BAR 68 Barking Town Urban District Council. THE OF THE School Medical Officer For the Year 1926. K. SIMPSON, M.D., Ch. B„ M.R.C.P., D.P.H. 3 SCHOOL MEDICAL STAFF, 1926. School Medical Officer: K. SIMPSON, M.D., Ch.B., M.R.C.P., D.P.H. Deputy School Medical Officer: MURIEL J. LOUGH, M.B., B.S., B.Sc., M.R.G.S., L.R.C.P., D.P.H. Orthopaedic Surgeon: B. WHITCHURCH HOWELL, M.B., B.S.. F.R.C.S. Radiologist: ANGUS E. KENNEDY, M.R.C.S., L.R.C.P., L.S.A. Dental Surgeon: W. W. F. DAWE, L.D.S., R.C.S. (Eng.). Masseuse: Miss A. E. FINDLAY, C.S.M.M.G. School Nurses: Miss L. F. SWAIN. Miss F. YOUNG (Dental Nurse). Miss S. E. W. GIBSON. * Clerical Staff: E. W. WINCHESTER (Chief Clerk). Miss A. SHAW. Miss V. SHEAD. Miss B. INGHAM. * ⅓ of Salaries charged to School Medical Service. 4 ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER. (1) STAFF. During the year Dr. Simpson continued as School Medical Officer, the remaining personnel of the School Medical Service suffering no change throughout the year. (2) CO-ORDINATION. (a) Infant and Child Welfare. The School Medical Officer and Assistant School Medical Officer are also Medical Officer of Health and Assistant Medical Officer of Health respectively. As pointed out in my Report for the past year— "The nursing staff of the Education Authority is not engaged "in the work of the Sanitary Authority, so that co-ordination in "the fullest sense of the word is not complete. Although the present "position is unavoidable, a distinct gain would result were the "school nurses employed also, as part-time health visitors, so that "the care of children of all ages up to 14, and in some cases even "later, could he carried out by the same nursing staff." The School Medical Service is run in close touch with the Maternity and Child Welfare schemes of the district, the Tuber culosis Dispensary, and the Barking Tuberculosis After-care Committee. (b) Nursery Schools.—There are no nursery schools in the district, but in certain selected cases children between 4 and 5 years of age were admitted to the Infants' Departments of certain elementary schools during the year. 5 (c) Care of Debilitated Children under School Age.— Orthopaedic treatment where necessary is available for children under school age, joint arrangements existing therefor between the Education and Public Health Committees, treatment required being given at the Orthopaedic Clinic of the Spccial School. Dental treatment and that for enlarged tonsils and adenoids is provided, the former, by arrangement with the Education Committee and available at the School Dental Clinic, the latter under similar arrangements to those for children of school age. The School Clinic for the treatment of Minor Ailments is available for children under school age by arrangement with the Education Committee. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. (3) SCHOOL HYGIENE. Excepting the Roman Catholic and Church of England Schools, the general hygienic conditions of the remaining elementary schools of the district can be considered satisfactory. Hygienic defects are more keenly felt in the case of the Roman Catholic School, which continues to be considerably overcrowded. Both schools lack, to some extent, open surroundings, and from the points of view of lighting, ventilation and heating, leave something to be desired. A site has been secured for an additional Roman Catholic School which, on completion, will go some way in minimising existing overcrowding at the present school. The New Park Central School commenced in January, 1926, was partially occupied on the 22nd November, 192G by the admission of 120 boys and 120 girls. The question of type of desk, blackboard, sanitary conveniences, water supply, etc., was dealt with at length in my Report for 1923. With the exception of the Special School, no facilities exist at any of the others for the drying of children's clothes or boots. 6 School. Number of children who do not return home for midday meal. Whether facilities exist for heating of children's meals. Whether facilities exist for the drying of children's clothes and boots. C.of E. Boys - No School fires in winter only. Girls — ,, „ „ Infants — „ „ „ Ripple— Boys - ,, „ „ Girls - ,, „ „ Infants - ,, „ „ Catholic Mixed 18-20 ,, „ „ Infants 4 ,, „ „ Gascoigne Boys 8 ,, „ „ Girls 2 Gas ring „ „ Infants — No „ „ Westbury Boys 4 ,, „ „ Girls — ,, „ „ Infants — ,, „ „ North Street- — Boys 5 ,, „ „ Girls 2 ,, „ „ Infants 2 ,, „ „ Crecksmouth- — ,, „ „ Castle— 40-50 Small stove in teachers' private room „ „ Faircross— All children stay at school for mid-day meal, the food being supplied from Municipal Kitchen Yes Yes 7 PROVISION OF MEALS. (i) A hot mid-day meal of two courses is provided for children attending the Special School, parents contributing to the cost thereof according to means. Meals are served in the Dining Hall of the School under the supervision of certain teachers, who, at the close of the children's dinner, are supplied with meals at a nominal charge. Food is cooked in the Municipal Kitchen, arrangements existing for keeping food hot during transit and at the school before service. The actual service of meals is in the hands of assistants, although selected children take part in its distribution. (ii) All but a few children as shown by the foregoing table can return home for the mid-day meal. (4) MEDICAL INSPECTION. The first table in the appendix shows the number of children inspected and ages at inspection, the Board's scheme being followed throughout. Every child is submitted to routine medical inspection three times during its school life as one of the fundamental functions of the School Medical Service, the system employed ensuring that no child is omitted. Briefly all the schools in the district are visited in rotation each term. Head Teachers sending to parents notice thereof according to an arranged programme. Parents are specially urged to attend the Inspection. The number of children examined as entrants, intermediates and leavers, besides those examined otherwise than during routine inspection, together with the percentage of defectives found, is furnished by the subjoined table:— 8  Entrants. Intermediates Leavers. Specials. Other Routine Examinations. Total. No. of children examined 1038 738 677 153 142 2748 No. referred for treatment 201 172 134 94 18 619 No. referred for observation 186 134 101 41 10 472 Percentage of defective children 37.2 41.4 34.7 88.2 19.7 39.7 The proportion of children, whose parents were present at school examination, was 60.7 per cent., compared with 65.5 per cent. daring the preceding year. The number of children on the school register on 31st December, 1926, was 6,855, compared with 6,794 on 31st December, 1925. During the year, the Medical Officer paid 116 visits to 22 departments for inspection purposes, examinations being con ducted throughout the year on the various school premises Certain cases of defect were, as in previous years, referred to the School Clinic for further examination and treatment. Very little disturbance of school routine is occasioned by these inspections, the convenience of teachers being followed as far as possible. The following table shows the number of children examined at routine and special inspections during 1926, classified according to the schools attended, the number of inspections held in each school and the number of parents or guardians present:- 9 COUNCIL SCHOOLS. School. No. of inspections. Numbers inspected. No. of parents present. Boys. Girls. Gascoigne 26 317 299 374 North St. 22 278 231 346 Castle 2 28 27 22 Creeksmouth 1 6 5 11 Westbury 22 302 282 367 Ripple 19 224 221 304 Faircross 4 79 63 60 VOLUNTARY SCHOOLS. Church of England 13 130 142 137 Roman Catholic 7 57 57 49 (5) FINDINGS OF MEDICAL INSPECTIONS. Table II, Appendix (a), gives a return of defects found during the course of routine examination. Of those examined at routine and special inspections, 1091, or 39.7 per cent., had some defect, and the actual percentage requiring treatment was 22.5. (a) Uncleanliness.—This defect in more recent years has shown a constant and satisfactory decline. Owing to the condition of some of the homes from which the children come, and of the other inmates, this defect cannot be stamped out by the School Medical Service alone. In this connection, close co-operation with the sanitary authority is valuable, though the homes of children are visited and parents instructed in the cleansing of heads, bodies, etc. as the case may be. Surveys under the above heading were carried out at (i) routine medical inspections, and (ii) special inspections conducted by the school nurses. (i) At the former, 299 children out of a total of 2,748, or 10.8 per cent., had nits in their hair, while 3 or 0.1 per cent. had head 10 or body vermin. As formerly, cases were seen at the School Clinic after exclusion by nurses or teachers, of which number 63 had nits and 76 head or body vermin. (ii) During the year the school nurses made 17,952 individual investigations, compared with 17,504 in 1925, of which number 198S children were found to have nits only, 131 harboured nits and head vermin, whilst 6 had verminous bodies and clothing. 278 visits in connection with uncleanliness were made during the year. For purposes of these inspections the various schools undivided between two school nurses, every school is fully inspected during each term, and the results of these examinations are as follows:— School. Dept. Nits only. Nits and Vermin (head) Body and clothing verminous. Gascoigne Infants 137 7 — Boys 43 3 1 Girls 268 11 — North St. Infants 112 10 1 Boys 30 4 1 Girls 151 5 - Castle Infants 56 6 — Boys Girls Creeksmouth Infants 12 - - Boys Girls Westbury Infants 132 13 — Boys 33 10 — Girls 208 8 - Ripple Infants 58 7 - Boys 19 3 — Girls 109 6 — C. of E. Infants 135 7 — Boys 41 1 - Girls 211 13 - RC. Infants 42 6 1 Boys 117 8 1 Girls Faircross - 74 3 1 11 Printed instructions are in all cases sent to parents or guardians of children excluded from school as result of verminous conditions, cleansing of the verminous person and clothing when necessary being subsequently undertaken at the School Cleansing Station. During 1926, 120 cases were dealt with. Clothing.—Children with dirty clothing numbered 14 or 0.5 per cert., compared with 10 or 0.47 per cent. in 1925. Children with defective footgear numbered 10 or 0.3. Cases of children with defective footgear were as heretofore referred to the Boots Minor Sub-Committee, who considered applications for the provision of boots in 198 cases, compared with 133 in 1925. In all 186 children were supplied with boots during the year. (b) Heights and Weights.—The following table gives the average heights and weights of children examined at the three undermentioned age periods in four of the schools, compared with the results at similar age periods in 1925. Age Period Average Height in inches. Average Weight in pounds 1925. 1926. 1825. 1920. 5 years 42.1 42.4 41.1 40.3 8 years 49.05 49.9 54.1 54.6 12 years 56.5 57.5 78.8 82.4 (c) Minor Ailments.—Minor ailments are seen, daily at 9 a.m., excepting Sundays, at the Clinic premises in East Street, the staffing of this Clinic being provided by nurses of the Plaistow Maternity Charity. For particulars of cases treated, see Table IV, Group I. Instances of uncleanliness found amongst children seen at this Clinic were those excluded by teachers, school nurses, or attendance officers prior to being re-admitted to school. 12 (d) Skin Disease.—The common skin diseases met with are Impetigo, Septic Sores, Seborrhoea, Scabies and Ringworm Table II gives the numbers found among the routine and special examinations. They amount to 1.6 per cent, among routine cases No case of Ringworm of the scalp was met with during the year. (e) Eye Diseases.—These diseases chiefly comprising Blepharitis, Conjunctivitis and styes, either indicate faulty personal hygiene or some error in refraction. They form a very important section of the minor ailments found in school children. Table II gives the findings under the respective heads. They amount to 25 among routine and special cases. (f) Vision and Squint.—169 cases of defective vision weft found and 26 cases of Squint, 135 and 16 cases respectively beirg referred for treatment. This gives 5.4 per cent, requiring treatment (g) Ear Disease.—Defective hearing is measured by means of the whisper test at 20 feet. 23 children, or 0.8 per cent., were found to be deaf, while 47 or 1.7 per cent., suffered from ear disease, the latter generally having discharging ears and a certain amount of deafness in consequence. Defective hearing is either due to wax or middle ear disease which is much more untractable, a third and very common cause of defective hearing being adenoids, the removal of which usually cures the deafness. The prevalence of ear disease among entrants amounted to 1.4 per cent. (h) Tonsils and Adenoids.—357 children, or 12.9 per cent of those examined, were found suffering from enlarged tonsilsor adenoids, or both, with such symptoms that it was found necessary to refer them for treatment or further observation Of cases referred for treatment, 185 were found on re-inspcctien to have been treated. As in former years arrangements for the operative treatment of post-nasal growths at the Threat Departments of St. Mary's Hospital, Plaistow, and Queen Mary's Hospital, Stratford, parents contributing to the cost thereot according to means. 13 Adequate facilities at either of these hospitals do not exist for the overnight detention of all children after operation. Home visits by the school nurses to children operated upon are paid on the patient's return home, while in certain cases children are brought home by ambulance after operation. A distinct advantage would result were this arrangement made a general one. The percentage of the above affection found among entrants was 17.5. (i) Tuberculosis.—The total number of cases of tuberculosis in school children notified to the Medical Officer of Health during the year was 50. During the year 27 cjses were referred to the Tuberculosis Officer, of whom 5 were subsequently notified as tuberculous. The total number of attendances by children of school age at the Dispensary amounted to 259, while during the year 11 children were recommended through the Essex County Council for hospital or sanatorium treatment. Quiescent cases of the disease were as in previous years admitted to the Open-air School, Faircross, and numbered 55. (j) Dental Defects.—The findings at Medical Inspection mostly relate to oral sepsis, i.e., gum boils and inflamed gums due to decayed teeth. These are matters of some urgency leading to digestive and other troubles due to absorption of purulent matter. The amount of dental trouble amongst entrants amounted to 42.87 per cent. This matter is further dealt with in the dental surgeon's report on pages 32 and 33. (k) Crippling Defects.—Marked deformities of such a degree as to cripple a child are becoming less numerous, as these conditions are being dealt with under the orthopaedic scheme now in existence in the pre-school age. Such defects as come to notice are found in Table II of the Appendix and consist of various degrees of flat foot, knock knee and spinal curvature. Cripple children are educated at the cripple class of the Special School, Faircross. (6) INFECTIOUS DISEASE As the School Medical Officers are also the Public Health Medical Officers, the occurrence of infectious disease is. known to them at once and steps taken accordingly. 14 Code: Articles 45 (b), 53 (b) and 57.—No schools were closed during 1925 for infectious disease, nor was the School Medical Officer required to submit any certificate under the Board of Education Amending Regulations, No. 2 (a), 1924, for purposes of apportioning grant. (a) Scarlet Fever.—78 children were reported in 1926, compared with 35 in 1925, the number of contacts excluded numbering 160. (b) Diphtheria.—35 cases were reported in 1926 compared with 37 in 1925, contacts excluded, numbering 68. (c) Measles and German Measles.—353 children were reported from schools during the year, compared with 61 in 1925. (d) Chicken-pox and Whooping Cough.—153 children were reported during the year. 533 home visits were paid by the school nurses in connection with infectious disease during the year, whilst 206 visits were paid by the sanitary inspectors in connection with notifiable cases. (7) FOLLOWING UP. Arrangements for following up cases of defect are as follow-: Children referred for treatment from routine inspection artvisited and advice offered the parents by the school nurses as how best whatever treatment may be necessary can be obtained Following-up cards are kept in respect of all children referred for treatment from routine or special examination, and on subsequent visits of the medical officer to the school such children are re-it) inspected as to whether treatment has been carried out and it results. Children for whom glasses have been prescribed are re-inspect": within three months of the original examinations. Children whose tonsils and adenoids have been operated upon are re-inspected at 15 the Clinic, the necessity for further attendance at hospital being thus minimised. Cases where treatment is not obtained elsewhere and which fall within the category of Minor Ailments are dealt with at the school Clinic. It is gratifying to notice that of the number of children referred for treatment during the year, 59.45 were found to have been treated, compared with 56.79 in 1925. A summary of the work of the two school nurses during the year is as follows:— No. of visits to schools 220 No. of visits to schools for medical inspection 116 No. of home visits in connection with:— (a) Routine Medical Inspections 2989 (b) Infectious Disease 533 (c) Uncleanliness inspections 278 (d) Non-attendance for treatment, etc. 603 No. of children cleansed at cleansing stations 120 (8) MEDICAL AND SURGICAL TREATMENT. The presence of defects having been ascertained, provision is made for treatment as follows:— Parents are notified as to what has been found, and requested to make arrangements for medical attention either locally, if possible, or with neighbouring hospitals or institutions. There are numerous conditions, minor ailments especially, which would escape attention altogether unless the authority arranged for their official attention. The number of cases referred for treatment will be found in the sub-divisions of Table II, while the numbers treated, and whether by the authority's scheme or not are set forth in Table. IV. 16 The methods adopted to secure treatment are the consistent following up of cases; the provision of clinics (set forth as under) and other items referred to in this Report such as transference fo. the Open air School, etc. in regard to dental work, there were as usual too many refusals. Parents do not yet appreciate the necessity of proper attention to teeth. It has not been necessary to institute proceedings in 1926, but much pressure has been necessary in some cases to secure that treatment is accepted even when offered Ifree In 1926 the various clinics established included:— 1. Minor Ailments Clinic, East Street.—Mornings on days at 8.30 o'clock. 2. Opthalmic Clinic, Central Clinic, East Street.— Half day, Saturday mornings. 3._ Throat and Nose.—Operations for tonsils and adenoids are carried out by arrangement with neighbouring institutions, no facilities for the purpose being available locally. 4. Examination Clinic, East Street.—For the further tion of special cases and cases referred from routine inspections which are seen at the close of the Minor Ailments Clinic. Examination of backward children and the subjects of suspected mental or physical dcfect are carried out by the School Medical Officer at the Public Offices. arrangements are made to suit the convenience of parents and others. 5. Dental Clinic, East Street.—Twice daily except one session per week employed on dental inspections at school 6. Tuberculosis.—By arrangements with the Essex County Council, the Medical Officer of Health is Tuberculosis Officer for the district. Suspected cases of tuberculosis are referred from routine inspections or from any of the 17 special clinics to the Tuberculosis Dispensary at 37, Linton Road. The Tuberculosis Dispensary is run in close touch with the open-air classes of the Special School, arrangements being made through the Essex County Council for appropriate cases being admitted to hospital or sanatorium. 7. Ringworm Clinic.—Attendance by arrangement at the rooms in Plaistow of the Radiologist, Dr. A. Kennedy. 8. Orthopaedic Clinic.—Massage, electricity, radiant heat, remedial exercises, etc., are provided for cripples and others at the Orthopaedic Clinic of the Special School during six sessions per week, when the masseuse is in attendance. Artificial sunlight treatment now forms part of the treatment of rickets, surgical tuberculosis, and various other debilitating conditions. Advantage is taken of the facilities provided at this clinic by the Public Health Committee for children under school age by arrangement with the Education Committee. Monthly visits to the clinic are paid by the orthopaedic surgeon for purposes of examining rew cases and those undergoing treatment. When necessary children from the Orthopaedic Clinic are admitted to Brookneld Orthopaedic Hospital, Walthamstow, and Queen's Hospital, Hackney, for operation or other special surgical treatment, facilities also existing for X-ray examination at the latter institution. Payment for Clinic Treatment.—By instruction of the Board of Education, the following scale of charges has been made:— (a) Spectacles—2/9 per pair. (b) Tonsils and Adenoids operations—5/- per operation. (c) X-ray Treatment—No charge. (d) Minor Ailments—1/- per 3 monttis alter 14 days free treatment. (e) Dentistry—6d. per extraction, and 1/- fillings or wiring. (f) Orthopaedic Treatment—No charge. 18 Free medical treatment will continue to be given where parents cannot afford to pay. During 1926 payments made in accordance with scale amounts to £92 15s. 3d. CLINICS.—The numbers of school children attending in 1926 were as follows:— Clinic. No. of children seen. Total No of attendances. Minor Ailments 1070 8085 Opthalmic 98 390 Dental 2365 2736 Ringworm 5 5 Orthopedic FOR EXAMINATION 30 1262 FOR TREATMENT 72 Minor Ailments Clinic. No. of days clinic was open 302 Total No. of attendances 8085 Dailv average attendance 26.7 No. of cases treated 1070 In the absence of local hospital facilities, this clinic continues to supply among school children an undoubted need within the district. Three nurses on the staff of the Plaistow Maternity Charity attend daily from 8.30 a.m. to 11.30 a.m. The work of the practitioner is encroached upon as little as possible, although cases do at times arise which must under certain circumstances be relieved The faulty state of the premises and the interference of the due efficiency of the work to some extent in consequence was derlt with in last year's report. Skin Diseases.—Most skin diseases fall within the group of Minor Ailments, the following being under treatment during the year:— 19 Ringworm. Scabies. Impetigo. Other Skin Diseases. Minor injuries. Head. Body. 7 13 15 209 125 197 Ringworm of the Scalp constitutes the most difficult problem to be dealt with necessitating in every case the services of a competent radiologist, the consensus of opinion now being that treatment other than by X-rays is of very doubtful utility, necessitating even if successful a protracted period of exclusion from school—six months or more. For parents who consent to X-ray treatment this is carried out by Dr. Kennedy. As previously, the cleansing station proved a valuable adjunct in the treatment of Scabies, 14 cases being dealt with during the year. Dental Defects.—Statistics dealing with the year's work will be found under Table IV, Group IV, of the Appendix, while the Dental Surgeon's Report appears separately on pages 32 and 33. Crippling Defects and Orthopaedics.—This subject has been specially dealt with by Mr. Whitchurch Howell, F.R.C.S., Orthopaedic Surgeon, whose report appears separately on pages 28 to 31. 11 monthly visits were paid by Mr. Howell during the year, while 159 sessions of 3 hours were attended by the masseuse. 13 children were treated by massage, 5 by electricity, 2(3 by re-educational exercises, while 8 children were admitted to Brookfteld Orthopaedic Hospital or Queen's Hospital, Hackney, for special surgical treatment. Ultra violet light forms part of the routine treatment for many conditions of and under school age, 13 of the former and 25 of the latter being so treated during the year. Total attendances at this Clinic during the year numbered 1,483. 20 Particulars of work done in connection with Orthopaedic Clinic. No. of visits by Orthopedic Surgeon No. of visits by Masseuse ATTENDANCES Primary Examination Re-Examination For Treatment Total School Children Under School Age School Children Under School Age School Children Under School Age 11 *159 30 17 123 20 1109 184 1483 TREATMENTS Massage Electricity Remedial Exercises Ultra Violet Therapy Radiant Heat Dressings and Splintage No. of Children No. of Treatments No. of Children No. of Treatments No. of Children No. of Treatments No. of Children No. of Treatments No. of Children No. of Treatments No. of Children No. of Treatments School Children 13 341 5 109 26 836 13 160 1 7 14 119 Under School Age 5 88 4 76 4 89 25 88 1 28 — — Admission to Orthopadic Hospitals On waiting List for Admission 31/12/26. School Children Under School Age Total School Children Under School Age Total 8 4 12 2 1 3 visits increased from 3 to 6 per week from 23/8/86. 21 Children on the Physically Defective Register may be classified under the following groups:— Atrophic and paralytic. Spastic. Tuberculosis (Surgical) Injuries. Congenital defects Severe heart affections. Acute infections. Others (including marked postural defects.) 11 8 9 1 3 4 4 2 (9) OPEN-AIR EDUCATION. (а) Playground Classes.—All schools including the Openair School have playground classes during the summer months when weather is suitable. Drill is also taken in the open when weather permits. (б) School Journeys.—No school journeys were undertaken, although several visits were paid to places of educational interest. (c) School Camps.—No school camps were held, but four holiday camps were held as in previous years at Hainault for necessitous children where short holidays of two weeks were followed by improvement in general health and physique. The children were medically examined by the staff prior to going to camp. (d) Open-air Class-rooms in Public Elementary Schools.— Apart from the class-rooms of the Special School which belong to the type of open-air rooms, none of the elementary schools of the district possess open-air class-rooms. To some extent this difficult}' is provided against in the classes of the Park Central School now in process of erection. (e) The. Authority possesses an Open-air School at Faircross, situated centrally and upon probably what is the highest ground of the district. During the year 186 children were on the register, 55 were admitted, and 95 sufficiently improved to permit of their return to ordinary elementary school. The school combines separate departments for delicate children and mentally and physically defectives, such cases being found from routine and 22 special inspections at school, besides those referred from the inspection clinic and tuberculosis dispensary. The general routine of the school was described in my Report for 1924. The benefit derived here is marked but slower than at a residential open air school, probably on account of the intervening home environment. (/) Residential Open-air Schools.—The Authority possesses no residential open-air schools. (10) PHYSICAL TRAINING. Since the resignation of Mr. Hoare, in 1924, no area organiser of physical training has yet been appointed. Physical training, which forms an important item in the child's school life is but at present represented in exercises on the Swedish drill principle which are given by teachers, no other satisfactory means existing for dealing with the minor postural defects met with during school life and remediable by simple appropriate exercises by a competent instructor. (11) PROVISION OF MEALS. Extra feeding in the form of milk, cocoa, cod liver oil, etc., is supplied to children attending the open-air classes of the Special School throughout the year, while all children at this school receive a hot mid-day meal. Under the provisions of the Meals Act, 1906-14, the of necessitous school children was continued as heretofore at the Municipal Restaurant. Dinners and breakfasts were provided a cost of 5d. and 2£d. each respectively. During the year 36,531 dinners and 52 breakfasts were supplied to 797 children, suitable cases being selected by the medical officers, school teachers, nurses and attendance officers. The menus in use are from time to time submitted for the approval of the School Medical Officer, and the various arrangements continue suitable and adequate for the purpose. 23 (12) SCHOOL BATHS. With the exception of the Special School which is provided with spray baths, no baths exist in any of the other schools. In connection with verminous conditions and scabies, baths and disinfestation are provided at the cleansing station Public swimming baths in East Street, belonging to the Council, are available for children attending the elementary schools on certain week-days during part of the year, when swimming instruction is given. (13), (14), (15) & (16). CO-OPERATION OF PARENTS, TEACHERS, SCHOOL ATTENDANCE OFFICERS, AND VOLUNTARY BODIES. The attendance of parents at the medical inspections throughout the year was 60.7 per cent., compared with 65.5 per cent. in 1925. The teachers take a kindly interest in the work of medical inspections in spite of the educational interruption in the course of duties, and their help is most valuable, while communication and mutual assistance are constant between the medical staff and the school attendance department. A large percentage of persons now realise that the School Medical Service is not in the position of a censor but rather that of a mentor, ready to help them in their difficulties as regards the health and welfare of their children. The number of parents actually refusing medical examination during the year was 29. The following is a brief resume of the work dene by the Society for the Prevention of Cruelty to Children in the district during the year:— Total number of cases investigated 7 (a) neglect 5 (b) ill-treatment 2 (c) proceedings instituted — 24 There are no Children's Care Committees, the additional duties which are usually carried out by such voluntary bodies, being carried out as far as possible by appropriate Sub-Committees, of the Education Authority. An After-care Committee has been formed in connection with children attending the special school. (17) BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. (a) Children subjects of the above defects are ascertained through routine medical inspection or in more severe cases necessitating school absence through the activities of attendance officers, the information so acquired being passed to the school medical officer, when any subsequent arrangements necessarv for the child's disposal are made. Arrangements exist whereby exceptional children may, if necessary, attend non-residential certified schools or classes outside the district, and 7 deaf and dumb children so attended at Frederick Road Centre, Custom House, during the year. The number of blind and deaf children maintained at residential institutions during the year was 3. The number of blind and deaf children in this district is insufficient to justify the provision of special classes for these defects locally. The number of known epileptics of all grades is 18. Unless the defect is of quite a minor character (when the child may attend an ordinary elementary school), epileptic children can only satisfactorily educated in special residential schools or colonics. Where epilepsy is combined with mental defect, the disposal of such cases is difficult, since few institutions throughout the country are prepared to receive them. One epileptic child was examined during the year. The child also suffered from spastic hemiplegin of the left leg and was recommended as unsuitable for any school The question of mentally sub-normal and mentally and physically defective children was considered at length in my Report for 1924. 25 During the year, suspected mentally sub-normal and backward children were referred from various elementary schools to a temporary class at the Special School, and subsequently after a few months' observation submitted for more detailed examination by the School Medical Officer. During the year 19 such children came before the School Medical Officer, out of which number, and including those whose period of observation expired during the year, 7 were certified mentally deficient, and arrangements made for their admission to the special class for such children. Mentalfy defective Children.—11 children were examined as to their mental condition during the year, all of whom were certified educable and arrangements made for their admission to the special class. During the year one child attending the Special School was notified to the Local Control Authority as having attained the age of 16 years, while 2 cases left school on attaining the age of 16 years. The number of physically defective children in attendance at the. cripple class was 42; 7 cases left the class on attaining the age of 16 years. The School Medical Officer examined and certified 20 cases suitable for admission to the cripple class, in addition to one case unsuitable for any school. (b) There are no educable mentally defective children in the district for whom the Education Authority is responsible and who are not either at the Special School or in residential institutions. Ineducable mentally defective children of school age come within the responsibility of the Essex County Council. (c) The question of the after-care of mentally defective children, i.e., after attaining the age of 16 years becomes the statutoryduty of the Local Control Authority, and is carried out by the Essex County Council who arrange for guardianship or institutional care in necessary cases. 26 Though no provision had up to the present been made for the after-care of blind or deaf children or cripples, an after-care Committee has recently been formed for that purpose. (18) NURSERY SCHOOLS. There are no nursery schools in the district. (19) SECONDARY SCHOOLS. The only secondary school in the district is the Abbey School, which comes under the Essex County Council. Arrangements exist whereby routine inspection is carried out by the School Medical Officer of the district. No arrangement exists with this authority either for "following up" or treatment of necessary cases. Details of inspections carried out are supplied from the following table:— Entrants. Intermediates (12 years old.) Leavers. (15 years old.) Boys. Girls. Boys. Girls. Boys. Girls. No. examined. 5 — 17 15 35 10 No. referred for Treatment . 2 — 2 5 16 8 No. referred for observation. — — — 2 1 5 Re-Inspections. Number re-inspected. Number found to have been treated. Boy3 11 5 Girls 13 8 (20) CONTINUATION SCHOOLS. There are no continuation schools in the district. 27 (21) EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. Milk and newspaper deliveries, general errands, hawking and newspaper selling are the usual forms of employment of children and young persons. In accordance with the Bye-laws of the Education Authority, 8 applicants of school age submitted themselves for examination prior to employment, of which number it was unnecessary to refuse any applicant on medical grounds. Street trading is permissible to boys of 15 years, although licence is refused girls under 16 years, no prior medical examinations being required of applicants. Certain conditions, however, such as mental defect, prevent street trading being engaged in. Legal proceedings during the year were instituted in one case for infringement of Bye-laws in respect of the employment of children, and in no case in respect of the employment of young jiersons in street trading. (22) SPECIAL ENQUIRIES. During the 3rd term a survey of school children was made to elicit the presence of rheumatism or its complications in children of various age groups, the report subsequently submitted being printed as an appendix to this report. (23) MISCELLANEOUS. Eight young persons, who desired to become bursars and student teachers, were medically examined during the year, out of which number no one was rejected on medical grounds. 28 REPORT OF THE ORTHOPAEDIC SURGEON. Orthopaedic Clinic, Faircross School, Barking. Essex. March, 1927. To the School Medical Officer. The year 1926 has shown a very definite increase in the amount of work undertaken by the Orthopaedic Clinic as will be seen on reference to the accompanying tables, and as a consequence it has been found necessary to double the number of attendances of Miss A. E. Findlay, the Orthopaedic Masseuse. The Ultra-Violet Lamp has now been installed, and is being used in the treatment of Rickets, Tuberculosis and other suitable cases, and the results are being investigated. It will now be possible to secure earlier admission to hospital, owing to the increase in the number of beds at my disposal since appointment as Honorary Surgeon to the Cheyne Hospital for Children, Chelsea. This institution is recognised by the Board of Education and the Ministry of Health as affording facilities for the combined treatment and education of cripples. Beds arc also still available at Brookfield Orthopaedic Hospital, and the Queen's Hospital for Children, Hackney Road. At the latter, I can obtain the expert opinion of Dr. Tindal Atkinson, Radiologist to the Hospital. Earlier ascertainment of crippling disorders is now made possible owing to the active co-operation of the medical officers in charge of the Infant Welfare Centres, and a number of local medical practitioners. Further advances are being made along the lines of the training and employment of the cripples, so that they may become self-supporting citizens. It is therefore humbly put forward that the Orthopaedic Clinic might now serve as an example which any public or voluntary body in Essex or elsewhere might see fit to copy. 29 Thirty school children and seventeen children under school age were examined by me for the first time during the year, my findings being as follows:— SCHOOL CHILDREN. Diseases and Injuries of Bone— (1) Tuberculous Joints: (a) Knee 1 (b) Hip 1 (c) Spine 3 5 (2) Osteo-myelitis Humerus and Tibia 1 (3) Hallux Valgus 1 (4) Fracture—forearm (left) 1 8 Paralysis :— (1) Anterior Polio-myelitis— (a) Right Lower Limb 1 (b) Left Lower Limb 1 2 (2) Hemiplegia 1 (3) Diplegia 2 5 Congenital Deformities (1) Torticollis Rt. 1 (2) Club-foot R. and L. 1 (3) Winged Scapula—L. 1 (4) Webbed Hand R. and L. 1 4 Spinal Curvature:— (1) Scoliosis 2 (2) Kyphosis 1 (3) Kypho-lordosis 1 4 30 Various:— (1) Pes Planus 1 (2) Contracture of digits right-hand (resulting from severe burn) 1 (3) Injury to wrist with ulnar neuroma, right 1 (4) Cretinism 1 (5) Alopoecia 1 (6) Ringworm 1 (7) Glands (? T.B.) 3 9 Total 30 CHILDREN UNDER SCHOOL AGE. Rickets 10 Paralysis:— (a) A.P.M. (L.L.L.l-R.L.L. 1) . 2 (b) Erb's paralysis, right . 1 Congenital Deformities:— 3 (a) Club-foot 1 (b) Amputation of forearm, left 1 2 Tuberculosis of Spine 1 Glands 1 Total 17 123 school children and 20 children under school age were, re-examined by me during the year. The following operations have been carried out:— (a) School Children:— (i) Tenotomy-Tendo Achillis 2 (ii) Stoffel's-Median Nerve 1 (iii) Osteotomy-Phalanx Digit 1st R. & L. 1 (iv) Tenotomy, sterno—mastoid, right 1 (v) Osteotomy—elbow joint 1 Total 6 31 (b) Children under School Age:— (i) Osteoclasis, Tibia 1 (ii) Osteotomy—Femur R. and L. (Genu Valgum) 1 (iii) Osteotomy—Tibia R. and L. (Rickets) 1 Total 3 B. WHITCHURCH HOWELL, F.R.C.S. 32 REPORT OF THE SCHOOL DENTAL SURGEON. To the School Medical Officer. I beg to present my report for the year ended December 31st. 1926. The progress of dental treatment at the Municipal Clinic is extremely encouraging. From the total of 7,550 children examined in the nine schools in the area 3,736 were found to require treatment. This represents a percentage of 49.48, a decrease of 20 per cent. defective on the number in 1925. The number of parents accepting treatment for their children has increased considerably, and the percentage of children actually treated during the years 1924, 1925 and 1926, being 38.69 per cent., 52.36 per cent. and 63.3 per cent. respectively. This amply justifies the reorganising of the Clinic on a whole-time basis in that, since its institution, the percentage of parents refusing Clinic treatment has been nearly halved. There are still, however, only too many parents, as in all areas, not sufficiently enlightened to realise that it is as much a disgrace to allow a child to continue with a dirty mouth as with a verminous head. A disquieting feature of school inspection is the number of entrants found with defective teeth—of 842 inspected children of 4 and 5, no less than 361 or 42.87 were found to require treatment. This, in my opinion, may be accounted for to a great extent by artificial feeding in infancy and faulty diet subsequently. Artificial feeding only too often results in malformation of the soft bone of the jaws with consequent misplacement of teeth on their eruption leading to food lodgement and decay. With regard to diet in childhood a noticeable feature of the inspection is the extraordinary number of "mottled teeth" found in the area. This is thought by many authorities to be due to lack of lime salts in the local water supply, and this, in conjunction with neglect of fresh fruit and vegetables and milk in diet, results in faulty formation of the enamel covering the teeth thus rendering them more easily attacked by decay. The present cramped and none too clean clinic premises naturally form a deterrent to the attendance of patients and are distinctly discouraging to the staff. 33 The dental treatment of mothers, and children under school age, continues satisfactorily. The number of children under age, who have attended for treatment at the clinic, has doubled in the year as has the number of mothers supplied with dentures subsequent to extraction of teeth. Particulars of this work may be found in the subjoined table. Number of children treated under school age 80 Number of mothers who accepted treatment:— (a) New cases 119 (b) Old cases 556 Total number of Fillings 36 ditto Scalings 23 ditto Dressings 86 ditto Extractions 867 ditto Administrations of Anaesthetics:— (a) General 138 (b) Local 28 Number of dentures supplied 51 Number of sessions devoted to mothers, and children under 5 years 44 W. W. F. DAWE, L.D.S., R.C.S. (Eng.), 34 BARKING TOWN URBAN DISTRICT COUNCIL. Public Health Offices, Barking, Essex. 19th November, 1926, RHEUMATISM IN SCHOOL CHILDREN. As directed, I beg to report upon the question of Rheumatism in the school child, a disease with Cancer and Consumption responsible for roughly one-third of the Country's death rate. The following facts are interesting in the light of recent investigations:— 1.—The total number of deaths in England and Wales in 1924 attributed to heart disease and other affections for which rheumatism is responsible was 60,050, yielding the highest proportion per 1.000 deaths from all causes, while if deaths of the circulatory system be added (as probably in many cases the}' should be), the figure becomes still further augmented. Turning to local statistics for 1925, much the same ratio is found, 12.17 per cent, of the total death rate being due to cancer 10.62 (exclusive of diseases of the circulatory system), due to rheumatism, and 10.88 due to tuberculosis. 2.—Besides being a fertile cause of death at all ages, rheumatism is known to materially shorten life, 30 per cent. of all cases where the disease has been contracted in early childhood dying before the twentieth year, and a further 10 per cent. before the thirtieth year. At least 50 per cent. of all rheumatic cases develop and die from heart affections. 35 3.—One-sixth of the industrial invalidity of the country arises from rheumatic infections. The annual loss to the Approved Societies is £2,000,000 and the work lost to the members equivalent to three million weeks per year. Among the principal causes of rheumatism may be mentioned enlarged and septic tonsils in some 50 per cent. of cases, while dental sepsis, damp houses and damp clothing are correlated in the causation of the disease in a large proportion of cases. Rheumatism is common in all low lying and damp localities, an increased incidence of the disease in London having been shown to follow the course of the River Thames, and explaining probably some of the reasons for the prevalence of rheumatic affections in this neighbourhood. Through the kindness of Dr. Adshead, I am able to produce the following statistics relative to the prevalence of rheumatism in 784 school children examined during the last two months:— Of 245 "entrants," 15.1 per cent. were rheumatic. early symptoms being present in 9.3 per cent. and heart complications in 5.7 per cent. Among 259 "intermediates," 10.4 per cent. showed early symptoms, while heart complications had increased to 7.7 per cent. Among 280 "leavers" early cases had fallen to 5.7 per cent., while those with the more severe type of heart affection had then risen to 13.2 per cent. Among a school population therefore of 784, the percentage of those suffering from rheumatism may be said to be 17.4, while those leaving school with permanently damaged hearts would be 9.05 per cent., a state of matters in great measure preventable. I append the following suggested lines of prevention and treatment of this disease. 1.—In order to gain a better supervision of the growing child, it is necessary that the artificial barrier which now exists between the School Medical Service and Infant Welfare Departments be broken down, the same nurse-visitor becoming responsible for the care of all children from birth to fourteen years. Damage to health is most frequently done in those years immediately preceding the child's entry to school, as, for example, in the large number of 36 neglected conditions of the teeth and throat found in the entrant, and due very largely in my opinion to the loss of touch between these two departments which takes place during this transition period. 2.—Adequate means for the drying of children's clothes and boots should be provided in all elementary schools. 3.—A register of all known cases of rheumatism should be compiled, cases attending the school clinic for periodic examination in much the same way as patients attend the Tuberculosis Dispensary. 4.—There should be medical and surgical treatment suited to each case in school, home or clinic, and particular care should be taken to remove any local infection in teeth or tonsils. 5.—Parents and teachers should be informed of the significance of rheumatism and its early symptoms, of the dangers of neglecting growing pains, sore throats, anaemia, etc., the symptoms explained which indicate the possible onset of rheumatism, the importance of rest in its treatment, and other means which may be taken to guard a child from conditions such as damp rooms, damp boots and clothing which predispose to the disease. 6.—Lastly where definite evidence of heart disease is apparent, the child should be certified as a cripple and admitted to the Special School where appropriate treatment could be meted out for his condition. Although hospital accommodation throughout the country for the treatment of rheumatism is hopelessly inadequate, this lack may to some extent be surmounted locally by keeping such children under regular supervision at the Child Welfare Centre, the Special School and School Clinic, active and close co-operation existing between such Centres and a Care Committee, who, with the School Medical Officer, would advise in regard to the home and social environment, after care, upbringing and employment. K. SIMPSON, School Medical Officer 37 TABLE 1.—RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Number of Code Group Inspections: Entrants 1,038 Intermediates 738 Leavers 677 Total 2,453 Number of other Routine Inspections 142 B.— Other Inspections. Number of Special Inspections 153 Number of Re-inspections 1,295 Total 1,448 38 TABLE II.— A. RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED 31st DECEMBER, 1926. Defect or Disease. Routine Inspections. Special Inspections No. of Defects. No. of Defects Requiring Treatment. Requiring to be kept under observation, but not requiring Treatment. Requiring Treatment. Requiring to be kept under observation, but not requiring Treatment (1) (2) (3) (4) (5) Malnutrition 14 17 4 1 Uncleanliness — — - — Skin Ringworm—Scalp — — - — Body — — - — Scabies 10 — - -- Impetigo 16 — 1 - Other Diseases Tuberculous) 10 6 - Eye Blepheritis 15 — — - Conjunctivitis 4 — 1 - Keratitis 1 — — - Corneal Opacities 1 1 — - Defective Vision (excluding Squint) 105 26 30 8 Squint 13 10 3 — Other Conditions 1 — 1 — Ear Defective Hearing 9 3 11 — Otitis Media 39 — 7 — Other Ear Disease 1 — — — Nose and Throat Enlarged Tonsils only 22 68 3 — Adenoids only 33 15 5 3 Enlarged Tonsils and Adenoids 139 60 9 - Other Conditions 25 17 5 — Enlarged Cervical Glands (NonT.B.) 5 21 1 2 Defective Speech — — 2 1 Teeth—Dental Diseases (See Table IV., Group IV.) Heart and Circulation. Heart Disease Organic — 75 1 3 Functional — 24 - 3 Anæmia 15 13 4 1 Lungs Bronchitis 26 12 — 2 Other Non-Tuberculous Diseases 3 13 — - 39 TABLE II.—Continued. Defect or Disease. Routine Inspections. Special Inspections No. of Defects. No. of Defects. Requiring Treatment Requiring to be kept under observation, but not requiring Treatment Requiring Treatment. Requiring to be kept under observation, but not requiring Treatment. (1) (2) (3) (4) (5) Tuberculosis - Pulmonary: Definite — 1 - -— Suspected 2 17 - 2 Non-Pulmonary: Glands 4 17 1 2 Spine — 1 - - Hip - 1 - 1 Other Bones and Joints - 1 - 1 Skin - - - - Other Forms - 2 - - Nervous System Epilepsy 1 — - - Chorea 5 30 2 - Other Conditions 1 4 1 2 Deformities Rickets 1 — — — Spinal 19 3 3 — Other Forms 15 12 4 1 Other Defects and Diseases 20 32 7 12 40 B.—Number of Individual Children FOUND AT Routine MEDICAL INSPECTION TO REQUIRE TREATMENT (EXCLUDING UNCLEAN LINESS AND DENTAL DISEASES). Group. Number of Children. Percentage of Children found to require treatment. Inspected. Found to require treatment CODE GROUPS : Entrants 1038 201 19.36 Intermediates 738 172 23.306 Leavers 677 134 19.79 Total (Code Groups) 2,453 507 20.66 Other Routine Inspections 142 18 12.67 41 TABLE III.—RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. Boys. Girls. Total. Blind (including partially blind.) (I.) Suitable for training in a School or Class for the totally blind. Attending Certified Schools or Classes for the Blind 1 - 1 Attending Public Elementary Schools - - - At other Institutions - - - At no School or Institution - - - (II.) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind - 1 1 Attending Public Elementary Schools - - - At other Institutions - - - At no School or Institution. - - - Deaf (including deaf and dumb and partially deaf.) (I.) Suitable for training in a School or Class for the totally deaf or deaf and dumb. Attending Certified Schools or Classes for the Deaf 2 5 7 Attending Public Elementary Schools - - - At other Institutions - - - At no School or Institution. - - - (II.) Suitable for training in a School or Class for partially deaf. Attending Certified Schools or Classes for the Deaf - - - Attending Public Elementary Schools - - - At other Institutions - - - At no School or Institution... - - - Mentally Defective Feeble Minded cases not notifiable to the Local Control Authority. Attending Certified Schools for Mentally Defective Children 25 23 48 Attending Public Elementary Schools - - - At other Institutions - - - At no School or Institution - - - Notified to the Local Control Authority during the year. Feeble mined - - - Imbeciles - - - Idiots - - - Epilepsy. Suffering from severe Epilepsy. Attending Certified Special Schools for Epileptics. - 2 2 In Institutions other than - - - Attending Public Elementary Schools - - - At no School or Institution — — — Suffering from Epilepsy which is not severe. Attending Public Elementary Schools 7 4 11 At no School or Institution - — — 42 TABLE III.—continued. Boys. Girls. Total. Infectious pulmonary and glandular Tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 1 1 2 At other Institutions — — - At no School or Institution. - — — Non-infectious, but active pulmonary and glandular tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board - - - At Certified Residential Open Air Schools. - - - At Certified Day Open Air Schools - - - At Public Elementary Schools — — - At other Institutions — — - At no School or Institution. - - - Physically Defective. Delicate children (e.g., preor latent tuberculosis, malnutrition debility, anaemia, etc.) At Certified Residential Open Air Schools. - - - At Certified Day Open Air Schools 51 40 91 At Public Elementary Schools 1 — 1 At other Institutions. — — — At no School or Institution - — — Active non-pulmenary tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 1 1 2 At Public Elementary Schools - - — At other Institutions — —. — At no School or Institution. — — — Crippled Children (other than those with active tuberculous disease), e.g., children suffering from paralysis, etc. and including those with severe heart disease. At Certified Hospital Schools 2 1 3 At Certified Residential Cripple Schools - - - At Certified Day Cripple Schools 22 20 42 At Public Elementary Schools — — - At other Institutions - - - At no School or Institution 1 - 1 43 TABLE IV.—TREATMENT TABLE. Group I.—Minor Ailments (excluding Uncleanliness, for which see Group V.). Disease or Defect. Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. Skin:— Ringworm—Scalp 7 1 8 Body 13 — 13 Scabies 15 — 15 Impetigo 209 1 210 Other Skin Diseases 125 — 125 Minor Eye Defects (External and other, but excluding cases falling in Group II.) 119 8 127 Minor Ear Defects 124 15 139 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.). 419 - 419 Total 1,031 25 1,056 44 Group II.—Defective Vision and Squint (excluding Minor Eye Defects Treated as Minor Ailments—Group I.—.) Defect or Disease. Under Authority's Scheme. Number of defects dealt with. Submitted to refraction by private practitioner or at hospital apart from the Authority's Scheme. Otherwise Total. (1) (2) (3) (4) (5) Errors of Refraction (including Squint) 106 27 - 133 Other Defects or Diseases of the eyes (excluding those recorded in Group I.) — — — Total 106 27 — 133 Total number of children for whom spectacles were prescribed:— (a) Under the Authority's Scheme 101 (b) Otherwise 27 Total number of children who obtained or received spectacles:— (a) Under the Authority's Scheme 101 (b) Otherwise 27 Group III.—Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received Operative Treatment. Received other forms of treatment. Total number treated Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (1) (2) (3) (4) (5) 208 69 277 64 341 45 Group IV Dental Defects. (1) Number of Children who were:— (a) Inspected by the Dentist Routine Age Groups. Age 3 4 25 5 817 6 1,082 7 653 8 699 9 794 10 921 11 813 12 801 13 752 14 188 15 5 Total 7,550 (b) Found to require treatment 3,736 (c) Actually treated 2,365 (2) Half-days devoted to Inspection 42 Treatment 377 Total 419 (3) Attendances made by children for Treatment 2,736 (4) Fillings— Permanent Teeth 1,077 Temporary Teeth 13 Total 1,090 (5) Extractions— Permanent Teeth 350 Temporary Teeth 3,753 Total 4,103 (6) Administrations of general anaesthetics for extractions 550 (7) Other operations— Permanent Teeth Total 182 Temporary Teeth 46 GROUP V.—UNCLEANLIXESS AND VERMINOUS CONDITIONS. (i) Average number of visits per school made during the year by the School Nurse 3 (ii) Total number of examinations of children in the schools by School Nurses 17,952 (iii) Number of individual children found unclean 2,125 (iv) Number of children cleansed under arrangements made by the Local Education Authority 120 (v) Number of cases in which legal proceedings were taken (a) Under the Education Act, 1921 — (b) Under School Attendance Bye-laws —