (School for maladjusted 1) (Spastic unit 1) (Institutional care 1) Cases re-opened Still open 18 Under treatment 4 Under investigation 14 Closed 19 Improved 3 Before end of treatment (improved) 1 " " " " (not improved) 1 Diagnosis only , 5 Psychological test only 8 P.S.W. advloe only 1 141 HANDICAPPED CHILDREN CATEGORIES OF HANDICAPPED PUPILS: SPECIAL EDUCATIONAL TREATMENT The several categories of handicapped pupils requiring special educational treatment were re-defined by revised Regulations made during the year 1953. The new definitions are quoted in the various sections dealing with the particular handicap. The main changes from the previous Regulations affected six categories of handicapped pupils. The definition of a partially deaf pupil was amended with a view to clarification. Previously, epileptic and physically handicapped pupils were so defined as to imply that they could not be educated in an ordinary school. In fact, many of these children can be educated in ordinary schools if special arrangements are made or facilities provided to enable them to overcome their particular difficulties. In practice it is, fortunately, rarely necessary to "ascertain" a child as epileptic and still more rare to take the drastic step of arranging special educational treatment for him. Few children are "ascertained" as physically handicapped, consequently there continue to be many vacancies at the Elizabeth Fry Special School. The definition of a pupil with speech defect was slightly simplified. Those children who stammer or who have other defects of speech are given treatment at the speech clinic to which they go while attending ordinary primary and secondary schools. In addition, the day special schools for educationally sub-normal and physically handicapped children are visited by the speech therapists so that any children needing treatment may have it. The usual treatment given at the speech clinics is not regarded as special educational treatment. The definition of delicate pupils was considerably broadened so as to make it a kind of residual category, covering all handicapped pupils who do not specifically come under any other headings diabetic pupils now come under this heading. The definition has also been extended to take account of the fact that some delicate pupils can be educated under the normal regime of an ordinary school but need a change of environment to make this possible, e.g., some asthmatics and diabetics. It may also open the way for a prolonged stay at a residential school for those children whose handicap is so severe that a change away from home is necessary - where the poor home circumstances have a good deal to do with their debility. Provision for diabetic pupils needing special care exists in boarding homes approved by the Ministerj and this category has now disappeared from the Regulations entirely as a separate entity. By livipg together these children can be given the careful medical supervision they need and can be trained to give themselves the correct dosage of insulin. BLIND AND PARTIALLY SIGHTED CHILDREN. A blind pupil is defined as one who has no sight, or whose sight is or is likely to become so defective that it requires education by methods not involving the use of sight. Blind pupils must be educated at a special school unless the Minister determines otherwise. A partially sighted pupil is one who, by reason of defective vision, cannot follow the normal regime of an ordinary school without detriment to its sight or to its educational development, but can be educated by special methods involving the use of sight. In classing a child as partially sighted both ophthalmic standards and educational needs are taken into account. 142 ASCERTAINMENT OF BLIND AND PARTIALLY-SIGHTED PUPII5. The medical examination for the ascertainment of blind and partially sighted pupils is carried out by a medical officer of the Authority in the same way as for any other category of handicap. As a preliminary step the recommendation of an ophthalmic specialist must be obtained, the specialist completing at the same time the revised form B.D.8. Form B.D.8, used for blind and partially sighted pupils, was revised in March, 1955 and the Minister of Education in his Administrative Memorandum No.4-93 dated 2nd March, 1955, hoped that local education authorities would normally ensure that a report on this revised Form by an ophthalmologist of consultant standing is available to them when they are considering the provision of special educational treatment for any pupil whose eyesight is thought to be defective. The former "certificate" in form B.D.8 has been supplemented by a "recommendation" as to the educational needs of a child under 16 years of age. The Minister, however, made it clear that this recommendation was only one factor, though a most important one, in deciding what special educational treatment was appropriate to a particular child. The responsibility both for ascertaining which children require education as blind or partially sighted pupils and also for the provision of special educational treatment, rests with the local education authority. For children whose visual acuity will have a bearing on the appropriate methods of education, the following represent the modern standardsj- (a) severe visual disabilities - to be educated in special schools by methods involving vision - 3/60 to 6/24 with glasses; (b) visual Impairment - to be educated in ordinary schools by special consideration better than 6/24 with glasses. When the form B.D.8 Is received by the School Health Service two copies are made. One of the copies is retained in the School Health Service and Inserted In the child's dossier; uhe original and the other copy is passed to the Chief Welfare Officer. This document is sent to the Chief Welfare Officer irrespective of whether or not the child is considered to be a handicapped pupil and irrespective of whether or not it is considered likely that the child would qualify for inclusion in the Blind Register after leaving school. If the ophthalmologist's opinion indicates that the child is likely to be ascertained as blind or partially sighted the normal procedure under Section 34 of the Education Act, 1944, is put into operation. In addition to the revised form B.D.8 the Local Education Authority have before them advice from the School Medical Officer and information from teachers and others who have known the child, and will consider his age, attainments and intelligence and qualities of character which may influenza his suitability for one school or another. The Authority has no schools of its own for the education of blind and partially sighted pupils owing to insufficient numbers, but where possible arrangements are made for these children to be admitted to day or residential schools conducted under other auspices. 143 Nursery education up to the age of six or seven years is provided mainly by the Sunshine Home nursery schools which are managed by the Royal National Institute for the Blind. At the age of six or seven children ase transferred to schools for the blind. The instruction for boys includes woodwork, basket work and modelling: for girls, housecraft, knitting, light basketry and simple sewing. Reading and writing are taught through the medium of Braille, arithmatic by a system of arranging types in a board, and geography by means of embossed maps. Typewriting is also taught at a later age. Certain pupils can continue their training beyond the age of sixteen and, in addition to typewriting, take up shorthand or telephony, pianoforte tuning, basket weaving or machine knitting. In the case of partially sighted children the curriculum resembles that in schools for children with normal sight. Written work is done by using chalk on blackboards or with thick crayon on large sheets of paper. Reading books with large type are used by the Junior children and a special reading lens on a stand is supplied for every pupil of secondary school age. The following figures relate to work carried out in connection with blind and partially sighted children during the year:- BLIND Number ascertained during the year Nil Number in residential special schools at the end of the year 2 Out of school 2 PARTIALLY SIGHTED Number known to the Authority during the year 10 Number ascertained during the year 1 Position at the end of the year: In day special schools 8 In residential special schools 1 Out of school 1 The incidence of partial sightedness for special educational provision remains fairly constant at 0.33 per 1,000 registered pupils. There is close liaison between the Chief Assistant School Medical Officer and the ophthalmologist on this subject. DEAF AND PARTIALLY DEAF CHILDREN. A deaf child is defined as one who has no hearing or whose hearing Is so defective that it requires education by methods used for deaf children without naturally acquired speech or language. A deaf child must be educated at a special school unless the Minister determines otherwise. In all the schools for the deaf the oral system of speech and lip reading is used. Those children who have enough hearing make full use of group hearing-aid apparatus in specially equipped classrooms and are supplied with individual hearing aids for personal use. The normal curriculum is followed as far as possible but with particular stress on speech training and lip reading and language development. Some of our children with the highest academic ability go at the age of twelve to a voluntary special school, the Mary Hare Grammar School for the Deaf, Newbury, which is the only one of its kind in the country, A partially deaf child is one who has some naturally acquired speech and language but whose hearing is so defective that it requires for its education special arrangements or facilities though not neoassarily all the educational methods used for deaf children. 144 This Includes lip reading and training in the use of individual hearing aids. Occasionally some of these partially deaf pupils return to ordinary schools and are able to work with other children, provided that they are placed in a favourable position in the classroom and continue to use hearing aids. Figures relating to work carried out in connection with deaf and partially deaf children during the year are set out below:- Number ascertained during the year: Deaf 4 Partially deaf Nil Disposal of ascertained cases: Admitted to day special school (Deaf) 3 Awaiting admission to day special, school (at present out of school) (deaf) 1 Number known to the Authority at the end of the year; In residential special schools (deaf) 6 In day special schools (deaf) 22 In day special schools (partially deaf) 7 Out of school (deaf) (This case is included in the disposal of ascertained cases) 1 EDUCATIONALLY SOB-NORMAL CHILDREN. These children are defined as pupils who, by reason of limited ability or other conditions resulting in educational retardation, require some specialised form of education, wholly or partly in substitution for the education normally given in ordinary schools. Children who possess limited intelligence and In consequence become retarded may make little progress in ordinary schools. The following figures relate to work carried out in connection with educationally sub-normal children:- Number ascertained during the year 16 Disposal of ascertained cases: In ordinary schools 3 Recommended day special schools 10 Recommended residential special school 2 Removed from the district 1 Number of cases known to the Authority at the end of the year: In ordinary schools 82 In day special schools 150 In residential special schools 13 Fresh admissions to special schools during the year: In day special schools 30 In residential special school 1 145 EPILEPTIC CHILDREN, The definition of an epileptic child for our purpose is one who, by reason of epilepsy, cannot be educated under the normal regime of an ordinary school without detriment to himself or other pupils. There are many epileptics whose disability is not so severe as to be incompatible with a normal school life, and it is in their best interests that they should he educated at an ordinary school. The more closely a child can live like his fellows the more likely he is to grow up mentally balanced with a normal healthy outlook. Many children with the less serious forms of epilepsy can be educated at ordinary schools if facilities are provided to enable them to overcome their particular difficulties. It is only when an epileptic is clearly unable to fit into an ordinary school and home life that he should be "ascertained" and the rather drastic step taken of arranging special education for him. Fortunately this is rarely necessary as will be seen from the figures given below. When epileptic children do require special educational treatment at a special school the Authority places them in the care of voluntary organisations who manage special establishments for epileptic people. Occasionally such a child is placed in the day special school for physically handicapped pupils. The number of non-ascertained cases of epilepsy known to the Authority is 53. Data relating to ascertained cases of epilepsy during the year may be summarised as follows:- Number of ascertained cases known to the Authority 4 Number of cases in residential speeial schools 3 In day special school 1 Number of fresh ascertainments during the year 1 PHYSICALLY HANDICAPPED CHILDREN. Physically handicapped pupils are pupils not suffering solely from a defect of sight or hearing, who by reason of disease or crippling defect cannot, without detriment to their health or educational development, be satisfactorily educated under the normal regime of ordinary schools. The purpose of a school for physically handicapped children is to provide an environment appropriate to their special needs; an environment where their particular disabilities may receive proper and continuous care while their education continues. The Authority maintains a day school for physically handicapped pupils. The curriculum includes opportunity for practical work and a full range of general and cultural subjects. Special equipment, furniture and apparatus are supplied to meet the needs of individual children; physiotherapy and remedial exercises and speech therapy are given to those requiring them. Fortunately, a number of children improve so much in health and in ability to conquer their handicap that they are able to be transferred to ordinary schools. Eight children were transferred to ordinary schools during the year. The following figures set out the position regarding physically handicapped children in the Borough during the year 1955s- Total number known to the Authority! (includes all children on register at any time during the year) Heart cases 10 Cripples 60 Miscellaneous 12 146 Physically handicapped children in residential special schools (including hospital schools so far as information is available}! Heart cases Nil Cripples 1 Miscellaneous Nil Physically handicapped children in day special schoolsi Heart cases 9 Cripples (non-tubercular conditions) 59 Miscellaneous 12 Out of school cases: Heart cases 1 Cripples Nil Miscellaneous Nil Fresh ascertainments during the year: Heart cases Nil Cripples 8 Miscellaneous 1 DELICATE CHILDREN. These are children not falling under any other category of the School Health Service and Handicapped Pupils Regulations, 1953, who by reason of Impaired physical condition, need a change of environment or cannot, without risk to their health or educational development, be educated under the normal regime of ordinary schools. So far as possible delicate children are sent for treatment to the West Ham Residential Open Air School, Pyfield; some are sent to convalescent homes approved by the Ministry of Education for long-term cases. Children suffering from asthma, bronchitis, debility, poor physical condition, anaemia and chronic catarrh do well at these residential schools. Figures relating to admissions to Pyfield and to convalescent homes will be found on pages 150 & 152. The number of children "ascertained" as delicate during the year was 118, and their disposal was as followsj- Admltted to West Ham Residential Open Air School 74 Admitted to other residential open air schools 3 In day open air school (other authority) 1 To Norway (International Help for Children) 3 Refused to go away 9 On waiting list at the end of the year 28 MALADJUSTED CHILDREN. These are children who show evidence of emotional instability psychological disturbance, and require special educational treatment in order to effect their personal, social or educational readjustment. Some children of normal Intelligence find difficulty in making good relationships with adults or other children either at home or at school. They are often retarded in school subjects and sometimes delinquent. Such children are first investigated at the Child Guidance Clinic and the diagnosis established. lhe special educational treatment required is advised by the clinic and often wholly or partly carried out there. A number of acutely maladjusted children need a period away from hone and in these cases the Authority make arrangements with voluntary organisations managing special schools or with independent boarding schools. The number of children "ascertained" as maladjusted during the year was 45 they were all recommended for admission to a residential school. 147 PUPILS SUFFERING FROM SPEECH DEFECTS. These are pupils who, on account of defect or lack of speech not due to deafness require special educational treatment. Children suffering from disturbances of speech need only be formally ascertained as handicapped pupils if the disability is so great that they need special educational treatment, i.e., some modification of the educational regime as distinct from medical treatment. No children were ascertained under this category during the year. Children who stammer or who have other defects of speech are given special treatment at the speech clinics to which they go while attending ordinary schools. The day special schools for physically handicapped pupils and educationally sub-normal pupils are also visited by the speech therapists so that any children needing the specialised treatment may have it. An account of the speech clinic appears on page 134. CHILDREN WITH MULTIPLE DEFECTS. Children handicapped by more than one defect often present a serious problem in arranging suitable education, as there are so few schools which specialise in the education of children with dual disabilities. There is a real need for further provision which can only be made on a national basis, since no authority is likely to have more than two or three children with any particular combination of disabilities. In the year 1955, three cases were known to the Authority. The particulars are as followsi- Elizabeth Fry Physically Handicapped Special School 1 boy, aged 11 years Physically handicapped, epileptic and educationally sub-normal. 1 girl, aged 14 years Physically handicapped (alopecia) and educationally sub-normal. 1 girl, aged 9 years Physically handicapped and educationally sub-normal jn addition two boys and two girls attending Gurney (Educationally Sub-normal) Special School were ascertained as delicate and admitted to the West Ham Residential Open Air School, Fyfield. EDUCATION SERVICES Close liaison with many of the education services is essential in the interests of the health and well-being of the pupils. Among those which present special considerations relating to physical or mental health are the nursery and special schools, the youth employment bureau and also the remedial classes for backward children mentioned on page 137 which come within the scope of the school psychological service. All these are the responsibility of the Chief Education Officer to whom I am indebted for much of the material in these sections of the report. SPECIAL SCHOOLS The Authority is responsible for the following special schools! Name of School Purpose for which used Gurney Educationally sub-normal Elizabeth Fry Physically Handicapped West Ham School for the Deaf Deaf and partially deaf West Ham Open Air School, Fyfield Delicate children 148 GURNEY SPECIAL SCHOOL This school caters entirely for educationally sub-normal pupils of all ages. The capacity of the school is 160. The maximum number on the roll during the year was 160. During the year 30 children were admitted by reason of educational retardation and 31 left. The leavers were dealt with as follows:- Twelve left at 16 years. No action. Twelve were notified to the Local Health Authority two by reason of a disability of mind of such a nature or to such an extent as to make them incapable of receiving education at school; ten as requiring supervision after leaving school. One committed to an Approved School. Three returned to ordinary school. Three admitted to residential schools. ELIZABETH FRY SPECIAL SCHOOL This school caters entirely for physically handicapped pupils of all ages. The capacity of the school is 100. The maximum number on the roll during the year was 86 of whom 18 were extra-district children. During the year 19 children were admitted to the school on account of a physical handicap, including 10 extra-district children; thirteen West Ham children and 1 extra-district child left the school, and 1 West Ham child and 1 extra-district child died. The West Ham leavers were disposed of as followsj- Returned to ordinary school 8 Left school at 16 years and reported to the Youth Employment Officer as Disabled Juveniles 3 Left district 2 An analysis of the causation of defect in 80 West Ham cases and 20 extra-district cases which were in the Elizabeth Fry Special School during the year 1955 is set out below:- Defect West Ham Extra-District Heart conditions 9 3 (congenital and rheumatic) Paralysis 17 4 Spastic conditions 17 10 Quiescent T.B. bones and Joints 10 Muscular dystrophy 5 Amputations 2 Fragilltas ossium 2 Miscellaneous conditions 18 80 20 The miscellaneous conditions include such cases as myositis ossificans, severe congenital scoliosis, Hand-Schuiler Christian disease, achondroplasia, post-vaccinal encephalitis, ectopiae vesicae, arthogryphosis, cerebellar tumours, congenital absence of limbs, post-operative rupture of liver and other defects. The incidence of physically handicapped pupils In the day special school remains fairly constant In the region of 2 Per 1,000 registered pupils. The Ministry of Education favour the retention of handicapped children in ordinary schools whenever possible and this is followed in practice. 149 ELIZABETH PRY SPASTIC UNIT This Unit, attached to the Elizabeth Pry Special School was opened in June, 1954. The Unit is under the control of the Head Teacher of the parent school and is a specially designed single-storied building. A full account of the Unit appeared in the report for 1954. The procedure for the admission and the attendance of pupils was also described at the same time. In addition to the children in the nursery class of the Unit a large number of pupils from the parent school attended for treatment in the large appropriately equipped physiotherapy treatment room and in the speech section. The progress of the children has been most satisfactory. As was to be expected, the Unit has aroused great interest, not only locally, but over a wide area and many visitors, both individual and in groups, have visited in order to observe its working. By the end of the year 12 children under the age of seven years were in the Unit. All were receiving physiotherapy and 11 speech therapy. Of these twelve cases five were extra-district. In addition four cases attended the Unit on an out-patient basis, one under two years of age. Of these four cases two were extra-district. WEST HAM SCHOOL FOR THE DEAF The capacity of this school, which also takes children from East Ham and contiguous areas of Essex is now 120 and the maximum number of children on the roll during the year was 88, including 58 extra-district cases. New additional buildings were brought into use during the year which increased the capacity from 70 to 120 pupils. Of the 94 children in attendance during the year, 24 West Ham cases and 48 extradistrict cases were regarded as deaf and 8 West Ham cases and 14 extra-district cases as partially deaf and suited for instruction with hearing aids. The admissions to and discharges from the school are set out below Admissions West Ham Extra-district Deaf 4 4 Essex Partially deaf Nil 4 Essex 3 East Ham Leavers Deaf 4 1 Essex 2 Barking Partially deaf Nil 2 Essex WEST HAM RESIDENTIAL OPEN AIR SCHOOL, FYFIELD During the year 63 West Ham boys and 48 West Ham girls were admitted, and 77 West Ham boys and 6l West Ham girls were discharged. Of extra-district children 27 boys and 11 girls were admitted and 28 boys and 14 girls were discharged. The West Ham children are relnspected by the area medical officers a few months after they leave the school to ascertain if their improvement has been maintained. Of the 95 who attended for examination, 88 showed continued improvement, but 7 children had not maintained their condition and were given the opportunity of having a further stay at the school. Children are admitted to the school each term and a few at mid-term. 150 During the year the Chief Assistant School Medical Officer made six visits to the school for the purpose of reinspeeting the pupils and carrying out Immunisations, I have again to report that It has been difficult to ascertain as "delicate" a sufficient number of pupils to maintain the school at its full complement; this again particularly applied to girls. There are several reasons that may possibly account for this happy state of affairs. The physical condition of the children has improved. It is most significant that of suspected cases of malnutrition referred to the paediatrician for Investigation no frank eases have been confirmed since 19^9. The provision of milk and meals in schools, a slow but gradually improving housing position, and a rising standard of living all help to improve the health of the child. Bearing these points in mind and with a fuller appreciation in the ordinary schools of the varying needs of individual children, the time is coming when there will be little need for open-air schools for "delicate" children. Our new schools can offer facilities similar to those found in open-air schools and there may not be much physical advantage in a transfer. It has always been necessary to send a certain number of children to residential openair schools and it Is significant that whereas formerly there were long waiting lists for these schools now there are vacancies. Residential school accommodation will always be required for a certain number of pupils who are severely handicapped - namely those suffering from asthma, bronchitis, chronic upper respiratory catarrh and the like. NURSERY SCHOOIS The Authority has four Nursery schools; two, the Edith Kerrison and the Rebecca Cheetham, of long duration; and two, Osborne Road and Station Street - previously Day Nurseries, of short duration. Children in attendance are examined quarterly and the results are set out below;- Number examined Number found to Percentage found to require treatment require treatment 616 19 3.08 When the children were examined for the first time during the year, their general condition, using the Ministry of Education classification, was assessed as followsj- Number examined Good Percentage Fair Percentage Poor Percentage 187 60 32.09 124 66.31 3 1.60 The percentage of poor general condition of these children corresponds with the reduction noted in connection with periodic inspections in primary and secondary schools during the past few years. It is interesting to note that this low percentage fits in with the findings at the special toddlers clinics given on page 45. The defects which are most frequently found at the medical inspections are bronchitis and upper respiratory catarrh, nose and throat conditions, and minor orthopaedic defects. The great importance of medical supervision of nursery schools lies In the opportunity to detect the earliest beginnings of disease at a stage when remedial measures are comparatively easy to apply and may prevent the development of more serious trouble. The aim of nursery education is to footer by means of carefully planned educational methods the fullest possible development of a child in body, mind and spirit between the ages of two and five. 151 Nursery schools do not set out to give formal instruction hut rather to produce a condition of willing readiness for such instruction, and so to prepare the children for the infantsr school. The carefully balanced diet at the midday meal, the afternoon rest, the regular medical inspections and the frequent visits to the school of a nurse who promptly reports any abnormality, all contribute to the physical and mental wellbeing of the children. Playrooms are as light and airy as possible, and whenever the weather permits most activities take place outside in the open air. Special attention is given to hygiene? each child has his own comb, face flannel and towel; high standards of personal cleanliness are set. The nursery school is to some extent an observation centre, both medically and socially, where the progress of health and development of character can be carefully watched and guided in the child's best interests. Facilities are also given to the medical officers to visit the schools from time to time to observe the environmental conditions and to make a critical assessment of their value in promoting health. It can be truly said that a well planned and well run nursery school with good open air life, plenty of space, adequate clothing for their "in-and-out" life, and a really high standard of feeding, will ensure the well-being of the children, increase their resistance to disease and reduce the risk of infection. NURSERY CLASSES After a period in which nursery classes were closed down three re-opened for the Autumn term - New City, Carpenters and Tollgate, Children uhder five are educated in these classes in primary schools. These classes are run on the same lines as nursery schools but must not admit any children below the age of three. It has been found that children from two to five years of age develop best in small communities which have some of the features of a good home, which provide a simple life where the children can find security and satisfaction, and where there are opportunities for caring for the children as individuals. Our aim is to provide an environment and regime which will be instrumental in raising the condition of these young children nearer the optimum and in reducing to a minimum the risks involved in bringing them together into groups. The findings at these nursery classes are similar to those in the nursery schools. CONVALESCENT TREATMENT Children are sent away mainly through the Invalid Children's Aid Associations occasionally a child is dealt with by the Jewish Board of Guardians. Children are also sent away for holidays in the summer to private homes through the Children's Country Holiday Fund. These cases, however, do not come within our convalescent scheme. Children who are sent to convalescent homes usually require short-term treatment. These children are generally below par and are classed as debilitated and need a change of environment. Some however, have had a recent illness such as influenza, bronchitis, pneumonia, or are troubled with attacks of upper respiratory catarrh, and are often recommended by their general practitioners for a change of air. The average length of stay is three weeks but in a few special cases an extension of a week or two Is requested. This is usually granted. The maximum stay is six weeks, Should a child be so debilitated as to require a longer stay than this then it must be admitted to a convalescent home providing educational facilities. The child would then have to be "ascertained" as delicate and dealt with under Section 34 of the Education Act, 1944. 152 The mothers take a great deal of interest in these convalescent cases and when invited to bring their children for purposes of re-inspection attend in good numbers. The results from such a short stay are generally very satisfactory and at reinspectlon the improvement had in most cases been maintained. The administrative arrangements have been in the hands of the West Ham branch of the Invalid and Children's Aid Association for some years, and have this year again been carried out in a most efficient manner. The personal interest shown by the staff, backed by their experience of such cases, has been much appreciated. During the year 146 children were sent to convalescent homes in the way described. EMPLOYMENT OP CHILDREN AND YOUNG PERSONS The present Bye-laws regulating the employment of children outside school hours were adopted by the Council in 1949. These Bye-laws made under the Children and Young Persons Act, 1933, replaced the Bye-laws made by the Council in 1934. Important alterations werej- (a) No child under the age of 14 years shall be employed. (b) No child shall be employed on any week-fiay except from 7 a.m. to 8 a.m. provided that the employment during this hoar is restricted to the delivery of milk, bread or newspapers. Other features of the Regulations are that Sunday is prescribed as a whole holiday and no child shall be employed on that day. No child taking papt in any entertainment in pursuance of a licence under Section 22 of the Children and Young Persons Act, 1933, shall be employed on the day or days of, or on the day following, such entertainment, in any other employment. No child shall be employed in any work out of doors unless he Is suitably shod and is suitable clad for protection against the weather. Furthermore, under Section 18 of the Act mentioned, no child shall be employed to lift, carry, or move anything so heavy as to be likely to cause injury to him. Employment of children in West Ham is restricted to the delivery of bread, milk or newspapers. Occasionally a girl is examined in connection with paper delivery. The medical officer carrying out the examination gives a certificate on the condition of the child at the time of examination and it is to the effect that the employment will not be prejudicial to the health or physical development of the child and will not render him unfit to obtain proper benefit from his education. In practice children from all types of school - grammar, technical, modern and special (educationally sub-normal) are examined in this connection. In the case of che special school child it is the higher grade child who is presented for examination. In practice over the years it is found that there are ordinarily very few children indeed who are fit to go to school but are not fit to undertake the one hour's employment on schooldays which is allowed by the Bye-laws of the Council. It Is very rarely that a child is found unfit. The number submitted for examination since 19^9 has progressively declined, the number in that year being 229, and for 1955, 64. The number of certificates granted for girls to participate in singing and dancing under the Entertainments Rules has remained fairly constant. The number examined during 1955 was 52. 153 THE SCHOOL LEAVER AND EMPLOYMENT - DNSUITABILITY FOR CERTAIN OCCUPATIONS The School Health and the Youth Employment Service work closely together during the last two years of the child's school life and one of the last duties which the former service does for a child on leaving school is to give the Youth Employment Officer an indication of the child's fitness for employment. The school medical officer, at the last inspection of the child at 14 years plus, makes out a general school-leaving report indicating appropriate unsuitabilities for employment. Twenty years ago the Board of Education issued an Administrative Memorandum in which it was agreed that the most useful form of advice to be given to the Youth Employment Officer was in terms related to the specific unsui-tability of certain children for particular types of work and that a list of such terms should be printed for use by the medical officer at the last routine examination of the children. The form which is used lists seventeen limitations to employment such as heavy manual work, sedentary work, exposure to bad weather, work in damp atmosphere, work in dusty atmosphere, work involving normally acute vision, work involving normal colour vision and so on. Any necessary investigations and treatment are carried out before a pupil leaves school. It is found in practice that limitations are most frequently recommended on account of eye strain and normally acute visiont nerrt in order of frequency are heavy manual work, exposure to bad weather, prolonged standing, much walking or quick movement from place to place, and work in damp or dusty atmosphere. Following the passing of the Disabled Persons (Employment) Act, 1944 the Minister issued a Memorandum dealing with choice of employment for handicapped children. A form was issued which listed the same seventeen unsuitabilities mentioned In the general school-leaving mediasl report and, in addition, a section for recording the nature of the child's disablement, its probable duration, and its bearing on the obtaining or keeping of suitable employment. This form, however, was not to be used without the consent of the parent or guardian. This form is used mainly for children in attendance at special schools, which are visited each term for the purpose of reviewing the capabilities of the school leavers. Registration under this Act gives the disabled juvenile a better chance of obtaining and keeping a job. During the year 8 reports were submitted for this purpose. The great majority of children subject to limitations for certain occupations have the general Form used for which no parental consent is required. MISCELLANEOUS Among other types of examinations may be mentioned the followingj- (a) Medical examinations of children boarded out in foster-homes or in the Children's Homes are carried out for the Children's Officer by medical officers of both the School Health and Maternity and Child Welfare Services, So far as practicable each cf the Children's Homes has a medical officer attached to it to take a personal interest in the welfare of the children and to give the occasional services required. During the year the medical officers of the School Health Service examined 49 children; (b) Medical examination of children prior to participating in school Journeys 311; all were found fit; (c) Examinations by medical officers and nurses in connection with the Children's Country Holiday Fund - 111; 154 (d) Medical examination of children In connection with the Committee's Holiday Camps - 440: one child was found unfit. (e) Medical examination of boys prior to engaging in boxing bouts - 550; four were found unfit to box. In addition, certain children brought before the Juvenile Court, are submitted by the Children's Officer for physical examination. The medical officers also examine entrants to the Council's service and applicants for admission to the superannuation scheme as well as duties in connection with the Council's Protracted Sickness Scheme. Finally, the medical officers carry out examinations for fitness of teachers, college students and nursery students. Candidates applying for admission to colleges are examined and a report on Form 4 R.T.C. Completed for sending to the appropriate college authority. Entrants to the profession completing an approved course of training are medically examined and a Form 28 R.Q. completed for sending to the Ministry of Education. In all these cases an x-ray examination is compulsory. Teachers entering the service of the Council from other authorities are also examined as to their fitness for employment. 155 156 APPENDIX I. CAUSES OF DEATH IN AGE GROUPS - 1955 (as supplied by Registrar-General). Causes of Death All Ages Deaths at different periods of life of residents (civilians) whether occurring within or without the district. Under 1 Year 1-5 Years 5-15 Years 15-25 Years 25-45 Years 45-65 Years 65-75 Years 75 and upwards M F M F M F M F M F M F M F M F M F 1, Tuberculosis, respiratory 22 7 - - - - - - - - - 3 12 3 6 1 4 - 2. Tuberculosis, other 1 - - - - - - - - - - - 1 - - - - - 3. Syphilitic disease 7 4 - - - - - - - - 1 - - 1 4 1 2 2 4. Diphtheria - 1 - - - - - 1 - - - - - - - - - - 5. Whooping cough - - - - - - - - - - - - - - - - - - 6. Meningococcal infections - 1 - - - - - 1 - - - - - - - - - - 7. Acute poliomyelitis - - - - - - - - - - - - - - - - - - 8. Measles - - - - - - - - - - - - - - - - - - 9. Other infective and parasitic diseases 1 - - - - - - - - - . 1 — - - - - - - 10. Malignant neoplasm, stomach 37 21 - - - - - - - - 3 - 20 5 9 6 5 10 11. Malignant- neoplasm, lung, bronchus 75 10 - - - - - - - - 4 - 40 3 23 6 8 1 12. Malignant neoplasm, breast - 15 - - - - - - - - - 2 - 4 - 6 - 3 13. Malignant neoplasm, uterus - 7 - - - - - - - - - 1 - 3 - 1 - 2 14. Other malignant & lymphatic neoplasms 88 61 - - 1 2 - - - 4 5 22 18 33 17 28 19 15. Leukaemia, aleukaemia 4 3 - - - - 1 - - 1 - - - 2 2 - 1 16. Diabetes 2 2 - - - - - - - - - 1 - 1 - - 2 17. Vascular lesions of nervous system 80 98 - - - - - - - - - 3 - 15 19 27 28 38 48 l8. Coronary disease, angina 131 73 - - - - - - - - 6 1 46 25 50 24 29 23 19. Hypertension with heayt disease 15 18 - - - - - - - - - - 2 3 7 7 6 8 20. Other heart disease 89 165 - - 1 - - - 1 - 4 8 15 13 20 25 48 119 21. Other circulatory disease 45 43 - - - - - - - - - - 9 9 16 9 20 25 22. Influenza 13 6 - - - - - - - - 2 - 2 1 4 1 5 4 23. Pneumonia 48 39 1 3 - - - - 2 - - 1 3 3 12 8 30 24 24. Bronchitis 85 41 1 1 - - - - - - 3 34 5 25 12 22 23 25. Other diseases of respiratory system 17 8 1 - - - - - - - 1 - 5 2 7 1 3 5 26. Ulcer of stomach and duodenum 13 8 - - - - - - - - - - 7 2 4 3 2 3 27. Gastritis, enteritis and diarrhoea 3 5 2 1 - - - - - 1 - - 1 - - 2 — 1 28. Nephritis and nephrosis 8 9 - - - - - - - - 1 1 4 3 1 3 2 2 29. Hyperplasia of prostate 13 - - - - - - - - - - - 1 - 3 - 9 - 30. Pregnancy, childbirth, abortion - 1 - - - - - - - - - 1 - - - - - - 31. Congenital malformations 7 7 7 2 - - - - - 1 — 1 - 1 - 2 - - 32. Other defined and ill-defined diseases 65 72 19 16 - - 1 1 - 1 2 4 11 17 16 16 16 17 33. Motor vehicle accidents 10 1 - - 1 - 1 - 2 - 1 - 2 - 1 1 2 - 34. All other accidents 15 7 2 — - - 1 - 1 — 5 1 2 1 - 3 4 2 35. Suicide 8 5 - - - - - - - - 2 - 5 2 1 1 - 2 36. Homicide and operations of war l - - - - - - - 1 - - - - - - - - TOTAL (All causes) 903 738 33 23 3 2 4 3 7 4 40 32 260 145 272 184 284 345 APPENDIX II Particulars of Bodies Received into the Mortuary During 1955 Month Number Received Males Females Over 5 yrs. of Age Under 5 years 1 Sent in by the Coroner Sent in by the Police Sent in for Sanitary Reasons No. of PostMortem Examinations held No. of Inquests Held No. of Bodies Temporarily Embalmed January 37 26 11 34 3 32 5 - 37 4 3 February 34 20 14 31 - 28 6 - 34 5 1 March 44 30 11 37 7 39 5 - 44 7 3 April 22 16 6 21 1 15 7 22 8 1 May 27 11 16 27 - 23 4 - 27 5 4 June 18 13 5 18 - 17 1 - 18 1 2 July 14 7 7 13 1 14 - - 14 2 1 August 18 13 5 15 3 14 3 1 17 4 2 September 21 13 8 20 1 18 3 - 21 3 1 October 19 10 9 19 - 18 1 - 19 5 1 November 24 14 10 24 - 20 - 24 2 1 December 34 23 11 30 4 28 6 - 34 5 3 Total 312 196 116 2 92 20 266 15 1 311 51 ► 23 157 APPENDIX III STATISTICS RELATING TO THE SCHOOL HEAITH SERVICE COMPARISON OF CERTAIN TYPES OF WORK CARRIED OUT IN THE YEARS 1952, 1953, 195^ AND 1955 School Populations 1952s 29,135 1953: 29,653 1954: 29,707 1955: 29,487 TYPE OF WORK Number of cases dealt with 1952 1953 1954 1955 Periodic Medical Inspections 9.264 9,032 9,110 8,072 Special Inspections and Reinspections 15,905 16,265 14,463 12,088 Nutrition Surveys by school nurses 28,899 36,600 22,769 20,629 Uncleanliness Inspections by school nurses 62,525 58,296 68,839 68,971 Percentage of children found unclean 6.5 4.6 2.95 2.59 Minor ailments treated at the school clonics 4,683 3,888 3,145 2, 3l2 Attendances at minor ailment clinics 26,160 20,132 18,760 17,751 Tonsil and Adenoid operations known to have been 188 228 451 218 Orthopaedic defects known to have been treated at hospital orthopaedic clinics 311 192 172 118 Orthopaedic defects treated at the Council's physiotherapy clinics 124 114 96 111 Cases treated at the Light clinics 92 190 182 185 Admissions to West Ham Open-Air School, Fyfield 141 141 149 119 Reinspections at West Ham Open-Air School, Fyfield 803 814 821 811 Reinspections of children on return from West Ham' Open-Air School, Fyfield 153 132 73 95 Children examined for employment 86 93 78 61 Children examined for entertainments . 75 45 58 52 Children admitted to convalescent homes 197 119 104 116 Children found in need of speech therapy 82 91 58 78 Children referred to child guidance treatment 191 189 182 20I DENTAL WORK Children treated 5,700 5,468 4,701 5,009 Number of fillingsj Permanent teeth 1,108 886 2,162 5,205 Temporary teeth 379 250 1,329 2,613 Number of extractions! Permanent teeth 1,395 l,4o8 1,051 1,215 Temporary teeth 6,518 5,903 5,702 1,762 Administrations of general anaesthetics 2,332 2,440 2,466 2,251 Other operations; Permanent teeth 3,158 3,318 1,312 3,693 Temporary teeth 3,820 2,651 544 1,189 Number of orthodontic cases treated 115 168 181 161 158 APPENDS IV SCHOOL HEALTH SERVICE STATISTICS RELATING TO INSPECTION AND TREATMENT OP NURSERY, SPECIAL, PRIMARY, SECONDARY AND GRAMMAR SCHOOL PUPILS, 1955. TABLE I Return of Medical Inspection A. Periodic medical inspection: Code Group No. examined Entrants 2,668 Second Age Group 2,329 Third Age Group 1,871 Total 6,868 Additional periodic inspections 1,204 Grand Total 8,072 B„ Other inspections: Number of special inspections 6,062 Number of reinspections 6,026 Totalj 12,088 C. Pupils found to require treatments Age Groups Inspected < For defective vision (excluding squint) For any of the other conditions recorded in Table IIA Total individual pupils Entrants 28 149 174 Second Age Group 146 82 220 Third Age Group 83 49 130 Total 257 280 524 Additional periodic Inspect ions 58 53 109 Grand Total 315 333 633 159 TABIE II A. Return of defects found by medical inspection in the year ended 31st December, 1955, Defect Code Number Disease or Defect Periodic Inspection No. of defects Special Inspections No. of defects Requiring treatment Requiring to be kept under observation Requiring treatment Requiring to be kept under observation 4 Skin 30 8 953 35 5 Eyes - (a) Vision 315 96 307 131 (b) Squint 48 24 63 31 (e) Other 5 5 210 7 6 Ears - (a) Hearing 10 18 109 88 (b) Otitis media 3 10 42 18 (c) Other 4 3 86 7 7 Nose and throat 63 110 175 168 ' 8 Speech 25 59 84 121 9 Cervical glands 2 10 8 56 10 Heart and circulation 8 23 35 4l 11 Lungs 10 23 66 61 12 Developmental - (a) Hernia 3 10 2 7 (b) Other 3 23 5 57 13 Orthopaed ic - (a) Posture 16 13 21 33 (b) Plat foot 4i 20 4l 69 (c) Other 31 48 68 56 Nervous system - (a) Epilepsy 1 4 12 18 (b) Other 10 15 23 38 15 Psychological - (a) Development 2 12 103 108 (b) Stability 16 90 131 108 16 Other 70 181 1,781 434 B. Classification of the General Condition of children Inspected during the year in the Periodic Age Groups. Age Groups Inspected Number of pupils Inspected A (Good) B (Pair) C (Poor) No. % of col.2 No. % of col.2 No. % of col,2 (1) (2) (3) (1) (5) (6) (7) (8) Entrants 2,668 992 37.18 1,641 61.51 35 1.31 Second Age Group 2,329 868 37.27 1,441 61.87 20 0.86 Third Age Group Additional Perioc Inspections 1,871 ic 1,204 870 585 46 .50 48.59 978 598 52.27 49.67 . 23 21 1.23 1,74 Total 8,072 3,315 41,07 4,658 57.70 99 1.23 l60 TABLE III Verminous Conditions (1) Total number of examinations of children in the schools by the 68,974 (2) Number of individual children found unclean 765 (3) Number of individual children in respect of whom cleansing notices were issued 275 (1) Number of individual children in respect of whom cleansing orders were issued 18 TABLE IV Defects Treated Group 1, Diseases of the Skin (excluding uncleanliness) Number of cases treated or under treatment during the year By the Authority Otherwise Ringworm Scalp - 1 Ringworm Body 3 - Scabies 6 Impetigo 59 7 Other Skin Diseases 845 9*+ Totals 913 102 Group 2. Diseases of the Eye, Defective Vision and Squint Number of cases dealt with By the Authority Otherwise External and other, excluding errors of refraction and squint 192 29 Errors of refraction (including squint) - 1,419 Total: 192 1,448 Group 3, Diseases and Defects of the Ear, Nose and Throat Number of eases treated By the Authority Otherwise Received operative treatment (a) For diseases of the ear - - (b) For adenoids and chronic tonsillitis - 248 (c) For other nose and throat cond it ions - - Received other forms of treatment 156 381 Total; 156 629 l6l Group 4„ Orthopaedic and postural defects. (a) Number treated as in-patients in hospitals 4 By the Authority Otherwise (b) Number treated otherwise, e.g., in clinics or out-patient departments 111 118 roup 5. Child Guidance Treatment. Number or cases treated In the Authority's Child Guidance Clinic Elsewhere Ijumber of pupils treated at Child Guidance Clinics 331 5 Group 6. Speech Therapy Number of cases treated By the Authority Otherwise Number of pupils treated by Speech Therapists 169 13 Group 7. Other treatment given Number of cases treated By the Authority Otherwise (a) Miscellaneous minor ailments l,08l 138 (b) Other than (a) above;Hernia, etc. – 31 Epilepsy and other conditions of the nervous system 21 49 Cervical glands 3 16 Heart and circulation 17 25 Lungs 20 72 Other conditions not minor ailments 207 331 Total; 1,349 665 162 TABLE V Dental Inspection and Treatment (1) Number of pupils Inspected by the Authority's Dental Officers: (a) At periodic inspections 3,771 (b) As specials 3,547 (2) Number found to require treatment 5,839 (3) Number offered treatment 5,123 (4) Number actually treated 5,009 (5) Attendances made by pubils for treatment 16,364 (6) Half days devoted to Periodic inspection 33 Treatment 1,972 Total half-days; 2,005 (7) Fillings; Permanent teeth 5,205 Temporary teeth 2,613 Total fillings: 7,818 (8) Number of teeth filled: Permanent teeth 4,646 Temporary teeth 2,526 Total of teeth filled 7,172 (9) Extractions; permanent teeth 1,245 Temporary teeth 1,762 Total extractions: 6,007 (10) Administration of general anaesthetics for extraction 2,251 (11) Other operations Permanent teeth 3,693 Temporary teeth 1,189 Total of "other operations" 4,882 (12) Orthodontia: New Cases 161 Total attendances 1,676 Completed cases 59 163 INDEX Sub .1 ec t Page Adulterated Samples 39 After Care 73-83,88 Ambulance Service 71.72 Analgesia 59 Ante Natal and Post Natal Care: facilities provided for 45 Appendices 1-4 156-163 Artificial light treatment 126,158 Atmospheric Pollution 27 Audiometric Surveys 124 Audiology Unit 1,48 Aural Clinics 122 B.C.G. Vaccination 132 Births 1,5.6 Blind Children 142,144 Blind Persons 101 Blindness, Incidence of 101-106 Blood Tests 44 Bronchitis 5 Cancer 2,5,21 Cancer Education l,8l Care of Mothers & Young Children 44-57 Cerebral Palsy 108 Chest X-ray - Expectant Mothers 45 Child Guidance 135-141 Child Minders 51 Child Welfare 45 Chinese Egg Albumen 30 Clean Air Bill 1,27-29 Clean Food Advisory Association 99 Cleanliness - School Children 115,159 Colour Vision 121 Condensed Milk 40 Committees, List of 3 Consultant Clinics 47 Co-ordination of Maternity Services 60 Convalescence 53,76,79.91.152 Day Nurseries 51 Deaf Children 144 Deaths 5,6,56 Deaths - Causes and age groups 156 Delicate Children 147 Dental Treatment 1,46,129-131,158,163 Diabetic Liaison 98 Diphtheria 1,5.7.8-13 Diphtheria Immunisations 10 Disabled Persons (Employment) Act, 1944 154 Disinfection & Dlsinfestation 37-39 Domestic Fires 28,29 Domestic Help 84-86 Subject Page Domiciliary Midwifery 1,58-61 Dried Milk 40 Drugs 10 Dysentery 1,5,7,15 Ear, Nose & Throat Clinics 122 Ear, Nose & Throat Defects, and defective hearing 119,122,l60,l6l Education Services - Liaison with 148 Educationally Sub-normal Children 145 Employment of children and young persons 153 Employment of School Leavers 154 Elizabeth Pry Special School 149 Elizabeth Fry Spastic Unit 150 Epileptic Children 146 Epilepsy 107 Erysipelas 7,11 Factories Act, 1937 23-26 Fertilisers and Feeding Stuffs Act, 1926 4l,42 Following-up (school children) 116 Food Inspection 29 Food Poisoning 5,7,15,16 Food Samples 30,31 Food Unsound 30 Foreign matter in articles of food 32,33 Fyfield Open-Air School 150 General Health and Welfare Services 100-108 General Practitioners, Liaison with 98 Geriatric Liaison 98 Guardianship of Mental Defectives 93 Gurney Special School 149 Handicapped Children 49,142 Health Education 64,80 Health Visiting 1,62-65 Hearing of School Children 123 Heart Disease and Rheumatism 127 Home Nursing 1,66-68 Home Nursing Centre 67 Hospital Services - Liaison with 97 Housing 34-37 Housing Repairs and Rents Act, 1954 35 Houses - Unfit 35 Hygiene of School Premises 114 Ice Cream 31,32,40 Ice Lollies 32,40 Immunisations - Diphtheria 1,10,69-70 - Whooping Cough 10,69-70 Infant Mortality 1,5,6,57 Infant Welfare 45 Infectious Diseases 1,5,7 Jelly Tests (Tuberculosis) for Children 1,46 Laundry Service 67 Leavers (school) 154 Liaison 1,53,97~99 Subject Page Library Service 73 Lunacy and Mental Treatment Acts 91 Maladjusted Children 147 Malaria 7 Male Nurse 67 Mass Miniature Radiography 45,76 Maternal Mortality 1.5,6,56 Maternity Outfits 59 Maternity and Child Welfare 44-57 Analgesia 59 Audiology Unit 1,48 Blood Tests 44 Chest x-ray 45 Child Welfare 45 Convalescence 53 Day Nurseries & Child Minders 51 Dental Treatment 1,46 Handicapped Children 49 Health Visiting 1,62-65 Liaison with Children's Officers 53 Midwifery 58-6l Mothercraft Training 60 Perinatal Mortality 54 Physiotherapy 1,49 Premature Births 51 Relaxation Classes 60 Sunlight Treatment 49 Specialist Clinics 47 Toddlers' Clinics 45 Unmarried Mother and Child 45 Welfare Foods 53 Maternity Services - Co-ordination of 60 Measles 1,5,7 Meat Pies 33 Medical Examinations (staff) 109 Medical Inspection Rooms 113 Medical Inspection (school children) 110,158-163 Meningococcal Infection 5,7,14 Mental Deficiency 90,92-96 Mental Health 87-96 Mental Health Social Work 88-90 Midwifery 1,58-61 Milk, Samples taken 31,40,41 Minor Ailments (school children) 118,158-163 Miscellaneous Examinations 154 Mortuaries 157 Mothercraft Training 60 Multiple Defects (school children) 148 National Assistance Act, 1948, Section 47 100-108 National Health Service Act, 1946 44-99 Nose and Throat Defects (school children) 119,122,160, l6l Subject Page Nursery Schools and Classes 151,152 Nursing Requisites 83 Nutrition 114,158 Occupation Centre 91 Occupational Therapy 79 Ophthalmia Neonatorum 7 Ophthalmic Clinic 120 Orthopaedic and Postural Defects 125 Outworkers 26 Paedlatrlc Clinic 128 Paedlatrlc Liaison 98 Partially Deaf Children 144 Partially Sighted Children 142-144 Perinatal Mortality 54 Physically Handicapped Children 146 Physiotherapy 1,49,125 Pneumonia 5,7,17 Poliomyelitis 1,5,7,11 Population 1,5,6 Premature Infants 51 Prevention of Break-up of Families 64 Prevention of Illness, Care and After-Care 73-83 Preservatives 40 Psychiatric Club 90 Public Analyst, Report of 39~42 Puerperal Pyrexia 7,15 Pupil Midwives, Training of 60 Rag Flock 42 Refresher Courses - Midwives 60 - Health Visitors 63 Rehabilitation of Tuberculous Patients 75 Relaxation Classes 60 Removal of Persons in need of care and attention 100 Research and Investigation 116 Rheumatism 127 Ringworm 117 Rodent Control 37-39 Sanitary Circumstances 23-44 Sanitary Inspectors, Work of 43 Sausages 31 Scabies 120 Scarlet Fever 1,5,7 School Dental Service 129-131 School Health Service 1,110-153,158-163 School Leavers and Employment 154 School Nurses, Work of 114 School Population 110 Senior Staff, List of 4 Short-term Care of Mental Defectives 90 Site and Area 6 Smallpox 5,7 Subject Page Smoke Abatement 27 Spastics 108 Spastic Unit 150 Special Schools 148 Speech Defects 133,118 Speech Clinic 134 Statistics 5,22,54,124,156-163 Stillbirths 5,6,54 Sunlight Treatment 49 Supervision of Midwives 59 Swimming Baths 37 Throat Defects 119,122,160,l6l Toddlers' Clinics 45 Tuberculosis 1,5,7,17-20,46,73-79,132 After-Care 73-79 B.C.G. Vaccination 75 Convalescence 76 Deaths 5,7,17,20,156 Health Visitors 59 Jelly Tests for children 1,46 Notifications 17-20 Rehabilitation 75 School Children 132 Typhoid and Paratyphoid 5,7,16 Uncleanliness 115,l6l Unmarried Mother and Child, Care of 45 Vaccination 69 Venereal Diseases 22 Visual Defects 122,160 Vital Statistics 5,22,54,124,156-163 Voluntary Organisations, liaison with 99 Water Supply 23,41 Welfare Foods 53 Welfare and Health (General) Services 100-108 Welfare of School Children 112 West Ham Residential Open-Air School, Fyfield 150 West Ham School for the Deaf 150 West Ham Tuberculous Voluntary After-Care Committee 78 Whooping Cough 1,5,7 Workshop Facilities for Tuberculous Patients 76