BARK 70 Barking Town Urban District Council. THE ANNUAL REPORT OF THE School Medical Officer For the Year 1928 C. LEONARD WILLIAMS. B.Sc., M.R.C.S., L R.C.P., D.P.H. 2 SCHOOL MEDICAL STAFF, 1928 School Medical Officer: C. LEONARD WILLIAMS, B.Sc., M.R.C.S., L.R.C.P., D.P.H. Deputy School Medical Officer: MURIEI J. LOUGH, B.Sc., M.B., B.S., M.R.C.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: H. S. SMYTH, 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. HILL (Chief Clerk). (Commenced June 1928). E. W. WINCHESTER (Chief Clerk). (Resigned May, 1928). D. G. TONKIN. Miss V. SHEAD. Miss H. NUNN. Miss H. KING. * ½ of Salaries charged to School Medical Service. 3 Barking Town Urban District Council. PUBLIC HEALTH OFFICES, BARKING, ESSEX. April, 1929. To the Chairman and Members of the Local Education Authority. Mr. Chairman, Ladies and Gentlemen, Herewith I beg to submit for your favourable consideration my First Annual Report on the Public Medical Services which are carried on by you. The report deals with the year ending 31st December, 1928. My first year of office has naturally been one of stocktaking and enquiry. I am happy to be able to inform you that the various services you have inaugerated compare, so far as their scope is concerned, more than favourably with the services provided by Local Authorities with resources comparable with your own. You carry out the routine medical examination of children, and children are specially examined for admission to and for report on progress at your Open-air School and your Special Classes at Faircross for mentally-defective children and for children suffering from crippling defects. Your children are further examined before they go to week-end camps and before they go to your summer holiday camp, and other necessary special examinations are carried out. You have a Minor Ailment Clinic open every day in the week, and at Faircross there is a clinic for remedial exercises, ultra violet light and other forms of treatment, including electricity and massage advised by your consulting orthopaedic surgeon, Mr. Whitchurch Howell. 4 You have made special arrangements for the surgical treatment of tonsils and adenoids, and, where necessary, your own nurses conduct your little patients to and from the hospital. You have also provided facilities for the cleansing of verminous children and the inspection of the children at your schools for cleanliness is carried out by your nurses regularly three times yearly. In addition to these activities, children's eyes are examined specially to see if and whether they require glasses, and, where necessary, glasses are prescribed and provided. The dental service you have in operation deals comprehensively with oral hygiene. Mr. Smyth attends every day of the week, and very fortunately he undertakes not only the work for the ' school children, but also for the children under school age, which latter work he carries out under the Maternity and Child Welfare Scheme administered by your Council. Dr. Kennedy, of Plaistow, undertakes on your behalf the X-ray treatment of ringworm, and your officers are in constant touch with the various general hospitals in East London with reference to defective and debilitating conditions that do not come within the scope of your approved schemes. Your officers, in their joint capacity, are able to co-ordinate your work at the Municipal Hospital at Upney with school work, so that the Infectious Fever Hospital is largely a children's hospital, the work at which and the records of which are linked up with the services more directly under your control. During the past year an attempt has been made to lay the basis of co-ordination between the various activities which are undertaken under your supervision, and it has been found that the first essential is a more comprehensive system of recording the physical condition of the children under your charge This would entail extra work. It has been found also that with the medical service available you are not deriving the maximum benefit from the various special 5 services you have inaugurated. These naturally have developed since their inception, and time is required not only to cope with their development, but also with their co-ordination. As an illustration of the possibility of further development, I would call your particular attention to the figures given in Table IV, where it will be seen that the number of defects treated during the year at your Minor Ailment Clinic are roughly double those treated last year. This means extra time and extra service. The adverse criticism I have to offer is that you have started a large number of different services, covering a very wide scope of medical activity. These naturally have now attained a state of development where co-ordination is essential if the best use is to be made of them. They have developed too out of proportion to the medical services actually available. Yours very faithfully, C. LEONARD WILLIAMS. 6 ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER For the Year 1928. (1) STAFF. The Public Health staff is an administrative unit, albeit responsible to two separate committees of the Council. The Medical Officer of Health and the School Medical Officer are one. It is the same with the Assistant School Medical Officer, the Dental Officer and the other officers engaged in the promotion of public health among the school children. The Ministry of Health was established in 1918 with the object of promoting co-ordination amongst the different Public Health Services, and in writing a report for a year ten years after the inception of the Ministry, it can hardly be out of place to ask seriously if and whether the time has not come when the aims which called the Ministry into existence may not be achieved. The Central Government, in conformity with past precedent, will await a definite lead from Local Authorities and it seems to me reasonable that you should give this necessary lead to the Government by unifying your divided committee work in the supervision of this single Service. During the year under review the question of increasing the medical staff has been entertained. The clerical staff during the year has been increased, Mr. D. Tonkin having been released from the Education Department to work in this department. This has relieved the complaint I made last year that the then present amount of clerical work took more than the ordinary working hours of the then present clerical staff, but such has been the growth of the clerical work that the staff are now again working under pressure. 7 Miss F. Young, the Dental Nurse, resigned in December, 1928. Her resignation takes effect in January, 1929, and steps have been taken to fill the vacancy. (2) CO-ORDINATION. The unified Public Health Staff makes for co-ordination between the various sections of the Public Health Department, and Infant and Child Welfare work is intimately associated with the work amongst children actually attending school. It will be unnecessary for me this year to speak expressly on the question of nursery schools. The matter was discussed at length in my report for the year 1927. I have nothing to add to, and nothing to modify what I said in my report for that year. In speaking of the Maternity and Child Welfare Service and its unification with the other Public Health Services, I wish to include not only the work at the actual Maternity Centres but also the work carried out at your Orthopaedic Clinic and at your Dental Centre, all of which is unified in one department, notwithstanding the fact that for different parts of the work we are responsible to different committees. (3) SCHOOL HYGIENE. Last year it was my duty to call to your attention the need there is for facilities at your schools for the drying of children's clothes and boots. This was previously brought to your notice in the report for the year 1926 and is a matter I have very much at heart. You realise, I know, full well, the necessity for making some provision for drying children's clothes and boots, and I realise the difficulties you experience in obtaining these facilities. I do, however, feel the time has come when, notwithstanding all the difficulties, a move should be made towards providing an amenity so necessary to the health of the children. Provision of Meals.—The provision of meals in Barking for school children has reached a very high level of efficiency. Meals are prepared at the Municipal Kitchen and are distributed to the 8 Municipal Restaurant and to Faircross School. Not far short of 100,000 meals are thus provided during the year, the far greater proportion of which are mid-day dinners. The problem of catering for children who stay behind at your ordinary school for their mid-day meal does not arise to any significant extent in Barking, except, of course, at Faircross and at Castle School, a'^hough a relatively large number do so stay behind at St. Mary's and St. Ethelburga's, and at St. Joseph's School. In the table given below, details of this matter are set out. School. No. of children who do not return home for mid-day meal. Whethe facilities exist for heating of children's meals. Whether facilities exist for the drying of children's clothes and boots. Park Modern— 40 Yes Yes C. of E. Boys - No School fires in winter only. Girls - „ „ Infants - „ „ Ripple— Boys - „ „ Girls - „ Infants - „ „ Catholic Mixed 18-20 „ Infants (St. Josephs) 30 Yes „ Gascoigne Boys 8 No „ Girls - „ „ Infants - „ „ Westbury Boys 7 „ Girls - ,, Infants - „ „ North Street- Boys 10 „ „ Girls 1 „ „ Infants - „ „ Castle— 20 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 9 (4) MEDICAL INSPECTION. The foundation of a School Medical Service is laid in medical inspection, and every child is submitted to routine medical inspection three times during its school life. These medical inspections have for their object the detection of unrecognised and untreated defects, but they have an objective much wider than this in the classification of all defects, whether recognised or unrecognised, treated or untreated. These routine inspections are a health census of the school population and enable you to determine if and whether your system of education is being carried on without detriment to the health of the children, or, as I prefer to put it, to enable you to determine what physical benefits are conferred on the children by the course of education you provide. From this wider standpoint it is necessary to examine physically healthy children as well as defective children, because otherwise your statistics are likely to represent a state of affairs less favourable than actually exists. The table I am herewith including, which is a modification of Table II B to be found in the appendix to this Report, shows the number of children who have been examined and the number of defective children referred either for treatment or for observation. Entrants. Intermediates Leavers. Specials. Other Routine Examinations. Total. No. of children examined 946 687 581 141 126 2,491 No. referred for treatment 143 115 71 70 22 421 No. referred for observation 184 113 54 53 10 414 Percentage of defective children 34.6 33.2 21.2 87.3 26.9 33.5 10 It will be seen that all along the line there has been an increase in the number of children examined. The old days of rushing these examinations is past. To be worth while they must be done well. These figures indicate, at least to a certain extent, the reason why during 1928 I have from time to time been constrained to ask you for extra help in carrying out this work. It is refreshing to see that, contrariwise, there has been throughout a decrease in the percentage of defective children found at these examinations. A step such as this is a step in the right direction, and, although I am not going to draw any hasty conclusions, I am glad to think that on the whole the year has shown not only an increased activity in inspection, but also an increased healthiness amongst the children examined. In 1928 the parents of 64.8 per cent, of the children were present at examination, the comparable figures for the three previous years being, in 1927 62.7 per cent., in 1926 60.7 per cent., and in I925 65.5 per cent. The number of children on the school register on 31st December, 1928, was 7,201, compared with 7,001 on 31st December, 1927. During the year, the Medical Officer paid 131 visits to 20 departments for inspection purposes, examinations being conducted 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. The following table shows the number of children examined at routine and special inspections during 1928, classified according to the schools attended, the number of inspections held in each school and the number of parents or guardians present:- 11 COUNCIL SCHOOLS. School. No. of inspections. Number inspected No. of parents present. Boys. Girls. Park Modern 7 61 58 32 Gascoigne 27 267 292 357 North St. 23 226 209 299 Castle 2 16 27 31 Westbury 22 227 205 323 Ripple 20 184 212 284 Faircross 7 67 59 80 VOLUNTARY SCHOOLS. Church of England 12 125 99 113 Roman Catholic 11 89 87 108 (5) FINDINGS OF MEDICAL INSPECTIONS. Table II on page 44 gives in detail a return of defects found during the course of routine inspection. It will be seen that the number of cases of malnutrition found during these inspections remains practically the same as last year. It may be taken that, generally speaking, a fairly high standard is demanded, and that there are very few children indeed in Barking who are in dire need of something to eat. The part you play in supplying free meals is a small price to pay for such an assurance as this. (a) Uncleanliness.—With reference to uncleanliness and inspections for this condition, I have to report thai not quite so many children were actually examined as last year and that happily an even smaller number actually and relatively were found unclean. Herewith, in deference to precedent, I am submitting a table of the inspections which have been carried out in the different schools, but, as last year, I wish to make it perfectly clear that the figures cannot be used strictly for comparing school with school as to the efficiency. Different schools have vastly different problems to face, and strict comparison is impossible. There is, however, one fact I wish to stress, and that is that for any boy to have vermin of the head is an utter disgrace to himself 12 if he is of senior school age, and to all those who are in any way in charge of him. A pair of clippers do for a whole family and they are quite cheap, and if parents claim they have not time and opportunity to keep their boys' heads clean by other methods, at least they can keep them clean by keeping their hair clipped short. There is no hardship in proceeding with every .coercive measure you have to enforce absolute cleanliness so far as infestation is concerned amongst boys, and I do not see why every boy with an infested head should not be excluded forthwith and the parents proceeded against, as vou are empowered to do, for his absence from school. You might wish to modify your action by only proceeding to this extremity after a preliminary notice, but so easy is it to keep a boy's head clean that it is difficult to find any justification for it being dirty. School. Dept. No. of Examinations Nits only. Nits and Vermin (head) Gascoigne Infants 1300 119 6 Boys 1517 33 1 Girls 1212 187 7 North St. Infants 1001 61 4 Boys 767 18 1 Girls 650 82 3 Castle Infants Boys 486 64 2 Girls Creeksmouth Infants Boys 32 4 - Girls Westbury Infants 1196 99 2 Boys 701 18 2 Girls 986 109 2 Ripple Infants 1033 51 3 Boys 1136 28 4 Girls 1007 109 5 C. of E. Infants 570 79 1 Boys 635 41 3 Girls 633 210 7 RC. Infants 607 80 7 Boys 620 53 — Girls Faircross — 349 29 1 Park Modern Mixed 708 9 — 13 During the year under review your nurses have striven really hard to try to get children's infested heads cleaned up at home, which, of course, is the right place for this work to be undertaken. This is reflected in the diminished number of cases which have been cleansed under arrangements made by the Local Authority. Before leaving this rather unsavoury subject, I want to make it perfectly clear that the greater part of the figures submitted to you of dirty people refer to children who are constantly dealt with and whom indeed it is sometimes impossible to keep clean because they are living with adults whose heads are literally crawling. Indeed on one occasion not so long ago I had a parent protesting she could not possibly understand why her little girl could not keep her head clean, and I may mention that she was protesting so vigorously and shaking her head so firmly that I was mightily afraid she would shake some of the crawlers on to me, because her head was so full that they themselves could scarce find purchase. The work undertaken by your nurses is shown at the end of the appendix to this Report. Defective Footgear.—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 159 cases, compared with 172 in 1927. In all 209 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, 1926 and 1527. Year. Average Height in Inches. Average Weight in Pounds. 5 yrs. 8 yrs. 12 yrs. 5 yrs- | 8 yrs. 12 yrs. 1925 42.1 49.05 56.5 41.1 54.1 78.8 1926 42.4 49.9 57.5 40.3 54.6 82.4 1927 42.2 49.3 57.1 40.6 52.5 80.1 1928 42.1 49.5 57.2 40.2 56.4 81.2 Average for 4 years 42.2 49.4 57.07 40.5 54.4 80.6 14 (c) Minor Ailments.—Although there is no significant alteration in the number of minor ailments found during routine inspections it is significant that a much larger number of children have actually been treated at your Minor Ailment Clinic. It will be seen readily that this increase in work does not mean an increased incidence of minor ailments but that your children have, during the year under review, presented themselves in larger numbers than heretofore for treatment at your Clinic. The Clinic at East Street too has been used for a certain number of re-inspections, and many mothers have brought their children up during the year for advice for conditions other than those included under the heading " Minor Ailments." This has been of very considerable helpfulness to the children, to their parents and to you as an Education Authority, and development along these lines cannot but be beneficial to the town. (d) Skin Disease.—The common skin diseases include impetigo, septic sores, scabies, ringworm, etc. These showed on the whole a decline compared with previous years, and, although it is wrong to argue that these conditions occur only amongst dirty people, it is right to say that on the whole they are less frequent among cleanly than they are amongst people of indifferent cleanliness. The treatment of impetigo is sometimes fought with much difficulty. In its most severe forms it occurs usually amongst children whose parents are indifferent to their condition. Rigorous medical treatment with ointment will cure these cases, but unfortunately without co-operation from the parents your work at the Clinic is brought to nought. Some of these intractable cases, so it is presently taught, are not true cases of impetigo at all but are really a very mild form of lupus. This has suggested the use of artificial sunlight in the cure of these cases and I have begun to use this form of treatment. Your artificial sunlight lamp, however, is of a form which does not lend itself to economic treatment in these cases and an extension of services will be necessary if we are to take up this work seriously. 15 (e) and (/) Eye Disease, Vision and Squint.—With reference to the findings of School Medical Inspection with regard to eye diseases, I have to report that on the whole, with the exception of defective vision, including squint, these diseases have shown a decrease. These diseases, too, tend rather to manifest themselves amongst communities that are not particularly devoted to hygiene, so that here too your figures give a reassuring message that, generally, personal cleanliness is being more and more appreciated by the parents of the children attending your schools. With reference to the increase in the number of cases of defective vision found and the number of cases of squint, I am unprepared at the present time to make any serious statement, but perhaps I might suggest that the total number of children of the intermediate code group examined this year was considerably in excess of that for last year, and that it is amongst these children defects of vision are chiefly discovered. It will be noted that there were no less than seventeen cases of squint found requiring treatment among the schoolchildren during the year 1928. The corresponding figure for last year was seven. These cases of squint are naturally found chiefly among the children who are entrants. The number of these cases is sufficient to indicate the wisdom of the Council in deciding to take up refraction work for children , under school age. (g) Ear Disease.—The condition of your children with regard to ear disease remains practically as it was last year. It will be a long time before we deal effectively with this problem, which is intimately associated with the kindred problem of enlarged tonsils and adenoids, with which I am dealing in the next paragraph of this report. (h) Tonsils and Adenoids.—There is a decrease this year in the number of cases of tonsils and adenoids found, but, although this decrease is material, it is by no means sufficient to make the problem anything other than a very grave one. Nature never intended such a vast number of children to have tonsils and adenoids which are interfering with their growth and development. 16 I want to make it perfectly clear that enlarged tonsils (these are glands at the back of the throat) and enlarged adenoids (i.e. an overgrowth of a loose tissue at the back of the nose) are not in themselves looked upon as warranting surgical interference. The Board of Education has very wisely unified our views on the subject by explaining very carefully the conditions under which surgical interference should be recommended, and, avoiding all technicalities, it may be said that these conditions virtually mean the tonsiL and adenoids should only be taken out if and when these structures are definitely interfering with the growth and development of the child and/or are so diseased as definitely to interfere with the health of the child. One thing learnt in our Infant Clinics is that the problem of health amongst young children is essentially a problem of right feeding, and I feel sure when we have mastered the principles of right feeding amongst children the surgical treatment of tonsils and adenoids will be considered a definite indication of the ignorance of the age in which we live. A technical discussion on this point would be out of place, but I will go so far as to say that we are reasonably assured that development of the type of tissue found in tonsils and adenoids is due to a diet in which there is an excess of starch, or at least an amount of starch in excess of the vitamin which is found in the germ of wheat. It may seem a far cry-from the question of white bread to the question of the prevention of tonsils and adenoids, but I feel it will be only by means of an enquiry into the subject from this standpoint that we shall do away with our present necessary and necessarily barbaric methods of dealing with a common ailment of children. Although it is premature to express a considered opinion, it does seem, not only from the statistics but from our general personal observations, that defective tonsils and adenoids do not constitute quite the same problem that they did even a few years ago, and I am happy to be able to say that, although I am not prepared quite to prove my words, I do believe that this is due to the work in our Maternity and Child Welfare Clinics, where a considerable amount of time is spent in teaching mothers the hygiene of the mouth and of the nose, and in teaching mothers the value of right feeding. 17 May I this year again call your attention to the fact that adequate facilities at either of the hospitals to which you send cases do not exist for the over-night detention of all children after operation. It is my considered opinion that all these cases should be retained in hospital after this operation, which, after all, is by no means a minor one. It is estimated that this practice will treble the present cost of this service—perhaps increase it four-fold; and, indeed, when hospital services are put on a sound financial basis the increase in the future will be even greater. I do, however, look upon this change, involving whatever expenditure it does, as essential. («) Tuberculosis.—There were 14 cases of tuberculosis amongst children of school age notified to the Medical Officer of Health during the year. The total number of attendances by your school children at the dispensary amounted to 377 during the year under review. It has been my care, so far as possible, to examine children away from the dispensary. {j) Dental Defects.—The findings at medical inspection leave no doubt that the work of your dental officers is making itself felt. The dentition of children among the school-leaving group is creditable compared with what it was even five or six years ago. (k) Crippling Defects.—With reference to crippling defects, by which I am referring to those children who are classified as being subjects of deformity in Table 11, I would like to say that, although the figures have increased, actually there is a very considerable improvement, especially in the minor disabilities such as curvature of the spine. Although from a surgical standpoint the lesser degrees of curvature of the spine must be looked upon as minor disabilities, there is no doubt that actually this curvature of the spine is often the cause of a loss of efficiency apparently out of proportion to the actual physical disability, and that therefore a general improvement in these minor disabilities means a general improvement in the efficiency of your school services. 18 (6) INFECTIOUS DISEASE. The prevention of the spreading of infectious diseases in your schools is carried on by the united efforts of the teachers and your public health staff. Notified cases are followed up, and, so far as is practicable, steps are taken to minimise the possibility of infection at school. The difficulties, however, are very considerable. The beginnings of most infectious diseases are so vague that if every child who suffers from a sore throat were forthwith advised to stay home, not only would many children remain away from school with very minor disabilities, but any child who wished to remain off school would have a ready-made excuse, well nigh impossible to disprove. It is remarkable under these circumstances how very much is done by our teachers. In cases of notifiable infectious disease the sanitary inspectors call at the home, make all possible investigations, and on their report, if necessary, your medical staff take further action. As you know, where the attendance of a school falls below 60 per cent., and in the opinion of the Medical Officer this bad attendance is directly due to the prevalence of an infectious disease, the school sessions so affected are not counted in estimating the average attendance for the purpose of grant. The following table shows briefly the number of children notified and reported suffering from some of the commoner infectious diseases:— Scarlet Fever 132 Diphtheria 67 Measles and German Measles 342 Chicken-pox 215 Whooping Cough 47 19 (7) FOLLOWING UP. A summary of the "following up" work undertaken by your school nurses is given herewith:— Number of visits to schools 219 Number of visits to schools for medical inspection 131 Number of home visits in connection with— 1927. 1928. (a) Routine medical inspections 3,419 3,345 (b) Infectious disease 137 571 (c) Uncleanliness inspections 251 212 (d) Non-attendance for treatment, etc. 367 542 It will be noted that the home visits in connection with routine medical inspection are slightly lower than last year, but that, contrariwise, those with regard to infectious disease .and nonattendance for treatment are very much higher. The arrangements for following up have not been materially altered during the year 1928. <» Clinics.—The numbers of school children attending in 192 were as follows:— Clinic. No. of 1st attendances of children. Total No. of attendances Minor Ailments 2059 12749 Ophthalmic 128 559 Dental 1852 2787 Ringworm 9 18 Orthopaedic FOR EXAMINATION 29 2427 FOR TREATMENT 62 Minor Ailments Clinic. No. of days clinic was open 302 Total No. of attendances 12749 Daily average attendance 42.2 No. of cases treated 2059 20 (8) MEDICAL AND SURGICAL TREATMENT. Minor Ailment Clinic.—Minor ailments are treated daily at the Clinic at East Street. Three nurses attend from the Plaistow Maternity Charity, and the Clinic is opened at 8.30 a.m. During the year, on three half-days a week, one of these nurses has taken the place of the Dental Nurse, and has been in attendance on the dentist; and has also been in attendance, together with the Dental Nurse, on the mornings when there have been gas sessions. That this Minor Ailment Clinic is capable of meeting a very real need, for which there is a demand, is seen from the figures for the current year. It will be noted that the attendance was nearly doubled. This is due to the fact that the term " minor ailment" has been generously interpreted, and without in the least encroaching on the realms of private practice it has been found a large amount of work can be done to the benefit of the scholars of the town and to their parents. This has meant time, not only for the work to be done, but for it to be co-ordinated, and I very much regret that with our available medical staff the Minor Ailment Clinic cannot take the place it could take, and in my opinion cannot undertake the work it should undertake. Not only have we undertaken work prescribed by ourselves, but in many cases children have attended the large London hospitals for advice, and, by arrangement, we have carried out the treatment they have prescribed, to the considerable financial advantage of the parents of these children. Tonsils and Adenoids.—Operations for the surgical treatment of tonsils and adenoids are carried out by arrangement with Queen Mary's Hospital, Stratford, and St. Mary's Hospital, Plaistow. I have indicated to you in a previous part of the report how necessary I think it is to revise the present contract so that it shall include the detention of these children following operation. 21 Tuberculosis.—The care of tubercular children as such is entirely in the hands of the County Council, but every effort has been made to co-ordinate the amenities available under your own and under the County Council schemes. The present position with regard to surgical tuberculosis is rather open to criticism. A child is seen at the County Dispensary by me ; if necessary, it is sent to Sir Henry Gauvain, as the county specialist, and a report received by me. The child may then be sent to Alton or some other similar institution, after which it is returned to Barking and most probably will then attend the Open-Air School, where, so far as you as a local authority are concerned, Mr. Whitchurch Howell is in charge of the case for all educational purposes; but, nevertheless, the county are still responsible for the case if for any reason attendance at school is discontinued. This overlapping is further augmented by the fact that oftentimes these and similar cases are taken by the parents to the large London hospitals, and the whole question calls for discussion, because unquestionably there is quite a lot of misdirected effort which could be used for more useful purposes. Skin Diseases.—With reference to the treatment of skin diseases, I have already indicated that further amenities are desirable for the treatment of intractable cases of impetigo. The treatment of ringworm is satisfactorily carried on by X-ray, and you yourselves have provided amenities for treating cases of scabies. It is, perhaps, in the treatment of skin diseases that the lack of continuity of supervision at the Minor Ailments Clinic is most felt. Thus children are often On the books here for an unconscionable length of time. The nurses at the Clinic are provided by rota by the Plaistow Maternity Charity ; both your medical officers take the Clinic from time to time, and there is no continuity of supervision. Add to this the system of record keeping does not facilitate the 22 history of any one child being rapidly brought before the officer investigating the case, and you will see it is an easy matter for a child to attend longer than it should have to attend, and that it is a difficult matter in the time available to prevent them from so continuing to attend. External Eye Disease.—It will have been noted that external eye disease is to some extent associated with indifferent home circumstances, and I have noted with pleasure the general improvement taking place in the last few years in the home conditions of the little patients who constitute the group of children that come up for diseases of the external eye. This is fortunately reflected in the fact that it has been noted now for the past year or so that, with the exception of a very small number of intractable cases, these conditions have proved themselves more amenable to the simple treatments carried out at the Minor Ailment Clinic than hitherto. It has never been necessary to refer any large number of these cases whatsoever to hospitals for special treatment. This means a considerable saving in money and time to the parents, and of course a similar improvement in the efficiency of school life. Vision.—The treatment of defective vision is carried out on Saturday mornings at the East Street Clinic. The pupils of the children's eyes are dilated, and refraction is carried out. It is only when children's eyes are so dilated that refraction can be carried out properly, and although this does mean that for a few days the children themselves cannot see so well as usual, and this interferes with their school work, it is an interference no one yet has found a means of mitigating. We had hoped during the present year to be able to carry out on Saturday mornings also a certain number of special appointments of children referred to the clinic from routine inspection, and otherwise in whom complete examination could not be carried out at school. This attempt, however, seriously interfered with the eye work, which is somewhat behind. I regret these special appointments will have to be curtailed. 23 Ear Disease.—The most common ear disease with which we have to deal is the ordinary discharge from the external ear. The treatment usually employed is that of putting in special drops which tend to lift the corruptible matter from the bottom of the ear. This is followed by thoroughly cleansing the ear, which is afterwards dusted with a special preparation of thioform. This method of treatment has been found reasonably satisfactory, but the period of invalidity and incapacity, i.e., the period during which the children are oftentimes off school, could materially be decreased if we could offer the more up-to-date electrical treatment known as ionisation. The introduction of this treatment could be undertaken for a very modest expenditure of money, and is only really a question of providing the necessary time for your medical officers to carry it out. This extra time would be required because, whilst the present treatment is carried out by your nursing staff, the electrical treatment would require the constant attendance and supervision of a medical officer. Dental Defects.—Dental defects are very adequately dealt with at the Dental Clinic. The work at this Clinic is set forth in detail in a report by Mr. Smyth. Crippling Defects and Orthopaedics.—" Crippling defects" within the meaning of the Board of Education has rather a wider application than is usually understood by this term. It includes severe cases of heart disease. With special reference to crippling defects that come under the heading of orthopaedics, I may say these are dealt with bv your consultant, Mr. Whitchurch Howell, who holds a Clinic at Faircross one half-day a month. Miss Findlay carries out the prescribed treatment on three days a week. This work is very highly appreciated by parents and teachers, and I know that you value it highly. The time has come when an extension of these services is urgently required, and you have quite enough work for the services of a whole-time nurse. You 24 could achieve this end by either employing a special orthopaedic nurse for the whole week or, by arrangement with a neighbouring authority, employing two nurses for three days a week. With the amenities you have available at Faircross, undoubtedly the former would be rather more practicable than the latter ; although, if the Tatter procedure were adopted, it would mean that you could retain the services of your present masseuse and have an assistant nurse to work with her. The question of the provision of this extra service is intimately linked up with the extension of the medical service as a whole, and, although highly desirable, I do not advise it until the general extension can be undertaken as well. In necessary cases, children are sent by you to Brookfields Orthopaedic Hospital where they still remain under the care of Mr. Whitchurch Howell. You pay £2 2s. a week for this form of treatment. There appears to have been a general impression that these cases could only remain in Brookfields Hospital for short periods of time, whereas, during the year under review, we have had in one case for the whole of the year. The cost to the authority has been very considerable, and of course your special services will cost you considerable while you very rightly undertake such necessary work as this. There is at the present time a lack of co-ordination between various hospitals, and one child may during the course of treatment come under two or three surgeons, as the parent moves from hospital to hospital according to necessity or choice. In cases such as these children present, where continuity of treatment over oftentimes a long period of years is essential to success, this is to be deprecated, and co-ordination is a matter of pressing moment. Mostly this is a matter for the hospitals themselves, in which the local authority, although vitally interested, has no opportunity of expressing an opinion; but in one particular instance the question does essentially lie within the purview of the local authority and of the Essex County Council. 25-26 PARTICULARS OF WORK DONE IN CONNECTION WITH ORTHOPÆDIC CLINIC. No of visits by Orthopædic 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 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 3 123 1 1 34 1462 24 878 - — 1 37 Under School Age 6 310 — — 2 62 63 757 — 5 121 Admission to Orthopedic Hospitals On waiting List for Admission 31/12/28. School Children Under School Age Total School Children Under School Age Total 6 3 9 1 " 1 2 27 This I have already dealt with in reporting on the case of children the subject of surgical tuberculosis. My submission is that the time is overdue for a conference between all the hospitals engaged in orthopaedic work and the local authorities who are financially or otherwise interested in that work. (9) OPEN-AIR EDUCATION. Playground Classes.—Barking is fortunate in having some schools built in a modern style of architecture on sound, practical, sanitary lines ; but, on the other hand, some of the schools were built, not wisely, but too well. They are gaunt premises, built rather as places of monastic seclusion for the forcing of intellect than places of health-producing educational activity. In these factories of education it is desirable that every opportunity should be taken of conducting studies in the open air, and the desirable point of view is that all classes should take place in the open air unless the climatic conditions prohibit it, or the special nature of the work demands that it should be done indoors. School Journeys.—School journeys, as such, are not a feature of school life in Barking, but their place is more than satisfactorily taken by the numerous school camps which are held, and the holiday camps which are run during the summer vacation. These school camps are admirable features of your educational activities. Children go out on Friday evening and come back on Monday evening. At Hainault t hey live an open-air life, and many of the children, by means of these camps, spend a day or two in the country for the first time in their lives. All the girls and boys are medically examined before they go, and only in one instance has it been necessary for me to send a child home from Hainault. The summer camps during the holidays are of a fortnight's duration each, and here again every child is fully examined before he or she leaves Barking. Particular stress is laid on the condition 28 of the throat; general cleanliness is insisted upon, and all the children are specially examined to make sure they are quite fit to stand the rather vigorous life they naturally live during their holidays. Open-Air Classrooms in Public Elementary Schools.—At the Park Modern School it is possible to turn the rooms into modified open-air classrooms, and this school and the Open-air School should be looked upon as standards of school architecture for the future. Of course, St. Joseph's School is also a school recently built on modern lines, and I do hope we shall see no more schools of the factory type. Ultra Violet Light Treatment.—Ultra violet light treatment has been carried out at Faircross School during the year, the total cases treated being 34. The period of treatment of these cases varied from one month to twelve months and the total number of doses was 872. Children diagnosed as suffering from Tuberculous Glands, Alopaecia, Rheumatism, Anaemia, Debility, Impetigo and Cervical Adenitis are among those who have derived considerable benefit from this treatment. (9) OPEN-AIR SCHOOLS (e) The Open-air School at Faircross is one of the most valued possessions of the Local Authority, and I naturally regret that we have lost one classroom, which is now being devoted to ordinary elementary education. I should look with the greatest disapproval on any invidious distinctions drawn between the children who are attending Faircross School for ordinary elementary education and those who attend there for special reasons, because we have been at great pains to make sure no one attends the Open-air School who is likely to spread infection, of whatsoever nature such infection 29 may be, and anything which might lead the parents of the children at the Open-air School to suppose that they incur any risk from infection by reason of the fact their children attend this school will be detrimental to the interests of the Open-air School and of education generally. The fact that there is a waiting list for admission to the Open-air School makes it, to my mind, unfortunate that a classroom should have been taken for purposes other than official open-air education. In making this statement I am not unmindful of the fact that there are other reasons which have urged you to take the action you have taken. This brings me naturally to the questions: " How many places do you really want in any educational system for open-air school education ? " " How many debilitated children are you likely to meet who cannot obtain proper benefit from education in an ordinary elementary school ? " " Have we nearly enough places in Barking ? " The answer to these questions is that we do not exactly know how many places are required; but I am persuaded that the number of places is far beyond those we have already built, although at the same time I must gratefully and readily acknowledge you have more such places in Barking compared with the size of your town than any other authority; that is, so far as I know. If we are going to have great gaunt school premises, halfway between a factory and a prison on the one hand and a monastery on the other, so far as architecture is concerned, then, of course, we shall want a large number of places for open-air education. • (/) Residential Open-air Schools.—We have no residential openair school as such, and I do think the time has come when something should be done, at least during the summer months, to make Faircross a residential school. 30 So far as possible in the selection of cases for admission to Faircross, I try to make sure that there is some real physical disability by reason of which the child is debarred from gaining adequate benefits from tuition in an ordinary elementary school, and that the case is not one merely of maternal indifference militating against the efficiency of the child's school life ; but, notwithstanding my efforts in this direction, I do feel that home circumstances are a very pertinent factor in the conditions of many of the children attending your Open-air School, and that the benefits of the few hours a week they spend at that school are brought to naught by the many hours they spend in the uncongenial atmosphere of their own homes. For my part I am willing to look upon it as a definite possibility that an equal amount of money spent on a residential institution of fewer places would give more definite and lasting results than that amount of money spent on an ordinary non-residential open-air school. What I suggest is that, at least during the summer months, with at least a small number of children, an attempt be made on a voluntary basis to keep the children at the school throughout the whole of the week with the object of expediting the recovery of such debilitated children, and the further object of investigating the possibilities of such a course of action on a permanent basis. (10) PHYSICAL TRAINING. The Local Education Authority have no officer with special duties for organising physical training in your schools. A large amount of work, however, is carried out, and .the provision of a playing field at the Park Modern School is, I hope, to be regarded as a precedent which will be a standard in all our future school planning. The spectacular efficiency of physical exercises, whilst, indeed, an index of the efficiency of these exercises, must not keep us from recognising that the very best exercises of all are those in which the movements of the body are purposeful and free from restraint. 31 In this connection, organised games fulfil a very useful function, and no scheme of physical exercises is complete in which such organised games do not find a very prominent place. There is one matter of very considerable interest of which I am constantly speaking, and which cannot be emphasised too often. There are a large number of children who do not learn to breathe properly. There is, as you know, a great deal of difference between the breathing of an infant and the breathing of an adult, and these children carry into their adult lives the infantile type of breathing. It is to be remarked that these children who breathe defectively are usually of lesser intelligence than those who breathe properly. It would be unwise at the present juncture to state that by teaching these children to breathe properly they will of necessity become more intelligent ; but this may be so, and in so far as correct breathing will increase their physical vigour, it certainly will in some measure be so. The fault lies in the fact that our physical exercises have developed as a modification of the bad old army methods of training, in which an expanded chest was looked upon as the quintessence of everything to be desired, even when it was attained not by actually increasing the volume of the chest, but by pressing abnormally on the contents of the abdomen and thrusting the liver abnormally high into the chest itself. There is, too, an idea that putting the shoulders back increases the capacity of the chest. This is not so. When the chest is expanded the shoulders will naturally be carried somewhat backwards, but merely by muscular activity to null the shoulders backwards and so to expose the greater part of the upper chest has nothing whatsoever to do with chest expansion, and, however spectacular, does not add one iota to the efficiency of the ventilation of the chest. The erect posture, too, is a matter which has received very considerable attention of late, and I am convinced that too much attention cannot be given to it at the present time. 32 If a' child stands correctly it will do so naturally and easily, without effort and without fatigue. If a child stands incorrectly it will become fatigued readily, and, not only so, the first attempts to stand properly will be found difficult and wearisome, because the muscles will not have only to help to maintain the erect posture, but they will also be doing considerable work overcoming the deformities which have been encouraged by incorrect posture. The straight back is the ideal, and the hollow backs seen in many of our children are much to be discouraged. In boys they detract from mechanical efficiency, and in girls they do even more, because they militate against " normal deliver}' " when in process ,of time the selfsame girls become the mothers of the nation. (n) PROVISION OF MEALS. With reference to the provision of meals I have dealt with this elsewhere, and it only remains for me to add that the dietaries are submitted to me for approval. (12) SCHOOL BATHS. School baths are provided at the Special School and the Park Modern School, and I hope they will soon be found in every school, and that certainly provision will be made for baths at every new school opened by the Local Education Authority. It cannot be too often enforced that the skin is an organ of the body as much as the heart and the lungs. It requires to be kept clean, and requires to be kept working if it is to be healthy. The stimulus of bathing makes the skin react naturally, and the more people accustom their skin to this and similar reactions the less are they likely to find themselves subject to colds. There are public swimming baths at East Street. These belong to the Council. Children attending elementary schools are instructed in swimming at these baths, and here is a healthy exercise which should be encouraged. 33 (13). (14). (15) and (16) CO-OPERATION OF PARENTS, TEACHERS, SCHOOL ATTENDANCE OFFICERS AND VOLUNTARY BODIES. The attendance of parents at routine medical inspection is considerable, no less than 64.8 per cent, having attended during the year 1928. The teachers, too, take a remarkable interest in this work, and their help is invaluable. I would like here, once again, to call your attention to the fact it is highly desirable to include in your statistics the children who come within the code groups, whether they are suffering from any disability or not, because only by so doing can you test the efficiency of your educational system as a public health measure for the promotion and maintenance of health. The school attendance work in Barking is carried out by investigation officers who undertake, not only the ordinary duties of school attendance officers, but also duties in connection with maternity and child welfare, etc. The closest co-operation is maintained, and through these officers, as well as directly, any necessary help is sought and obtained from the various voluntary organisations which interest themselves in the happiness of children. I am credibly informed that the National Society for the Prevention of Cruelty to Children have dealt with 17 cases. The following table shows the way in which these cases have been dealt with:— Total number of cases investigated 17 (a) Prosecutions Nil (b) Warnings 15 (c) Otherwise dealt with 2 It is always a pleasure when I am able to support this very deserving charitable organisation, and the fact there has been no prosecution this year shows how essentially preventive is the work this association is carrying on. 34 The figures given relate to all cases in the town, and not expressly to cases in which school children only are involved. (17) BUND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. It may be taken that substantially every blind, deaf, defective or epileptic child is known to the authority. To make absolutely certain it would be necessary to hold a special census, but even if this were done the result would be uncertain unless exceptional measures were taken, so that although, of course, we cannot declare that our returns under these headings are absolutely accurate, we know them to be sufficiently accurate to make any alternative method of ascertainment unnecessary. You, as the Local Education Authority, have so many agencies at work interested in child welfare that I can scarcely believe that any children who should be known to you are not known. Even the Municipal Hospital plays a part in this ascertainment, because every child in there is very closely watched, and any necessary information is filed with the school dossiers. Six deaf and dumb children have attended at Frederick Road Centre, Custom House, during the year, and one child has been maintained in a residential institution. The number of known epileptics of all grades is 13, and you have been much exercised in the problem presented by epilepsy where it is associated with other defects. Mentally Defective Class, Open-air School.—This class serves a very useful purpose. It takes out from the ordinary elementary schools a number of scholars who would unquestionably clog the machinery of ordinary elementary education. Further, it gives these children a training from which they can benefit educationally. To a certain extent, and in certain cases to a considerable extent, the actual intelligence of the children is increased. This, however, as I shall show, is a two-edged sword. There are no clear lines of demarkation between the highest intelligences and abject idiots and imbeciles, and if you have only a mentally deficient class, naturally there would gravitate into that class a certain number of children who are on the border 35 line between " mental deliciency" and low-grade " dull and backwardness." It is invidious that these dull and backward children, however low grade, should be classified as mentally defective, and no scheme is complete which deals only with mentally defectr children and leaves the larger class of dull and backward children uncatered for. It may be possible for these dull and backward children to get along somehow in the ordinary elementary schools. My submission is their education is even more important than that of ordinary children and that of specially intelligent children, because, apart from any question of ordinary education, of which I cannot speak expressly, there is the question of the further development of these children after they leave school. In the ordinary way the education of a child goes on long after the age of fourteen. An impetus has been given, the momentum of which is felt for several years, and, either consciously, by attending evening schools or by other means, or unconsciously, the child still continues to learn and the intelligence still continues to expand ; but in the case of these dull and backward children there is, as a rule, no momentum. They are only educable under the influence of a constant stimulus. Directly they leave school they not only entirely discontinue their education, but actually go backwards. These are the children who bring great discredit on our educational system, and are the evidence on which the critics of education found their biting sarcasm. If this were all, it would be bad enough, but worse remains yet to be told. These are the children who become the " work-shys " of later life. The women often become harlots and the men petty thieves, with not enough intelligence to excel even in that art, with the result that they spend long terms of servitude at the expense of the State. It is these dull and backward children who decrease the productivity of industry; they increase expenditure, not only on prison services, but also on relief work and many other forms of public enterprise, including expenditure on hospitals and other 36 medical organisations, because the health of these people is visually below the average to begin with, and invariably gets worse owing to their hand-to-mouth level of existence. It is from this particular standpoint I would commend to you the need there is for looking after the dull and backward children. In referring to the double-edged sword, of which I spoke previously with reference to the education of the mentally defective, I would say we have seriously to consider as to if and whether a large amount of the money spent on these children does not in reality only turn them from people who would merely be a charge on the State for themselves into the rather higher grade of which I have already written, who, in addition to being a drain on the resources of the nation, are a positive danger to society. (18) NURSERY SCHOOLS. There are no nursery schools in the district. (19) SECONDARY SCHOOLS. Last year I pointed out it seemed invidious that many of the children, passing from your elementary schools to the secondary school should lose the benefit of your very comprehensive scheme of medical inspection and treatment, and I still feel something should be done to co-ordinate or to re-distribute your duties and those of the county with reference to education, so that the amenities for treatment open to the children of your ordinary schools should be available for the children at the secondary school also. (20) CONTINUATION SCHOOLS. There are no continuation schools in the district. (21) EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. Milk and newspaper deliveries, general errands, etc., are the usual forms of employment of children and young persons. In accordance with Bye-laws of the Education Authority, 14 applicants of school age submitted themselves for examination prior to 37 employment, of which number it was necessary to refuse two applicants 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. (22) SPECIAL ENQUIRIES. There have been no special enquiries within the meaning of the Board of Education. There is plenty of work waiting to be done, and I hope the time will soon come when, not only in Barking hut throughout the country, it will be recognised that staffs should lie sufficiently large to allow a reasonable amount of research to be undertaken. (23) MISCELLANEOUS. Three young persons who desired to become bursars and student teachers were medically examined during the year by a private medical practitioner, none being rejected on medical grounds. 38 REPORT OF THE ORTHOPAEDIC , CLINIC. Orthopaedic Clinic, Faircross School, Barking, Essex. To the School Medical Officer. The Orthopaedic Clinic this year has shown a slight increase in numbers. Twenty-nine school children and 22 children under school age were examined by me for the first time, and 119 school children and 67 children under school age were re-examined during the year, the findings of my primary examinations being as follows:— SCHOOL CHILDREN. Deformities—Bones and Joints— (a) Congenital (b) Acquired— (i) Fractures 1 (ii) Arthritis 1 (iii) Genu Valgum 4 (iv) T.B. Hip 1 — 7 Muscular Deformities— (a) Congenital abnormality— (i) Absence of Pectoralis Major 1 (b) Acquired— (i) Pes Piano Valgus 9 (ii) Kyphosis 2 (iii) Kypho-lordosis 2 (iv) Scoliosis 1 — 15 Paralysis— (a) Congenital (b) Acquired— (i) Anterior Polio Myelitis 2 — 2 39 Various— (i) Hydrocephalus 2 (ii) Contracture following burn 1 (iii) Baker's Cyst 1 — 4 CHILDREN UNDER SCHOOL AGE. Deformities—Bones and Joints— (a) Congenital— (i) Abnormal skull 1 (b) Acquired— (i) Rickets 7 (ii) Genu Valgum 3 — 11 Muscular Deformities— (a) Congenital— (i) Torticollis 3 (ii) Talipes 5 (iii) Hemihypertrophy 1 (iv) Hypotonia 1 (b) Acquired— (i) Pes Piano Valgus 2 — 12 Paralysis— (a) Congenital (b) Acquired— (i) Double Erb's 1 — 1 During the year, four school children and three children under school age were admitted to hospital. The following operations have been carried out"— (a) School children— _(i) Manipulation for congenital dislocation of hip joint 3 (ii) Tenotomy Tendo Achilles1 (iii) Steindler's operation 1 (iv) Manipulation—foot 1 (v) Tenotomy of Adductors 1 — 7 40 (6) Children under school age— (i) Osteoclasis Tibiae (bow legs) 1 (ii) Osteotomy Femur, right and left (Genu Valgum) 1 (iii) Manipulation and P.P.'s—Talipes, right and left 2 — 4 Total ii The special features of this year's work are the successful results of the operations, particularly the cases of Talipes, and the increasing number of children under school age sent up for advice and treatment. For example, a case of Club Foot, seen and treated from the moment of the child's birth, can be cured within a few months,, often without operation. The motto of the Orthopaedic Clinic should always be " Prevention is better than cure," and this idea is fostered by the medical examination at an early age of every child, whereby defects are discovered and treated, and potential weaknesses, strengthened and often cured. B. WHITCHURCH HOWELL, F.R.C.S. 41 report of dental surgeon. To the School Medical Officer. I have pleasure in submitting to you the report and the figures of work done in the Dental Clinic during the year ending 31st December, 1928. Throughout the year, the routine of work at the clinic has gone on in circumstances of fullest cordiality and co-operation with the parents. Every endeavour has been made to afford every encouragement by the treatment, by the courtesy, and by the advice given towards the good name and reputation of the clinic. It is the wish, I feel sure, of the governing authorities that in this clinic, as in all others which they govern, the standard and reputation should be of the highest, and this, therefore, has been the keenly sought objective throughout the past year. There has been very little leakage of time for treatment. Unfortunately, as in all clinics where fixed appointments are made, there have been times when appointments have not been kept. This difficulty, though, in a great measure has been overcome by slightly increasing the daily number of appointments and then, in the event of a rush occurring, distributing the work evenly throughout the session. It has also been found that the erratic attendances of mothers from the Child Welfare Centres has continued, the cause for this irregularity more than probably being due to domestic duties. In this latter case, rather than letting an opportunity occur for time wastage, a few urgent child cases have recently been included in their gas session. It must be stated, however, that these have not been allowed to encroach in any way upon the due treatment for each individual mother, but that the children cases have been worked into the session as opportunity occurred. Conservation Work.—It will be seen from figures included that a considerable amount of saving of deciduous teeth has been resorted to. The temporary teeth certainly do a short time of service in the mouth, but indisputably the service which they 42 do is at a very important age of the child's development. Justification in filling them is also afforded by the fact that the process is a comparatively speedy one, and, too, it is an excellent foundation upon which to overcome the old-fashioned prejudice against fillings, as very little pain is experienced by the child, and the lasting results very satisfactory. The number of permanent teeth saved by conservation treatment, as indicated in the returns, is also very satisfactory. These fillings call for a considerable period of time if they are to be satisfactorily and lastingly done. Upon a fair average, twenty minutes can be allocated to each of them. It can readily be seen, therefore, how working time is very quickly absorbed. It is to be remembered also that permanent fillings in a child should be made with the consciousness that they will be called upon to serve many more years than in an adult, and in the all-important developing years. Fraenum Cases.—A fair number of cases of slight severance of the fraenum have been undertaken. These cases do, of course, bear upon the orthodontic branch of dentistry. Usually, this minor operation has been done in cases requiring this treatment where the oral hygiene has been obviously well attended to. It has been found necessary to make application for an additional gas session per fortnight in order to cope with the gas cases. If this request be conceded, the number of gas sessions now will be exactly equal to the number utilised by my predecessor whereas if not conceded I shall be having exactly half of the number which he had and he found necessary. With the work of the clinic growing, it seems inevitable that in the latter circumstances a congestion must occur. It must be pointed out also that these gas sessions accelerate the work, it being possible to do two to three times the amount of work in one of these gas sessions as compared with the amount of extraction in a normal session by local injections. H. S. SMYTH, L.D.S., R.C.S.(Eng.). 43 BARKING TOWN URBAN DISTRICT COUNCIL. SCHOOL MEDICAL SERVICE. TABLE I.—RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Number of Code Group Inspections: Entrants 946 Intermediates 687 Leavers 581 Total 2214 Number of other Routine Inspections 126 B.—Other Inspections. Number of Special Inspections 141 Number of Re-inspections 1347 Total 1488 44 TABLE II—A. RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED 31st DECEMBER, 1928. 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 12 12 1 1 Uncleanliness — — — — Skin Ringworm.—Scalp — — — - Body - — — - Scabies 2 — 1 - Impetigo 3 — 1 - Other Diseases (NonTuberculous) 1 2 1 - Eye Blepheritis 3 2 — - Conjunctivitis — — 1 - Keratitis — — — - Corneal Opacities — — - - Defective Vision (excluding Squint) 90 14 22 - Squint 17 3 2 - Other Conditions 2 — — - Ear Defective Hearing 1 — 3 - Otitis Media 9 — 4 - Other Ear Disease — — — - Nose and Throat Enlarged Tonsils only 42 58 7 1 Adenoids only 8 14 1 2 Enlarged Tonsils and Adenoids 70 51 6 1 Other Conditions 21 11 3 2 Enlarged Cervical Glands (NonT.B.) 1 48 1 3 Defective Speech - 1 - 1 Teeth—Dental Diseases (See Table IV., Group IV.) Heart and lation. Heart Disease: Organic 1 25 - 2 Functional - 38 1 9 Anœmia 9 9 1 3 Lungs Bronchitis 19 20 2 — Other Non-Tuberculous Diseases — 3 — — 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 - — - - Suspected - 2 - - Non-Pulmonary: Glands 1 10 - 1 Spine - — - - Hip - - - - Other Bones and Joints - - - - Skin - - - - Other Forms 1 2 - 2 Nervous System Epilepsy - 2 - — Chorea 4 8 1 — Other Conditions — 5 - — Deformities Rickets 12 9 2 1 Spinal 1 1 1 1 Other Forms 3 4 1 — Other Defects and Diseases 11 48 9 30 46 B.—Number of Individual Children FOUND AT Routine MEDICAL INSPECTION TO REQUIRE TREATMENT (EXCLUDING UNCLEANLINESS AND DENTAL DISEASES). Group. Number of Children. Percentage of Children found to require treatment. Inspected. Found to require treatment CODE GROUPS: Entrants 946 143 15.1 Intermediates 687 115 16.7 Leavers 581 71 12.2 Total (Code Groups) 2,214 329 14.8 Other Routine Inspections 126 22 19.0 47 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 - - - 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 3 6 9 Attending Public Elementary Schools - - - At other Institutions — — — At no School or Institution... 1 - 1 (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 21 22 43 Attending Public Elementary Schools - - - At other Institutions — — — At no School or Institution... — — — Notified to the Local Control Authority during the year. Feebleminded - - - Imbeciles 1 1 2 Idiots - - - Epilepsy. Suffering from severe Epilepsy. Attending Certified Special Schools for Epileptics 1 2 3 In Institutions other than Certified Special Schools - 1 1 Attending Public Elementary Schools - - - At no School or Institution - - - Suffering from Epilepsy which is not severe. Attending Public Elementary Schools 6 4 9 At no School or Institution - - - 48 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 2 1 3 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 63 65 128 At Public Elementary Schools 14 16 30 At other Institutions - - - At no School or Institution - - - Active non-pulmonary 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 - - - At Certified Residential Cripple Schools - - - At Certified Day Cripple Schools 21 15 36 At Public Elementary Schools — — — At other Institutions — 1 1 At no School or Institution - 1 1 49 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 10 — 10 Body 13 — 13 Scabies 8 — 8 Impetigo 326 1 327 Other Skin Diseases 101 — 101 Minor Eye Defects (External and other, but excluding cases falling in Group II.) 66 4 70 Minor Ear Defects 109 1 110 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.) 1385 1 1386 Total 2,018 7 2,025 50 Group II.—Defective Vision and Squint (excluding Minor Eye Defects Treated as Minor Ailments—Group I.) Defect or Disease. (1) Under Authority's Scheme. (2) Number of defects dealt with. Submitted to refraction by private practitioner or at hospital apart from the Authority's Scheme. (3) Otherwise (4) Total. (5) Errors of Refraction (including Squint) 144 37 - 181 Other Defects or Diseases of the eyes (excluding those recorded in Group I.) - - - — Total 144 37 — 181 Total number of children for whom spectacles were scribed:— (a) Under the Authority's Scheme 141 (b) Otherwise 37 Total number of children who obtained or received spectacles:— (a) Under the Authority's Scheme 141 (b) Otherwise 37 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) 122 33 155 14 169 51 GROUP IV.—Dental Defects. (i) Number of Children who were:— (a) Inspected by the Dentist. Routine Age Groups- Age 3 — 4 3 5 323 6 571 7 527 8 509 9 450 10 398 11 401 12 332 13 287 14 148 15 6 Special 1 Total 3956 (b) Found to require treatment 2945 (c) Actually treated. 2787 (d) Re-treated (included in (c)) 935 (2) Half-days devoted to Inspection 26 Treatment 352 Total 378 (3) Attendances made by children for Treatment 2787 (4) Fillings—Permanent Teeth 853 Temporary Teeth 980 Total 1733 (5) Extractions—Permanent Teeth 379 . * Temporary Teeth 3671 Total 4050 (6) Administrations of General Anaesthetics for Extractions 665 (7) Other Operations—Permanent Teeth Temporary Teeth 169 52 GROUP V.—Uncleanliness 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 17153 (iii) Number of individual children found unclean 1545 (iv) Number of children cleansed under arrangements made by the Local Education Authority 25 (v) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 - (b) Under School Attendance Bye-laws -