WAL 38 BOROUGH OF WALTHAMSTOW Committee for Education REPORT of the BOROUGH SCHOOL MEDICAL OFFICER for the year 1953 A. T. W. POWELL, M.C., M.B., B.S., D.P.H. BOROUGH SCHOOL MEDICAL OFFICER BOROUGH OF WALTHAMSTOW Committee for Education REPORT of the BOROUGH SCHOOL MEDICAL OFFICER for the year 1953 A. T. W. POWELL, M.C., M.B., B.S., D.P.H. BOROUGH SCHOOL MEDICAL OFFICER CONTENTS Accommodation 9 Artificial Light Treatment 51 Boarding School Education 36 B.C.G. Trials 32 Cardiac Clinic 23 Child Guidance 24 Clinics 7 Committee Members 4 Convalescent Home Treatment 31 Co-ordination 9 Crippling 20 Dental Defects 13 Dental Hygiene 16 Dental Treatment 15 Diphtheria Immunisation 35 Disinfection of Gym Shoes 36 Ear Disease 13 Ear, Nose and Throat Clinic 18 Employment of Children 46 Enquiry Officers 39 Epidemic Nausea and Vomiting 34 Exclusion 33 Eye Clinic 17 Eye Disease 13 Follow-up 14 Good Grooming 46 Handicapped Children 41 Health Education 46 Hearing 13 Heart Disease 14 Hygiene 9 Impetigo 12 Invalid Children's Aid Association 39 Infectious Disease 33 Jelly Testing of School Children 33 Liaison with Hospital Services 9 Mass Radiography 32 Meals, Provision of 38 Medical Inspection 11 Medical Treatment 14 Milk in Schools Scheme 38 Minor Ailments 14 Miscellaneous 46 N.S.P.C.C 40 Nursery School 46 Nutrition 12 Open Air Education 36 Orthopaedic Treatment 20 Orthoptic Treatment 18 Pediatric Clinic 27 Parents, Co-operation of 38 Physical Training 36 Re-inspection 11 Ringworm 12 Scabies 12 School Hygiene 9 School Camps 36 Skin Diseases 12 Special 'Schools 42 School for the— Deaf 44 Educationally Sub- Normal 45 Partially Sighted 42 Physically Handicapped 43 Specialist Clinics— Cardiac 23 Child Guidance 24 Ear, Nose, Throat 18 Ophthalmic 17 Orthopaedic 20 Pediatric 27 Speech Therapy 28 Squint 13 Staff 7 Statistical Summary 48 Swimming 36 Teachers, Co-operation of 39 Tonics 14 Tonsils and Adenoids 13 Tuberculosis 14, 31 Uncleanliness 12 Vaccination 35 Vision 13 Voluntary Bodies 39 Whooping Cough 33 Whooping Cough Immunisation 35 WALTHAMSTOW COMMITTEE FOR EDUCATION 1953 - 1954 Chairman : Councillor S. N. Chaplin. Deputy Chairman: Alderman W. H. Shaw. Ex-Officio: The Worshipful the Mayor: Alderman T. W. Smith, j.p. The Deputy Mayor : Councillor W. F. Savill. Chairman of the Finance Committee (W.B.C.) : Alderman Ross Wyld, o.b.e., j.p. Ald. Mrs. L. P. Bailey, j.p. Ald. G. S. Mace. Ald. H. C. Fisher. Ald. Lady C. McEntee, j.p. Ald. W. B. Fitt, o.b.e. Ald. A. E. Manning. Ald. E. C. Redhead, j.p. Coun. C. Clayden. Coun. Mrs. E. M. Miller. Coun. A. W. Ellis, m.b.e. Coun. J. W. Pringle. Coun. H. Fulton. Coun. E. G. Richards. Mrs. H. A. Christy. Rev. D. A. King. Rev. K. H. Druitt. Mr. R. Lamb. Mr. C. S. Garratt. Rt. Rev. Mgr. W. O'Grady, v.G. Borough Education Officer: E. T. Potter, B.Sc. 5 To the Chairman and Members of the Walthamstow Committee for Education. I beg to present in the following pages a report on the work of the School Health Service in the Excepted District of Walthamstow during 1953. The following matters seem to call for comment:— There have been fewer changes in the senior staff, one only in the medical staff, none amongst the dental surgeons, and a net gain of one in the combined health visiting/school nursing staff. Pressure on accommodation still grows since the number of children on the school registers at the end of the year shows an increase of 22.5% on those at the end of 1947. This increase affects the School Health Service in at least two ways. Firstly, there is a greater pressure on the inadequate sanitary accommodation of some of the older schools, increasing the risk when cases of bacillary dysentery occur. Secondly, the conditions under which medical inspections are carried out become more difficult. It is gratifying, therefore, to record the improvement resulting from the rebuilding of two blocks of sanitary accommodation affect ing five departments and the remodelling of cloakrooms in two other departments. Routine medical inspections and re-inspections increased owing to the more static staff and as a result more defects were found and treated or watched. Cleanliness again improved to a new low record of 2.16% in the number of children found to be unclean to average attendance over the whole year. Although 387 children were found to be infested this leaves no room for complacency especially as these children mainly come from a "hard core " of dirty families. Following from the appointment of an additional dental team at the end of 1952, dental inspection and treatment was increased. After a period of some anxiety the threat to transfer specialist clinics into the hospitals receded and no change occurred. On the retirement of Mr. Whitchurch Howell, F.R.C.S., Con sultant Orthopaedic Surgeon, the Committee placed on record their thanks and appreciation for the fine service which he had rendered to the crippled children of Walthamstow over a period of thirty years. 6 The report of Dr. Hinden, Consultant Pædiatrician, on the facilities which exist for the treatment of cerebral palsy at the Hale End School is of interest, and especially his view that it needs comparatively little additional equipment to make it into a completely adequate treatment centre so few of which exist in the country. Amongst the mechanical aids provided during the year was a group hearing aid at the School for the Partially Deaf, and the loan from County sources of a tape recorder for speech therapy. The usual measures have been followed in preventing and minimising the infection of school children with tuberculosis, i.e., the chest X-ray examination of staff, mass radiography, and the B.C.G. trials. At the end of the year the Committee agreed to the tuberculin testing of school entrants as a means of case finding. Visits were paid by medical officers of the Ministry of Education and two of H.M. Inspectors of Schools to the various special schools, to the school nurses and the Dental and Child Guidance Clinics. Dr. Watkins undertook a duplicate set of First Aid lectures to teaching staff. Once again I wish to express appreciation to the Chairman and members of the Committee, to the Borough Education Officer and his staff, and particularly to the staff of the School Health Service, a record of whose work appears in the following pages. I am, Your obedient Servant, A. T. W. POWELL, Medical Officer of Health and Borough School Medical Officer. 7 1. STAFF OF THE SCHOOL MEDICAL DEPARTMENT The staffing position was reasonably static. There was only one change in the medical staff, none in the professional dental staff, and one net gain in the combined Health Visiting/School Nursing staff. Appointments in the School Health Service still remain delegated to the Health Area Sub-Committee, subject to review from time to time by the Committee for Education. Appointments. Date Appointed Miss J. Ayrton Miss B. Dale, s.r.n., r.m.n. Mrs. C. H. Gillan (nee Pask) - Mrs. M. A. Hay Mrs. A. I. Howe, s.r.n., s.c.m., h.v.cert. Miss R. F. Millington, s.r.n., s.c.m., h.v.cert. Mrs. P.J. Thome (nee Houchin), l.r.c.p., m.r.c.s.,, d.c.h. Clerical Assistant School Nurse Dental Attendant Temp. Relief Clerk Health Visitor/School Nurse Health Visitor/School Nurse Asst. County Medical Officer 30.11.53 20.7.53 1.1.53 29.1.53 1.9.53 27.7.53 28.9.53 Resignations Date Resigned Mrs. J. L. Collmann, m.b., b.s. Miss E. M. Downing, s.r.n. Mrs. C. H. Gillam (ne'e Pask) Miss D. Lane - - Mrs. G. Roberts Mrs. M. West Asst. County Medical Officer School Nurse Dental Attendant Clerical Assistant Clerical Assistant (Part-time) Clerical Assistant (Part-time) 5.9.53 31.8.53 11.12.53 18.11.53 31.10.53 31.12.53 2. SCHOOL CLINICS Aural— Monday 2 p.m.—4.30 p.m. Town Hall. Cardiac and Rheumatism— Alternate months (Friday) 2 P m—4 P m- Town HalL Child Guidance— Monday to Friday 10 a.m.—1 p.m. 2 p.m.—5 p.m. Child Guidance Clinic, 263, High Street, E.17 8 Dental Clinics— Monday to 9 a.m.—4.30 p.m. Town Hall. Friday J Saturday 9 a.m.—12 noon. Town Hall. Monday to 9 a.m.—4.30 p.m. l,Guildsway. Friday J Saturday 9 a.m.—12 noon. 1, Guildsway. Wednesday 9 a.m.—4.30 P.m. Sidney Burnell School. Tuesday 2 p.m.—4.30 p.m. West Avenue. Thursday 9 a.m.—4.30 p.m. West Avenue. Friday 9 a.m.—4.30 p.m. West Avenue. *Minor Ailments— Monday Wednesday Friday 9 a.m.—12 noon. Town Hall. Saturday Friday 9 a.m.—lla.m Sidney Burnell School Thursday 9 a.m.-11 a.m. Low Hall Lane. Pediatric— Thursdays 9 a.m.—12 noon. Town Hall. Ophthalmic— Tuesday 2 p.m.—4 p.m. Town Hall. Friday 9 a.m.—12 noon Town Hall. 2 p.m.—4 p.m. Town Hall. Saturday 9 a.m.—12 noon. Town Hall. Orthopaedic— (Wednesday) 9 a.m.-12noon Open-Air School. Massage and Sunlight— Monday to 9 a.m.—5 p.m. Open-Air School. Friday J Orthoptic— Tuesday Wednesday 9 a.m.—4.30 p.m. Town Hall. Thursday 9 Speech Therapy— By appointment 263, High Street and Open Air School * Immunisation— Wednesday 2 p.m. Town Hall. All Clinics, except those marked * are "appointment" Clinics. 3. CO-ORDINATION (a) Staff.—Co-ordination is secured by the fact that all the school health staff also carry out duties for other health services. The school nursing staff is equivalent to 7 whole-time nurses. (b) Family Doctors.—Family Doctors are informed as to the findings of specialists in regard to children referred for specialist diagnosis and treatment. (c) Reports from Hospitals.—Except in one notable instance (the paediatric department of a nearby hospital), few hospitals send a summary on discharge of children from their wards. When such summaries are received they are of great value and are attached to the appropriate medical files. (d) Liaison with Hospital Services.—The medical and nursing staff continue to visit in turn the ward rounds of Dr. Hinden, Paediatrician, at Whipps Cross Hospital. 4. SCHOOL HYGIENE AND ACCOMMODATION Accommodation.—The following table shows the number of schools in the Borough at the 31st December :— Boys Girls Mixed Infants Nursery County Secondary Grammar 1 2 — — — County Secondary Technical — — 2 — — County Secondary Modern 2 2 6 — — County Primary Junior 2 2 12 — — County Primary Infants — — — 15 — Voluntary Secondary Modern — — 1 — — Voluntary Primary — — 3 2 1 County Nursery — — — — Special Schools for :— Deaf — — 1 — — Educationally Sub-normal — — 1 — — Partially Sighted — — 1 — — Physically Handicapped — 1 — Number of Children on 1953 1952 1951 1950 1949 Register, 31st December 20174 19975 18970 18211 17652 Average attendance 17936.9 16587.8 16561.6 15993.5 15950.7 Percentage attendance 88.9 82.9 87.0 87.8 90.3 10 The increase in the number of children on the school registers over the last seven years amounts to 3711, i.e. 22.5 per cent, of the 1947 roll. Mr. Frank H. Heaven, A.R.I.B.A., Architect to the Education Committee, contributes the following:— Additions and Alterations.—A Group Hearing Aid Room with equipment has been provided at the William Morris Deaf School. Cloakrooms have been remodelled and portable hat and coat stands provided at two schools. Amenities.—These have been provided at a number of the schools in the form of seats in playgrounds, and by the sealing of floors of halls and classrooms. Central Kitchens.—The buildings and apparatus have been maintained in good order, sundry improvements made at Pretoria Avenue, and the kitchen at Wood Street converted from steam to gas operation with new equipment. Gymnasia.—Several halls in secondary schools have been equipped with gymnastic apparatus, such as booms, climbing ropes, wall bars, etc., and floors sealed with plastic. Heating.—Existing systems have been maintained, and major extensions and improvements ordered at two schools. Supplementary heating has been installed at one school and new boilers installed at two schools and a propulsion fan in the heating chamber of another school. Lighting.—Improved external lighting has been installed at one school used as a Youth Centre. Contracts have been let for the replacement of existing gas lighting by electric lighting at the Woodford Green Primary School and for complete remodelling of the electric lighting at the Woodford High School. Maintenance.—All education properties have been maintained in a good condition of repair, vacuum cleaning of newly decoratcd premises continued and windows cleaned four times a year. Playgrounds.—These have been repaired and re-surfaced at all the schools. A large area has been regraded and resurfaced and brought into use at the George Gascoigne Secondary School. Provision of Meals and-The canteens at schools are maintained in good condition. Six have been renovated during the year. Rinsing sinks with remodelling of washing-up arrangements and the installation of extraction fans have been carried out at four canteens. 11 Renovations.—Complete renovation of the eight exteriors and and three interiors of schools has been carried out during the year, also two exteriors and seven interiors of other buildings, and interiors of three craft rooms and several staff rooms. Sanitation.—The conversion from automatic flushing to individual flushing of W.C.s has been carried out at two schools. New lavatory basins with cold and hot water services have been installed at two secondary schools and two primary schools. New W.Cs. and lavatory basins with cold and hot water services for both sexes have been completed at the Coppermill Road Secondary and Junior Schools and the Forest Road Junior Mixed and Infants Schools, and similar erections for the Coppermill Road Infants School are in course of construction. Showers in connection with the gymnasium have been installed at the Chapel End Secondary School. Additional sinks and services have been provided at one domestic science room and two craft rooms. All external lavatories have been distempered. Sanitary Arrangements.—Routine inspections have been made by the Sanitary Inspectorate and minor defects reported and remedied. Sidney Burnell Infants' School.—'This school moved into its new premises in mid-December. The accommodation is for 240 children and the facilities provided are excellent in all respects. Particularly noteworthy is the provision of a sink and porcelain slab, with hot and cold water in each classroom. This arrangement is of great value in the teaching of personal hygiene to the children, and was particularly appreciated early in 1954 when cases of dysentery were suspected. 5. MEDICAL INSPECTION The following gives a summary of the returns:— A. Periodic Medical Inspections— Entrants 1,982 Second Age Group 2,908 Third Age Group 1,648 Others 181 Total 6,719 B. Other Inspections— Special Inspections 493 Re-inspections 3,502 Total 3,995 12 Owing to the increase in the number of children on the school rolls (22.5%) since 1947 and the consequent overcrowding of accommodation it was not always possible for medical inspection to take place under satisfactory conditions. Special facilities have been provided in the newer schools. 6. REVIEW OF THE FACTS DISCLOSED BY MEDICAL INSPECTION (N.B.—The numbers given below refer to medical and special inspections at Schools and do not include other examinations at clinics). (a) Classification of the Nutrition of Children inspected during the year in the routine age groups:— Number Inspected "A" Good "B" Fair "C" Bad No. % No. % No. % Entrants 1982 1452 73.26 520 26.24 10 0.50 Second Age Group 2908 1879 64.62 1010 34.73 19 0.65 Third Age Group 1648 1197 72.63 440 26.7 11 0.67 Others 181 90 49.72 82 45.31 9 4.97 Totals 6719 4618 68.73 2052 30.54 49 0.73 (b) Uncleanliness.—The following table gives comparative figures for the past two years:— 1953. 1952. Average visits to schools 4 4 Total examinations 36,031 38,733 No. of individual pupils found unclean 387 479 Percentage uncleanliness of average attendance 2.16 2.9 The highest and lowest percentages since 1947 were 6.2 in 1949 and 2.16 in 1953. The average number of children found to be unclean during these seven years was 787 or 3.9% of the school population. Individual inspections in the schools ranged between 43,141 in 1950 and 32,671 in 1947. Although the percentage found unclean in 1953 was the lowest ever recorded, the existence of 387 unclean children in the schools leaves no room for complacency. (c) Minor Ailments and Skin Defects.—The following was the number of skin defects found to require treatment and observation:— Treatment Observation Ringworm—Head 1 — Body 5 — Scabies — —. Impetigo 3 — Other skin diseases 200 133 13 (d) Visual Defects and External Eye Diseases.—The number of patients requiring treatment and observation was as follows :— Treatment vation Visual Defects 452 240 Squint 156 26 External Eye Diseases 79 98 Squint.—The totals of children requiring treatment or observation for squint during the last five years, and the totals of medical inspections and re-inspections were:— 1953 1952 1951 1950 1949 Treatment and observation 182 144 88 68 82 Medical inspections and re-inspections 10,714 7,194 7,600 7,042 7,342 The reason for the increase in the number of children referred for treatment and observation was noted in the Report for 1952. (e) Nose and Throat Defects.—The number of patients requiring treatment and observation was as follows:— Treatment Observation Enlarged Tonsils 102 200 Adenoids 12 10 Enlarged Tonsils and Adenoids 20 30 Other conditions 133 101 (f) Ear Disease and Defective Hearing. — The number of patients requiring treatment and observation was as follows:— Treatment Observation Defective Hearing 88 32 Otitis Media 38 15 Other Ear Disease 38 13 (g) Orthopaedic and Postural Defects.—A total of 269 deformities were found to require treatment. (h) Dental Defects. Inspection at Schools. Requiring Children Actually treated. Fillings. Extractions. General Anesthetics. Other Operations. Inspected. ment. Per Cent. 3,476 2,138 61.5 6,773 7,125 8,515 4,572 11,203 14 (i) Heart Disease and Rheumatism.—The findings were as follows:— Treatment Observation Heart Disease—Organic 10 11 Functional 7 124 Anaemia 13 8 (;') Tuberculosis.—All children suspected of either pulmonary or glandular tuberculosis are referred to the Chest Physician for final diagnosis. The notifications of tuberculosis in the age group 5—15 years have been as follows:— 1949 1950 1951 1952 1953 Pulmonary 9 5 9 5 3 Non-pulmonary 5 2 4 4 4 Totals 14 7 13 9 7 (f) Other Defects and Diseases. — The following shows the number of various other defects which were found to require treatment:— Enlarged Glands 29 Epilepsy 6 Bronchitis 79 Other Defects 254 Speech 95 7. FOLLOW-UP The School Nurses paid a total of 1,370 home visits during 1953. 8. ARRANGEMENTS FOR TREATMENT (a) Tonics.—The following shows the quantities of tonics issued during 1953:— Cod Liver Oil. Parrish's Food. Syrup Lacto Phosphate Cod Liver Oil and Malt. Cod Liver Oil and Malt and Parrish's Food. Emulsion. 4½ lbs 384 lbs. 36½ lbs. 763 lbs. 1,599 lbs. 23½ lbs. (b) Uncleanliness.—Treatment with Suleo was carried out with satisfactory results, and advice and treatment is available at all clinics and welfares. Steel combs are supplied at the various centres at cost price, and on loan in cases of necessity. Special treatment is available at the Borough Council's Cleansing Centre. (c) Minor Ailments and Diseases of the Skin.—Treatment of minor ailments is carried out at the eight sessions of the school clinics, all of which are in charge of a medical officer. The number 15 of cases of skin disease is shown in the following table detailing the work done at the school clinics:— First Inspections Re-inspections Boys Girls Boys Girls Ringworm—Scalp 1 — 1 1 Body 2 4 6 5 Scabies 1 2 — — Impetigo 13 12 27 16 Other Skin Defects 44 49 113 157 Verminous Head 15 41 41 194 Tonsils and Adenoids 11 14 12 17 Other E.N.T. conditions 31 31 115 106 Defective Vision (including squint) 44 61 17 14 External Eye Disease 80 82 78 92 Sores — — — — Various 991 868 2,590 2,545 Totals 1,233 1,164 3,000 3,147 First attendances number 2,397 against 2,990 in 1952, and re-attendances 6,147 against 7,644, the total attendances being 8,544 against 10,634. The following table shows the new cases and attendances at Minor Ailment Clinics since 1948. The decrease probably reflects the tendency for children to be taken to family doctors : 1948 1949 1950 1951 1952 1953 New cases 5,086 3,757 3,356 3,106 2,990 2,397 Attendances 16,490 14,112 11,515 10,000 10,634 8,544 Of the conditions referred to under "Other E.N.T. Conditions," there were only two cases of discharging ears. This favourable condition is largely due to routine treatment by ionisation which has been carried out by Dr. Clarke for many years and also to the general use in medical practice of anti-biotics. This favourable position also occurs at the School for the Deaf where there was no case of discharging ears. (d) Dental Treatment.—Mr. L. W. Elmer, Senior Dental Surgeon, submits the following report:— In my report for 1952 I expressed hopes that the improvement in the staffing position towards the end of that year would lead to an increase in the number of routine inspections and treatments, especially conservative work. I am thankful to say that this increase has taken place, the number of fillings in permanent teeth having increased by over 2,000 or 50%. The corresponding figures for fillings in temporary teeth being 331, or nearly 50%. 16 The number of routine inspections has increased somewhat to 3,476 and the special inspections from 6,578 to 7,438. This means that 10,914 of the children in Walthamstow schools have been dentally inspected during the year. It is recognised that ideally, all children should be inspected annually at routine inspections, and in 1954 the whole dental staff has been instructed to inspect all 5 and 6-year-old children early in the year, followed by a further inspection of these children, together with all new entrants, within at least twelve months. It is hoped thus to gradually obtain the ideal of an annual dental inspection of all school children. During the year 1,755 permanent and 6,760 temporary teeth were extracted, as against 1,626 and 5,543 respectively. It is worthy of note that these teeth were not all extracted because of sepsis or pain, 246 permanent and 701 temporary were removed for the correction of irregularities. The number of general anaesthetics has again increased slightly. The number of children treated during the year has increased to 6,773 from 6,153, whilst the attendances for all dental reasons have increased to 18,218 from 14,645. The number of sessions worked has increased from 2,251 to 2,614. It is with pleasure that I am able to record these all-round increases. Dental Hygiene.—Miss Watts has continued to give very satisfactory service, especially in her individual and group tuition. Fortunately, the incidence of really "dirty" mouths continues to be very low and she has been able to give an increasing portion of her time to dental health education. I still feel very strongly that much of the dental surgeons time might be saved if she were allowed to apply "medicaments" such as silver nitrate to carious temporary teeth. SPECIALIST CLINICS (Note.—All Specialist Clinics are staffed by the Regional Hospital Board. Day to day administration has continued unaltered). In February it was reported to the Committee that apparently it was the intention of the Regional Hospital Board to transfer some or all of the specialist clinics to the out-patient departments of hospitals as soon as practicable. The Committee decided to make strong representations to the Local Education Authority to inform 17 the Members of Parliament for the Borough of the Committee's representations and requesting their intervention, and to acquaint the Ministry of Education with the correspondence. By June a letter had been received from the Local Education Authority indicating that agreement had been reached with the Regional Hospital Board as a result of which existing arrangements at the Hale End Orthopedic Clinic would continue on the retirement of Mr. Whitchurch Howell, Orthopedic Surgeon. Mr. G. Rigby Jones, M.C., Consultant Orthopedic Surgeon at the Connaught Hospital, has been appointed to succeed Mr. Whitchurch Howell. The Committee noted with satisfaction that their representations regarding the continuance of specialist clinics generally and the Orthopedic Clinic in particular, had been successful. (a) Eye Clinic.—The following tables show the work done in 1953:— New Cases. Under 7 years. 7-11 years. Over 11 years. Total. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Hypermetropia 18 26 56 72 37 72 1ll 170 Hypermetropic Astigmatism 32 21 40 36 14 18 86 75 Myopic Astigmatism - - 2 - - - 2 - Mixed Astigmatism 6 - - - 4 - 10 - Myopia 1 5 9 15 26 31 36 51 Other Eye defects 12 18 10 4 8 3 30 25 No visual defects — — 3 5 — — 3 3 Totals 69 70 120 132 89 124 278 326 Number of children for whom glasses were:— Prescribed 1,063 Obtained 1,063 Number of re-inspections 3,224 Number of treatments 212 Total attendances 4,040 Supply of Spectacles. The attendance at Eye Clinics of the dispensing optician provided by the Hospital Management Committee is of very great advantage to all concerned. There is no compulsion to obtain spectacles through official sources and parents can go to their own opticians if they prefer. 18 (b) Orthoptic Clinic.—The following shows the work done at the Clinic Number of cases investigated 143 Number of cases treated 347 Number referred to hospital for operation 40 Number operated on 26 Number discharged 4 Total attendances during year 1,998 (c) Ear, Nose and Throat Clinic.—Dr. Francis Clarke reports as follows:— The number of new cases seen at the Aural Clinic during 1953 was approximately the same as that of the previous year. The majority of these new cases have been discovered by the School medical officers during school medical inspections and at the school clinics. A number have been referred by local practitioners. Parents also have requested examinations of their children complaining of ear, nose or throat signs or symptoms. The nature of the abnormal conditions found on examination at the clinic was much the same as that of previous years. The number of cases of chronic otorrhoea (running ears) for a school population the size of Walthamstow remains as in previous years, very small. There were about a dozen cases in all, and of these, three were old post operative mastoids, which are usually the most . difficult to cure. For these chronic cases zinc ionisation, correctly applied, has been found by far the most efficient and quick method of treatment. It saves time at the clinic and the patient's time from school. The noticeable decline in the number of cases of chronic ear discharge with its marked effect on the hearing is no doubt due to a large extent to the early and efficient clinical treatment of early acute ear discharge and any contributing or predisposing factors found to be present. The use of such new drugs as penicillin and the sulpha drugs, administered in the earliest stages of acute otitis, have contributed considerably in the prevention and early cure of discharging ears. The most important point to remember in the clinical treatment of acute otorrhoea is to get the ear 'dry' as quickly as possible in order to prevent any impairment of the hearing, and the most efficient way to secure this desired result is to employ the correct technique. This can be done efficiently only by daily attendance at the clinic, where complicating defects, as well as the ear can be attended to. Home treatment is unsatisfactory and usually a failure. In the absence of effective treatment the condition becomes chronic, the one thing that it is essential to avoid. 19 Such common abnormal conditions as nasal obstruction, mouth breathing, nasal discharge, deafness (in the absence of present or previous discharge), frequent colds, recurring colds and sore throats, etc. are in the main due primarily to defects in the nose and its related accessory sinuses. These cases form a large proportion of those children referred to the aural clinic. The essential thing required in dealing with these various abnormalities is to make a detailed examination, including the history, and a correct evaluation of the signs and symptoms found so as to make an accurate diagnosis, and then adopt the appropriate line of treatment. It is important to remember that nasal defects of one kind or another are responsible for a very large proportion of the impaired hearing found in young children and it is only by a correct diagnosis of the cause that cure or improvement in the hearing can be obtained. In this connection it is interesting to know that sinus disease in a child can cause a serious hearing loss and prompt treatment of the sinus disease will effect a cure of the defective hearing. During the year a certain number of cases of this description have had their hearing restored by correcting the sinus trouble. One of the most valuable forms of diagnosis and treatment for a very large percentage of children with sinus disease is the Proetz displacement method. It is vitally important here that the tech' nique be carried out correctly and in detail as described by Professor Proetz in order to get the desired results. For this reason all the sinus displacement cases are treated during the course of the clinic sessions. The importance of detecting and curing sinus disease in children cannot be over-stressed. It is quite common and only too frequently overlooked in hurried examinations. It can be responsible for a number of symptoms such as nasal obstruction, deafness, nasal discharge, recurring colds and sore throats, etc. which, while infection of the sinuses is present, will not be cured by any measures short of removing the sinus disease. A large number of children suffering from certain common nasal conditions such as mouth breathing, deafness, nasal obstruction, rhinitis, etc. have been treated very successfully during the year by the method of nasal diastolization, for many years employed in this clinic and referred to in detail in previous reports. This is an especially valuable treatment for deafness in children due to nasal defects. An average course is about 15-16 treatments and it must be carried out at the treatment clinics. In the course of the year some children have been referred to the clinic as possible suitable cases for removal of tonsils and adenoids. Experience of the results of the all too frequent removal of tonsils for various complaints, including colds, ' enlarged tonsils, deafness, otorrhoea, mouth breathing, so-called nasal catarrh, rhinitis, etc. confirms our decision to adopt a conservative line in the 20 mendation for operation to relieve these complaints. It is essential in these conditions to seek the primary cause and treat that. Only a cure of the primary cause will effect a cure of the complaint. Hypertrophied tonsils are commonly only a result and sign of a primary source elsewhere and, naturally, a removal of the sign only will not cure the disease. A special clinical session was held at the School for the Deaf. Arrangements were made for cases found on examination to require special treatment to have this carried out at the clinic. In the course of the year only one case of discharging ear occurred in this school. The new Western Electric group hearing aids supplied to the school over a year ago have been very successful and the teachers are very enthusiastic about the help in teaching that these aids provide. The general health and standard of nutrition of all the children seen at the aural clinic during the year were very good. The number of children who attended the clinic and total attendances during the year are shown in the Statistical Summary at the end of this Report. (d) Orthopaedic and Physiotherapy Clinic.—Following the retirement of Mr. B. Whitchurch Howell, F.R.C.S., Mr. G. Rigby Jones, M.C., F.R.C.S., Consultant Orthopaedic Surgeon at the Connaught Hospital took charge. Mr. Whitchurch Howell retired in May, 1953, on reaching the age limit laid down by the Regional Hospital Board after 30 years' devoted service to the crippled children of Walthamstow. Up to July, 1948, Mr. Whitchurch Howell was directly employed by the Walthamstow Education Committee and subsequently by the North East Metropolitan Regional Hospital Board. The record of Mr. Whitchurch Howell's service is that of the orthapaedic scheme which has been built up in Walthamstow and commencing with a monthly orthopædic ascertainment session held on a voluntary basis at Lloyd Park Mansion in 1923. This was followed by the opening of a "Physically Defective Centre " at the Joseph Barrett School in February, 1924. Under Mr. Whitchurch Howell's general direction a daily physiotherapy service was provided. In June, 1924, a residential school for physically defective children was opened at "Brookfield," Highams Park, with accommodation for 36 children. This was a voluntary hospital and Mr. Whitchurch Howell was in orthopaedic and surgical charge and 21 operated regularly at the hospital. The school was recognised by the then Board of Education as a hospital school. The hospital continued until the outbreak of war in 1939, when several circumstances combined to bring about closure. In the meantime the Physically Defective Centre had been transferred to the newly erected Open-Air School at Hale End in September, 1936, and at the same time an excellent suite of rooms was made available for physiotherapy. In June the Committee placed on record their sincere thanks and appreciation of the service rendered by Mr. B. Whitchurch Howell, F.R.C.S., during the thirty years he had served the Committee as their Consultant Orthopaedic Surgeon. The following tables compiled by Miss Garratt, C.S.P., Physiotherapist, show the work done at the clinic:— 22 ORTHOPAEDIC SCHEME Boys. Girls. 5—16 years. Under 5 years. 16—18 years. 5—16 years. Under 5 years. 16—18 years. Anterior Poliomyelitis 11 1 2 11 3 2 Surgical Tuberculosis 1 — — — 1 — Scoliosis, Lordosis, Kyphosis 39 1 — 39 1 — Arthritis 1 — — 1 — — Genu Valgum 17 14 — 15 7 — Genu Varum 3 12 — 6 — Pes Valgus and Valgus ankles 126 23 — 94 12 — Spastic Paralysis 6 2 1 6 2 1 Progressive Muscular Atrophy 2 — — — — 2 Osteo Genesis Imperfecta 1 — — — — Talipes—(a) Equino Varus 7 2 1 3 — 1 (b) Calcaneo Valgus 3 1 — 4 — (c) Pes Cavus 5 — — — — — (d) Mid Tarsal Varus 2 1 — — — — Torticollis 7 2 — 1 1 — Congenital dislocation of the hip — — — 5 — — Cerebellar Ataxia 1 — — 2 — — Spina Bifida 2 — — — — — Hallux Valgus — — — 15 — 1 Hammer toe 6 — — 6 — — Perthes Disease — — — — 1 — Slipped Epiphysis — — — 2 — — Achondroplasia — — — 1 — — Diaphyseal Aclasis 3 — — — — — Digitus Varus 2 — — 4 1 — Internal derangement of knee 1 — — 2 — — Kohlers Disease — — — 2 — — Overlapping toes 10 1 — 8 2 — Other congenital defects 5 2 — 8 — 1 Miscellaneous (including chest conditions) 42 5 — 37 3 — Total 303 67 4 262 44 8 23 New cases seen by Surgeon:— School Age 78 Under School Age 23 Total 101 Number of cases seen by Surgeon From Physically Defective School 23 From other Schools 289 Under School Age 75 Over School Age 13 Total 400 Total number of examinations made by the Surgeon 501 Total number of cases discharged by the Surgeon 147 Average number of examinations per session 45.5 Number of treatments given 4,816 Number of attendances for after-care 2,915 Number of sessions held—Inspection 11 Treatment 445 Number of visits by Instrument Maker 15 Admissions to Hospital 15 Operated on in Out-patients Department 3 Operations performed 15 Children transferred from Connaught Hospital 15 (e) Cardiac Clinic.—The Specialist Clinic in the charge of Dr. Mary Wilmers has continued. The fewer sessions now necessary— seven during 1953—are a reflection of the fewer cases of these conditions now found in children. The following is a report on the work done at the Clinic during 1953:— Number of sessions 7 „ „ attendances 62 „ „ new cases 22 „ „ old cases 19 „ discharged 17 „ of new cases with rheumatic or cardiac defect 6 „ referred to Hospital—Out-patient 1 In-patient 3 „ referred for convalescent home treatment 1 „ still under treatment at end of year 23 24 (f) Child Guidance Clinic.—The Consultant Psychiatrist, Dr. Helen Gillespie, reports as follows:— Staffing.—'The appointment of Dr. C. L. Casimir to the clinic staff in January is welcome. Dr. Casimir attended for two sessions per week until July, and since then for five sessions per week. Comments.—There has been an increase in the length of the waiting list from 62 at the end of 1952 to 91 at the end of 1953 (these figures include those for Walthamstow, Leyton and Forest Divisions). I am glad therefore that the number of play therapy sessions has been increased from six to eight per week. This takes some of the psychotherapy load off the psychiatrists, who will thus be able to devote more time to diagnostic work, and this shortens the waiting list. It is satisfactory to note that there has been a decrease in the number of cases whose treatment was interrupted on the parents initiative, a matter which caused some concern last year. In part at least this result may be attributed to the fact that whenever possible, preliminary interviews were arranged with the parents in order to explain to them the purpose and mode of operation of the clinic. The following tables show the work of the clinic during the year. Figures for Walthamstow cases only are shown. TABLE I. Analysis of Figures for 1953 Number of cases Referred to the Clinic 93 „ „ „ Diagnosed at the Clinic 44 (a) Psychiatrist. Diagnostic Interviews 44 Treatment Interviews 331 (b) Psychologist. Clinic cases tested 54 Cases given remedial education 14 Treatment interviews (remedial education) 147 School visits on behalf of clinic cases 31 Other interviews 44 25 (c) School Psychological Service. Individual cases seen 221 No. referred to clinic 12 No. of school visits 107 (d) Play Therapists. Treatment interviews 186 (e) Psychiatric Social Workers. Interviews at clinic 636 Interviews elsewhere 22 (f) Waiting list at 31.12.53. Cases for diagnosis 43 Awaiting treatment — Cases suspended — TABLES II and III. Analysis of Problems Referred and Cases Diagnosed Referred Diagnosed I. Nervous disorders, e.g., fears; depression; apathy; excitability 17 12 II. Habit disorders and physical symptoms, e.g., enuresis; speech disorders; sleep disturbances; tics; fits; etc. 24 14 III. Behaviour disorders, e.g., unmanageable; tempers; stealing; lying; sex problems, etc. 39 14 IV. Educational, e.g., backwardness; failure to concentrate 13 2 V. No basic disturbance of child, i.e., mainly parental over-anxiety — 2 93 44 TABLE IV. Analysis of Cases Closed during the Year (including cases Referred in previous years) Improved and recovered after treatment 19 Improved after partial service, i.e., before diagnosis 7 Diagnosis and advice only 7 Interrupted, e.g., on parents' initiative 22 Closed for miscellaneous causes (removed from area, placement at E.S.N. School, etc.) 3 58 26 REPORT OF THE EDUCATIONAL PSYCHOLOGIST FOR 1953 Miss E. M. Smith, M.A., contributes the following:— As in previous years I have been concerned with both the clinical and educational aspects of the work in Walthamstow and Chingford areas. The following figures refer to Walthamstow only. In all, 221 individual tests were given to children, and nonverbal group tests of intelligence were administered in three schools. Request for individual tests came largely from Head Teachers, but Psychiatrists, School Medical Officers, Youth Employment Officers, Probation Officers and Speech Therapists have also asked for estimates of children's intelligence. It should be pointed out that among the group of children who came within the E.S.N. range, only 14 were attending the appropriate school, 10 had physical handicaps for which they were placed in Physically Handicapped schools and three were under school age. The majority, forty, were seen in normal schools. During the year 107 visits were made to schools, 28 of which were directly concerned with clinic cases, the remainder with educational problems in school. Twelve children were referred for treatment at the Child Guidance Clinic. Fifty-four tests were given at the clinic to children referred for treatment. Four tests were given to children in their own homes. Fourteen children were given individual remedial teaching in reading or arithmetic, and in all 147 such lessons were given. A survey of the reading ability of children leaving Secondary Modern Schools was made in July, as part of a County survey, and this was followed in Walthamstow by a similar survey for children leaving school in December. These surveys enabled me to recommend children leaving school with poor reading attainment to attend the special group organised by the Youth Employment Officer. A course of lectures on "Teaching Backward Readers in Junior Schools" was given in the autumn term. This was very well attended by teachers from a wide area. In co-operation with the Physical Education Organiser a course of lecture-demonstrations was given to unqualified people in charge of classes in Infants' schools on the basic principles of education. During the year talks were 27 given to a variety of groups—parent-teacher associations, social study groups, etc. on topics of psychological or educational interest. At the end of the summer term a student in training for psychological work came to Walthamstow for a month's practical work, and gave useful help at a busy time of the year. In January a visit was paid to the Child Guidance Clinic by a Medical Officer of the Ministry of Education and two of H.M. Inspectors of Schools. The matter is more fully referred to in the section of this report dealing with handicapped pupils. (g) Paediatric Clinic.—The clinic was continued under the clinical charge of Dr. Elchon Hinden, Pædiatrician to Whipps Cross Hospital, who reports as follows:— There have been no major changes in the work of the clinic during the past year. Children continue to be referred by the School Medical Officers, so that the bulk of the patients are suffering from abnormalities of growth or development or from behaviour disorders; ordinary organic disease is not commonly seen at the clinic. One of the most serious diseases interfering with normal growth and development is cerebral palsy. This has many causes—birth injury, infantile infections, and the like—but the end picture is the same; a child who has difficulty in making his muscles do what he wants them to do, and with varying degrees of mental defect as well. The disease can have any degree of severity, from the bedridden idiot to the seemingly-normal child with a clumsy right hand. This makes diagnosis very hard, particularly in the important early months of growth. "Is my child 'spastic'?" is a thought in the mind of many a parent when babyhood seems prolonged more than usual; and although often a true answer can be given, occasionally only time can tell. The treatment of these unfortunates is a long and tedious business, and must last as long as life itself. Many disciplines are needed to enable the child to make the best possible use of his damaged motor apparatus, and these must be combined with schooling, so that the development of his brain does not lag behind that of his body. I doubt whether it is possible to set up sufficient 'cerebral palsy units' to cope with all the children needing special 28 treatment—for one thing they are excessively expensive. But a special school for the physically handicapped, such as exists in the Borough at Hale End, is able to make a very real contribution to the problem. In such a school physiotherapy, remedial exercises and speech therapy are available actually in the school building; so that the pupils may use them with the minimum disturbance to their learning. The consultative clinic is already being used as a diagnostic centre for suspected spastic children; it would not take much to equip Hale End as a completely adequate treatment centre. Under 5 years. Over 5 years New cases 104 27 Total attendances 143 39 Physical Defects: — No. of cases 48 24 Referred to hospital 24 6 Discharged 27 4 Psychological Disorders: — (a) Enuresis 52 3 (b) Other 4 — Referred to hospital 46 — Discharged 2 3 (h) Speech Therapy.—Treatment centres are provided at the Old Education Offices, High Street, and at the Open-Air School. The arrangements of previous years have continued in regard to the selection and reference of children for speech therapy. Cases are brought forward as a result of medical inspection and re-inspection and by reference through head teachers. In order to exclude any medical condition and in order to assess the degree of the speech defect to negative the possibility of deafness, partial deafness, or of a psychological cause of the defect, a full medical report is recorded on the case papers sent to the Speech Therapist. The School Medical Officers are invited to follow up their cases during the course of treatment and arrangements have been made for a review of the case, preferably by the School Medical Officer who referred the case, and before discharge from treatment. Miss C. M. Gregory reports as follows:— There were 144 children treated during 1953, practically the same number as in the previous year. The intake accent is still on the infant and pre-school age—of 52 new cases this year, only seven children were over 6 years of age and none were over eleven. 29 Forty-five per cent. of the total number treated this year were under 7 years. The average age of the rest was 9 years 8 months. In 1947 the average age was nearer 11½ years. Seventy-five school visits have been made and seventy-five interviews given, also ten home visits as follow-up measures. I have obtained the use of a Grundig Tape Recording machine this year, and I have recorded the voices of 29 children. It is interesting to note that whilst most children were spurred on to greater effort by hearing their defects, one or two were so upset at what they really sounded like, they refused to make further recordings. I have received help and co-operation from the Child Guidance Clinic for which I would like to thank them. The transport officer has again, this year, as in all past years, been most co-operative. Miss A. M. Hemmings reports:— It will be seen from the accompanying figures that the number and distribution of cases has changed little from last year. In addition to those treated, seventeen were interviewed and some are under observation. I should like to record that a diagnosis was made of a child with a webbed larynx. This is a most rare condition; the child is now awaiting operative treatment. Early in the year we were granted the use of a Grundig Tape Recording machine. Although the technique of using a recording machine in speech therapy is in its infancy, results already have been most interesting. Fifteen children have made permanent recordings; these children having a gross defect and the possibility of only slow improvement. I intend to record these children at intervals so that on joining several recordings of one child, one may note the difference. This should prove enlightening, especially in the case of dysarthrics with fairly low I.Qs. who make very slow progress— often insufficient to note a phonetic change. Many children have taken part in recordings which were afterwards erased. These recordings were often made to enable the children to hear their mistakes; this of course is the first stage in correction. A limited number of children who stammered, mainly those near discharge, also used the machine. I have found the tape reproduction of speech fairly accurate with the exception of two types of defect, those of hyper-rhinophonia and sigmatismus. In both instances the reproduction has been an improvement on the original. 30 As previously mentioned I intend to have a continuous recording made over a period of months of a child's speech. Tape is easily cut and re-joined, but there arises the problem of storage. Apart from the cost, the standard sized reels are too bulky. In my opinion a possible solution would be the manufacture of small reels. These problems might be solved if a tape recording company could be found to take an interest in Speech Therapy. A disc recording company has already met our specific requirements, but a disc machine can be of no use in a country district where a portable machine is necessary. The microphone is very sensitive and of course picks up any extraneous noises. The ideal would be a sound-proof room for recording, but this is an individual problem according to the situation of the clinic. Annual Report and Clinical Analysis. High St. Clinic Open-Air Sch. Clinic No. of cases in attendance at beginning of year 92 58 New cases admitted during year 52 58 Transfers from other Clinics — 1 144 117 Cases ceasing attendance before cure or discharge 5 7 Cases discharged improved and incapable of benefitting by further treatment 14 2 Cases temporary discharged before cure, to resume treatment later 7 5 Cases discharged cured 50 35 Transfers to other Clinics 2 1 Cases still in attendance at end of year 66 67 Total attendances during year 2,170 2,469 No. of Cases suffering from:— 1. Physiological or Psychological defects: (a) Stammer 39 26 (b) Clutter — — 2. Voice defects— Rhinophonia 8 8 3. Defects of articulation— (a) Dysarthria 1 2 (b) Dyslalia 91 82 4. Language defects—Delayed speech 4 2 5. Probable mental deficiency 1 2 6. Other types of defect — 1 144 123 31 Convalescent Home Treatment.—148 children were sent away for convalescence during 1953. There were 7 children remaining in convalescent homes and hospital schools on December 31st, 1953. Tuberculosis.—The number of school children examined for the first time during the year was 105 boys and 143 girls, of whom 31 boys and 32 girls were referred by the school medical staff, and 74 boys and 111 girls by private practitioners. 87 girls and 69 boys were examined as contacts. Artificial Light Treatment.—The total attendances for treatment were 2,315. 9. PROTECTION OF SCHOOL CHILDREN AGAINST TUBERCULOSIS (a) Chest X-ray Examination of Teachers on Appointment. The position in regard to this matter was set out in the Report for 1951, including the reasons leading to the cessation of the former practice of requiring all newly-appointed staff (except clerical) to undergo a chest X-ray examination. Although the local chest clinic has been equipped with an Odelca miniature X-ray apparatus, it has so far not proved possible for staff to be referred as a routine. Instead, every endeavour has been made to refer staff for chest X-ray examination at the Mobile Mass Radiography Units and the static unit at Finsbury, but the difficulties in such an arrangement are obvious when compared with local facilities. The recommendations contained in Ministry of Education Circular No. 248—"Protection of School Children against Tuberculosis," previously considered by the School Management Committee, referred to the Minister's recommendation that all teachers should have an X-ray examination of the chest annually. The matter was considered by the Teachers' Joint Consultative Committee in March, 1953, with an indication that the Committee for Education were strongly in favour of the recommendation and expressed the hope that the Teachers' Panel would join with the Committee in a joint appeal to teachers to have such an examination. The Teachers' Panel unanimously agreed with this proposal. The Committee for Education also decided to make further representations to the Local Education Authority for the reimbursement of the travelling expenses of teachers attending Mass Radiography Units for X-ray examination prior to appointment. The Local Education Authority approved of this recommendation. Every endeavour was made during 1953 to operate the recommendations of the Ministry of Education's Circular in regard to the initial and annual chest X-ray of all staff concerned with groups of children. 32 (b) Mass Radiography. A report was made to the March Committee of the excellent response which had been received to the invitation to pupils over 14 years of age and to all members of the Committee's administrative, teaching and manual staff to attend for X-ray examination during the visit of the Unit to Walthamstow. The Unit carried out the second survey of school leavers in April, 1953, and the attendances were as follows:— Group Male Female Total Schoolchildren— Number X-rayed 1,629 1,787 3,416 Recalled for large film 20 30 50 School Staffs— Number X-rayed 157 170 327 Recalled for large film 3 5 8 The total of 3,743 compares with 3,680 examined in the 1950 Survey. Of the 50 children recalled for large films, 27 were normal, 9 had healed primary tuberculosis, 3 had healed post primary tuberculosis and one had tubercular pleural effusion. Of the others, 3 had pneumonitis, 2 had congenital heart lesions and there were single cases of bronchiectasis, bony abnormality, acquired heart lesion, and azygos lobe. Of the 8 school staff recalled, there were 2 with healed primary tuberculosis, one with healed post primary tuberculosis, one with bronchiectasis and one with an acquired heart lesion. (c) Tuberculosis Vaccine Clinical Trials (Medical Research Council). The follow-up of the vaccinated and control groups which was begun in June, 1952, continued throughout 1953. As will be seen from the following report contributed by Dr. T. M. Pollock, Physician-in-Charge of the trials, 77 per cent. attended for the second annual re-examination as compared with 81 per cent. for the first re-examinations in 1952. In view of all the difficulties involved, this is regarded as a reasonably satisfactory response. Dr. Pollock reports as follows:— "The Tuberculosis Vaccines Clinical Trial in which Walthamstow Health authorities are co-operating with the Medical Research Council, continued to make good progress during 1953. Eight hundred and sixty-three volunteers in the borough who joined the scheme at school are taking part. The Trial began in Walthamstow in 1950 and is also taking place in 24 other North London boroughs, 33 and in Birmingham and Manchester. All those who joined were X-rayed and skin-tested at school, and some were given the vaccine. The last of the volunteers to enter the Trial left school in the Summer of 1952, and all are now being followed up to determine the value of the vaccine. The home of each young person concerned is visited twice a year by a Health Visitor who answers questions about the scheme, encourages the volunteer to continue to attend for examination, and records the data essential to the investigation. As in previous years this important work has been successfully carried out by the nurses, who deserve every credit for the excellent way in which the work has been done. It is hoped to X-ray all those taking part once a year, and in 1953 the Mass Radiography Unit visited West Avenue Clinic in October. The group invited were those who left school at Easter and Summer of 1951. This was their second annual reexamination, and 77% of those invited returned. This good figure was of importance both from the point of view of the investigation and also because it represented a great health safeguard to those taking part. It is hoped to continue the high standard of co-operation already set." (b) Jelly Testing of School Children. Routine tuberculin jelly testing takes place at school clinics. In November the Committee agreed to authorise the examination, by means of jelly testing, of children on their admission to infants' schools subject to written parental consent being obtained. Such a scheme had become possible following from the compulsory pasteurisation of milk in the London area generally and to the adequacy of facilities for X-ray examination at the Chest Clinic of children found to be positive to the jelly test and of their home contacts. Although primarily the scheme is for the purpose of case finding, it would have the added advantage of bringing a child who shows a positive patch test, under immediate supervision and further treatment where indicated. 10. INFECTIOUS DISEASES Non-notifiable diseases are usually brought to light by the weekly returns made by Head Teachers under the local Regulations as to Infectious Diseases in Schools. The number of children reported by Head Teachers in conformity with the Regulations was as follows:— Sore Throat 5 Mumps 6 Measles 93 Chickenpox 46 Whooping Cough 50 Various 53 Total 253 34 Notifications from general practitioners of infectious diseases occurring in the 5—15 year age group were as follows:— 1952 1953 Measles 868 413 Whooping Cough 81 352 Scarlet Fever 327 217 Bacillary Dysentery 2 34 Pneumonia 15 15 Tuberculosis 8 8 Food Poisoning 5 5 Poliomyelitis 3 2 Meningococcal Infection 1 1 Encephalitis — 1 Paratyphoid — 1 Enteric — 1 1,310 1,050 Bacillary Dysentery. Out of a total of 84 cases notified in the Borough during 1953, 34 were in attendance at school. The cases were spread over 20 departments, one having 5 cases, three having 3 cases, four having, 2, and twelve departments having 1 case each. In view of the high infectivity of this disease, the comparatively slight spread is of interest. Epidemic Nausea and Vomiting. (a) During 1953 one "outbreak" was reported in January at a Girls' High School. It was found to have extended back into 1952 and approximately 4 staff and 19 children had been affected in 1952. During January approximately 6 further staff and 20 further children were affected, but few, if any of these, had obtained medical advice. Later two members of the staff and 3 pupils were reported to be suffering from jaundice. (b) In mid. November, 18 children were reported to be away from a Junior Mixed School, most of them suffering from sickness. All the affected children had partaken of a school meal and the usual samples were submitted for examination. Three of the adult helpers had taken the first course only and were unaffected, and another had both courses and was sick during the night. Investigations were carried out at the central kitchen with completely negative results. All the children were soon back at school and during the subsequent week there were four further cases and during the next week another 3 cases. 35 All the pathological specimens taken were negative and the "outbreak" was regarded more in the nature of winter vomiting than of food infection. 11. IMMUNISATION (a) Against Diphtheria.—One hundred and ninety-one primary immunisations were done in children of school age and 1,526 "booster" doses were given at school immunising sessions. During the five years to 1953 the percentage of children protected in the various age-groups were as follows:— Year Population Percentage Immunised 0-15 years Under 5 years 5-15 years 1949 123,400 62.5 96.2 82.1 1950 122,700 60.5 96.5 81.9 1951 120,900 58.1 99.3 83.0 1952 120,400 49.4 98.3 79.6 1953 119,400 44.4 92.5 73.8 (b) Against Whooping Cough.—Immunisation against whooping cough has been available for many years to children of pre-school age but in April, 1953, immunisation was made available to children of all ages. Eight children in the 5/11 year age group were immunised against whooping cough during 1953 but it should be stressed that the main effort was directed towards children of pre-school years, of whom 746 were immunised. (c) Vaccination.—The vaccinal condition of each child examined at routine medical inspection was noted, and a summary shows the following:— Number examined. Number found to be vaccinated. Percentage vaccinated. Entrants Boys 951 338 35.5 Girls 1,031 367 35.6 2nd Age Group Boys 1,507 511 33.9 Girls 1,401 518 36.9 3rd Age Group Boys 732 124 16.9 Girls 916 244 26.6 Others Boys 108 33 30.6 Girls 73 19 26.0 Totals 6,719 2,154 32.1 36 12. OPEN AIR BOARDING SCHOOL EDUCATION During the past year 4 boys were medically examined prior to returning at each term, to Elmbridge Boys' School, Cranleigh, Surrey, and a further 16 boys and girls received examinations before proceeding to Kennylands Park School, Reading, Berks, for the Spring, Summer and Autumn terms Premises at the Jubilee Retreat have again been used by parties from most of the Special Schools. 13. PHYSICAL TRAINING The Committee shares the services of two whole-time Organisers with a neighbouring area. Co-operation has continued along the lines of previous years. Disinfection of Gym Shoes.—Disinfection is carried out before shoes are used by another child. Shoes were left in contact for 60 minutes with formaldehyde vapour in the chamber of a steam disinfector, sufficient steam being admitted to produce a slightly humid atmosphere. Swimming.—The following has been contributed by Mr. L. E. Last, Organiser of Physical Education. School Classes.—During 1953 a total of 51,339 attendances was recorded at the High Street Baths for swimming classes, representing an increase of 2,073 on the figure for 1952. At the beginning of the Autumn term, with the large influx of beginners from the Junior Schools, approximately 25 per cent. only of the children who attended the bath were able to swim, but owing to the successful modern methods adopted by the instructor, Mr. A. Smith, and valuable help of the visiting teachers, whereby children received instruction in the fundamentals of all the major swimming strokes instead of concentrating solely upon the teaching of the breast stroke, a large number of non-swimmers gained their first certificate (25 yards) very quickly and many found it easier to use some form of the back stroke rather than the breast stroke or front crawl. Full use has been made of the S.W. Essex Technical College bath during normal school hours by the S.W. Essex Technical School, the Sir George Monoux Grammar School and the Walthamstow County High School, and by voluntary classes from the first two of these schools on Saturday mornings. Particular mention must be made of the highly successful work of the Sir George Monoux School. As the result of a well organised four-year plan over 90 per cent. of the boys at this school can now swim—a very fine record which very few schools in the country can even approach. 37 Holiday Swimming.—The usual facilities for the cheap 2d. swim were continued and the substantial increase shown over the 1952 attendances provide a reliable indication of the growing enthusiasm for this healthy form of recreation. In 1953, 12,257 boys and 6,683 girls made use of this concession as compared with 10,816 boys and 5,553 girls in 1952. Life Saving Classes..—Two weekly classes for boys and one for girls were conducted by Mr. A. Smith during the spring and autumn terms, and a good standard of work was maintained. There was also a pleasing increase in the number of classes arranged by individual schools. The following awards were gained:— Intermediate Certificates 46 Bronze Medallions 98 Bars to Bronze Medallions 41 Bronze Crosses 7 Awards of Merit 3 Scholar Instructors Certificates 11 Many of the children who gained these awards have now left school, but have continued working for higher R.L.S.S. awards by joining clubs and life saving classes The Walthamstow Schools Swimming Association.—The following information taken from the 1953 Annual report of the Hon. Sec., Miss L. B. Thrippleton, indicates the value and scope of the work of this Association. Swimming Certificates awarded in 1953 (1952 figures in brackets) : Primary 826 (905) Intermediate 20 (20) Elementary 250 (312) Advanced 7 (3) Speed Tests.—1st Class—8 (6); 2nd Class—9 (19); 3rd Class—14 (15). During 1953 the usual School Swimming Gala was held and the general standard, particularly of girls' swimming, appeared even higher than in previous years. The report refers to the competition for the W. E. Taylor Shield, the special training classes at Barking, participation in the County Team, the County Schools, the Eastern Counties and the English Schools Championships. 38 14. PROVISION OF MEALS During October and November the daily number of meals exceeded 8,000 or some 40% of the numbers on the school roll. During the same period the daily milk meals total averaged over 15,000 per day or some 75% of the total on the school roll. Inspection.—Visits were made by the medical and other staff to school canteens and kitchens, and suggestions were made from time to time in order to try and minimise food-borne infection. The quality of the food supplied, and the standard of cooking has been maintained at the previous high level. Routine inspections were carried out by the Sanitary Inspectorate. Improvements in the arrangements for the drying of crockery are gradually taking place, but cloth drying is still practised to a considerable extent and will continue until such time as it is possible to provide draining racks and adequate and modern sterilising sinks or rinsing sinks fitted with very hot water supplies. Additional washing facilities for scholars are very necessary especially in view of the endemicity of bacillary dysentery. Milk in Schools Scheme.—The arrangements detailed in the previous reports were continued in 1953, all the milk supplied being pasteurised milk sold under licence. Sixteen samples of pasteurised milk were taken for bacteriological examination during the year. All satisfied the methylene blue and phosphatase tests. It was not considered necessary to obtain samples for biological examination. 15. CO-OPERATION (a) Co-operation of Parents. The following table shows the attendance of parents during 1953 at the periodic medical inspections:— Number Inspected Number of Parents Per cent. 1953 Per cent. 1952 Entrants— Boys 951 865 90.9 91.8 Girls 1,031 961 93.2 92.15 2nd Age Group—Boys 1,507 1,204 79.9 70.2 Girls 1,401 1,176 83.9 78.8 3rd Age Group—Boys 732 170 23.2 37.9 Girls 916 329 35.9 39.5 Others— Boys 108 70 64.8 52.6 Girls 73 44 60.3 57.9 39 The importance of parental attendance at medical inspections cannot be overstressed. It is regrettable, but understandable, that the percentage should decrease with the increasing age of the child, and with the considerable employment of mothers. The "leaver" inspections are of importance in regard to fitness for employment, and the attendance of parents at these inspections is to be encouraged. (b) Co-operation of Teachers. Renewed and grateful acknowledgement for the co-operation of Head Teachers and their staffs must be made. Generous help and co-operation has invariably been experienced, especially in the use of their private and staff rooms for medical inspection—often at great inconvenience. (c) Co-operation of School Enquiry Officers. The Senior School Enquiry Officer and his staff have again co-operated most effectively with the work of the School Health Service. (d) Co-operation of Voluntary Bodies. The existing arrangements for the admission of pupils to holiday convalescent homes by arrangement with the Local Branch of the I.C.A.A. continued, and included a grant of some £200 per annum plus a placement fee of 23/- per child to the Association. (i) The Invalid Children's Aid Association.—Mrs. Osora, Secretary of the local branch, has kindly contributed the following report:— Children referred by:— Under 5 years. Over 5 years. Hospitals 1 32 School Health Service 3 63 General practitioners 3 54 7 149 40 Classification of Cases:— Under 5 years. Over 5 years. Anaemia, debility 1 11 After-effects of acute or infectious illness or operation 3 68 Bronchitis or Pneumonia 2 15 Asthma — 2 Rheumatism, Chorea, Heart 1 6 Nervous conditions — — Diseases of— (a) Ear, Nose and Throat — 45 (b) Eyes — — (c) Skin — 2 7 149 Children referred for visiting, advice, help or follow-up:— Hospitals 5 11 Local Authority under schemes for:— (a) Rheumatism — 6 (b) Orthopædic care — 15 (c) Child Guidance — — Voluntary Bodies 2 — General practitioners — — Parents 4 8 I.C.A.A. Branches 3 8 14 48 Children sent for convalescence 7 141 Children sent to R.O.A.S. — 2 Children sent to R.H.B. — 6 7 149 Number of visits paid 735. (ii) National Society for the Prevention of Cruelty to Children.—The following is a summary of the work done in Walthamstow during 1953:— Nature of Offence How dealt with Neglect 24 Warned 28 Ill-treatment 4 Advised 13 Advice sought 13 41 41 Number of Children dealt with:— Under 5 years Over 5 years Boys Girls Boys Girls 25 19 39 35 41 HANDICAPPED CHILDREN The following number of special examinations were carried out by the medical staff in respect of the categories stated: Examinations Re-examinations (a) Blind — — (b) Partially Sighted 2 — (c) Deaf 1 2 (d) Partially Deaf — — (e) Educationally Sub-normal 28 16 (/) Epileptic 3 1 (g) Maladjusted 3 1 (h) Physically Handicapped 13 — (i) Speech — — (j) Delicate 23 — Totals 73 20 Special Visits. During the year visits were paid on three separate days by a Medical Officer of the Ministry of Education accompanied by two H.M. Inspectors for Schools. On the first day the School for the Partially Sighted was visited and a suggestion was made in regard to the provision of a hot drink and a biscuit to offset the possibility of some children not having had breakfast before arrival at school. Later the Physiotherapy Clinic was visited and a school meal sampled at the Hale End School Dining Centre. In the afternoon visits were paid to the three special schools at the Hale End site, i.e., the School for the Physically Handicapped, for the Educationally Subnormal, and lastly for the Deaf and Partially Deaf. On the second day, the work of the health visitors and school nurses was reviewed with special reference to the time allocated to cleansing inspections. Visits were paid to the Central School Clinic and the Central Dental Clinic and the Dental Workshop, with special reference to the supply of orthodontic appliances. In the afternoon the Group Hearing Aid recently installed at the School for the Deaf was seen and later the speech recording apparatus used in the Speech Clinic at the Hale End School, and lastly the Orthopaedic Clinic. On the third day a general discussion took place with regard to the Child Guidance Service and a visit was paid to the West Avenue Centre where child guidance in regard to the children of pre-school age is undertaken. The Central Child Guidance Clinic in High Street was then visited and a discussion ensued with Dr. 42 Gillespie, Consultant Psychiatrist and the Borough Education Officer, with particular reference to child guidance in pre-school children. Later the Educational Psychologists, the Psychiatric Social Workers and the Play Therapists took part in the discussions and reference was made to the adult reading classes which were being undertaken during the evenings by Miss Smith, Educational Psychologist, and Miss Lock, Headmistress of the Special School for the Educationally Subnormal. Walthamstow Special Schools.—The numbers of children at the special schools in Walthamstow at the end of 1953 were as follows:— Partially Sighted E.S.N. Physically Handicapped Deaf Total Percentage Walthamstow 7 65 65 8 145 61.9 Forest 5 8 9 16 38 16.2 Middlesex 24 — — — 24 10.2 Ilford 2 — — 7 9 3.9 Romford 6 — — 2 8 3.4 Leyton 1 — — 5 6 2.6 Dagenham 1 — — 2 3 1.3 South Essex 1 — — — 1 0.5 Totals 47 73 74 40 234 100.0 The numbers of children in residential special schools and homes at the end of the year were as follows:— Maladjusted 16 Delicate 7 Deaf 4 Blind 4 Epileptic 2 Cardiac 1 Educationally Sub-normal 2 36 (a) School for the Partially Sighted.-—Mr. G. M. Williams, Head Master, reports as follows:— The following table gives the classification of children attending the school on a locality basis at the end of the year. Walthamstow Other Essex Divisions Out County Boys 4 10 11 Girls 3 6 13 7 16 24 43 At the ophthalmic session held at the school in December it was found that 14 children had visual acuity (Snellen), after correction, of 6/18 or more; five children visual acuity of 6/24; eight children visual acuity of 6/36; and seventeen children visual acuity of 6/60 or less. Three children were certified as blind and were awaiting transfer to Blind Schools. As in previous years the medical supervision has been well maintained, for Dr. I. Gregory, M.B., D.O.M.S., has made two visits and given much helpful advice. Dr. Watkins has medically examined all school leavers and selected children. There have also been regular inspections by the School Nurses, and four home visits and reports were obtained by the Health Visitors of different cases. Dr. Bulsara and the staff of the Eye Clinic have made regular ophthalmic and optical examination of all children in the school, and their very willing help has been much appreciated. Miss Smith, the Educational Psychologist, has made four visits for the purposes of intelligence testing, and there have also been visits by the Educational Psychologists of Tottenham and Edmonton. The school was visited earlier in the year by Dr. Llewellyn of the Ministry of Education. The senior girls have attended the Hale End School for Domestic Science, which has proved a very valuable addition to the curriculum. During the year nine children left the school as follows:— 2 transferred to ordinary schools. 2 transferred to Blind Schools. 5 to employment. I would like to express my appreciation of the teaching and welfare staff for their constant and unremitting efforts on behalf of the children. During the year the average number on roll was 45, with an average attendance of 40.2. (b) School for the Physically Handicapped.—Mr. G. M. Williams, Head Master, reports as follows:— The average attendance during the year has been well up to the average of previous years, showing that the general health of the children has been well maintained. Full use was made of the premises at Jubilee Retreat, Chingford, which were in continual use from May to the end of September, each group of children visiting in turn. 44 Certain small structural alterations, and equipment enabling simple cooking to be done, greatly contributed to the welfare of the children visiting this centre. As in former years the school was opened during the summer holidays, and an excellent voluntary attendance was maintained. The former school kitchen was adapted and equipped for use as a Domestic Science room, and under the supervision of Mrs. Maxwell, has proved to be a valuable addition to the school. The school was visited by Dr. Llewellyn of the Ministry of Education, Student Health Visitors, Student Teachers and visitors from India and South Africa. Miss Smith, Educational Psychologist, has made six visits for the purpose of testing selected children. Dr. Watkins has made regular weekly visits, and his continued interest in the children has been of much help. A total of 1,697 minor treatments has been given. Miss Austin resigned from the teaching staff in August, her place being taken by Mrs. Abbs. The children on roll at the end of the year was as follows:— Delicate (Ministry of Education category J) 38 Physically Handicapped (Ministry of Education category H) 30 Other (Ministry of Education categories F & G) 6 74 I must again thank all my colleagues on the staff, teaching, nursing, welfare, domestic and transport for their very valued co-operation in the work of the School. Swimming Instruction for cases of Poliomyelitis.—This has been in operation in Walthamstow for some two or three years, and a weekly 'bus party is made up from the special schools. (c) School for the Deaf.—Mrs. I. J. M. Burt, Headmistress, reports as follows:— When the School re-opened in January, 1953, the number on roll was forty-two. A general medical inspection was carried out on five days in February and March. The health of the children continued to be very good. By the Easter vacation the numbers had risen to forty-four. In May the new Western Electric Hearing Aid was used for the first 45 time, with most gratifying result. All classes now use it regularly, for practice in listening both to their own and the teacher's voices, and to the wireless. On June 12th we had a visit from Her Majesty's Inspector, who spent the day with us, observing the work in all the classes, and on June 17th another of H.M. Inspectors spent a short time in the school. Both commented on the friendly, oral attitude of the pupils. On June 29th Dr. Clarke came to see the hearing-aid in use and was pleased to see how much it helped the partially-deaf children to improve the pitch and volume of their own voices, and the joy it gave them in enabling them to join in choral singing. The pleasure which the children derive from singing together is out of all proportion to the quality of their performance. We find that even the children whose deafness is almost total seem to experience great pleasure from the very faint sensation of hearing which they have when using this powerful aid. The psychological effect of this is very valuable, even though the actual instructional benefit of so small an amount of hearing is worthless—children who are severely handicapped are apt to suffer from a deep sense of inferiority. If a child who has never heard can be made to feel that even if he doesn't hear well, he does hear, that sense of inferiority is lifted. Miss Baker and Miss Black, both of New Zealand, left us in the Autumn and were replaced by Miss Read and Miss Buckell, the former from Manchester University and the latter with experience of day and residential schools and private tutoring, both at home and abroad. We are still staffed entirely by qualified teachers of the deaf. During the year the children have visited the Coronation Route, the Zoo and the Circus, and have seen the Coronation and Everest films. In September Dr. Clarke made his usual aural inspection, as in past years. There are still no cases of regularly discharging ears (a somewhat unusual experience in such a school). One child had a slight discharge, which was arrested and cured by Dr. Clarke by ionisation treatment. The number on roll at the close of 1953 was forty, the ages ranging from three to fifteen years. (d) School for the Educationally Sub-Normal.—Miss R. E. A. Lock, Headmistress, reports as follows Two boys made such good progress that they were able to return to secondary modern schools on trial. Both have made good. 46 The school was again used in connection with the London University Diploma. The school has been visited by two German students. In March last a new method was begun in regard to the selection of entrants into the school. Dr. Watkins, the Educational Psychologist and the Headmistress now confer to ensure that the children on the waiting list are placed in the right vacancy. In December an infant teacher was appointed. This will mean that additional younger children can be admitted. 17. FULL-TIME COURSES OF HIGHER EDUCATION FOR BLIND, DEAF,, DEFECTIVE AND EPILEPTIC STUDENTS The Authority for the provision of such courses is the Essex County Council. 18. NURSERY SCHOOL Miss F. D. Harris, the Headmistress, reports as follows:— During the year there were 19 cases of measles, 5 of dysentery and 4 of mumps, but apart from these the health of the children was very good. At the annual medical inspection in May it was clearly seen how very much the children benefit from the ordered routine, balanced diet and fresh air which they enjoy at the Nursery School. 19. MISCELLANEOUS (a) Health Education.—A talk on the School Health Service was given at a "Parents' Evening" at a Secondary Modern Boys' School. Clean Food.—Ten copies of a new wall sheet provided by the Ministry of Health were distributed to and exhibited at school kitchens. Good Grooming.—Thirteen lectures on good grooming were given at schools during the year. (b) Employment of Children.—143 children were examined by the medical staff. (c) Employment of Children in Public Entertainment.—23 children were examined under these regulations. (d) Staff Appointments.—113 teaching staff and 318 other staff were examined during the year. 47 (e) Medical Examination of Prospective Teachers.—43 candidates for admission to Training College were examined during the year. (/) Sanitary Towels in Schools.—All schools have means of issuing sanitary towels on request. Supplies are held by Head Teachers and assistant teachers. (g) Private Residential School for the Deaf.—In October the Committee resolved that the Local Education Authority be informed that the Committee was agreeable to the extension of the School Health Service to a private residential school for the deaf situated in the Borough. (h) First Aid Lectures.—A series of six First Aid Lectures to teaching staff was commenced in February and owing to the numbers wishing to attend, the course had to be duplicated. Dr. Melville Watkins, Deputy Borough School Medical Officer, who undertook the lectures, has contributed the following account:— "In any large school population the amount of first aid undertaken by the teaching staff is considerable. It was therefore decided to hold a series of lectures on First Aid to members of the teaching staff with special reference to the problem of known hazards and those likely to occur during school hours. Six lectures were given in all and there was a good attendance. About thirty teachers attended in each of the two classes. It was generally agreed that the lectures and following discussions served a very useful purpose." The total numbers of the various items of consultation and treatment carried out in the School Health Service during 1953 have been extracted and are set out below:— Head Inspections 36,031 Dental Treatment 18,218 Dental Inspection 10,914 Orthopædic and Physiotherapy 10,046 Minor Ailments 8,544 Medical Inspections 7,212 Speech Therapy 4,639 Eye Treatment 4,040 Re-Inspections 3,502 Orthoptic 1,998 Child Guidance 1,685 Home Visits 1,370 Aural Clinic 931 Pædiatric Consultations 182 Cardiac Clinic 54 Total 109,366 48 20. STATISTICAL SUMMARY I. MEDICAL INSPECTION. A. Routine Inspections 6,719 B. Special Inspections and Re-inspections 3,995 C. Pupils found to require treatment 1,856 II. DEFECTS FOUND AT MEDICAL INSPECTION. Requiring treatment 2,189 For observation 2,509 CLASSIFICATION OF GENERAL CONDITION OF PUPILS. Nutrition 'A'—Good 4,618 „ 'B'—Fair 2,052 „ 'C'—Bad 49 III. INFESTATION WITH VERMIN. Total number of examinations 36,031 Individual pupils found to be infested 387 IV. TREATMENT. (a) Minor Ailments—total defects treated 2,397 (b) Defective Vision and Squint— Cases treated for errors of refraction 1,971 Other defects 87 Pupils for whom spectacles were—prescribed 1,063 obtained 1,063 Orthoptic Clinic—cases treated 347 (c) Nose and Throat Defects—number treated 295 total attendances 931 (d) Orthopaedic and Postural Defects— Treated as in-patients 26 Treated otherwise 786 (e) Child Guidance and Speech Therapy— Number treated under Child Guidance arrangements 229 Number treated under Speech Therapy arrangements 261 49 Dental Inspection and Treatment:— Periodic Specials (a) Number of pupils inspected 3,476 7,438 (b) Number found to require treatment 2,138 7,164 (c) Number referred for treatment 2,138 7,164 (d) Number actually treated 1,528 5,245 (e) Attendances made by pupils for treatment 4,648 13,570 (f) Half days devoted by— (a) Dental Officers to (i) inspection 32 (ii) treatment 2,582 (b) Oral Hygienists to (i) treatment 73 (ii) other purposes 14 (g) Fillings (i) Permanent teeth 6,070 (ii) Temporary teeth 1,055 (h) Number of teeth filled (i) Permanent teeth 5,551 (ii) Temporary teeth 1,024 (i) Extractions (i) Permanent teeth— (a) on account of caries 1,509 (b) for other purposes 246 (ii) Temporary teeth— (a) on account of caries 6,057 (b) for other purposes 703 (j) Anæsthetics (i) Local 613 (ii) General 4,572 (k) Other operations (i) Permanent teeth 7,012 (ii) Temporary teeth 4,191 (1) Number in (k) carried out by oral hygienists 403 (m) Analysis of figures in (k)— Orthodontic treatment 2,511 Silver Nitrate treatment 3,933 Scaling 452 Syringing Sockets 36 Other 4,271 E. G. Ellis & Sons, Willow Street, E.4