BARK 71 Barking Town Urban District Council. THE ANNUAL REPORT OF THE School Medical Officer For the Year 1929 C. LEONARD WILLIAMS. B.Sc., M.R.C.S., L.R.C.P., D.P.H. 2 SCHOOL MEDICAL STAFF, 1929 School Medical Officer i C. LEONARD WILLIAMS, B.Sc., M.R.C.S., L.R.C.P., D.P.H. Deputy School Medical Officer : MURIEL J. LOUGH, B.Sc., M.B., B.S., M.R.C.S., L.R.C.P., D.P.H. (Died May, 1929). J. GWEN BEVAN, B.Sc., M.R.C.S., L.R.C.P. 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.) (Resigned August, 1929). W. H. FOY, L.D.S., R.C.S. (Eng.) (Commenced November, 1929). Masseuse : Miss A. E. FINDLAY. C.S.M.M.G. Nurses : Miss L. F. SWAIN. Miss S. E. W. GIBSON. Miss G. GEDEN (Dental Nurse). * Clerical Staff: E. W. HILL (Chief Clerk). 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. June, 1930. 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 report on the public medical services which are carried on by you, for the year ended 31st December, 1929. The opening months of 1929 found you face to face with one of the most pathetic troubles you have been called upon to encounter. Dr. Lough, whose name in Barking was a by-word for everything that was honest and homely and thorough, succumbed to an illness which had been threatening her for the past few years, and her death removed from amongst you one whose place it will be impossible to fill. « ... Dr. Lough had not only had a very thorough training in medicine and particularly in those aspects of medicine in which she had specialised, she had also a much wider training in many aspects of life, and her outlook on her duties and responsibilities was correspondingly comprehensive, added to which she had a predilection for hard work. 4 Together with the members of the Committee who knew her personally, I feel I have indeed lost something more than an ideal colleague. I have lost a real friend. It is, however, fortunate that during the time of Dr. Lough's last illness we had with us Dr. Bevan, who was already working part-time in Barking and who was intimately acquainted with the' work Dr. Lough had been carrying on. The Council decided to appoint Dr. Bevan to the vacant post, and Dr. Bevan, 1 know, leaves no stone unturned to merit the great confidence which has been reposed in her. The year under review represents, as it were, the last year under the old order of things. Henceforth in all your deliberations you will take into your consideration the opening up of the Becontree Estate and look upon Barking as a township with a potential population of 100,000. In January, 1929, I asked for an extension of staff. At that time you decided to wait before acceding to my request. You did not grant this addition to my staff during the year in question but you have done so during the time this report has been in course of preparation. I want to make it quite clear that in assessing the future requirements of Barking you should build as though you had appointed this additional medical staff early in 1929. Towards the end of 1929 the question of nursery schools has been authoritatively raised by the Minister of Health and the President of the Board of Education. It is significant that squalid home conditions are again the only substantial plea for these schools. I feel that any palliative measures are open to grave objection. Bad environment should be dealt with radically. Money spent on palliative measures merely 5 tends to hide the real trouble, and after all, nothing can take the place of a home for young children, and those homes should be sufficiently good to make palliative measures unnecessary. We have continued to attempt and to achieve closer coordination between the various allied medical activities which are undertaken under your supervision. At the end of July Mr. Smyth relinquished his appointment as dentist in the public medical services to take up private practice in South Africa. Mr. Smyth, throughout the whole of his period of office has maintained a very high standard of professional work, which is appreciated now and which will be appreciated even more in the years that are to come. His place has been most happily tilled by Mr. Foy, who comes to us from Cambridge, and I look forward with confidence to the continued success of this department. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, C. LEONARD WILLIAMS, School Medical Officer. 6 ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER For the Year 1929. (i) STAFF. The staff of the public medical services is still responsible to two separate committees of the Council. The central government, in conformity with past precedent, will probably await a definite lead from Local Authorities on this important question. I would like Barking to give the necessary lead to the Government by unifying the divided committee work on matters affecting the health of the people. Dr. M. J. Lough died in May, 1929, and Dr. G. Bevan was appointed to fill the vacant post. Mr. H. Smyth left us in July, 1929, and Mr. \Y. H. Foy was appointed to fill his post. The resignation of Miss F. Young was mentioned in the Annual Report for 1928. This took effect in January, 1929, and Miss G. Geden was appointed as dental nurse in her place. (2) CO-ORDINATION. Elsewhere I have been happy to pay tribute to the very real team spirit which I have found in Barking, in which all the various departments of your municipal activities play a part. It is this team spirit which makes possible any scheme of government, which on paper might appear rather disjointed. 7 The fact that Medical Officers in Barking carry out work for both the Health Committee and the Education Committee leads to internal co-ordination, and the team spirit of which I have spoken co-ordinates the work of my department with that of other departments. Without my omission of others suggesting anything invidious, I would like to pay tribute to the unification brought about by the appointment Mr. Goodaker fills as Chief Investigation Officer. Mr. Goodaker carries out the duties not only of a School Attendance Officer but also investigates cases for the Public Health Committee, and so has become the repository of an amazing amount of information, which is most helpful to us in our divers capacities. Elsewhere I have called attention to the need there is for unification and although I certainly think we stand in need of unification all the way round, I feel it only right to quote from Sir George Newman's Report on the Health of the School Child for the year 1928, in which he deals with the effective co-ordination between the Ministry of Health and the Board of Education. " The passing of the Ministry of Health Act in 1919 further strengthened the public health association with the school medical service (Section 3 (i) (d).). In accordance with this section a Circular was issued by the Board of Education (Circular 1136, November, 1919), explaining that the Ministry of Health would exercise the provisions of the section and determine the scope and standards of medical inspection and treatment of school children, and the Board 01 Education would be responsible for approving Schemes, paying grants and carrying on the service. In my Report to the Board of Education for 1918 this question was fully discussed (pages 35-39) and the lines of local co-operation suggested. Effective co-ordination between the Ministry of Health and the Board of Education has been in operation since the Act was passed." (3) SCHOOL HYGIENE. For the third time in succession it is my duty to call vour attention to the need there is for the provision at school of facilities for the drying of clothes and boots. 8 This matter was, previous to my appointment, brought to your notice in the report for the year 1926, and is a matter about which I feel quite strongly. I am still prepared to recognise the difficulties which confront you, but do believe that year should not follow year without this matter being dealt with in a radical way. Provision of Meals.—The same arrangements for the provision of meals obtain for 1929 as obtained in previous years, and, having regard to the fact that we can no longer look upon the provision of meals as a purely temporary measure, I think the time has come when the temporary building in which the children are given these meals should be'replaced by a better and a bigger building. I wish to pay the highest tribute to those who are in charge of the children. I think a very high level is indeed reached not only in the meal as such, but also in the way in which the children are given an opportunity of taking the meal under advantageous circumstances; but the building available is so small and the general amenities so inadequate that those who are responsible for looking after the children do not get any real chance of obtaining results commensurate with their efforts. The problem of catering for children who stay behind at their ordinary elementary schools for their mid-day meal is not a very real one, as the following table shows. It must, however, be remembered that where the children who remain behind are few in number, there is oftentimes the more need for supervision, and although it might appear at first sight that the public gain from the supervision is hardly commensurate with the effort, it cannot be too often emphasised that correct table manners are far more necessary in after life than many things which find a prominent part in our scholastic curriculum. 9 There is, perhaps, nothing which limits a man's activity and tends to develop an inferiority complex than a feeling of awkwardness when in company at mealtimes, and in addition slovenly habits at the dinner table lay the foundations of dental trouble and of stomach diseases. School. No. of children who do not return home for mid-day meal. Whether facilities exist for heating of children's meals. Whether facilities exist for the drying of children's clothes and boots. Park Modern— 25—40 Yes Yes C. of E. Boys — No School fires in winter only. Girls - „ „ Infants — „ „ Ripple— Boys - „ „ Girls — „ „ Infants — „ „ SS. Mary & Ethelburga Mixed 10 Yes „ St. Joseph's Infants 25 „ „ Gascoigne Boys - No „ Girls - „ „ Infants - „ „ Westbury Boys - „ „ Girls - „ Yes—at Laundry Infants - „ School fires in winter only. North Street— Boys 3 „ „ Girls — „ „ Infants - „ „ Castle— 25 • Small stove in teachers private room. School fires in winter only. Faircross— All children stay at school for mid-day meal, the food being supplied from Municipal Kitchen Yes Yes (4) MEDICAL INSPECTION. Routine and special examinations, to be of any worth, must be done well. On no account should more than twelve children be seen in any hour at routine school medical inspection unless there is some definite explanation or excuse. The average number of inspections per hour should be in the neighbourhood of nine or ten. 10 In Barking we visit most schools three times a year for the purposes of school medical inspection. It is found generally that this does not take up much more time than visiting at less frequent intervals and leads to increased efficiency, the visiting medical officer having an earlier opportunity of following up cases which are required to be kept under observation. I wish to stress the need there is for medical officers to visit schools on their own initiative and at the request of the Head Teachers, apart from these routine visits, and I hope that time will be afforded for this to take place. May I once more take upon myself what has begun to be a perennial task of explaining that routine inspections are essentially a census of the health of the school population, and that people who object to having their children examined at school because they know them to be healthy or because they are already receiving attention for such disabilities as they may suffer from, make it impossible for you to assess the standard physique of the children who are attending your schools and so make it impossible for you to determine the physical benefits which are conferred on the children under your charge by the form of education you provide. I do hope that everybody interested in the welfare of children will teach in season and out of season that education can only be carried on with physical welfare to the children if you as a Committee have this data, which can only be provided by the examination of all children, ailing or well, under treatment or not under treatment, at routine medical inspections at school. The table herewith included, 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 during the years 1928 and 1929. 11  Entrants Intermediates Leavers Specials Other Routine Examinations Total 1928 1929 1928 1929 1928 1929 1928 1929 1928 1929 192S 1929 So. of children examined 946 914 687 958 581 572 141 162 126 339 2491 2945 No. referred for treatment 143 129 115 156 71 76 70 51 22 14 421 426 No. referred for observation 184 251 113 198 54 104 53 67 10 1 414 621 Percentage of defective children 34.6 41.6 33.2 37.0 21.2 31.5 87.3 72.8 26.9 4.4 33.5 35.6 Last year I pointed out that the figures showed an increase on previous years, and again this year I have to report that the amount of work done is again an increase on last year. I do not look upon the increase in the percentage of defective children as really significant. It will be noted that the only significant increase is amongst the children who have been referred for observation and not amongst the children who have been referred for actual treatment. The following table shows the percentage of the children examined who were accompanied by their parents or guardians. Year. Percentage of Children Examined who were Accompanied by Parents. Year. Percentage of Children Examined who were Accompanied by Parents. 1925 65.5 1928 64.8 1926* 60.7 1929 65.7 1927 62.7 The number of children on the school register on 31st December, 1929, was 7,284, compared with 7,201 on 31st December, 1928. 12 During the year, the Medical Officer paid 149 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 1929, classified according to the schools attended, the number of inspections held in each school and the number of parents or guardians present:— School. No. of inspections. Numbers inspected. No. of parents present. Boys. Girls. Park Modern 6 49 55 35 Gascoigne 30 310 297 408 North St. 19 213 196 276 Castle 2 22 21 29 Westbury 22 198 217 299 Ripple 28 250 300 423 Faircross 18 178 161 226 St. Joseph's SS. Mary's and Ethelburga's 11 91 99 101 Church of England 13 150 129 138 (5) FINDINGS OF MEDICAL INSPECTIONS. Table II on page 46, gives in detail a return of defects found during the course of routine inspection. The figures in brackets are the comparable figures for last year. (a) Malnutrition.—Malnutrition is not a serious problem in Barking. The provisions you make are adequate and run very smoothly, and 1 have yet to learn that there is any need for any child to attend school feeling really hungry. The number of children who require treatment for malnutrition remains practically constant with last year and is negligible. The number of children who have been kept under observation is somewhat increased. This, however, does not of necessity imply that the situation generally is any different from last year. 13 (b) Uncleanliness.—With reference to uncleanliness the really significant figures are to be found not in Table II on page 46, but in Table V on page 54. More children were examined than last year and more children actually and relatively were found to require treatment. There is a tendency throughout the country to place the cleansing of verminous children where in ordinary cases it should rest, i.e., on the parents—and, as Sir George Newman says in his report for 1928, there is much to be said for this attitude. My own opinion is that unless the circumstances are exceptional, actual cleansing of children by a public authority should only be done in default, and that whenever carried out a prosecution should follow—the parents being prosecuted for the child having been off school. It is to be remembered that the High Court has decided that absence from school by reason of exclusion for being verminous is not sufficient excuse and is punishable. I wish once more to say that there is no hardship whatever in proceeding with every coercive measure you have to enforce absolute cleanliness so far as infestation is concerned amongst boys. I do not see why every boy with an infested head should not be excluded forthwith and the parents proceeded against. Tiiis year, as last, I want to make it perfectly clear that the greater part of the figures submitted to you of dirty people are children who are constantly dealt with and that, generally speaking, the standard of cleanliness in Barking, is commendable. 14 It is for this reason that the parents of children habitually infested are a greater nuisance, and I do feel that the mothers of Barking who are striving to keep their children scrupulously clean should have every support the Committee can afford them and that this support can only be given by proceedings being taken where friendly advice and reasonable co-operation have failed. School. Dept. No. of Examinations Nits only. Nits and Vermin (head) Gascoigne Infants 1168 118 4 Boys 1488 33 — Girls 1251 176 1 North St. Infants 943 65 1 Boys 1032 31 1 Girls 1021 88 3 Castle Infants 238 27 - Boys Girls Westbury Infants 1147 61 3 Boys 1075 18 - Girls 1177 162 3 Ripple Infants 655 45 1 Boys 719 18 — Girls 699 64 4 C. of E. Infants 562 83 3 Boys 624 27 — Girls 573 162 3 St. Joseph's Infants 635 94 6 SS. Mary s & Ethelburga's Boys 362 40 4 Girls Faircross — 509 36 — Park Modern Mixed 710 9 — 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 193 cases, compared with 159 in 1928. In all, 214 children were supplied with boots during the year. (c) Heights and Weights.—The following table gives the average heights and weights of children examined at the three undermentioned age periods in all of the schools, compared with the results at similar age periods in 1925, 1926, 1927 and 1928. 15 Year. Average Height in Inches. Average Weight in Pounds. 5 yrs. 8 yrs. 12 yrs. 5yrs. 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 1929 41.9 50.5 56.3 40.9 56.3 83.5 Average for 5 years 42.14 49.65 56.9 40.6 54.78 81.2 (d) Minor Ailments.—The incidence of minor ailments remains approximately the same as for last year. (e) Skin Disease.—The number of cases of skin disease found at routine inspection was quite small. This is a testimony to the efficiency of the service you carry on at the Minor Ailment Clinic. I am sure that most of these cases are dealt with as they arise, with the result that but few of them are found at any school inspection. (/) Eye Disease.—The findings of school medical inspection show no significant deviation from last year and are generally satisfactory. As for diseases of the skin, this circumstance is a tribute to 'he work which is being carried on at the Minor Ailment Clinic. (g) Vision and Squint.—Defective vision, however, showed a slight increase on last year, but on the other hand the number of cases of squint was less than for last year. It is interesting to remark that now, under the Council's Maternity and Child Welfare Scheme, there is an Eyesight Clinic for toddlers—i.e., for children under five. 16 (//) Ear Disease.—The condition of your children with regard to ear disease remains practically as it was last year. (i) Tonsils and Adenoids.—The number of cases of tonsils and adenoids shows a perfectly unwarrantable incidence. There is evidently something basicly wrong with the upbringing of the children. Last year I tentatively suggested a possibility of it being due to an error of diet and I find myself being driven to the conclusion that this opinion is right. Exactly where the deficiency lies I would not like to say, although I shrewdly suspect that the deficiency is really related to bread. A part of the actual increase in the number of cases found requiring treatment may be due to a rather higher standard being set than previously, but I want to make it perfectly clear that no operations are undertaken except on the advice of the surgeon specialist at the hospital where the children are treated. (j) Ttiberculosis.—There were II cases of tuberculosis amongst children of school age notified to the Medical Officer of Health during the year. Of these one was pulmonary and ten Were non-pulmonary. The following table shows the position with regard to notification of tuberculosis amongst children of school age during 1929:— Notified during 1929 Pulmonary 1 Non-Pulmonary 10 Total 11 De-notified (of the above) Pulmonary — Non-pulmonary 1 Total 1 17 As reported elsewhere, the revision of the Tuberculosis Register has now been going on for some time, and during the year under review the following numbers of school children have been removed from the Notification Register. Removed from Register. Pulmonary. Non-Pulmonary. Cured 4 12 Amended Diagnosis 25 12 Left District 7 5 Died — *3 Total 36 32 * These 3 deaths did not all occur during the year under review, although all the names have been removed during 1929. Tuberculosis of the lungs amongst children is a relatively rare disease. It is, however, sufficiently common in Essex for there to be need for the County to make special provision to deal with it. This they have to a certain extent done, and I regret to say that pulmonary tuberculosis amongst school children is definitely existing in Barking. (k) Dental Defects.—Routine medical inspection bears testimony to the efficiency of your dental service. There is yet work to be done by co-ordinated effort in making a higher standard for the first teeth, but generally speaking the permanent teeth are relatively well cared for, and the children leaving your schools show a very good percentage of sound, useful dentures. (I) Crippling Defects.—With reference to crippling defects, we have a very happy state of affairs to record. The findings of routine inspection show a considerable decrease in the number of cases found last year. 18 These figures will vary, up and down, from year to year, and even though they increase, I can assure you there is a progressive movement in the right 'direction. This movement will not be shown actually by figures because as year succeeds year we hope to be able to maintain a much higher standard. The Orthopaedic Clinic on the Maternity and Child Welfareside is now working so well that gross cases of crippling defects amongst your school children are now quite incidental. There is no way in which your Council has spent more wisely than in looking after the very young children whose deformities would mean serious disablement not only throughout the whole of school life but throughout the whole of life itself. I must, however, point out that there are quite minor physical disabilities which provoke a loss of efficiency apparently out of proportion to the disability, e.g., minor deformities of the spine due to the children adopting negligent attitudes when seated at desks and when standing. These not only throw an undue strain on the whole of the body skeleton, but actually alter the normal relationship of the heart and other organs, with great detriment to the well-being and intelligence of the children. It is in this connection I would stress the importance of the closest co-operation between the teachers and the school medical inspectors. It is only when teachers have an opportunity of having these minor disabilities pointed out to them while the children are being actually examined that their importance can be rightly appreciated. (6) INFECTIOUS DISEASE. The spread of infectious disease is a matter primarily associated with the home life of the children. Last year I pointed out the very considerable difficulties which present themselves to your teaching staff in helping to prevent the spread of infection and I expressed my appreciation of the very real help we had received from them notwithstanding these difficulties. 19 I would wish this year to discuss the matter from another standpoint, and that is that the education of the mothers and fathers of to-morrow should definitely include positive teaching on the principles underlying the spread of infectious disease. It is in this way only that we can look forward with confidence to the future. It is obvious on all hands that we have to-day as high, indeed a higher, conception of the responsibilities of parents than we have had for a very long time in this country, but nevertheless we are face to face with the fact that parents are still negligent when it comes to their attitude towards the spread of infection. To a certain extent this is because the home circumstances do not lend themselves to the necessary isolation, and indeed it may be said that in some cases adequate isolation is impossible, but I do feel that if we had a more informed public opinion on the questions involved, even our inadequate amenities could be used to better effect than they are at present. 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 infectious disease, the school sessions so affected are not counted in estimating the average attendance for the purpose of grant. During 1929 one certificate was granted for this purpose. The following table shows briefly the number of children notified and reported suffering from some of the commoner infectious diseases:— 1926 1927 1928 1929 Scarlet Fever 78 117 132 164 Diphtheria 35 39 67 44 Measles and German Measles 353 1 342 191 Chicken-pox. Whooping Cough 153 99 262 378 20 (7) FOLLOWING UP. A summary of the "following up" work undertaken by your school nurses is given herewith:— Number of visits to schools for medical inspection 131 Total number of visits to schools 245 Number of home visits in connection with:— 1927 1928 1929 (a) Routine medical inspections 3,419 3,345 3,549 (b) Infectious disease 137 571 520 (r) Uncleanliness inspections 251 212 80 (d) Non-attendance for treatment, etc. 367 542 124 (e) Dental Inspections — — 460 It will be noted that visits in connection with dental inspection are included in the above table for the first time. This is because during the year under review, owing to a rearrangement of duties, the dental nurse now only does home visiting during certain holiday times and the number of visits included in this table has actually been carried out by the school nurses, the which work they have not regularly undertaken heretofore. It has also been found practicable to draw up routine letters +0 send to parents in cases where they have failed to fill in the dental consent forms or where for no very obvious reason they have refused to consent to the work going on. The benefit of this system we hope to be able to show next year. The enormous drop in the number of home visits in connection with uncleanliness inspections is explained as follows:— During the year under review your school nurses report there has been a much better attendance at the Clinic on the part of children who have been excluded and that thus they have been able to deal with these children at the Clinic instead of having to follow them up at home. 21 Clinics.—The numbers of school children attending in 1928 and 1929 were as follows:— Clinic. No. of 1st attendances of children. Total No. of attendances. 1928 1929 1928 1929 Minor Ailments 2059 2139 12749 10757 Ophthalmic 128 139 559 482 Dental 1852 951 2787 2997 Ringworm 9 15 18 30 Orthopaedic for examination 29 28 2427 2997 for treatment 62 32 Minor Ailments Clinic. 1928 1929 No. of days clinic was open 302 331 Total No. of attendances 12749 10757 Daily average attendance 42.2 32.5 No. of cases treated 2059 2139 (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. On the days when there are gas sessions at the Dental Clinic, one of these three nurses assists the dental nurse. This Minor Ailment Clinic meets a very real need. Last year it will be noted that the attendance nearly doubled that of the previous year. This year we have roughly maintained the happy position of which I was able to advise you for 1928, but I feel that there is an even greater future for this type of work. • I want to make it quite clear that we run this Clinic without encroaching on the realms of private practice. The work carried out is the treatment of sores and scabs, bad eyes and running ears— the sort of work which wants the daily attention of a nurse rather than of a doctor, although, of course, all the nursing work must be carried out under the direct supervision of a doctor, who is responsible for the treatment undertaken in each individual case. 22 During 1929 the Minor Ailment Clinic has still suffered from a lack of continuity of supervision, but this I hope will be materially altered during the year 1930. 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. Wherever necessary the services of your ambulance are available for bringing children home after operation, but I do feel it wise that as and when possible, you should make arrangements for the detention of these children following the operation. Tuberculosis. —The care of tubercular children is in the hands of the County Council. There is a lot of overlapping. In London, tuberculosis, orthopaedics and many other special services are quite incoordinate, particularly so where people run from one hospital to another as their fancy takes them, and the time has come when there should be a general conference on the whole question, with the intent that a sound scheme should be evolved to prevent the present losses in time and efficiency. Skin Diseases.—The loss of time from school owing to various skin diseases amongst the scholars is still capable of improvement. I am hopeful that more continuous supervision of the Minor Ailment Clinic will achieve an improvement in this direction, and I do suggest you should entertain the possibility of appointing a nurse whose duty it would be to work continuously in the Clinic. We cannot over-estimate the very real work which is being done by the Plaistow nurses, but these are being replaced every few months, with the result that there is not that personal intimate acquaintance with the individual children who come up to the Clinic repeatedly and who could be dealt with more expeditiously than they are at present if the Clinic were in the hands of someone who had a permanent appointment there. The treatment of ringworm of the head is satisfactorily carried on by X — Ray and you yourselves have provided amenities for treating cases of scabies. 23 External Eye Disease.—The work with reference to external eye disease has gone on satisfactorily during the year under review. Looking after the children's eyes is one of the very well-worth schemes you have in operation. Not only by your efficient service do you reduce to a minimum the period the children are off school but you do specially increase the general efficiency of their school life. Vision.—The treatment of defective vision is carried out 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. Ear Disease.—The most common ear disease with which we have to deal is the ordinary discharge from the external ear. The suitable medical treatment is carried out, but the time has come for you to entertain the possibility of appointing a special aural surgeon, who would attend in the first instance, say once a month. He would inspect the ears of the children referred to him by the medical officers and would himself carry out any necessary emergency treatment and also indicate the line of treatment to be adopted between his visits. There is no doubt that a large amount of minor defects pass unnoticed, which defects often represent all the difference between what would be a bright boy and a boy rather below the average. There are now special instruments for testing the acuity of hearing, by which the acuity of hearing can be tested well-nigh as accurately as the acuity of vision. 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. Foy. 24 Crippling Defects and Orthopaedics.—The work carried out during the year in question has followed closely that of the previous year. In my last Annual Report I said that the question of the provision of extra service in orthopaedics was intimately linked up with the extension of the medical services as a whole, and that although highly desirable, I was not in that Report prepared to advise the inauguration of any extra service until the general extension had been undertaken. It is now, however, my privilege to be able to say that these general extensions are about to take place and that therefore i seriously urge you to increase your orthopaedic work. In the first place, whereas the services of an orthopaedic nurse are available only for three days a week, they should be made available for every day in the week ; and in the second place, arrangements should be made for extending the present clinic accommodation. This can be done either by taking in an adjoining classroom or alternatively by building in the precincts of the school. The fact that such buildings, perhaps of a temporary nature, are likely to be built for class purposes, suggests that they could be built so that they could later be used either as an Orthopaedic Clinic or to house the present manual instruction class, which would make this classroom adjoining the clinic available for clinic purposes. The lack of co-ordination between various hospitals interested in orthopaedic work is still a disadvantage to the work as a whole. We do what we can to a certain extent by correspondence, but as I said last year, the time is overdue for a conference between all the hospitals who are engaged in orthopaedic work and Local Authorities and others who are otherwise interested financially in this work. 25 — 26 PARTICULARS OF WORK DONE IN CONNECTION WITH ORTHOPAEDIC CLINIC. No of visits by Orthopaedic Surgeon No. of visits byMasseuse ATTENDANCES Primary Examination Re-Examination For Treatment Total School Children Under School Age School Children Under School Age School Children Under School Age 11 234 28 27 145 86 2824 936 4046 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 2 90 - — 17 1909 10 948 - - 3 83 Under School Age 7 157 — — 2 45 79 725 - - 6 142 Admission to Orthopaedic Hospitals On waiting List for Admission 31/12/29. School Children Under School Age Total School Children J Under School Age Total 6 2 8 2 — 2 27 (9) OPEN-AIR EDUCATION. Playground Classes. —May I take this opportunity of stressing the need there is for more classes to be held in the open air ? It is unfortunate that school furniture, school stationery and the school curriculum generally are not such as to make playground classes so easily arranged as they should be, and that on account of the inherent difficulties of arranging playground classes they cann'ot be so often arranged as they should be. It ought to be possible, with a minimum of effort, for any class of scholars to take the whole of the essential furniture into the open air without difficulty. For this purpose the furniture should be light and if necessary collapsible. Reading books and stationery should be of coloured paper, so that work can be undertaken in the open air without any eye strain, and the curriculum, etc. so arranged that there are lessons which can with advantage be taken out of doors. School Journeys. —The following school journeys were made by scholars during 1929:— Date. School. Place Visited. 17/6/29 Ripple Girls' School Valentine's Park, Ilford. 27/6/29 Westbury Boys' School East India Dock, Isle of Dogs, Blackwall Tunnel, Greenwich Museum, River Thames at Greenwich, Greenwich Observatory, Woolwich Foot Tunnel. 21/10/29 Westbury Girls' School Barking Church and Abbey Grounds. 21/10/29 Ripple Girls' School Barking Park. The question of school journeys on a much more comprehensive basis than that which has obtained in the past is being considered by you. 28 School Camps.—School camps are run during the week-ends from Friday to Monday evening. The camp is of a permanent nature and is situated at Hainault. . During the summer holidays, too, there are additional camps where children are taken for a fortnight at a time to the same huts at Hainault. All the children are medically examined before they proceed to camp and many children in this way get at least a short holiday in the open air who otherwise would probably never leave Barking from one year's end to another. Open-air Classrooms in Public Elementary Schools.—The more modern schools occupied in the town have facilities for turning the classrooms into modified open-air classrooms, and I do hope that in the schools which are being erected even more attention will be given to this. Children need light as much as plants do and they thrive best in the open air. Ultra Violet Light Treatment.—Ultra violet light treatment has been carried out at Faircross School during the year, the total cases treated being 10. The period of treatment of these cases varied from one month to twelve months and the total number of doses was 948. 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. With the increased medical staff which will be operating in the near future I hope it will be possible to maintain fuller medical supervision over this form of treatment than has obtained in the past. (10) OPEN-AIR SCHOOLS. Year after year I have discussed in my Annual Reports and elsewhere the alternative merits of Open-air Schools as such and the 29 same amount of money spent on residential schools for similar types of school children. Whilst in Switzerland last year I had an opportunity of examining not only ordinary elementary schools but also of seeing one of their special schools for debilitated children. In the special instance which came to my notice, what appeared to be an ordinary house which lent itself particularly to the purpose, had been taken high up from the valley. The type of children appeared to be very much the same as those we admit to our Open-air School. This special school was open all the summer-time. It has always appeared to me that an Open-air School open for about twenty-five hours during the week cannot be of the same economic value as a similar school where the children have the benefits of the exceptional amenities afforded for the whole duration of their stay. It must not be supposed I am speaking at all to the detriment of Open-air Schools as such. I do, however, look upon them as pioneer schools showing the line of future development rather than a fixed form of accommodation. If and when we learn the lessons these schools have to teach— i.e., as and when our other schools are so built that they afford similar amenities—the need for Open-air Schools will pass, although of course, the education of children who by reason of their physical defects are not quite fit for the curriculum of ordinary elementary schools will still remain an educational problem. During the year we have had an exceptional experiment by reason of the fact that the Authority have decided to use one of the classrooms at the Open-air School for ordinary elementary education. It is my unfortunate experience that we have not made the most intelligent use of this classroom. The children have not received their full maximum of open air by reason of the fact that the windows have been unnecessarily shut and the children have 30 often had their lessons indoors when I opine it should have been possible for them to be out of doors. This is most unfortunate because it was agreed when this class was inaugurated that there should be no invidious distinctions between the ordinary elementary school children and the open-air children, and it is futile to suppose it has been necessary for the normal children to be protected by closing the windows, etc., at the same time we have had the Open-air School being used as an Open-air School for the debilitated children. (ii) PHYSICAL TRAINING. The Local Education Authority have no officer with special duties for organising physical training in your schools. May I ask those who are interested in physical training to read again my Report under this heading for last year ? I am persuaded there are many minor disabilities causing a great deal of physical suffering and reducing the efficiency of education, which could be overcome by quite ordinary physical training within the scope of the curriculum of any ordinary elementary school. (12) 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. 33,991 free meals were provided during 1929. (13) 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. 31 Once again I want to plead that the skin is an organ of the body. It requires not only to be kept clean—it requires also to be kept working. Bathing is a very good way in which to give the skin some work to do. The exposure of the body to the air and the friction of the towel are very fine things, and I hope that even if it may not be necessary to give children baths in the schools, the effect of school life will promote a more extended use of the facilities for bathing which we have and hope to have in Barking. 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. (14), (15), (16) and (17) CO-OPERATION OF PARENTS, TEACHERS, SCHOOL ATTENDANCE OFFICERS AND VOLUNTARY BODIES. The attendance of parents at routine medical inspection is considerable, no less than 65.7 per cent. having attended during the year 1929. The teachers, too, take a remarkable interest in this work, and their help is invaluable. People are still found who do not understand that routine medical inspection, in addition to affording them an opportunity of having their children examined to see that there is no early disease, is also a census of the health of the school population of the town. Without the accurate knowledge obtained from such a census, you, as a governing authority, would be quite unable to determine to what extent school life is in the best interests of the health of the children. It is obvious, therefore, that if you are to have such a census, healthy children must be counted in as well as others and it is necessary for us from this standpoint to deal with the health}' as well as those who are ailing. 32 I have at times been dumbfounded to find that this point of view is not recognised, even when it has been quite clearly advanced, and J do hope that all those who are interested in the welfare, not only of children as infants, but in the education of children as a whole, will do their best to show the public that they cannot make the best use of their education rate unless you can have the facts revealed by such a census, and that such a census cannot be completed unless all children in the necessary age groups are examined. I have already called attention to the work which Mr. Goodaker undertakes as Investigation Officer. The information he is able to lay before us is of most valuable help to us in co-ordinating our work with the other services of the Authority. We ourselves are also in close co-operation with the other various schemes and agencies, voluntary and otherwise, which artinterested in the happiness of children and endeavour to work in a spirit of friendly co-operation with all of them. I am credibly informed that the National Society for the Prevention of Cruelty to Children have dealt with 22 cases. The following table shows the way in which these cases have been dealt with:— Total number of cases investigated 22 (a) Prosecutions 1 (b) Warnings 19 (c) Otherwise dealt with 2 In addition to the above, the local inspector, so I am advised, has paid 123 supervisory visits. May I take this opportunity of again assuring you that the National Society for the Prevention of Cruelty to Children are most helpful and that they never undertake a prosecution unless they are really driven to do so by circumstances they find unable to tolerate or remedy ? 33 (18) BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. \\'c believe that all the blind, deaf, defective and epileptic children are known to you. Your great difficulty is in obtaining the necessary accommodation, particularly for children who are suffering from more than one of these disabilities. It seems to me that concerted action should be taken in order to obtain the necessary accommodation, and although I do not wish to make any proposal which could possibly be thought to have in the least any political aspect, I do think that the possibility of establishing institutions with an income guaranteed by the State should be entertained, each Authority paying for their individual cases. Six deaf and dumb children have attended at Frederick Road Centre, Custom House, during the year. No deaf and dumb child has been maintained in a residential institution. The number of known epileptics of all grades is 8. Mentally Defective Class, Open-air School.—This class continues to serve a very useful purpose, and my submissions for last year on the problem involved remain, in my opinion, quite sound. In addition to what I said last year I would like to discuss the problem of the dull and backward child from the health standpoint. The percentage of physical defects amongst these children is higher than amongst normal children, and altogether their average physical development and endurance is considerably less. These dull children do not stand the same chance in life's battle as their better endowed brothers and sisters and may become the hewers of wood and the drawers of water of to-morrow. It is impossible to endow these children with forceful intellects. Their only chance in life rests on their physical fitness, without which they could never hope to obtain the necessities and the comforts of life. 34 This outlook should influence the whole of their education. Scholarship, as something different from education, is not of primary importance, and moreover, whereas the normal child at fourteen has a plastic mind and is still on the threshold of life mentally, the dull child at fourteen is a finished product. (19) NURSERY SCHOOLS. There are no nursery schools in the district. On the 5th December, 1929, the Ministry of Health and the Board of Education sent out a circular on the question of nursery schools. They say in the third paragraph of this circular that " many small children cannot get personal attention where the home is squalid, where food is bad and insufficient, where the only playroom is the gutter, and where ill-health passes unnoticed till chest trouble, rickets or other ailments have developed. These conditions, prevalent in parts of all our cities, cry aloud for attention." My own opinion is that nursery schools could be tried in a limited way as an experiment if and when the money is available, particularly in those parts of the town where there is most need, but I do feel that the real problem rests in the home and that no case has been made out for nursery schools until more intensive use has been made of the Maternity and Child Welfare organisation, which has done so much for the children during the first and second years of life and which could do much more for the children up to the age of five if more money and consequently a more comprehensive service were available. The Maternity and Child Welfare Service tends to call attention to environment and facts which require social measures for their alleviation. Taking children out of the home rather tends to hide these environmental difficulties. (20) SECONDARY SCHOOLS. Once again I want to point out how invidious it is for children leaving your ordinary elementary schools to proceed to a higher 35 education to be debarred from the very comprehensive medical services you have set up. It has so far proved itself impracticable for the County Council to offer amenities similar to your own. The difficulties they would find in setting up such services would be considerable, but there is no doubt that there is a very real need for the children to be looked after in the way in which you look after your own children, and I do hope that during the next year something will be done along the lines of the County handing over the whole of this work to you, whatever the financial consideration involved may be. (21) CONTINUATION SCHOOLS. There are no continuation schools in the district. (22) 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 Pye-laws of the Education Authority, 29 applicants of school age submitted themselves for examination prior to employment, of which number it was necessary to refuse one 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. (23) SPECIAL ENQUIRIES. There have been no special enquiries within the meaning of the Board of Education. The work we have been doing on industrial pneumoconiosis has been of great interest to the Local Authority, particularly to the Juvenile Employment Sub-Committee. 36 There is much more work waiting to be done, and it is unfortunate that the services available are only sufficient for the ordinary day to day routine. I do feel that not only in Barking but throughout the whole of the country much good would accrue if all services were sufficient for reasonable time to be allowed for independent research, which would naturally proceed along the lines presented by each several authority. (24) MISCELLANEOUS. Two young persons who desired to become bursars and student teachers were medically examined during the year by a private medical practitioner, neither being rejected on medical grounds. This closes the report for the year 1929. 1930 opens up new vistas. It is wise to pause and reflect, and I would urge you to remember that although this report deals with much work of an inspectorial nature and much work which is essentially curative, the aim of the service as a whole is that " Prevention is better than cure." The School Medical Service is a branch of preventive medicine and indeed the curative work is undertaken in the confident expectation that any such strictly curative measures will prevent the incidence of more serious illnesses and disabilities. One of the problems which will present itself to you on the development of the Becontree Estate is the possibility of co-ordinating maternity and child welfare and school work. The number of Inspectors and so forth visiting the homes of the people to-day is enormous, and anything which can be done to check the number of inspectors has much to commend it. It would be possible to redistribute the work, whereby maternity and child welfare work and school work would be carried out in any one area by one nurse. 37 Out of 2827 whole-time nurses employed throughout the country in school work, 1,298 engage in this work only, while 1,529 are combined health visitors and school nurses. These figures, of course, refer to rural as well as urban districts, and it is only right to mention that in urban districts it is easier than it is in rural districts to run separate nursing services for health and education, but notwithstanding this, I am of opinion there is a definite advantage in nurses having definite areas within which they are the competent nurse to deal with all cases, both under the Maternity and Child Welfare Scheme and under schemes approved by the Board of Education. It is estimated that in an urban area one nurse is required for 2,500 school population, in addition to a dental nurse where a dentist is maintained. It is, however, to be remarked that with this average a certain amount of time would be spent by these nurses on clinic work, but because these figures include both progressive and backward authorities, I am of opinion it is only right for me to advise you that the whole-time staff of two nurses which this town at present enjoys must be looked upon as a minimum and should not be taken as the basis for computations as to future requirements. During my visit to the Annual Conference of the Royal Sanitary Institute at Sheffield in July, 1929, amongst other things it was brought forward that:— 1. Ten per cent. of school children are more than two years behind normal. 2. We overestimate the exhibition of mental ability as to education and underestimate the virtue of behaviour. We should not ask what a child can do but how he does it and why. 3. Teachers should report difficult children quite as readily as children backward in their school work. 4. Food fads are due to bad parentage. 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, particularly in children under school age. The numbers are as follows:— School Children. Under School Age. Primary Examinations 28 27 Re-examinations 145 86 ,The findings of my primary examinations are as follows:— SCHOOL CHILDREN. 1. Deformities—Bones and Joints— (a) Congenital— (i) Shoemaker's Chest 1 (b) Acquired— (i) Fractures 4 (ii) Arthritis 2 (iii) Genu Valgum 4 (iv) Tubercle of Spine 1 2. Muscular Deformities— (a) Congenital— (i) Torticollis 1 (ii) Scoliosis 1 (b) Acquired— (i) Pes Piano Valgus 7 (ii) Kyphosis .. 5 (iii) Kypho-Lordosis 3 (iv) Injury to Ankle 1 39 3. Paralysis— (a) Acquired— (i) Anterior Poliomyelitis 1 (ii) Encephalo-myelitis 1 CHILDREN UNDER SCHOOL AGE. 1. Deformities—Bones and Joints— (a) Congenital— (i) Digits of Hand 1 (b) Acquired— (i) Genu Valgum 3 (ii) Genu Varum 1 (iii) Hallux Valgus 1 (iv) Digitis Varus 1 (v) Bow Legs 1 2. Muscular Deformities— (a) Congenital— (i) Torticollis 3 (ii) Talipes 4 (iii) Subluxation of Shoulder Joints . 1 (iv) Lower Limb, short and small 1 (v) Outward Rotation of Humerus 1 (b) Acquired— (i) Pes Piano-Valgus 6 (ii) Abnormal Gait _ . 1 3. Paralysis— (a) Congenital— (i) Spastic Hemiplegia 1 (ii) Spastic Diplegia 1 (iii) Erb's 1 (b) Acquired— (i) Paresis of Neck Muscles 1 40 During the year six school children and two children under school age were admitted to hospital. The following operations have been carried out:— (a) School Children— (i) Sliding osteotomy ulna 1 (ii) Cuneiform osteotomy femur tion of recurvatum and varum deformities) 1 (iii) Tarsectomy 1 (iv) Open elongation Tendo Achilles 4 (v) Stoffel's operation—median nerve (Hemiplegia) 1 (vi) Manipulation of foot and plaster splint 1 (vii) Plaster bed for scoliosis 10 (b) Children under School Age— (i) Tenotomy Tendo Achilles 1 (ii) Manipulation and Plaster Splint rection of equinus) 1 (iii) Skin grafts for webbed hand 1 (iv) Tenotomy sterno mastoid (Torticollis) 1 4 Total 14 The special features of this year's work are the successful results of the operations performed, particularly the case of torticollis under school age, and the treatment of club foot at an early age. B. WHITCHURCH HOWELL, F.R.C.S. 41 REPORT OF DENTAL SURGEON. To the Medical Officer of Health, Barking, Essex. From the Public Dental Officer, Barking, Essex. Sir, I have the honour to submit the annual report of the School Dental Services for the year ended 31st December, 1929. The control of the Dental Clinic during this period has been handed over on three occasions, Mr. Spencer Smythe resigning his appointment in August, 1929; a locum tenens maintaining service until November, 1929, when the present Dental Officer took over duties. In spite of these changes, the amount of work accomplished has not decreased in comparison with other years. A more intelligent acceptance by parents of the importance of dental treatment for children is a notable feature of the year's work. If a child requiring attention is accompanied by a parent, not only is advice given and accepted, but also reasons given for the treatment necessary in each case, a procedure which results in any objection on the part of the parent being voluntarily withdrawn. In this matter full credit must be given to the nursing and visiting staffs and also to the teaching staff for their excellent co-operation in matters relative to oral health. Dental education in Barking over a number of years has shown a markedly favourable result, a result that is both gratifying and stimulating, but by no means representing the full possibilities of what can be accomplished with every circumstance favourably inclined. The percentage of extractions to the number of teeth examined is a fair basis upon which to judge the dental health of a community, and more particularly is this to be applied to the permanent teeth. A child leaving school and retaining in sound condition and correct position all the permanent teeth that may have erupted, can be classed as orally healthy. At the present stage of Dental education in England it is not reasonable to expect a majority percentage of such cases but there is every indication of a progressively increasing number each year, and it is such a result that the professional staff of your Dental Clinic desire to attain. Considerable handicap must be encountered by the indifference of the child to oral cleanliness, the equal 42 indifference of many parents, and social difficulties such as the control of diet and environment. Dental caries is very prevalent among school children of the present day, but it should be remembered that most cases of decay, if treated in time, will mean saving a tooth which, if left without skilled treatment is surely doomed to extraction. If the case is one involving a permanent tooth there is no natural replacement, and if a temporary tooth then a detrimental effect upon the permanent teeth is usually resultant. A happv feature of the work for the year in Barking is the increase in the number of permanent fillings. It cannot be too strongly urged that the wholesale sacrifice of permanent teeth does not prove that a service is an economic or a professional success, and obviously only permanent teeth that present at the time of their examination a menace to the health and comfort of the patient should be removed. *! During the latter part of the year many cases of misplaced teeth and mal-developed jaws have been inspected. In the past it has been customary to refer such cases to the London Hospital. Such procedure is contra-indicated for the following reasons:— 1. Travelling expenses are incurred by the parents while the patient attends the hospital on the numerous visits necessary for each case. 2. Loss of school time. 3 Adequate treatment can be carried out at the Clinic where the patient can be constantly under observation with greater convenience. I have to report that several cases are now under treatment and show satisfactory progress. Jaw malformation and misplacement of teeth can be the result of many different causes, most of which are preventable by proper parental control and supervision of the child. 43 The common causes are :— 1. Too early extraction of temporary teeth due to decay, the decay itself being due to insufficient care of the child's teeth at an early age, or to injudicious diet. 2. A badly chosen diet insufficient in vitamins and mostly of a soft nature, a condition which does not give exercise to the jaw bones by not demanding vigorous chewing. 3. Mouth breathing, due to nasal obstruction or habit. One is tempted to say that in such cases not only is there a retarded oral development but also a retarded mental development. 4. Finger and thumb sucking, and that most pernicious of unsanitary childish habits—dummy sucking. It is to be noted that malformation of the jaws and misplacement of the teeth are more noticeable among children of comfortably placed parents, especially when there is an only child, than among children of large families in less fortunate social surroundings. Usually the single child is somewhat spoiled in the matter of desires and objections. The diet of the child is considered more for its tastiness than for its utility, and the habit of eating some sweet delicacy between meals is encouraged. Retarded development usually results. The poorer and more numerous family eat what they can get, when they can get it, usually hard tack, and development is more primitive, less refined and more strongly aggressive. The prevention of dental disease is simple. Natural foods, correctly cooked where necessary, and well chewed, and cleanly teeth at night before bed. If sweets are given at all, the old-fashioned barley sugar is best, but preferably children should be encouraged to eat .sound fruit and plenty of it. The ideal scheme of Dental treatment in Barking should permit the examination of each school child at least once a year, and the complete establishment of sound mouths by dental surgery of all those cases needing treatment. Regrettably this, has not been 44 possible in Barking for some years, due to the large number of children to be examined and to be treated. With the annual increase in the school-child population of the district the position becomes progressively difficult, and at present although all school children are examined and treatment completed, the period between two examinations is approximately fifteen months. Thus instead of a child receiving the opportunity of treatment every twelve months, thre? very serious months are added, serious inasmuch as they are prolonging the period in which dental disease may occur and thrive. It is hoped that the publicity given these comments in your report may form useful propaganda. I am Sir, Your obedient Servant, W. H. FOY, L.D.S., R.C.S. (Eng.), Public Dental Officer. 45 SCHOOL MEDICAL SERVICE. TABLE I.—RETURN OF MEDICAL INSPECTIONS. A.—Routine Medbal Inspections. Number of Code Group Inspections: Entrants 914 Intermediates 958 Leavers 572 Total 2444 Number of other Routine Inspections 339 B.—Other Inspections. Number of Special Inspections 162 Number of Re-inspections 1452 Total 1614 46 TABLE II.—A. RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED 31st DECEMBER, 1929. 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 13 26 1 - Uncleanliness 1 — — - Skin Ringworm—Scalp — 2 — 1 Body — — — - Scabies — — — - Impetigo 3 1 3 1 Other Diseases (NonT uberculoua) 3 1 2 - Eye Blepheritis 4 1 3 - Conjunctivitis — 1 1 - Keratitis — — 1 - Corneal Opacities — — — - Defective Vision (excluding Squint) 106 48 22 2 Squint 8 5 2 1 Other Conditions 1 — 1 — Ear Defective Hearing 1 3 1 — Otitis Media 6 4 6 — Other Ear Disease — — — — Nose and Throat Enlarged Tonsils only 97 161 9 6 Adenoids only 3 9 — 2 Enlarged Tonsils and Adenoids 78 87 4 3 Other Conditions 4 4 7 4 Enlarged Cervical Glands (NonT.B.) 1 73 - 6 Defective Speech — 3 2 4 Teeth—Dental Disease (See Table IV., Group IV.) 115 (f ound, not referred). Heart and Circulation. Heart Disease: Organic — 22 — — Functional — 53 — 12 Anæmia 12 11 - 1 Lungs Bronchitis 7 44 - 2 Other Non-Tuberculous Diseases 1 8 — — 47 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 — 5 — 1 Non-Pulmonary : Glands 1 3 — 1 Spine — — — 1 Hip — — — - Other Bones and Joints - - - - Skin — — — - Other Forms — 1 — - Nervous System Epilepsy — 2 1 - Chorea 3 1 - - .Other Conditions — 2 — 1 Deformities Rickets 1 2 — - Spinal 1 3 — - Other Forms 6 13 1 1 Other Defects and Diseases 6 41 3 23 48 (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 914 129 14.1 Intermediates 958 156 16.3 Leavers 572 76 13.3 Total (Code Groups) 2,444 361 14.8 Other Routine Inspections 339 14 4.1 49 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 - 2 2 Attending Public Elementary Schools 1 - 1 At other Institutions - — — At no School or Institution - — — Deal (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 3 6 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 22 24 40 Attending Public Elementary Schools - - - At other Institutions — — — At no School or Institution — — — Notified to the Local Control Authority during the year. Feeble minded 1 2 3 Imbeciles — — — Idiots Epilepsy. Suffering from severe Epilepsy. Attending Certified Special Schools for Epileptics 1 1 2 In Institutions other than Certified Special Schools - - - Attending Public Elementary Schools - - - At no School or Institution — — — Suffering from Epilepsy which is not severe. Attending Public Elementary Schools 2 4 6 At no School or Institution - - - 50 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 of Education 1 - 1 At other Institutions - 2 2 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 of Education - 1 1 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 52 71 123 At Public Elementary Schools 7 5 12 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 of Education 2 - 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. jand 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 - - - 51 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 17 — 17 Body 29 — 29 Scabies 7 — 7 Impetigo 306 2 308 Other Skin Diseases 47 5 52 Minor Eye Defects (Externa] and other, but excluding cases falling in Group II.) 70 5 75 Minor Ear Defects 121 2 123 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.). 1542 - 1542 Total 2139 14 2153 52 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. Ouierwise Total. (1) (2) (3) (4) (5) Errors of Refraction (including Squint) 103 42 - 145 Other Defects or Diseases of the eyes (excluding those recorded in Group I.) - - - — Total 103 42 - 145 Total number of children for whom spectacles were prescribed :— (a) Under the Authority's Scheme 103 (b) Otherwise 40 Total number of children who obtained or received spectables :— (a) Under the Authority's Scheme 98 (b) Otherwise 40 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) 189 16 205 23 228 53 GROUP IV.—Dental Defects. (1) Number of Children who were :— (a) Inspected by the Dentist. Routine Age Groups— Age 3 — 4 7 5 330 6 634 7 602 8 788 9 958 10 725 11 526 12 553 13 600 14 411 15 108 Special 13 Total 6255 (b) Found to require treatment 4153 (c) Actually treated 2997 (d) Re-treated (included in (c))2046 (2) Half-days devoted to Inspection 37 Treatment 356 Total 393 (3) Attendances made by children for Treatment 2997 (4) Fillings—Permanent Teeth 1063 Temporary Teeth 452 Total 1515 t (5) Extractions—Permanent Teeth 424 Temporary Teeth 4205 Total 4629 (6) Administrations of General Anaesthetics for Extractions 1058 (7) Other Operations—Permanent Teeth Temporary Teeth 304 54 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 16588 (iii) Number of individual children found unclean 1394 (iv) Number of children cleansed under arrangements made by the Local Education Authority 36 (v) Number of cases in which legal proceedings were taken :— (a) Under the Education Act, 1921 — (b) Under School Attendance Bye-laws —