CARl MED. LIBRARY Carshalton, Epsom and Leatherhead Urban, and Epsom Rural Districts. ANNUAL REPORT OF THE Medical Officer of Health, WILLIAMSON, M.D., D.P.H., For the Year 1925. Carshalton Urban District ANNUAL REPORT OF THE Medical Officer of Health, J. WILLIAMSON, M.D., D.P.H., For the Year 1925. CARSHALTON URBAN DISTRICT. Annual Report of the Medical Officer of Health for the year 1925. (1) Natural and Social Conditions of the Distriot. Area and Population.—The area of the District is 2,926 acres. The population at the Census, 1921, was 14,021 persons, and was estimated by the Registrar-General at 15,660 for the year 1925. The following Table shows, for each Census, 1881 to 1921, the total population, the population less special inmates of hospitals, and the number of inhabited houses:- Census. Gross Population Nett Population. Inhabited Houses. Persons. Males. Females. 1881 4811 4841 2331 2510 910 1891 5425 5425 2574 2851 1091 1901 6745 6714 3181 3533 1330 1911 11634 10S34 4777 6057 2073 1921 14021 13141 5748 7393 2736 In 1921 there were 1,582 persons in 12 Institutions in the District; 1,247 persons, of whom 880 were patients, were enumerated in hospitals ; included in this number were 771 patients, 364 males and 407 females, in the Queen Mary's Hospital. Physical Features.—The District is situated upon, and at the foot of, the northern slope of the chalk downs. The whole of the district south of the ponds, including the greater part Of the old village (120ft. above sea-level), a large residential district which has been recently developed to the south, and Carshalton-on-the-Hill (250ft. above sea-level), are on the chalk; the northern part is situated mainly on a bed of river-gravel and sand overlying the Thanet sand, the Woolwich and Reading beds, and the London clay (100ft. above sealevel). The drainage is to the River Wandle, one head of which rises from ponds and springs in the town. Inhabited Houses and Families.—At the Census, 1921, there were 2,751 inhabited separate dwellings-, occupied by 3,017 private families, There were in addition 13 other occupied dwellings. 4 Of the 2,751 occupied private dwellings 92, or 3 per cent, contained 1—3 rooms. 1,350, or 49 ,, ,, 4—5 ,, 1,097, or 40 ,, ,, 6—8 ,, and 212, or 8 ,, ,, 9 or more rooms. Two of the dwelling- which contained 1—3 rooms, 109 of those containing- 4—5 rooms, 79 of those containing- 6—8 rooms, and 37 of the remainder were occupied by more than one family. The total number of occupied rooms in these houses was 16,051, and the population was 12,433, or 1.29 rooms per person. The following Table shows the number and percentage of families occupying from 1 to 5 rooms, and over 5 rooms, with the respective populations and the percentage of the whole population in private families, and the corresponding percentages of families and population in 1911. Number of Booms. Number of Families. Percentage of Families. Population 1921. Percentage of Population. 1921 191.1 1921 1911 1 63 2.1 2.3 119 1.0 0.5 2 199 6.6 3.2 554 4.5 1.9 3 182 6.0 3.8 651 5.2 3.2 4 498 16.5 18.5 2126 171 18.4 5 875 29.0 26.7 3964 31.9 28.7 Over 5 1200 39.8 45.5 5019 40.3 47.1 Excluding families of one person only, 371 families, with an average of 3.4 persons per family, occupied tenements of less than 4 rooms; and 486 families, with an average of 4.3 persons per family, occupied four-roomed tenements. The average size of families in the District was 4.12, as against 4 36 in 1911. In 1921, 21 one-roomed tenements, 24 two-roomed tenements, 10 three-roomed tenements, 26 four-roomed tenements, and 8 five-roomed tenements, or 89 in all, were occupied under conditions of more than two person per room, and their occupants formed 5.0 per cent. of the population in private families. In 1911 there were 39 such tenements, containing 3.3 per cent. of the population. Rateable Value.—The rateable value of the District in March, 1926, was £127,904, and the amount represented by a penny rate was £453. Social Conditions.—The District is to a large extent residential, and there are no special industries. At the Census, 1921, the number of persons returned as engaged in occupations were 3,673 males and 2,107 females. The chief numbers recorded under various occupations were as follows:- 5 Occupation. Males. Females. Agricultural occupations 327 26 Metal workers 200 - Makers of textile goods and articles of dress 65 108 Workers in wood' etc 133 9 Builders, bricklayers, etc. 217 1 Painters and: decorators 128 - Transport workers 334 15 Commercial and financial occupations 607 123 Public administration and) defence 204 53 Professional occupations 188 373 Persons employed in personal service 85 1017 Clerks, draughtsmen, typists, etc 472 232 Included in the first class were 160 male and 5 female gardeners, 108 male and 18 female agricultural labourers; under the heading of professional occupations, 224 female sick nurses; and among those employed in personal service, 858 female domestic servants. There were also 44 male and 10 female leather dressers, etc. Vital Statistics.—The births registered in the District in the year 1925, and also' the nett births belonging to the District, numbered 312, giving a birth-rate of 20.0 per 1,000 of the estimated population. The rate for England and Wales for 1925 was 18.3 per 1,000. The deaths registered in the District in 1925 numbered 223, of which 52 occurred in the Queen Mary's Hospital, 39 in the Beddington Corner Isolation Hospital, 20 in the Memorial Hospital, and 2 in a Nursing Home; 106 deaths were transferred to other districts, and 39 persons belonging to Carshalton died elsewhere, leaving 156 nett deaths. The death-rate for 1925 was 10.0 per 1,000 of the population. The rate for England and Wales for 1925 was 12.2 per 1,000. For purposes of comparison of the local death-rates -with those of other districts, a factor is calculated by which the recorded death-rates are multiplied in order to correct for the differences in the age and sex distribution in different districts; the factor issued by the RegistrarGeneral for this District, based on the 1911 population, was 1.019, and that based on the 1921 population was .976; the standardised rates therefore differ but slightly from those recorded. The death-rate for 1925, thus corrected, was 9.8 per 1,000. The figures issued in the Tables in the Census Returns, showing the age-distribution of the population of this District, include the inmates of the Queen Mary's Hospital, and are not, therefore, reproduced. The deaths of infants under one year of age in 1925 numbered 13, viz., 10 males and 3 females, all legitimate; 7 of the deaths occurred within a month of birth; 5 were due to Congenital Debility or Prematurity, and 4 to Rronchitis or Pneumonia. The infant mortality rate was 42 per 1,000 births; the rate for England and Wales for 1925 was 75. 6 There were 8 deaths among children between the ages of one year and five years, with no outstanding cause of death. The following Table shows for the District the average annual birth-rate, death-rate, infant mortality rate, and number of deaths of children between the ages of one and five years, for each of the last ten quinquennial periods, and for the year 1925:- Birth rate. Death rate. Infant MorVy. Average Deaths 1-5 years. 1876-1880 34.4 16.6 139 10 1881-1885 20.8 14.7 129 8 1886-1890 27.2 13.1 1,18 7 1891-'1895 29.2 16.3 124 9 1896-1900 27.6 13.4 132 7 1901-1905 24.3 11,7 118 12 1906-1910 25.9 9.5 80 6 1911-1915 20.2 9.3 76 7 1916-1920 17.6 10.7 64 10 1921-1925 18.9 9.5 '53 5 1925 20.0 10.0 42 8 The number of deaths from various causes in the two periods 1916 to 1920, and 1921 to 1925, are shown in the following Table:- 1916-1920. 1921-1925. Cause of Death Male. Female. Male. Female. Enteric Fever - 1 - 1 Small-pox - - - - Measles 4 3 1 1 Scarlet Fever 1 - - 1 Whooping Cough 3 1 6 - Diphtheria 3 7 - 3 Influenza 12 35 6 9 Encephalitis Lethargica - - - 1 Meningococcal Meningitis - - - - Respiiratory Tuberculosis 28 26 24 16 0their Tuberculous Diseases 4 3 6 8 Cancer 28 49 48 51 Rheumatic Fever - 1 1 - Diabetes 3 2 1 3 Cerebral Haemorrhage, etc. 18 19 IS 23 Heart Disease 33 44 45 42 Arterio-sclerosis 9 8 19 5 Bronchitis 16 23 16 42 Pneumonia (all forms) 25 24 28 19 Other Respiratory Diseases 5 2 5 5 Ulcer of Stomaoh or Duodenum 2 - 2 2 Diarrhoea, etc. (under 2 years) 3 3 4 - Appendicitis and TyphTitis 4 4 5 3 Cirrhosis of Liver - 2 2 2 Nephritis 10 2 9 12 Puerperal Sepsis - .1 - 3 Other Accidents, etc., of Pregnancy - 2 - 6 Congenital Debility, etc 18 8 20 13 Suicidte 2 2 10 4 Other Violence 9 6 7 3 Other defined Diseases 64 64 60 74 Causes Ill-defined - - - - All Causes 304 341 344 352 7 Poor Law Relief.—The amount expended in outdoor relief in the District in 1925 was £1,577 6s. 3d. (2) General Provision of Health Services in the District. Hospitals Provided or Subsidised by the District Council or County Council.—Hospitals for Tuberculosis and Smallpox are available for the District under the schemes of the Surrey County Council. The Isolation Ho'Spital is the Cuddington Joint Isolation Hospital in the Epsom Rural District. The Carshalton, (Bedding-ton and Wallington (War Memorial) Hospital in Carshalton Park, which was opened in 1924, provides for general medical and surgical cases. It contains 26 beds and an emergency ward. The District Council made an agreement with the Committee of the Hospital at the end of 1925. for the reception of maternity cases which required special treatment, or from unsuitable homes. Ambulance Facilities.—A motor ambulance for the removal of cases of infectious disease is provided by the Joint Hospital Board. For non-infectious and accident cases a motor ambulance, provided by the Order of St. John and British Red Cross Society for the use of the Carshalton and Wallington Districts, is stationed at Messrs. Wardill's garage in Pound Street, Carshalton. Clinics and Treatment Centres. By whom Centre. Situation. Accommodation. Provided. Maternity & Child Rochester Waiting Room, District Council Welfare Centre (1) Road, Dressing Room Doctor's Room, &c. Ditto (2) Stanley Road. do. do. Carshalton Camden Road. 20 Children. Voluntary. Day Nursery. School Clinic Rochester Road, - County Council Tuberculosis Sutton. - do. Dispensary Venereal Diseases London Hospitals - do. On the opening of the War Memorial Hospital the District Council purchased the Cottage Hospital and converted it into a Municipal Institute and Clinic for Maternity and Child Welfare work, and the Surrey County Council utilise part of the premises as a School Clinic. The District Council make a subsidy of £50 annually to the DayNursery. 8 Public Health Officers.—Medical Officer of Health, Dr. J. Williamson, M.D. (Lond.), D.P.H.; whole time, combined district; salary contribution made. Medical Officers of Clinics, Dr. Elizabeth Sloan Chesser, M.B., B.Ch.; Dr. A. M. Gale, M.B., Ch.B., B.Sc., part time; salary contribution made. Sanitary Inspector, Mr. H. j. Spicer, C.R.S.I., M.S.I.A.; holds certificate for inspection of Meat and Foods; whole time; salary contribution made. Health Visitor, Miss E. L. Picard, C.M.B.; certificate of trained nurse; whole time; salary contribution made. Veterinary Inspector, Mr. Frank Wooff, M.R.C.V.S.; part time; no salary contribution. Professional Nursing in the Home.-—The Carshalton District Nursing Association, affiliated to the Queen Victoria Jubilee Nursing Association, provides two nurses for general nursing-. The District Council pay £75 annually towards their salaries, in return for which contribution they attend the Welfare Centres, take the holiday-duty of the Health Visitor, and undertake the nursing of cases of infectious disease as required by the District Council. Legislation in Force.—The following Adoptive Acts, etc., relating- to public health are in force in the District :— Acts, Bye-laws, and Regulations. Date of Adoption. Infectious Disease (Prevention) Act, 1890 Nov. 12th, 1890. Public Health Acts Amendment Act, 1890 April 1st, 1891. Public Health Acts Amendment Act, 1907 March 23rd, 1909. Parts II., (except sec. 28), III., IV., V. & VI., and sec. 95. Bye-laws with respect to Nuisances June 4th, 1884. ,, ,, Common Lodging Houses July 3rd, 1895. ,, Houses let in Lodgings July 3rd, 1895. ,, ,, New Streets and Buildings Nov. 3rd, 1909. ,, ,, Alterations of Buildings Nov. 3rd, 1909. ,, ,, Drainage of Existing Buildings Nov. 3rd, 1909. ,, ,, Nuisances and carriage of offensive matters through streets Sept. 18th, 1912. ,, ,, Tents, Vans, Sheds, etc. Sept. 18th, 1912. ,, Slaughter-houses Nov. 21st, 1923. Regulations as to Dairies, Cowsheds, and Milkshops July 12th, 1899. Certain sections of the Surrey County Council Act, 1925, are applicable to the District. 9 (3) Sanitary Circumstances of the Area. Water Supply.—The whole District, with the exception of a few outlying houses which have private wells, is supplied by a constant service from the mains of the Sutton District Water Company. The water is obtained from wells in the chalk at Sutton and Woodmansterne, and is softened. Rivers and Streams.—The District Council have from time to time taken action in respect of the discharge of polluting- or obstructing matters into the River Wandle. Under the Surrey County Council Act, 1925, the County Council have obtained powers to preserve and improve the flow and purity of the river, by cleansing, widening, and prohibiting the discharge of sewage or other offensive or injurious matter into the stream. Drainage and Sewerage.—The whole of the populated part of the District, except the Woodcote area, completely detached to the extreme south, and including the 72 Small Holdings of the Surrey County Council and 15 other dwellings, is sewered. There are 16 scattered dwellings to the north of the District for which sewers are not available. The District Council have endeavoured, as the sewerage system has been extended, to secure the connection of the drains of all houses within a reasonable distance of the sewers, and the number of such unconnected houses has been reduced to 27. In connection with the possibility of pollution of the water supply, 1 made a report in September upon the situation of cesspools in the chalk relative to the Sutton well of the Water Company. There was no cesspool within a quarter of a mile, but seven within half a mile ; it appeared to be improbable, however, from the known direction of the flow of water, that any of these could affect the water supply, although possibly two were on the border of the zone. As there was some doubt in a few cases as to the outlet of the drains, Mr. Spi'cer, the Sanitary Inspector, made full enquiry into the matter, and revised the list of unconnected houses. He approached the owners of all houses within 100 feet of a sewer which still drained into cesspools, and he reports that, at the end of the year, the drains of one had been connected with the sewer, andi that good progress was being made in the negotiations for the connection of nearly all the rest. At the Outfall Works the high level sewage is treated by continuous flow through sedimentation tanks, the effluent from which is treated on a specially prepared filtration area, folio-wed by passage over the land. The low level sewage is pumped into tanks in which it undergoes quiescent settlement for two hours, and is then treated by sprinklers; the effluent passes into a deep tank, the top water of which flows through humus filters. 10 Closet Accommodation.—Mr. Spicer reports that 3,715 houses have water closets discharging- to the sewers, and 68 to cesspools, and that 79 are provided with earth closets. Scavenging.—House refuse is collected weekly by the Council's staff, under the supervision of the Surveyor; it is deposited at the Sewage Farm, at a considerable distance from any dwellings. The houses are provided with movable covered ashbins. Sanitary Inspection of the Area.—The Sanitary Inspector gives the following summary of inspections during the year:- Total number of inspections 2980 Houses inspected under Housing Acts 139 ,, „ ,, Public Health Acts 324 Inspections of slaughter-houses 102 ,, dairies 51 ,, cowsheds 34 ,, bakehouses 30 „ laundries 33 ,, factories 80 „ workshops 75 ,, tents, vans, sheds, etc 54 ,, food shops ami business premises 199 „ rat-infested premises 150 „ schools 10 ,, premises re cesspools 115 Visits in connection with infectious disease 83 Re-inspections of work in progress 1501 During the year 159 complaints were received; 332 preliminary and 153 statutory notices were served, and at the end of the year 410 notices had been complied with, and work was proceeding in respect of 50 notices. The chief works carried out, with respect to' dwelling houses and drainage, in response to these notices were: roofs repaired, 87; spouting repaired, 55; windows repaired, 101; windows made to open, 10; dampness abated, 15; coppers repaired, 66; floors levelled and repaired, 21; fireplaces repaired, 11; interiors of houses cleansed, 160; sinks provided, 11; sinks replaced, 9; additional W.C.s. provided, 3; W.C. pans renewed, 21; W.C.s. cleansed, 37; flushing apparatus repaired, 19; urinals cleansed, 11; new drains, 9; drains reconstructed, 13; drains cleansed, 51; soil-pipes repaired, 3; gullies provided, 23; yards paved, 38; yards drained, 11; new ashbins provided, 75. Among other nuisances abated were nuisances from piggeries, 4; from keeping of other animals, 17; from accumulations, 32; from rats, 39. Smoke Abatement.—Several complaints were received of nuisance from smoke, particularly from two factory chimneys; 39 hourly and several casual observations, were made, but at no time was more than a transitory emission of black smoke observed, and the Sanitary Inspector was unable to report that it could be declared to; be a nuisance. 11 Bye-laws.—Action was taken by the Sanitary Inspector on ten occasions under the Bye-laws with respect to Tents, Vans, Sheds, etc. Factories and Workshops.—Under action taken by the Council two new W.Os. were provided, 11 were cleansed, and five urinals were cleansed at factories, one bakehouse was re-constructed, and three bakehouses and 15 other workshops were cleansed and limewashed. Schools.—Each of the four Elementary Schools has a water supply from the public mains, and is provided with water-closets draining to the sewers. Notices are sent to the Head Teachers on the receipt of notifications of infectious disease occurring in a house in which there are children attending school, and the teachers report the absence or exclusion of any children on account of infectious or contagious disease; in such cases the Health Visitor of the County Council inspects the children at the schools and visits their homes. I visited the sqhools and advised, at the time of prevalence of infectious disease. (4) Housing. General Housing Conditions.—The figures relating to housing at the Census, 1921, will toe found on pages 3 and 4. At the Census, 1911, there were 2,369 private families, with a population of 10,338 persons, in 2,235 houses; in 1921 there were 3,017 families, with a population of 12,433, in 2,751 houses. The number of persons per house had, therefore, fallen from 4.62 to 4.52, but there was an increase in the number of families per house from 1.06 to nearly 1.09. In order to meet the shortage of houses revealed by the survey of the District in 1919, the Council decided to build1 200 houses, and the scheme, consisting of 188 houses on the Culvers Estate, 11 in Nightingale Road, four in Green Wrythe Lane, two in William Street, and five fiats in Stanley Road, was completed in 1922. Applications for houses continued to be received, and the Council accordingly erected six houses in William Street, four in St. James Road, four in Palmerston Road, ten in Avenue Road, and four in Stanley Road, and four flats in Aultone Way and four in Stanley Road, under the Housing Act, 1923. Tenders were also received for the erection of four houses in St. Andrew's Road and eight in Stanley road, and negotiations were proceeding at the end of the year. The Council purchased 18 acres of land in Stanley Park Road in 1925, as a site for additional houses. At the end of 1925 the District Council had advanced the sum of £266,710 in loans under the Small Dwellings Acquisition Act and the Housing Act, 1925, in respect of 370 houses, and had issued 13 subsidies at £75 and 100 at £100. In the five years 1,065 houses in all were erected in the District, viz., 160 in 1921, 137 in 1922, 107 in 1923, 285 in 1924, and 376 in 1925. 12 Overcrowding.—The Census Returns for 1921 showed that 89 families, representing 5.0 per cent. of the population in private families, were living in conditions of more than two persons per room, as against 39 families, representing 3.3 per cent. of the population, in 1911; the percentage of the population living under these conditions in 1925 in the County generally was 4.3. In 1921, among 1,442 dwellings containing less than six rooms, 107 were occupied by two families, and 4 by three families; 7.7 per cent. of such dwellings were, therefore, occupied by two or more families. The number of rooms per person, in houses containing not more than 9 rooms, was 1.26 for the District, as against 1.21 for the whole County; the corresponding figures in 1911 were similar, viz., 1.25 for Carshalton and 1.20 for the County. The erection of the Council's houses has no doubt since mitigated the overcrowding, and it is now possible to deal with the majority of such cases. In 1925, of eight cases discovered, three were abated by the admission of families to Council houses, and four others by removal to better accommodation elsewhere. Fitness of Houses.—The number of houses in the District at the Census, 1921, was more than twice the number at the Census, 1911; at least 60 per cent. of the houses in 1921 had been built under the Bye-laws, and the percentage had increased to more than 70 per cent. by the end of 1925. Certain groups of houses require frequent attention, and these have all been dealt with during the period under review. Records of each house inspected in the past have been kept, and, on the appointment of Mr. Spicer in May, a re-inspection of the District was commenced, the envelope system for the preservation of records being adopted. He reports that, of the 463 houses inspected during the year, 15 per cent. were found to be in a very satisfactory condition, 20 per cent. were in a bad state, and that the remainder required attention to defects of various kinds. The character of the defects is indicated in his report upon the works which were done under notice, on page 10. In some instances the poverty of owners has led to delay in carrying out the requirements, and in others the employment of inexperienced workmen has brought about only temporary improvement, with the result that the unsatisfactory conditions have recurred, and re-inspection has been necessary in a short time. Housing Statistics for the Year 1925. Number of new houses erected during the year:- (a) Total 376 (b) With State assistance under the Housing Acts : (i.) By the Local Authority 18 (ii.) By other bodies or persons 27 13 I.—Unfit dwelling houses. Inspection. (1) Total number of dwelling-houses inspected for housing- defects (under Public Health or Housing Acts) 463 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910, or the Housing Consolidated Regulations, 1925 139 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 1 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found1 not to be in all respects reasonably fit for human habitation 359 II.—Remedy of defects without Service of formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers 232 III.—Action under Statutory Powers. A.—Proceedings under Section 3 of the Housing Act, 1925. (1) Number of dwelling-houses in respect of which notices were served requiring repairs - (2) Number of dwelling-houses which were rendered fit:- (a) by owners - (b) by Local Authority in default of owners - (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close - B.—Proceedings under Public Health Acts. (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 127 (2) Number of dwelling-houses in which defects were remedied:— (a) by owners 121 (b) by Local Authority in default of owners 1 C.—Proceedings under Sections 11, 14 and 15 of the Housing Act, 19 25. (1) Number of representations made with a view to the making of Closing Orders - 14 (2) Number of dwelling-houses in respect of which 'Closing Orders were made - (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwellinghouses having been rendered fit - (4) Number of dwelling-houses in respect of which Demolition Orders were made - (5) Number of dwelling-houses demolished in suance of Demolition Orders - (5) Inspection and Supervision of Food. Milk Supply.—There are 31 Purveyors of Milk registered, of whom 21 reside in the district; seven of them are cowkeepers. A large proportion of the milk is delivered in bottles. Frequent inspections of the cowsheds and dairies were made, and one dairy was repaired, four dairies were limewashed, and three cowsheds were cleansed, under notice. One cowshed was undergoing extensive re-construction at the end of the year with a view to the production of graded milk. The Veterinary Inspector paid 94 visits to cowsheds, and made 310 examinations of cows, but discovered no case of tuberculosis. Three principal and three supplementary licences to retail certified milk were issued during the year. No graded milk is produced in the District. Meat.—(Many visits were paid at the time of slaughter, and the carcases were examined, and 271 carcases were passed, viz., beasts, 32; calves, 14; sheep, 118 ; lambs, 14 ; and pigs, 193. The carcase of a sheep was found to be unfit for human consumption, and was destroyed. A very high proportion of the meat consumed in the district is brought from the wholesale markets of Smithfield and Croydon. When the Meat Regulations first came into' force there was some difficulty in obtaining compliance with them, but the Inspector reports that every assistance is now given, and all reasonable precautions against contamination are taken. One butcher has given notice of definite times of slaughter, and the required three hours' notice is given in all other cases. On two occasions the Inspector dealt with the unsatisfactory condition of vans used for the transport of meat. There are 13 purveyors of meat in the District. The number of slaughter-houses in use in the District at the undermentioned dates was In 1920. In Jan., 1925. In Dec.,1925, Registered 2 2 2 Licensed 1 2 2 3 4 4 15 Other Foods.—During- the year 193 visits were paid to food shops and business premises, and the following' articles were surrendered as unfit for human consumption:- Ten stone of Australian beef. Five tins of corned beef. Six stone of coal fish. Two tins of prawns. Two boxes of apples. Three tins of tomatoes. The four bakehouses were visited on frequent occasions, and were found to be satisfactory, except one bakehouse, which is inefficiently lighted and ventilated; the owner has submitted proposals for re-construction. In three instances cleansing and limewashing were carried out at the Inspector's request. Food Poisoning.—In March, four persons living in neighbouring houses, who partook, on different days, of some cheese which had been purchased in another district, were attacked from seven to nine hours later with severe gastric pain, vomiting, diarrhoea and weakness, and were ailing for several days. The other four inmates, who did not partake of the cheese, had no symptoms. The remainder of the cheese was submitted to the Ministry of Health for examination, but no suspicious organisms were found, and it had no ill-effect on mice which were fed on it. The cheese had been purchased several days before it was eaten, and inquiries failed to disclose any similar cases among the customers of the firm from which it was obtained, so it was probable that there had been some accidental contamination of the cheese after purchase. Two complaints were received that milk had caused illness, and samples were analysed, but no trace of injurious ingredients was discovered. Sale of Food and Drugs Acts.—The County Medical Officer of Health informs; me that 42 samples of milk, 2 of butter and 2 of other articles were analysed under these Acts, and that 2 samples of milk were found to be adulterated. (6) Prevalence of and Control over Infectious Diseases. The following Table shows, for each of the past five years, the number of cases of infectious diseases notified in the District, including those among the staff, but excluding those among the patients, at the Queen Mary's Hospital:- 1921 1922 1923 1924 1925 Scarlet Fever 55 43 18 17 23 Diphtheria 19 27 6 8 16 Enteric Fever 1 1 4 2 1 Puerperal Fever 1 1 - 1 - Pneumonia 11 9 4 9 21 Encephalitis Lethargica - - — 3 - Pulmonary Tuberculosis 16 13 13 11 13 Non-Pulmonary Tuberculosis 4 2 3 3 6 Ophthalmia Noenatorum 1 - 2 - - 16 In private houses, 136 cases of Scarlet Fever occurred in 115 houses, and 52 cases of Diphtheria in 47 houses. There was no special matter for comment in connection with either of these diseases ; on three or four occasions there was some special incidence among the children attending one or other of the schools, but there was no school outbreak. In 1921 a boy failed with Scarlet Fever in September, four days after the return of his brother from the Isolation Hospital, and in December the mother of two children failed with the disease five days after their return. In 1922 two children failed with Scarlet Fever in the fifth week after the return of a patient from the Hospital, and two other cases occurred in the house at considerable intervals later, but it appeared to be improbable that the original patient had infected the others. Bacteriological examinations are carried out at the Lister Institute of Preventive Medicine on behalf of the District Council. During the year 1925, 62 examinations were made for the diphtheria bacillus, with 9 positive results, and 21 for the tubercle bacillus, all with negative result; 3 for the Widal reaction, with 1 positive result; 1 for malaria! parasites, 1 for the anthrax bacillus, and 1 for the Amoeba histolytica, each with negative result. Diphtheria antitoxin is provided by the District Council, who issued 68,000 units during the year. No applications of the Schick or Dick tests in Diphtheria and Scarlet Fever were made. A case of Smallpox occurred in 1923. The patient had been in contact with about 150 persons after the appearance of the rash, but the contacts were promptly vaccinated or re-vaccinated, and there was no spread of the disease. The one death from Enteric Fever which occurred during the five years was that of a patient who had been notified in 1920, and died in January, 1921. The four cases of Paratyphoid B. Fever notified in 1923 formed part of a series of cases which occurred in this and neighbouring Districts in the first quarter of the year, and were attributed to the infection of confectionery by a carrier of the disease. The three cases of Encephalitis Lethargica in 1924 occurred in the second quarter of the year, but they were in different parts of the District, and no connection between them could be traced. Under the Public Health (Pneumonia, etc.) Regulations, 1919, 54 cases of Pneumonia and 2 of Malaria were notified in the five years. More than half of the deaths attributed to Pneumonia occur among cases that have not been notified ; the majority of these deaths are due to Broncho-pneumonia, but a considerable number of cases of Lobar Pneumonia are not notified. Early in 1925 I again drew the attention of the medical practitioners to the requirements of the Regulations. The notified patients were visited by the Health Visitor. 17 The deaths from Influenza in the five years numbered 15, representing an average annual death-rate of 0.22 per 1,000 of the population, as against an average rate of 0.37 for England and Wales for the same period. A considerable majority of the deaths occurred among persons above the age of 55 years. The Isolation Hospital for the District is the Cuddington Joint Isolation Hospital. In the five years, among the 146 cases of Scarlet Fever and the 55 cases of Diphtheria, other than the cases at the Queen Mary's Hospital, which were removed to hospitals of the Metropolitan Asylums Board, 121 cases of Scarlet Fever and 46 of Diphtheria were removed to the Cuddington Hospital, and 6 cases of Scarlet Fever and 2 of Diphtheria were removed to the Wandle Valley or Tolworth Isolation Hospitals; in the case of each disease, 87 per cent. of the patients were removed. Two cases of Enteric Fever were also removed. After the removal, recovery or death of a patient, the room was disinfected and bedding and other articles were removed to the Isolation Hospital and stoved in the Washington Lyons disinfector. Measles was extensively prevalent, as shown by the notifications received from the School Teachers, in 1922 and 1924, and Whooping Cough in each year except 1923. Measles caused 2 deaths and Whooping Cough 6, all among children under five years of age. The homes of the children are visited by the School Nurses of the County Council, and I visited the Schools when the diseases were prevalent and advised as to precautions. There are no facilities in the District for the cleansing of verminous persons or their belongings. Notifiable Diseases during the year 1925:- Total cases Cases admtd. Disease. notified. to hospital. Deaths. Scarlet Fever Diphtheria Enteric Fever Pneumonia Erysipelas 29 26 - 27 25 - 21 - 10 4 - - Included in these figures are 2 cases of Scarlet Fever and 3 of Diphtheria among the staff, and 6 cases of Scarlet Fever and 11 of Diphtheria among the patients at the Queen Mary's Hospital. Total cases at various ages:- Under 1 2 3 4 5 10 15 20 35 45 65 1-yr. Diphtheria - -5 2 3 11 3 2 3 - - - Scarlet Fever - - 3 5 1 68 1 2 - - Pneumonia 3 2 1 2 2 1- 22 4 1 13 Tuberculosis. New cases and mortality during 1925:- Age Periods. New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. m f m f m f m f 0 - - - - - - - - 1 - - - 1 - - - 1 5 - - - - - - - - 10 - - 2 1 - - 1 - 15 - 2 20 5 1 1 - - - - - 25 1 1 - - 2 4 - 1 35 2 - - 1 - 1 - - 45 - 1 - - - - - - 55 - - - - - - - - 65 & above - - - 1 - - - 8 5 3 3 3 5 1 2 The 8 deaths from Pulmonary Tuberculosis represent an annual death-rate of 0.51 per 1,000 of the population as against an average rate of 0.72 for the ten years 1916 to 1925. There were 2 deaths from Tuberculous Meningitis, and 1 death from Tuberculous Peritonitis. The following Table shows the mean population, the number of cases notified and the number of deaths from certain infectious diseases in each quinquennium during the period from 1876 to 1925, the population and cases among the patients at the Queen Mary's Hospital being excluded. Period. Mean Population. Cases. Deaths. Scarlet Fever. Diphtheria. Enteric Fever. Scarlet Fever. Diphtheria. Enteric Fever. Measles. Whooping Cough. Pulmonary Tuberculosis. 1876- 4440 - - 8 5 5 6 16 34 1881- 5090 89 9 15 9 1 3 13 6 35 1886 - 5540 48 18 13 - 2 1 11 13 37 1891- 5620 55 17 11 - 3 3 17 5 29 1896- 6330 111 51 21 5 8 5 4 2 26 1301- 7500 52 41 7 - 6 1 7 15 31 1906- 9500 166 56 5 2 11 - 7 8 36 1911- 11300 134 42 7 1 1 2 8 7 31 1916- 12400 121 131 4 1 10 1 7 4 53 1921- 13700 166 76 9 1 3 1 2 6 41 Notification was voluntary until 1889, and the figures representing the number of cases up to that year are, therefore, incomplete. 19 (7) Maternity and Child Welfare. The two Welfare Centres, in Rochester Road and Stanley Road, are open on Thursday in each week. Dr. Sloan Chesser holds a clinic at each meeting at the former Centre, and Dr. Gale at alternate meetings at the latter. Facilities are given for the examination of ante-natal cases before the regular meeting at each visit of the medical officers. Children attending the Centres are required to be seen by the medical officer at least once a month. During the year there were 2,402 attendances of children at 47 meetings at the Rochester Road Centre, and 906 at 48 meetings at the Stanley Road Centre. The attendance at the ante-natal clinics is poor, and, although the County Medical Officer of Health called a meeting of mid-wives at my request in the preceding year, at which the arrangements were explained, and the Superintendent of Midwives urged them to advise their patients to present themselves at the clinics, the total number of attendances in 1925 was only.31. The Health Visitor paid 195 first visits and 1,602 total visits to infants under one year of age, and 2,000 visits to children between the ages of one and five years during the year. The District Council pay £10 annually to the Committee of the Memorial Hospital for special treatment of children attending the Centres, and two children were admitted for operation during the year. They also made an agreement towards the end of 1925 with the Committee for the admission of maternity cases which are expected to present difficulty, or from unsuitable homes, and one case was admitted. There was one death in 1925 in connection with parturition, attributed to shock following labour, complicated by retention of the placenta, in a patient suffering from marked aneemia. There were five other maternal deaths, due to causes other than sepsis, in the five years; three of them occurred in hospitals after Caesarian section, undertaken in two instances on account of placenta praevia; one was due to phlebitis following labour, and the fifth to hydramnios. Milk is supplied free in necessitous cases; a special form signed by the applicant is considered by the Maternity and Infant Welfare 'Committee after investigation of the circumstances by the Health Visitor. During the year 56 grants were made, usually amounting to one pint daily for a month. Various special foods are provided at the Centres, and are sold at a low price, but sufficient to cover the cost to the Council; in exceptional cases they are issued free or at a reduced price, on the certificate of the medical officer. In the case of mothers requiring dental treatment, the District Council obtain an estimate from a dentist and defray the expense, which is recovered from the patient by a series of small payments. 20 A grant of £50 annually is made by the District Council towards the expenses of the Day Nursery in Camden Road. A grant of £75 annually is made to the Carshalton District Nursing Association for attendances of the nurses at the Welfare Centres, for taking duty for the Health Visitor during absence on holiday, and for nursing cases of infectious disease at times of epidemic. The proportion of notifications of births has from time to time been unsatisfactory; the District Council has issued frequent warnings, and in 1925 informed one of the medical practitioners that proceedings would be taken in the case of any further failure to comply with the requirements of the Act. During the five years three cases of Puerperal Fever, two of which were removed to hospitals, were notified in the District; one proved fatal in 1921 after removal, and there were in addition two fatal cases, in 1921 and 1924, among persons belonging to Carshalton, in a nursing home and a hospital in other districts. In 1923 the Wandle Valley Isolation Hospital Board entered into an agreement with the District Council to receive cases of Puerperal Fever into their hospital, which is situated in this District. Measles caused two deaths among young children, in 1921 and 1922; Whooping Cough caused six deaths, one in 1921, two in 1922, two in 1924, and one in 1925; Diarrhoea caused four deaths, one each in 1921, 1922, 1924 and 1925. Inquiries are made by the Health Visitor as to young children in houses in which cases of Measles and Whooping Cough are notified by the School Teachers, advice is given, and leaflets are distributed. During the summer months addresses upon the subject of Infantile Diarrhoea are given at the Welfare Centres, and leaflets are distributed. One case of Ophthalmia Neonatorum in 1921, and two cases in 1923, were notified, but no notification was received in the other three years. J. WILLIAMSON, Medical Officer of Health. Epsom, May, 7926 Epsom Urban District. ANNUAL REPORT OF THE Medical Officer of Health, J. WILLIAMSON, M.D.. D.P.H., For the Year 1925. EPSOM URBAN DISTRICT. Annual Report of the Medical Officer of Health for the Year 1925. (11 Natural and Social Conditions of the District. Area, Population, etc.—The area of the District is 4,423 acres. The population at the Census, 1921, was 18,804 persons, of whom 8,848 were, males and 9,966 were females ; it was estimated by the Registrar-General at 19,460 persons for the year 1925. A high proportion of the population at the Census was enumerated in the three Mental Hospitals of the London County Council, the Ewell War Hospital, the Queen Mary's Convalescent Centre, tlie Guardians' Institution and other Institutions. The total population of 14 Institutions, including schools, was 5,801. The following Table shows, for each Census 1891 to 1921, (i.) the gross population and (ii.) the population exclusive of the special inmates enumerated in the Guardians' Institution, Hospitals and Convalescent Institutions in the District:- Census. Total Population Nett Population. Persons. Males. Females. 1891 8417 8023 3861 4162 1901 10915 9746 4773 4973 1911 19156 13080 6096 6984 1921 18804 14 402 6720 7682 The following Table shows, for 1911 and 1921 for each Ward, the total population, the population exclusive of the patients or other special inmates of the Guardians' Institution, the Mental Hospital, the Ewell War Hospital, and the Queen Mary's Convalescent Centre, and the number of private families, the population in private families, and the structurally separate dwellings at the Census, 1921:- Ward. Total Population. Nett Population. Private Families, 1921. 1911. 1921. 1911. 1921. Families. Populat'n Dwellings College 2490 2708 2190 2708 560 2194 506 Court 2491 3304 2491 3304 826 3291 696 East Street 2188 2304 2188 2301 551 2207 484 Stamford 7809 5819 2212 2167 360 1540 332 Town 1727 1614 1727 1644 404 1597 376 Woodcote 2451 3025 1972 2275 430 2013 419 4 The following Table shows the total populations and the number special inmates of the larger Institutions at the Census, 1921:— Institution. Total Population. Special .Inmates. Persons. Males. Females. Persons. Males. Females. Guardians' Institution 492 203 229 446 258 193 Mental Hospitals (3) 3849 1299 2550 3311 1230 2081 Ewell War Hospital 395 360 35 341 341 - Queen Mary's Convalescent Centre 450 392 58 304 304 - Epsom College and Masters' Houses 405 333 72 - - - Dr. Darnardo's Home 98 91 7 — — - In 1924 the West Park Mental Hospital was completed and occupied, and in 1925 the Queen Mary'3 Convalescent Centre was closed. In November, 1925, the population of the four Mental Hospitals and the Ewell Ministry of Pensions Hospital was returned as 7,853 persons, consisting of 927 staff and 6,926 patients. Taking into consideration these figures, the natural increase in the population, and the number of houses that have been erected, the population for 1925 may be estimated as in the neighbourhood of 23,000, and the nett population, among whom the births and deaths of the District are recorded, as 15,700 persons. Physical Features.—The District is situated upon, and at the foot of, the northern slope of the chalk downs. The town itself, at a height of about 150ft. above sea-level, and Woodcote (190ft.), are situated chiefly on the Thanet sand and the Woolwich and Reading beds of the Lower London Tertiaries, which separate the chalk from the London clay ; a superficial deposit of valley gravel overlies a considerable area of the London clay and Lower London Tertiaries. The western and north-western parts of the District, including the Common and Horfcon, are on the London clay, at an elevation of about 200ft.; the eastern and southern parts are on the chalk, which rises to a height of about 500ft. at the south-eastern limit of the parish. The natural drainage is to the Hog's Mill River to the north and to the Rye Brook, a tributary of the River Mole, to the west. Inhabited Houses and Families.—At the Census, 1921, there were 2,813 inhabited separate dwellings, occupied by 3,181 private families; there were in addition 26 other occupied dwellings. Of the 2,813 occupied private dwellings 193, or 7 per cent, contained 1—3 rooms 1,732, or 62 „ „ 4—5 „ 622, or 22 „ „ 6—8 ,, and 266, or 9 ,, ,, 9 or more rooms. One of the dwellings which contained 1—3 rooms, 192 of those containing 4—5 rooms, 75 of those containing 6—8 rooms, and 15 of the remainder were occupied by more than one family ; in 30 of the houses there were three or more families. 5 The following Table shows the number and percentage of families occupying from 1 to 5 rooms, and over 5 rooms, with the respective populations and the percentage of the whole population in private families, and the corresponding percentages of families and population in 1911:— Number of Rooms. Number of Families. Percentage of Families. Population, 1921. Percentage of Population. 1921 1911 1921 1911 1 135 4.3 1.7 220 1.7 0.6 2 244 7.8 5.7 603 4.7 3.3 3 283 90 6.3 921 7.2 5.7 4 690 220 23.8 2886 22.5 22.9 5 974 31.2 30.0 4463 34.7 31.1 Over 5 805 25.7 32.5 3719 292 30.4 Excluding families of one person only, 512 families, with an average of 3.1 persons per family, occupied tenements of less than 4 rooms ; and 664 families, with an average of 4.3 persons per family, occupied four-roomed tenements. The average size of families in the District was 4.10, as against 4.43 in 1911. In 1921, 23 one-roomed tenements, 17 two-roomed tenements, 12 threeroomed tenements, 16 four-roomed tenements, and 7 five-roomed tenements, or 75 in all, were occupied under conditions of more than two persons per room, and their occupants formed 4.1 per cent, of the population in private families. In 1911 there were 71 such tenements, containing 4.9 per cent, of the population. Rateable Value.—The Rateable Value of the District at Lady Day, 1926, was £193,399. The sum represented by a penny rate was £732. Social Conditions.—The District is largely residential, and there are no special industries. A considerable number of persons are employed in the building trade, in brickmaking, at the Mental Hospitals, and in connection with racing stables. At the Census, 1921, the number of persons returned as engaged in occupations were 4,479 males and 2,546 females. The chief numbers enumerated under various occupations were as follows:— Occupation. Males. Females. Agricultural occupations 404 7 Metal workers 252 1 Makers of textile goods and articles of dress 59 96 Workers in wood, etc 135 4 Builders, bricklayers, etc 199 — Painters and decorators 116 2 Transport workers 520 31 Commercial and financial occupations 464 184 Public administration and defence 221 48 Professional occupations 468 582 Persons employed in entertainments, etc 204 21 Persons employed in personal service 276 1349 Clerks, draughtsmen, typists, etc 264 172 6 Included in the first class were 259 gardeners and gardeners' labourers; under the heading of professional occupations, 192 male and 401 female mental attendants; and among those employed in personal service, 1,052 female domestic servants. Vital Statistics.—The births registered in the District in 1925 numbered 248. The nett births belonging to the District were 225, of which 12 were illegitimate. Tbe deaths registered in the District in 1925 numbered 529, of which 183 occurred in the Union Hospital, 7 in the Cottage Hospital, 810 in the Mental Hospitals, 2 in the Ministry of Pensions Hospital, and 3 in other Institutions; 415 deaths were transferred to other Districts, and 16 persons belonging to Epsom died elsewhere, leaving 180 nett deaths. These figures represent a birth-rate of 11.6 per 1,000 and a deathrate of 6.'7 for the year, based upon the population estimated by the Registrar-General, who has also issued a factor by which the crude deathrate should be multiplied in order to allow for the age- and sex-distribution of the population, producing a standardised death-rate of 6-2, for comparison with other Districts. This estimate of the population, however, appears to include the inmates of the Mental Hospitals, whose deaths are deducted for distribution among the Districts to which they belong. For the reasons mentioned on page 4, the nett population, or number of persons amongst whom the recorded births and deaths have occurred, may be estimated at 15,700, giving a birth-rate of 14.8 per 1,000, and a death-rate of 8.8. The birth-rate for England and Wales in 1925 was 18.8, and the death-rate was 12.2. The deaths of infants under one year of age numbered 13, viz., 5 males and 8 females. The mortality rate was 58 per 1,000 births. The rate for England and Wales for 1925 was 75. Eight of the deaths wero due to prematurity or congenital debility, and 3 to whooping cough. Only two deaths occurred among children between the ages of one year and five vears. The following Table shows for the District the average annual birthrate, crude death-rate, infant mortality rate, and number of deaths of children between the ages of one and five years, for each of the last ten auinnuennial Deriods and for the vear 1925 :— Birthrate. Deathrate. Infant Mortality. Deaths, 1— 5 years. 1876—1880 27.7 16.0 115 10 1881-1885 27.0 15.6 107 11 1896—1890 25.4 13.4 107 11 1891—1895 22.6 14.6 123 10 1896—1900 23.2 12.8 119 6 1901—1905 25.0 11.9 96 10 1908 1010 24.8 11.5 90 10 1911—1915 19.2 10.6 77 8 1916-1920 17.3 12.4 66 8 1921—1925 16.0 93 54 4 1925 14.3 8.3 58 2 The birth-rates and death-rates are calculated upon the estimated nett populations. 7 The number of deaths from various causes in the two periods, 1916 to 1920 and 1921 to 1925, are shown in the following Table:— Cause of Death. 1916Male. 1920. Female. 1921— Male. -1925. Female. Enteric Fever — 1 1 1 Small-pox — — — — Measles 1 4 1 - Scarlet Fever 1 1 — — Whooping Cough 4 4 2 3 Diphtheria 2 3 1 1 Influenza 16 33 8 10 Encephalitis Lethargica — — — 4 Meningococcal Meningitis 1 — 1 — Respiratory Tuberculosis 38 21 27 20 Other Tuberculous Diseases 4 9 7 6 Cancer 32 42 49 42 Rheumatic Fever 1 3 — 2 Diabetes 2 2 3 1 Cerebral Haemorrhage, etc. 30 36 11 23 Heart Disease 37 21 39 31 Arterio-sclerosis 22 40 31 39 Bronchitis 31 24 35 29 Pneumonia (all forms) 38 25 26 18 Other Respiratory Diseases 2 2 5 1 Ulcer of Stomach or Duodenum . 3 2 2 — Diarrhcea, etc (under 2 years) 8 6 4 2 Appendicitis and Typhlitis 3 5 5 6 Cirrhosis of Liver 6 2 3 2 Nephritis 13 8 8 11 Puerperal Sepsis — 3 — 1 Other Accidents, etc., of Pregnane - 2 - 2 Congenital Debility, etc. 16 8 1 7 12 Suicide 1 — 2 4 Other Violence 22 4 14 5 Other Defined Diseases 78 84 61 60 Causes Ill-defined — — — — All Causes 412 395 363 336 Poor Law Relief.—The sum expended in outdoor relief in the District in 1925 was £1,512 18s. od. (2) General Provision of Health Services in the Area. Hospitals Provided or Subsidised by the Local Authority or the County Council.—Hospitals for Tuberculosis and Smallpox are available for the District under the schemes of the Surrey County Council. The Isolation Hospital, Hook Road, Epsom, belonging to the Epsom Urban District Council, provides for cases of Scarlet Fever, Diphtheria, and Enteric Fever. It comprises a Ward Block, with two wards of six beds each, a second Block, consisting of four small wards of ten beds in all, an Administrative Block, Laundry, Disinfector, Mortuary, and Ambulance Shed. The Epsom and Ewell Cottage Hospital, Alexandra Road, provides for general medical and surgical cases. 8 Institutional Provision for Unmarried Mothers, Etc.—The Mothers' Hostel, Worple Road, Epsom, accommodates 16 mothers with their infants; 5 beds are retained by the Surrey County Council and 6 by the Hampshire County Council. The Epsom Branch of the Dr. Barnardo's Homes, East Street, Epsom, provides for 80 homeless boys. Ambulance Facilities.—Cases of infectious disease are removed to the Isolation Hospital in the Horse Ambulance belonging to the District Council. A motor ambulance provided by the Order of St. John and British Bed Cross Society is stationed at the Woodcote Motor Co., Ltd., South Street. Clinics and Treatment Centres. Centre. Situation. Accommodation. By whom provided. Maternity & Child Wesleyan Hall, Waiting Boom Surrey County Welfare Centre. Church Street. & Doctor's Boom. Council. School Clinic. do. do. do. Public Health Officers.—Medical Officer of Health, Dr. J. Williamson, M.D. (Lond.), D P.H., whole time, combined district; salary contribution made. Sanitary Inspector, Mr. W. H. Martin, A.R.S.I., A.I.S.E.; whole time; salary contribution made; is also Inspector under the Petroleum Acts and the Celluloid and Cinematograph Films Act, 1922. Veterinary Inspector, Mr. F. W. Chamberlain, M.R.C.V.S. ; part time. Professional Nursing in the Home.— The Epsom District Nursing Association maintains two nurses for general nursing. There is no special provision for infectious cases. Midwives.—The Surrey County Council make a grant of two shillings and sixpence to the Nursing Association for each maternity case attended by the two nurses. There are 4 midwives practising in the District. Adoptive Acts, Bye-Laws and Regulations.—The following Adoptive Acts, etc., relating to public health are in force in the District:— Adoptive Acts, etc. Date of Adoption. Infectious Disease (Prevention) Act, 1890 Jan. 7th, 1891. Public Health Act Amendment Act, 1890 Jan. 7th, 1891. Public Health Act Amendment Act, 1907 Dec. 4th, 1908. Parts II., III., IV., Y., VI., & X. Bye-laws with respect to Slaughter-houses Jan. 17th, 1894. ,, ,, Tents, Vans, Sheds, etc May 3rd, 1897. ,, ,, Common Lodging Houses Sept. 6tli, 1899. ,, ,, Nuisances Feb. 28th, 1906. ,, ,, Height of rooms intended to be used for human habitation June 6tli, 1906. „ ,, New Streets and Buildings Jan. 29th, 1924. Regulations with respect to Dairies, Cowsheds, and Milkshops Sept. 27th, 1899. 9 (3) Sanitary Circumstances of the Area. Water—The water supply is obtained from bore-holes and an adit in the chalk at the District Council's Water Works in East Street. The main bulk of the water is derived from the adit, 90 feet from the surface of the ground. The top of the chalk is 65 feet below the surface, the strata above it consisting of sand, gravel, and a belt of clay 14 feet in thickness. The water is pumped into two reservoirs, having a total capacity of 930,700 gallons. A constant supply is maintained to all premises up to a height of 400 feet, and the plant is capable of giving a supply to a height of 550 feet. The amount of water delivered is calculated to be about 30 gallons per head per day, exclusive of waste. In July, 1925, the District Council obtained the sanction of the Ministry of Health to loans of £ 16,500 for the reconstruction and enlargement of the buildings at the works, for the sinking of a new bore-hole from the surface to the adit and the provision of additional plant, of £3,500 for the erection of the Manager's house and offices, of £6,528 for the extension of mains, and of £900 for land as a site for an additional reservoir. The bore-hole had been completed and the buildings were well in hand at the end of the year, and plans of the new reservoir, of a capacity of 2,000,000 gallons, were submitted by Mr. Vaux Graham. In 1925 the District Council laid 4in. mains in three roads at Langley Bottom, the only populous part of the District for which the public supply had not been available, and connections had been made to nearly all the houses in this neighbourhood by the end of the year. They also laid a new main in Wilmerhatch Lane, and extensions elsewhere in connection with building developments. Bacteriological and chemical examination of the water were made from time to time, with satisfactory results. Rivers and Streams.—No instances of pollution came to the notice of the Council during the year. Drainage and Sewerage.—The whole District is sewered except some roads at Langley Bottom, where the house drainage discharges into cesspools. The sewers are on the combined system over a large part of the District. The main system of treatment at the Sewage Farm is broad irrigation, the underdrainage of the land being passed through contact beds before it is discharged into the stream. In 1923 and 1924, mainly in order to deal with the sewage from the new West Park Mental Hospital, a scheme of disposal by the " Simplex " Surface Aeration Process was carried out, and came into operation at the end of the latter year. Mr. Capon, the Council's Surveyor, who prepared the scheme, informs me that, since some alterations have been made in the aeration tanks to overcome initial difficulties attributable to the exceptional lightness of the sludge, the system has given most satisfactory results. The effluent is passed through the contact beds before final discharge. The whole of the sewage from the Long Grove and West Park Mental Hospitals is treated in these tanks, which were designed to deal with 500,000 gallons daily. 10 The old defective sewer in East Street was relaid from Church Road to Hook Boad, a length of about 1,334 feet, during the year, and new sewers were laid in Wilmerhatch Lane and on the White Horse Estate. The houses are provided with water-closets, and the drains are intercepted from the sewers and ventilated. Frequent examinations of the effluent from the Farm are made by Dr. Dupre. Scavenging.—House refuse is removed weekly by the Council's staff, under the supervision of Mr. Capon, and is consumed in the Meldrum's Destructor at the Sewage Farm. The heat generated is utilised for working the pumping, air-compressing, and other machinery at the Farm. The houses are provided generally with covered movable galvanised-iron ashbins. Sanitary Inspection of the District.—The Sanitary Inspector makes the following report upon the number of inspections of premises, of defects or nuisances discovered, and the action and result of action taken:— Number of inspections of dwelling houses 981 Number of dwelling-houses at which nuisances were discovered 175 Number of cases of overcrowding 16 Number of informal notices served 147 Number of statutory notices served 4 Number of premises at which nuisances were abated or defects remedied 168 Defects remedied:— Water closets provided or repaired 23 Drains provided or repaired 37 Drains unblocked or cleansed 28 New manholes provided 16 Manholes repaired 7 New ventilation pipes provided 13 Ventilation pipes repaired 2 Cesspools cleansed 8 Dampness of houses remedied 62 Houses cleansed and whitewashed 96 Houses generally repaired 95 Eaves, gutters and downspouts repaired 22 Covered ashbins provided 30 Overcrowding abated 5 Paving of yards provided or repaired 22 Inspections of other premises:— Number on Number Defects Notices Premises. register, of visits, discovered, served. Slaughterhouses 2 301 2 2 Places where food is prepared — 93 8 8 Bakehouses 8 16 7 7 Other Workshops 106 15 8 8 Factories 23 3 2 2 Dairies, Cowsheds and Milkshops 16 13 2 2 Schools — 6 — — 11 Under the Rats and Mice (Destruction) Act, 1919, 31 complaints of infestation of premises by rats were received, and 83 inspections were made. Advice and assistance were given, with the result that 458 rats and 40 mice were destroyed. On the estate of the London County Council, 2,725 rats were destroyed. Smoke Abatement. — Eight complaints of smoke nuisances were received, but six of them related to an asphalte mixing plant, which was eventually removed. Bye-laws.— Complaints were received from time to time of nuisance from smells and flies from a large manure pit in connection with some racing stables. Owing to the large quantity of straw in the manure, the occupier experienced difficulty in disposing of it, but eventually complied with the requirements of the Bye-laws for weekly removal. Schools.—There are six Elementary Schools in the District, all of which obtain a water supply from the public mains. In 1925 a new Infants' School was opened off the Dorking Boad, to replace the old, inadequate building at West Hill, which was closed. Notices are sent to the Head Teachers on the notification of cases of infectious diseases in houses in which there are school children. The schools and homes of the patients are visited by the Health Visitor of the County Council on receipt of notifications from the teachers, and I also visited the schools at times of outbreak of infectious disease. (4) Housing. General Housing Conditions.—There is still a marked -shortage of working-class dwellings in the District. On the survey of the District in 1919 it was estimated that 800 houses were required to meet the shortage, and the Council still has a long list of applications, with many instances of a family occupying one room. The figures relating to housing at the Census, 1921, will be found on pages 4 and 5. At the Censns, 1911, there were 2,635 private families, with a population of 11,672, in approximately 2,474 houses; in 1921 there were 3,131 families, with a population of 12,842, in 2,813 houses. The number of persons per house had, therefore, fallen from 4.72 to 4.57, but there was a rise in the number of families per house from 1.07 to 1.14, and 193, or 10 per cent, of the houses containing less than six rooms, were occupied by more than one family, including 13 occupied by three or more families. The District Council erected a batch of 27 houses in 1921, and a second batch of 30 in the following year, under the first Housing Scheme. In 1925 a third batch of 20 and 13 of a fourth batch of 20 were completed, and all arrangements had been made for the building of an additional 51 houses. Four cottages were also in course of erection on land at the Outfall Works for employees of the Council. Under the Housing Act, 1923, the District Council had granted 46 subsidies of £75 each by March 31st, 1926, and advances had been made on 62 houses to the amount of £31,849 up to the same date. 12 Overcrowding.—The Census returns for 1921, quoted on page 5, showed that 75 families, representing 4.1 per cent, of the population in private families, were living under conditions of more than two persons per room, as against 71 families, representing 4.9 per cent, of the population, in 1911 ; the percentage of the populationliving under these conditions in 1921 in the County generally was 4.3. At the Census, 1921, the number of rooms per person, in houses containing not more than 9 rooms, was 1.14 for the District, as against 1.21 for the whole County. Sixteen cases of overcrowding were discovered in 1925; some of them were of a minor character, and five of them were abated by re arrangement of the sleeping accommodation, or the use of one of the living rooms as a bedroom. The worst cases were in four five-roomed houses, occupied respectively by two families, consisting of ten adults and two children ; by three families, in two instances, consisting of eight adults and eight children, and six adults and six children respectively ; and by four families, consisting of seven adults and three children. Fitness of Houses.— More than a half of the number of working-class dwellings are modern, and a considerable proportion of the older cottages are of good construction, but there are certain groups of cottages which require frequent attention. In 1925, out of 248 which were inspected, general want of repair was reported in 99 cases, dampness in 68, want of internal cleansing in 100, defective drainage in 37, and inadequate paving of yards in 22. In a large majority of the cases the defects were remedied without the service of a formal notice, but in some instances only after considerable delay. The owner of two cottages, against which the Council made a Closing Order, carried out works of repair, and the Order was determined. A cottage which had been closed in 1924 was pulled down, and another house was erected on the site. Bye-laws.—Action was taken from time to time to enforce the requirements of the Building Bye-laws. No proceedings under the Bye-laws with respect to tents, vans and sheds were necessary during the year. Housing Statistics for the Year 1925.— Number of new houses erected during the year :— (а) Total 189 (б) With State assistance under the Housing Acts:— (i.) By the Local Authority 83 (ii.) By other bodies or persons 28 I.— Unfit Dwellimj-Houses. Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 248 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910, or the Housing Consolidated Regulations, 1925 113 13 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation ... 3 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 97 II.— Remedy of Pefects without Service of 1'ormtU Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers ... 140 III.—Action under Statutory Powers. A.—-Proceedings under Section 3 of the Housing Act, 1925. (1) Number of dwelling-houses in respect of which notices were served requiring repairs — (2) Number of dwelling-houses which were rendered fit :— (a) by owners . — (J) by Local Authority in default of owners ... — (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close ... ... ... ... ... ... — B.— Proceedings wider Public Health Acts. (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 4 (2) Number of dwelling-houses in which defects were remedied :— (a) by owners 3 (b) by Local Authority in default of owners — C.— Proceedings unJer Sections 11, 14 and 15 of the Housing Act, 1925. (1) Number of representations made with a view to the making of Closing Orders 3 (2) Number of dwelling houses in respect of which Closing Orders were made 3 (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit 2 (4) Number of dwelling-houses in respect of which Demolition Orders were made — (5) Number of dwelling-houses demolished in pursuance of Demolition Orders — (5) Inspection and Supervision of Food. Milk Supply—One cowkeeper gave up business in 1925, and at the end of the year there were 5 cowkeepers and purveyors and 10 retail purveyors of milk on the Register. The premises were periodically inspected, and found to comply generally with the Regulations. A purveyor who was carrying on business under unsuitable conditions removed to other and more satisfactory premises. An unregistered purveyor from a neighbouring District, who was found to be selling milk in this District, made application on his attention being drawn to the requirements of the Milk and Dairies Acts, and was registered. 14 The Veterinary Inspector makes quarterly examinations of the cows, numbering slightly over 100, on registered premises. He found them to be healthy with the exception of one cow, which he suspected to be suffering from tuberculosis ; although two examinations of the milk failed to show the presence of tubercle bacilli, the owner had the animal slaughtered in view of its general condition. Under the Milk (Special Designations) Order, 1923, one licence only was issued to a purveyor to sell certified milk. Eighteen samples were examined for the presence of dirt and other abnormal matter, and ten of these were also examined for tubercle bacilli, in all cases with satisfactory results. Meat.—Copies of the Public Health (Meat) .Regulations, 1924, and explanatory circulars were issued to all butchers, stall-holders and grocers in the District. The Sanitary Inspector gave a large amount of attention to the inspection of meat, paying 301 visits to the two slaughter houses in the course of the year, generally at the time of, or shortly after, slaughter. He reports that 2 bulls, 3 cows, 30 bullocks, 23 heifers, 42 calves, 1,092 sheep, 289 lambs and 773 pigs were slaughtered, and that the majority of the carcases were examined. The whole carcase of a bull, the heads and organs of a cow and heifer, 3 beasts' livers, 5 beasts' lungs, 31 sheep's livers, 79 sets of sheep's lungs, 6 sheep's plucks, 8 pigs' livers, 7 sets of pigs' lungs, and 4 pigs' plucks were found diseased and were destroyed in the refuse destructor. In all, 4801b. of meat and 5741b. of offal were destroyed. Stores, shops, stalls and vehicles were inspected, and cleansing was carried out in four cases and repairs in three cases at the request of the Inspector. At one butcher's shop extensive alterations were carried out and a glass front was provided, and greater care is now generally exercised to keep meat well within the front line of the shops, as a result of the action of the Inspector. The number of slaughter houses at the dates undermentioned were :— In 1920. In January, 1925. In December, 1926. Registered '2 2 2 Licensed — — — In one case a wooden partition which separated the cooling room from some stables was replaced by a brick wall, the interior face of the walls was rendered with cement and sand to a height of 3ft. 6in., and the ventilation of the cooling room was improved. Action was taken to stop the habitual slaughtering of pigs on unlicensed premises, where the carcases were hung in the front room of the dwelling house, and the occupier gave an undertaking that he would discontinue the practice. Other Foods.—A considerable amount of unsound food was surrendered and destroyed in the refuse destructor. In all, 59 tins of potted meat, 17 of fish, 79 of tomatoes, 19 of other fruits, 9 of condensed milk, 5 of chutney 15 and 7 of other foods, 3 boxes of dates, 41b. of raisins, 17 packets of cornflour, 9 of blanc-mange, and a 61b. box of flour were destroyed as unfit for human consumption. The eight bakehouses were inspected and found to be generally satisfactory. In one case the lighting and ventilation were improved, and the roof was made weatherproof; four bakehouses were cleansed and two were repaired at the request of the Sanitary Inspector. The grocers' shops, fish shops and fried-fish shops were all inspected; more satisfactory means of storage were provided at a grocer's shop, where foodstuffs were being stored in an unsuitable stable, and repairs and cleansing were carried out at five grocers' shops ; a fish shop was enlarged, the interior of the walls was tiled and a proper sink was provided, and the sanitary fittings at another fish shop were improved ; at a fried-fish shop the floor of an outbuilding, in which the fish and potatoes were prepared, was relaid in cement concrete, the walls were rendered in cement and sand, and new drainage was provided. On other premises the ventilation of a room, in which foodstuffs are prepared, was greatly improved. Sale of Food and Drugs Acts.—The County Medical Officer of Health informs me that 86 samples of milk and 2 of cream were analysed during the year, and that 2 samples of milk were found to be adulterated. (6) Prevalence of and Control oyer Infectious Diseases. The following Table shows, for each of the past five years, the number of cases of certain diseases notified in the District, including those among the staffs, but excluding those among the patients, at the Mental Hospitals 1921. 1922. 1923. 1921. 1925. Scarlet Fever 65 24 5 8 4 Diphtheria 4 4 11 22 8 Enteric Fever 3 2 1 1 2 Puerperal Fever — 2 — 1 1 Encephalitis Lethargica 1 — — 8 6 Pulmonary Tuberculosis 16 27 13 20 12 Non-pulmonary Tuberculosis 2 4 3 3 5 Ophthalmia Neonatorium 3 1 4 1 3 In the five years, in private houses, 89 cases of Scarlet Fever were notified in 69 houses, 44 cases of Diphtheria in 39 houses, and 5 cases of Enteric Fever in 5 houses; 10 cases of Scarlet Fever and 2 of Diphtheria were notified at the Epsom Infirmary, Epsom College, and smaller Institutions. In the Mental Hospitals there were notified, among the staff and patients, 25 cases of Scarlet Fever, 4 of Diphtheria, 45 of Enteric Fever, 73 of Pneumonia, 65 of Dysentery, and 24 of Erysipelas. The cases of Scarlet Fever in 1921 extended over the whole year, with no particular outbreak at any time, not more than nine cases being notified in any month ; at two periods there was some special incidence on the children attending a department of two of the Schools, but not to any marked extent. The outbreak was of a very mild type. Two instances of return cases occurred in April of that year. 16 Ten of the 22 cases of Diphtheria in 1924 were among the children attending one or other of the departments of one of the Schools, six of them occurring in December ; the other 12 patients were not attending any of the Schools. Bacteriological examinations are carried out at the Lister Institute of Preventive Medicine on behalf of the District Council. During the year 1925, 44 specimens were examined for the presence of the diphtheria bacillus, with 3 positive results, and 1 for the Widal reaction, with negative result. These figures do not include the specimens from patients in the Isolation Hospital. The District Council provide diphtheria antitoxin for use in necessitous cases, and 13 phials of 8,000 units were issued during the year. No applications of the Schick or Dick tests in Diphtheria and Scarlet Fever were made. One case of Small-pox occurred in 1924. The patient, who had come from another District, was found to be suffering from the disease on his admission to the Casual Ward of the Guardians' Institution, and was removed to the County Small-pox Hospital at Clandon. The course of the illnesses in the two cases notified as Enteric Fever in 1922 rendered it improbable that the disease was of that nature. Two of the other private patients had Para-typhoid B. Fever, and the fifth patient, who was already suffering from the disease when he came into the District, died of Typhoid Fever. The remaining four patients included in the figures in the Table were members of the staffs at the Mental Hospital. Three of the cases of Encephalitis Lethargica notified in 1924 and 1925 had been admitted to the Infirmary from other Districts, and a fourth patient already had symptoms of the disease when he came on a visit to the District. The disease was found, on post mortem examination, to have been the cause of death of a woman in the Infirmary in December, 1925. The sex, age and time of onset of illness in the cases belonging to Epsom are shown below :— Sex. Age. Month of onset. Result. F 4 April, 1924 Suffers from sequelœ F 21 April, 1924 Suffers from sequelœ M 17 May, 1924 Suffers from sequelœ (severe) F 10 May, 1924 Suffers from sequelœ (severe) F 73 May, 1924 Died June, 1924 F 30 October, 1921 Suffers from sequelœ F 44 January, 1925 Apparently complete recovery F 52 May, 1925 .. Died June, 1925 M 63 September, 1925 Apparently complete recovery F 26 October, 1925 .. Apparently complete recovery All the invaded houses were in the northern half of the District. Eight of the patients were admitted to the Infirmary, and one to a London Hospital. An inquiry into the earlier cases was made by Dr. A. S. MacNalty, a Medical Inspector of the Ministry of Health. Under the Public Health (Pneumonia, etc.) Regulations, 1919, 58 cases of Pneumonia were notified, and 46 of these were in, or were subsequently admitted to, the Infirmary; during the period, 8 deaths from Lobar 17 Pneumonia, 9 from Influenzal Pneumonia, 21 from Broncho-pneumonia, and 11 from unspecified Pneumonia were registered in the District; the cases in the Mental Hospitals are excluded from these figures. No cases of Malaria, nor of Dysentery, other than at the Mental Hospitals, were notified. The deaths from Influenza in the five years numbered 1 in 1921, 9 in 1922, 2 in 1923, 3 in 1921 and 2 in 1925, or 17 in all, representing an annual death-rate of 0-23 per 1,000 of the population, as against a rato of 0-37 for England and Wales ; 8 were males and 9 were females. Among males there was no special incidence at any age; among females, 1 was nnder 1 year of age, 3 were between the ages of 55 and 65 years, and 5 were over 65 years of age. Measles was prevalent in 1922 and 1924, and Whooping Cough in 1922, 1923 and 1925. The outbreaks were for the most part mild in character; there were 4 deaths from Whooping Cough in 1925, but otherwise only 1 death from Whooping Cough in 1921, and 1 from Measles in 1924, all the deaths occurring among infants under one year of age with the exception of a death from Whooping Cough in the case of a patient aged 65 years, who was suffering from heart disease.. Notifiable Diseases during the Year 1925.—The following Table shows the cases notified in Epsom, the Union Hospital, and the Mental Hospitals, and the number of cases treated in hospital, and the number of deaths among the patients in the first two classes : — Disease. Total. Cases Mental Hospitals Notified. Epsom. Union Hospital Cases Treat in Hospital. Deaths. Scarlet Fever 4 1 3 — 3 - Diphtheria 8 1 7 — 7 - Enteric Fever 7 6 — 1 1 - Puerperal Fever 1 — — ] 1 - Pneumonia 38 21 1 16 ie 4 Erysipelas 8 2 2 4 4 - Encephalitis Lethargica 6 — 1 5 5 2 Cerebro-spinal Fever 1 — — 1 1 1 Dysentery 19 19 — - Ophthalmia Neonatorum 3 — 2 1 2 - Total cases in variousage groups:- - Under 1-yr. 1 2 3 4 5 10 15 20 35 45 65 Diphtheria — — — — — 2 — — 2 — — — Scarlet Fever — — — 1 — 4 1 — 2 — — — Encephalitis - - - - - - - - 1 1 4 — 18 Tuberculosis. New cases and mortality during 1925. Age Periods. New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M F M F M F M F 0 - - - - - - - - 1 - - - - - - - 1 5 — — - - - - - - 10 - - - - - - - - 15 1 — — 1 - - - — 20 - 1 - 1 - 1 - - 25 2 2 — 1 - - - - 35 1 - 1 — 1 2 - - 45 2 — - - 2 - - - 55 1 1 — — 1 — — 1 65 & above 1 — 1 — 1 — 2 — 8 4 2 3 5 3 2 2 The 8 deaths from Pulmonary Tuberculosis represent an annual deathrate of 0-51 per 1,000 of the estimated nett population, as against an average rate of 0'63 for the ten years 1916—1925. There were 2 deaths from Tuberculous Meningitis and 2 from Tuberculous Peritonitis. The following Table shows the mean population, the number of cases notified, and the number of deaths from certain infectious diseases in each quinquennium during the 50 years from 1876 to 1925 :— Period. Mean Population. Cases. Deaths. Scarlet Fever. Diphtheria. Enteric Fever. Scarlet Fever. Diphtheria. Enteric Fever. Measles. Whooping Cough. Pulmonary Tuberculosis. 1876— 6680 15 28 38 6 4 5 3 7 71 1881— 7230 245 5 7 30 3 1 4 5 60 1886— 7970 80 15 4 3 3 - 13 14 71 1891— 8770 148 48 14 - 19 1 6 5 62 1896— 9600 126 18 17 2 3 3 5 7 52 1301— 10900 115 12 19 2 2 5 15 16 42 1906— 12550 123 58 3 1 7 — 9 7 49 1911— 13800 119 78 9 1 4 3 7 4 53 1916— 13000 98 63 2 2 5 1 5 a 53 1925— 15000 106 49 9 — 2 2 1 5 47 The number of patients in the Mental Hospitals and the cases and deaths among them are excluded from these figures. Notification of infectious disease was voluntary until 1889, and the figures representing the number of cases up to that year are, therefore, incomplete. 19 (7) Maternity and Child Welfare. In the five years only 4 cases of Puerperal Fever were notified, and one of these, which ended fatally, was admitted to the Union Hospital from Banstead. There was 1 death among Epsom patients, in 1924. Twelve cases of Ophthalmia were notified, 2 of which were treated in the Union Hospital and 2 were removed to the St. Margaret's Hospital; in one case there was slight cloudiness of the cornia, but this appeared to have cleared up subsequently, and all the others made good recovery. There were 4 deaths from Whooping Cough, 1 death from Measles, and 6 deaths from Epidemic Diarrhoea, 3 of which occurred in 1921, among children, all under one year of age. Three of the deaths from Whooping Cough occurred in 1925. No case of Poliomvelitis in young children was notified. Ophthalmia Neonatorum, 1925. Cases Notified. Treated at Home. Treated in Hospital. Vision Unimpaired. 3 1 2 3 The work of Maternity and Child Welfare in this District is carried out under the Scheme of the Surrey County Council. Epsom, J.WILLIAMSON, May, 1926. Medilical Officer of Health. Leaterhead Urban District. ANNUAL REPORT OF THE Medical Officer of Health, J. WILLIAMSON, M.D., D.P.H., For the Year 1925. Leatherhead Urban District. Annual Report of the Medical Officer of Health for the Year 1 925. (1) Natural and Social Conditions of the District. Area and Population.—The area of the District is 3,508 acres. The population of the District at each'Census, 1891 to 1921, was as follows:— Census. Total. Males. Females. 1891 4,305 2,140 2,165 1901 4,694 2,394 2,300 1911 5,491 2,725 2,766 1921 5,817 2,761 3,056 It was estimated by the Registrar-General at 6,013 persons for the year 1925. Physical Features.—The south-eastern part of the District, including the greater part of the town, is situated on the chalk on the northern slopes of the Downs; the northern and western parts, including The Common, are on the London Clay; an intermediate part, about one-fifth of a mile in width, is on the Thanet Sand and the Woolwich and Reading beds of the Lower London Tertiaries. The slope of the ground is mainly from the 400-ft. contour line on the southeastern boundary to the river Mole to the west, on the 100-ft. contour line; the town is for the most part below the 200-ft. contour line. The Common and Kingston Road district are about 130-ft. above sea-level, and to the north of this the ground again rises to a height of about 200-ft. Inhabited Houses and Families.—At the Census, 1921, there were 1,161 inhabited houses—of which three contained two dwellings each—occupied by 1,271 private families, 93 of the houses containing two familes, and seven containing three families. There were in addition seven other occupied dwellings. Of the 1,164 occupied private dwellings 90 or 8 per cent, contained 1—3 rooms. 668 or 59 ,, ,, 4—5 ,, 285 or 24 ,, ,, 6—8 ,, and 101 or 9 ,, ,, 9 or more rooms, 4 The total number of occupied rooms in these houses was 6,466, and the population was 5,160, or 1.25 rooms per person. At the Royal School for the Blind there were 185 inmates and 53 members of the staff, etc., and 355 persons were enumerated in three other institutions, including- the St. John's School. The following Table shows the number and percentage of families occupying from 1 to 5 rooms, and over 5 rooms, with the respective populations and the percentage of the whole population in private families, and the corresponding percentages of families and population in 1911. Number of Rooms. Number of Families Percentage of Families. Population, 1921. Percentage of Population. 1921 1911 1921 1911 1 34 2.7 2.6 47 0.9 0.7 2 96 7.6 3.5 207 4.0 1.6 3 109 8.6 7.0 387 7.5 5.9 4 359 28.2 28.1 1455 28.2 26.6 5 334 26.3 28.6 1428 27.7 31.6 Over 5 339 26.6 30.2 1636 31.7 33 .6 Exclusive of families recorded as consisting of one person only, 172 families, with an average of 3.3 persons per family, occupied tenements of less than four rooms, and 342 families, with an average of 4.2 persons per family, occupied four-roomed tenements in 1921. The average size of families in the District was 4.06 as against 4.16 in 1911. In 1921, 3 one-roomed tenements, 4 two-roomed tenements, 7 threeroomed tenements, 13 four-roomed tenements and 3 five-roomed tenements, or 30 in all, were occupied under conditions of more than two persons- per room; the population of these tenements was 271, being 5.3 per cent, of the population in private families. In 1911 there were 14 such tenements, with 121 occupants, being 2.5 per cent, of the population. Rateable Value.—The rateable value of the District in March, 1926, was £52,013, and the sum represented by a penny rate was £174. Social Conditions.—The District is chiefly residential and agricultural, and there are no special industries. At the Ctensus, 1921, the number of persons recorded as eng-ae'ed in occupations were 1.700 males and 831 females. Ihe chief numbers enumerated under various occupations were as follows:— 5 Occupation. Males Females. Agricultural occupations 250 3 Metal workers 112 1 Workers in wood, etc 87 5 Builders, bricklayers, etc 121 — Painters and decorators 56 — Transport workers 235 7 Commercial and financial occupations 197 73 Professional occupations 89 81 Persons employed in personal service 64 528 Clerks, draughtsmen, typists, etc 84 55 Included in the first class were 130 male gardeners and 80 male agricultural labourers; and, among those engaged in personal service, 421 female domestic servants. Vital Statistics.—The births registered in the District during the year numbered 86. The nett births belonging to the District were 94, giving a birth-rate of 15.6 per thousand of the estimated population. The rate for England and Wales for 1925 was 18.3. The deaths registered in the District during the year numbered 52, of which 11 occurred in the Cottage Hospital; 4 of the deaths were transferred to other districts, and 21 persons belonging to Leatherhead died elsewhere, giving 69 nett deaths, and a death-rate of 11.5 per 1,000 of the estimated population. A correction for the age and sexdistribution of the population of the District would give a rate of 10.8 for comparison with that of other districts. The rate for England and Wales for 1925 was 12.2. There were 5 deaths among infants under one year of age, giving a mortality rate of 53 per 1,000 births. The rate for England and Wales for 1925 was 75. As in the preceding year, there were no deaths among children between the ages of one and five years. The following- Table shows for the District the average annual birth-rate, death-rate, infant mortality rate, and number of deaths of children between the ages of one and five years for each of the last ten quinquennial periods, and for the year 1925 :— Birth rate. Death rate. Infant Mort'y. Average Deaths 1-5 years 1876—1880 30.7 15.5 130 6 1881— 85 321 16.2 82 8 1686— 90 26.9 15.0 125 7 1891— 95 23.6 11.8 115 6 1896—1900 21.8 11.5 141 5 1901— 05 23.4 12.5 91 5 1906— 10 20.7 11.5 70 3 1911— 15 18.0 8.9 67 2 1916— 20 16.0 9.6 45 3 1921— 25 17.4 10.1 44 1 1925 15.6 11.5 63 - 6 The number of deaths from various causes in the two periods 1916 to 1920, and 1921 to 1925, are shown in the following Table :— Cause of Death 1916 Male. 1920. Female. 1921- Male. -1925, Female. Enteric Fever 1 — 1 1 Small-pox — — — — Measles 6 — 1 — Scarlet Fever — — — — Whooping Cough 1 1 2 — Diphtheria 3 2 2 — Influenza 5 6 1 5 Encephalitis Lethargica — — 1 — Meningococcal Meningitis — — — — Respiratory Tuberculosis 7 7 12 13 Otheir Tuberculosis Diseases 1 1 1 — Cancer 13 13 23 23 Rheumatic Fever 1 — — — Diabetes 2 1 1 3 Cerebral Haemorrhage, etc. 14 8 7 12 Heart Disease 16 10 16 17 Arteriosclerosis 5 2 10 7 Bronchitis 6 7 15 16 Pneumonia (all forms) 11 8 10 10 Other Respiratory Diseases 2 1 1 — Ulcer of Stomach or Duodenum — — 2 1 Diarrhcea, etc. (under 2 years) 1 — 1 2 Appendicitis and Typhlitis 1 1 — — Cirrhosis of Liver 3 1 — — Nephritis 6 1 7 5 Puerperal Sepsis — — — — Other Accidents, etc., of Pregnancy — 2 — 1 Congenital Debility, etc 7 3 3 6 Suicide 3 — 3 2 Other Violenco 5 1 3 1 Other Defined Diseases 33 23 22 26 Causes Ill-defined — — 1 — All causes 153 99 146 151 Poor Law Relief.—The amount expended in the District in outdoor relief in 1925 was £616 5s. lid. (2) General Provision of Health Services in the Area. Hospitals Provided or Subsidised by the Local Authority or by the County Council.—Hospitals for Tuberculosis and Smallpox are available under the schemes of the Surrey County Council. The Isolation Hospital for the District is the Guddington Joint Isolation Hospital in the Epsom Rural Distiict. General medical and surgical cases are admitted to the Leatherhead Cottage Hospital, Epsom Road, Leatherhead. Ambulance Facilities.—A motor ambulance for the removal of cases of infectious disease is provided by the Joint Hospital Board. 7 There is no ambulance in the District for general cases, but there is a local branch of the Red Cross Society, and the motor ambulance at Dorking belonging to the Society is available. Clinics and Treatment Centres. Accommo - By whom Centre. Situation. dation. provided. (Surrey County Leatherhead Welfare Centre The Institute, High St. Two Rooms Council School Clinic ,, ,, ,, „ ,, Public Health Officers.—Medical Officer of Health, J. Williamson, M.D., ID.P.H.; whole time, combined district; salary contribution made. Sanitary Inspector, S. R. Drake, A.R.San.I., M.I.M., & Cy.E. ; also Surveyor for all purposes ; whole time to District Council; salary contribution made. Veterinary Inspector, N. S. King, M.R.C.V.S.,; part time; no salary contribution. Professional Nursing in the Home.—A nurse for general nursing is provided by the Leatherhead Nursing Association. There are no special arrangements for the nursing of cases of infectious disease. Midwives.-—There is no midwife employed or subsidised by the Council. Four midwives practise in the District. Adoptive Acts, Bye-laws and Regulations..—The following Adoptive Acts, etc., relating to the public health are in force in the District:— Adoptive Acts, etc. Date of Adoption. Infectious Disease (Prevention) Act, 1890 March 25th, 1895. Public Health Acts Amendment Act, 1890 April 10th, 1895. Bye-laws with respect to Nuisances March 17th, 1896. ,, ,, ,, Slaughter-houses March 17th, 1896. ,, ,, ,, New Streets and Buildings June 15th, 1909. ,, ,, ,, Tents, Vans, Sheds, etc. February 24th, 1914. Regulations ,, Dairies, Cowsheds and Milkshops July 1st, 1899. (3) Sanitary Circumstances of the Area. Water.—The District is supplied by the Leatherhead Water Company with water obtained from borings in the chalk, between 250 and 300 feet in depth, through which it rises into a well, properly protected and lined throughout its depth of about 20 feet with an iron casing. The water is not softened. The supply is constant. Periodical analyses are made on behalf of the Water Company, and the reports have always shown the water to be free from contamination. A very few out-lying houses obtain a water supply from private wells. 8 Rivers and Streams.—Complaints have been received over a considerable time from the Thames Conservancy of the discharge of unsatisfactory effluents from the Council's Outfall Works into the River Mole, and the Council has been under notice to carry out works which would remedy the condition. Schemes for remodelling the Works were considered in 1923 and 1924, and in the latter year an Inquiry was held by the Ministry of Health into an application of the District Council for sanction to a loan for the purpose of carrying out a scheme on the activated sludge principle, prepared by Mr. Salkield. The application was opposed by the Epsom Rural District Council on the ground that treatment by sprinklers would be more efficient and less costly, and the Ministry informed the Council that they were not prepared to sanction the loan. Other schemes were prepared, and the Council eventually adopted that of Mr. Fairley, and steps were being taken at the end of 1925 to put it into operation. The discharge of liquid refuse from the Gas Works into one of the surface water sewers engaged the attention of the DistrictCouncil from time to time, and eventually they applied to the Ministry of Health for permission to take action under the Rivers Pollution (Prevention) Act, 1876. An Inquiry into the application was held by an Inspector of the Ministry, who subsequently wrote to the Council expressing the hope that it would not be found necessary to take further action. Drainage and Sewerage.—Sewers are available throughout the District, except for a few outlying houses. The sewers are on the separate system. The sewage is treated, together with that of Ashtead, at the Outfall Works at Pachesbam, by sedimentation followed by treatment in "double contact" beds, the effluent from which is passed over the land. During the year the District Council extended sewers for the reception of the drainage of newly developed areas. The house drains are intercepted from the sewers, and ventilated. Scavenging.—House refuse is collected weekly by the Council's staff, under the supervision of the Surveyor, and is taken to the Council's Depot in Bamett Wood Lane, where it is picked over, and the paper and other easily combustible constituents are burned in a brick chamber which has been erected for the purpose. Movable covered ashbins are general throughout the District. Work of Sanitary Inspector.—The Sanitary Inspector makes the following report :— Number of inspections of dwelling-houses 348 ,, houses at which nuisances or other defects were discovered 107 9 Number of other premises on which nuisances were discovered — ,, informal notices served 54 ,, statutory 4 ,, nuisances abated 210 Inspections of Other Premises:— Premises. No. on register. No. of visits. Premises where food is prepared — — Slaughter-houses 3 14 Common lodging houses 1 4 Bakehouses 7 11 Other workshops 34 28 Dairies, cowsheds and milkshops 10 20 The slaughter-houses and common lodging house were found to be kept in a satisfactory condition. Several complaints were received of nuisance from the storage of bones and from flies on premises used by a rag and bone merchant, and the nuisance was abated on action being taken by the Council. Schools.—The three elementary schools have a water supply from the public mains, and are provided with water-closets draining to the sewers. Two of the schools are of modern construction, and the third was entirely re-modelled in 1911. Notices are sent to the Head Teachers when a case of infectious disease is notified in a house in which there are children attending the school, and another notice is sent of the discharge of a: school child from hospital. The schools and homes of the patients are visited by the Health Visitor of the County Council, on receipt of notifications of nonnotifiable disease from the teachers, and I also visited the schools at times of outbreaks of infectious disease, and advised as to precautions. (4) Housing. General Housing Conditions.—The figures relating to housing at the Census, 1921, will be found on pages 3 and 4. At the Census,1911, there were 1,152 private families, with a population of 4,795, in approximately 1,090 houses ; in 1921 there were 1,271 families, with a population of 5,160, in 1,164 houses. The number of families per house was 1.09, as against 1.05 in 1911. At the end of 1923 a special inquiry was made as to the number of families and of inmates in the cottages throughout the District, and particulars were obtained at 656 houses. It was found that 71 houses, or 10.7 per cent., were occupied by two or more families, but in a majority of these cases the total number of inmates was small.- 10 The following Table shows the number of houses which contained varying numbers of inmates; the last column gives corresponding figures tor houses occupied by more than one family. No. of inmates. No. of houses. Percentage of houses Two or more families. 1 to 4 379 57.8 11 5 or 6 147 22.4 28 7 or 8 96 14.6 28 9 or 10 22 3.4 7 11 or more 12 1.8 3 656 100.7 71 Under their housing scheme, which was carried out in 1921 and 1922, the District Council erected 59 houses in Poplar Road. Many applications for houses have since been received, and at the end of 1925 the Council were enquiring- as to the purchase of a suitable site for additional cottages. During the five years, 153 houses in all were erected, viz., 38 in 1921, 35 in 1922, 16 in 1923, 25 in 1924, and 39 in 1925. The District Council advanced loans under the Small Dwellings Acquisition Act to the amount of £17,100 in 1925. Overcrowding.—The Census Returns for 1921 showed that 30 families, representing 5.3 per cent, of the population in private families, were then living under conditions of more than two persons per room, as against 14 families, representing 2.5 per cent. of the population, in 1911; the percentage of the population living under these conditions in 1921 in the County generally was 4.3. In 1921, among 778 dwellings containing less than six rooms, 44 were recorded as occupied by two families, and 3 as occupied by three families; 5.7 per cent. of such dwellings were, therefore, found to be occupied by more than one family. The number of rooms per person, in houses containing not more than nine rooms, was 1.18 at the Census, 1921, as against 1.20 in 1911; the corresponding figure for the County in 1921 was 1.21. The number of persons per house for the whole District in 1921 was 4.43, as against 4.40 in 1911. The figures obtained at the inquiry in 1923 showed that the average number of persons per house, in the cottages which were visited, was 4.56; it was found that there was overcrowding in 16 of the houses, or 2.4 per cent. The chief cases of overcrowding which came to notice in 1925 were the occupation of a five-roomed cottage by four adults and ten children, and of two three-roomed cottages by three adults and six children, and three adults and five children. One case of overcrowding was abated by the allocation of one of the Council's houses, but it was not possible to deal with the other cases owing to inability to find alternative accommodation. 11 Fitness of Houses.—The majority of the cottages are of fair standard, but a considerable number of the older cottages require frequent inspection, and certain groups of them, mainly old wooden cottages, are in such a structural condition that they cannot be made fit at a reasonable expenditure. All the cottages of the worse type have been inspected recently, and works of repair and cleansing have been carried out. The Council served notice under the Housing Act with respect to four cottages which had frequently come to their attention on account of recurrence of nuisance due to the failure of the owner to carry out the work of repair in an adequate manner, and the defects were then satisfactorily remedied. Housing Statistics eor the Year 1925. Number of new houses erected during the year:— (a) Total 39 (b) With State assistance under the Housing Acts:— (i.) By the Local Authority — (ii.) By other bodies or persons — I.—Unfit dwelling houses. Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 133 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910, or the Housing Consolidated Regulations, 1925 133 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation — (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation ... 107 II.—Remedy of defects without Service of formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers 107 III.—Action under Statutory Powers. A.—Proceedings under Section 3 of the Housing Act, 1925. (1) Number of dweling-houses in respect of which notices were served requiring repairs — (2) Number of dwelling-houses which were rendered fit:— (a) by owners — (b) by Local Authority in default of owners — (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close — 12 B.—Proceedings under Public Health Acts. (1) Number of dwelling-houses in respcct of which notices were served requiring- defects to be remedied — (2) Number of dwelling-houses in which defects were remedied:— (a) by owners — (b) by Local Authority in default of owners — C.—Proceedings under Sections 11, 14 and 15 of the Housing Act, 19 25. (1) Number of representations made with a view to the making of Closing Orders — (2) Number of dwelling-houses in respect of which Closing Orders were made — (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit — (4) Number of dwelling-houses in respect of which Demolition Orders were made — (5) Number of dwelling-houses demolished in pursuance of Demolition Orders — (5) Inspection and Supervision of Food. Milk Supply.—There are ten registered purveyors of milk, of whom five are cowkeepers, in the District. The premises were inspected and found to be kept in compliance with the regulations. The Veterinary Inspector makes quarterly examinations of the cows, numbering about 150, belonging to the registered cowkeepers. No case of tuberculosis was discovered during the year, but a few cases of simple mammitis were reported; the milk of these cows was kept from use for human consumption. One licence for the sale of certified milk was issued. Meat.—Notices of the requirements of the Public Health (Meat) Regulations, 1924, were sent to each butcher, and the slaughter-houses and shops were inspected. Regular notices of times of slaughter were received by the Sanitary Inspector, who paid occasional visits and examined the carcases. On one occasion the carcase of a bull was found to be extensively affected by tuberculosis, and was condemned. The number of slaughter-houses in the District at the undermentioned dates was:— In In Jan., In Dec., 1920. 1925. 1925. Registered — — — Licensed 4 3 3 4 3 3 13 Other Foods.—The seven bakehouses were inspected and found to be in a satisfactory condition, and -well kept. One box of fish was seized as unfit for human food. Sale of Food and Drugs Acts.—The County Medical Officer of Health informs me that 13 samples of milk, six of cream and five of butter were analysed under these Acts, and that the sample of butter was found to be adulterated. (6) Prevalence of and Control over Infectious Diseases. The following Table shows, for each of the past five years, the number of cases of certain infectious diseases notified in the District:— 1921 1922 1923 1924 1925 Scarlet Fever 10 13 5 2 7 Diphtheria 1 3 1 — 3 Enteric Fever — 1 — 2 1 Pulmonary Tuberculosis 6 7 9 5 8 Non-pulmonary Tuberculosis 1 1 — 3 3 In this period in private houses, 34 cases of Scarlet Fever were notified in 27 houses, six cases of Diphtheria in four houses, and three cases of Enteric Fever in three houses; three cases of Scarlet Fever and one case of Diphtheria were notified at St. John's School, and one case of Diphtheria and one of Enteric Fever at the Royal School for the Blind. In 1921 the return of patients from the Isolation Hospital was followed by the occurrence of another case of Scarlet Fever within a fortnight in two instances, and in 1922 two children failed with the disease a week after the return of their sister, and another child in the house failed subsequently. On the occurrence of two cases of Diphtheria in April, 1922, the nasal discharge of another child in the house, who had recently returned from a hospital in London after an operation, was found to contain the Diphtheria bacillus; further examinations continued to give positive results until July, when an animal test showed the bacillus to be still virulent; the child was then removed to the Isolation Hospital, where he was retained until the beginning of October before he could be pronounced to be free from infection. Bacteriological examinations are made at the Lister Institute at the expense of the District Council. During the year 1925, 33 examinations were made for the Diphtheria bacillus, with three positive results; two for the Tubercle bacillus, with one positive result; and two for the Widal reaction, both negative. The District Council arranged with a chemist in the town to stock phials of 8,000 units of Diphtheria antitoxin for use in necessitous cases, but none was issued during the year. No applications of the Schick or Dick tests in Diphtheria and Scarlet Fever were made. 14 The infection in two of the four cases of Enteric Fever was certainly, and in a third case was probably, contracted in other districts ; the course in hospital of the fourth case, which was notified in 1925, rendered it probable that the disease was not Enteric Fever. Under the Public Health (Pneumonia, etc.) Regulations, 1925, only three case of pneumonia were notified in the five years, although four deaths from Lobar Pneumonia, two from Influenzal Pneumonia, eight from Broncho-pneumonia, and five from unspecified Pneumonia were registered in the District. No cases of Malaria were notified. The deaths from Influenza in the five years numbered five, representing an average annual death-rate of 0.17 per 1,000 of the population, as against an average rate of 0.37 for England and Wales for the same period. The Isolation Hospital for the District is the Cuddington Joint Isolation Hospital. In the five years, 35 of the 37 cases of Scarlet Fever, five of the eight cases of Diphtheria, and two of the four cases of Enteric Fever were Removed. After the removal, recovery or death of each patient, the rooms were disinfected, and bedding and other articles were removed to the Isolation Hospital and stoved in the Washington Lyons disinfector. Measles and Whooping Cough were very prevalent in 1923, and there was a localised outbreak of the latter disease in 1925. There were two deaths from Whooping Cough and one death from Measles in the five years. The homes of the children who are reported by the School Teachers to be suffering from these diseases are visited by the School Nurses of the County Council, and I visited the schools at times of outbreak and advised as to precautions to be taken. There are no facilities in the District for the cleansing of verminous persons or their belongings. Notifiable Diseases During the Year:— Disease. Total Cases notified. Cases admitted to Hospital. Total Deaths. Scarlet Fever 7 7 — Diphtheria 3 2 — Enteric Fever 1 1 — Erysipelas 2 — 1 Pneumonia 1 — 6 Encephalitis Lethargica — 1 1 The patient who died from Encephalitis was found to be suffering from that disease on admission to the Epsom Union Hospital. Total cases at various ages :— 3 4 5 10 15 20 35 45 Scarlet Fever1 — 4 2— — — — Diphtiheria — — 1 — — 2 — — Enterio Ferer — — — — — — 1 15 Tuberculosis. New cases and mortality in 1925:— Age Periods. New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M F M F M F M F 0 — — — — — — — — 1 — — — — — — — — 5 — — — — — — — — 10 — — 1 1 — — — — 15 — — — — — — — — 20 2 — — — 2 — — — 25 — 4 — — — 1 — — 35 1 1 — — — — — — 45 — — — — — — — — 55 — — — — — — — — 65 above — — — — — — — — 3 5 1 1 2 1 — — The three deaths from Pulmonary Tuberculosis represent an annual death-rate of 0.50 per 1,000 of the population, as against an average rate of 0.66 for the ten years, 1916 to 1925. The following Table shows the mean population, the number of cases notified, and the number of deaths from certain infectious diseases in each quinquennium during the period from 1876 to 1925:— Period. Mean Population. Cases. Deaths. Scarlet Fever. Diphtheria. Enteric Fever. Scarlet Fever. Diphtheria. Enteric Fever. Measles. Whooping Cough. Pulmonary Tuberculosis. 1876— 3210 — — — 4 6 2 5 7 19 1881— 3710 62 12 18 3 3 4 6 5 21 1886— 4110 36 7 5 2 — 1 5 10 31 1891— 4400 44 30 5 — 3 1 6 10 20 1896— 4600 144 32 16 3 5 1 3 9 30 1901— 4880 126 11 11 2 2 1 2 9 25 1906— 5270 86 56 3 3 9 — 4 1 16 1911— 5510 67 16 4 — — 2 6 3 13 1916— 5230 42 82 5 — 5 1 6 2 14 1921— 6880 37 8 4 — 2 2 1 2 25 Notification of infectious disease was voluntary until 1889, and the figures representing the number of cases up to that year are, therefore, incomplete. 16 (7) Maternity and Child Welfare. Maternity and Child Welfare work in the District is administered by the Surrey County Council. During the five years, no case of Puerperal Fever was notified, and there was no death from that disease. There were two deaths from Whooping Cough, in 1923 and 1925, and three from Diarrhcea, viz., one in 1923 and two in 1924, all among infants under one year of age, but there was no death from Measles among young children, and no case of Ophthalmia Neonatorum. J. WILLIAMSON, Medical Officer of Health. Epsom, May, 1926 Epsom Rural District. ANNUAL REPORT OF THE Medical Officer of Health, J. WILLIAMSON, M.D„ D.P.H., For the Year 1925. EPSOM RURAL DISTRICT. Annual Report of the Medical Officer of Health for the Year 1925. I.—NATURAL AND SOCIAL CONDITIONS OF THE DISTRICT. Area, Population, etc.—The area of the District is 32,580 acres. The population at the Census, 1921. was 34,118 persons, of whom 15,355 were males and 18,763 were females; it was estimated by the Registrar-General at 37,030 persons for the year 1925. The population at each Census, 1891 to 1921, exclusive of the special inmates of the Banstead Mental Hospital, was as follows:— Census. Persons. Males. Females. 1891 16,006 7,662 8,344 1901 19,995 9,590 10,405 1911 27,267 12,613 11,654 1921 31,768 14,356 17,412 The following Table shows, for each Parish, the total populations in 1911 and 1921, and the population in private families and the number of structurally separate private dwellings occupied at the Census, 1921:— Palish. Area in Acres. Total Population. Private Families, 1921. 1911. 1921. Population. Dwellings. Ashtead 2651 2921 3226 3143 680 Banstead 5557 6731 7337 4237 918 Cheam 1909 6200 7849 7461 1684 Chessington 1702 583 630 630 146 Cobham 5332 4763 5103 4822 1092 Cuddington 1860 1194 1402 1310 311 Ewell 2437 3867 4187 3330 791 Feteham 1839 409 410 408 97 Great Bookham 3294 1515 1566 1531 355 Headley 1640 419 521 449 96 Little Bookham 929 404 372 360 76 Stoke d'Abernon 2038 722 848 827 193 Woodmansterne 1392 517 667 591 136 District 32580 30245 34118 29099 6605 In 1921 there were 2350 special inmates and 218 officials at the Banstead Mental Hospital, and 678 inmates and 64 officials at the Kensington, Chelsea and St. Marylebone Guardians' Schools, in. the Parish of Ewell. 4 The Tables in the Census Returns showing the age-distribution of the population of the District are complicated by the inclusion of the inmates of the Banstead Mental Hospital, and no useful purpose can, therefore, be served in reproducing them; the following figures give the number of persons below the age of 20 years at each Census:— Under 5 years. 5—9 10—14 15—19 Males— 1901 1075 1168 1255 813 1911 1308 1487 1509 967 1921 1135 1541 1688 1237 Females— 1901 993 1101 1093 937 1911 1236 1319 1334 1295 1921 1151 1424 1586 1529 Persons— 1901 2068 2269 2348 1750 1911 2544 2806 2843 2262 1921 2286 2965 3274 2766 It will be noted that, in a population which increased by 4,600 persons between 1911 and 1921, the number of children under 10 years of age showed a decrease. Physical Features.—The southern part of the District lies on the North Downs, and the northern part in the Thames Valley, the slope being generally from south-east to north-west. Woodmansterne, Banstead, Burgh Heath, Tadworth, Belmont and the neighbouring residential part of the Parish of Cheam, Headley and Banmore are situated on the Downs, which rise to a height of 700 feet above sea-level at the southern part of the Parish of Banstead, 628 feet at Headley Heath, and 620 feet at Ranmore. Tadworth is about 580 feet above sea-level, Burgh Heath 560 feet, Banstead 520 feet, the village of Woodmansterne just below the 500ft. contour line, and the village of Headley between 600 and 600 feet. Belmont lies about the 300ft. line. From north east to south-west the villages of Cheam (150 to 200 feet), Ewell (100 to 140 feet), Ashtead (200 to 240 feet), Fetcham (120 to 200 feet), Great Bookham (200 to 250 feet) and Little Bookham (150 to 220 feet) lie across the foot of the chalk and the Lower Loudon Tertiaries. To the north, Worcester Park and Cheam Common (70 to 140 feet), West Ewell (110 feet), Chessington (140 to 200 feet), Stoke d'Abernon (100 feet), Cobham (65 to 75 feet) and Downside (110 feet), and Ashtead, Fetcham and Bookham Commons, are on the London Clay. The ground again rises to the north of the Parishes of Stoke d'Abernon and-Cobham, at Oxshott and Fairmile (130 to 200 feet), on the Lower Bagshot Sand. The natural drainage is to the Beverley Brook, the Hogg's Mill river, and the river Mole and its tributaries. 5 Dwellings.—At the Census, 1921, there were 6,605 inhabited dwellings, occupied by 6,994 private families; there were in addition 47 other occupied dwellings. Of the 6,605 occupied dwellings 544, or 8 per cent., contained 1—3 rooms 3,387, or 54 „ ,, 4—5 ,, 1,657, or 25 ,, „ 6—8 ,, and 817, or 13 ,, „ 9 or more rooms. Six of the dwellings which contained 1—3 rooms, 224 of those containing 4—5 rooms, 111 of those containing 6—8 rooms, and 25 of the remainder were occupied by more than one family; in 23 of the houses there were three families. The following Table shows the number and percentage of families occupying from 1 to 5 rooms, and over 5 rooms, with the respective populations and the percentage of the whole population in private families, and the corresponding percentages of families and population in 1911:— Number of Rooms. Number of Families Percentage of Families. Population, 1921. Percentage of Population. 1921 1911 1921 1911 1 151 2.2 1.6 284 1.0 0.4 2 382 5.5 3.7 947 3.3 1.9 3 567 8.1 6.8 1921 6.6 5.5 4 1624 23.2 23.4 6437 22.1 21.4 5 1906 27.1 28.5 8276 28.4 29.0 Over 5 2364 33.9 36.0 11234 38.6 41.8 About 900 families of 2 or more persons, with an average of 3.3 persons per family, occupied tenements of less than 4 rooms, and 1,566 families, with an average of 4.1 persons per family, occupied four-roomed tenements. The average size of families in the District was 4.16, as against 4.38 in 1911. In 1921, 39 one-roomed tenements, 34 two-roomed tenements, 29 threeroomed tenements, 37 four-roomed tenements, and 11 five-roomed tenements, or 150 in all, were occupied under conditions of more than 2 persons per room, and their occupants formed 3.4 per cent. of the population in private families. In 1911 there were 79 such tenements, containing 2.8 per cent. of the population. Rateable Value.—The rateable value of the District at Michaelmas, 1925, was £321,320, and the amount represented by a penny rate was £1,283. Social Conditions.—The District is mainly residential and agricultural. There are no large works; bricks, tiles and pottery are manufactured in various parts of the District, there are engineering works at Bookham, a film factory and leather works at Ashtead, and a factory for the manufacture of fireworks at Cheam. 6 At the Census, 1921, the numbers of persons returned as engaged in occupations were 9,258 males and 4,936 females. The chief numbers enumerated under various occupations were as follows:— Occupation. Males. Females. Agricultural occupations 2100 56 Metal workers 527 7 Electrical apparatus makers, fitters, etc. 145 10 Makers of textile goods and articles of dress 140 194 Workers in wood, etc. 330 6 Builders, bricklayers, etc. 476 1 Painters and decorators 212 2 Transport workers 874 45 Commercial and financial occupations 1059 251 Public administration and defence 390 105 Professional occupations Persons employed in personal service 727 622 405 3135 Clerks, draughtsmen, typists, etc. 638 378 Included in the first class were 1,205 male and 16 female gardeners and gardeners' labourers, 673 male and 21 female agricultural labourers, and 82 male and 11 female farmers; under the heading of professional occupations, 163 male and 167 female mental attendants; and among those employed in personal service, 2,725 female domestic servants. Vital Statistics.— The births registered in the District in 1925 numbered 379; the nett births belonging to the District were 463. giving a birth rate of 12 6 per 1,000 of the population as estimated by the Registrar-General. The rate for England and Wales for 1925 was 18.3. The deaths registered in the District in 1925 numbered 489, of which 181 occurred in the Banstead Mental Hospital, 39 in the St. Anthony's Hospital, North Cheam, 5 in the Cobham Cottage Hospital, 34 in the Croydon Borough Sanatorium, and 9 in other Institutions; 268 deaths were transferred to other Districts, and 109 persons belonging to the District died elsewhere, leaving 330 nett deaths. In comparing the death-rates of Districts, it is necessary to take into consideration the age- and sex-distribution of the population, and factors for the correction of the crude death-rates are provided by the Registrar-General; the factor by which the death-rate for this District has to be multiplied, as calculated from this distribution of the population at the Census, 1921, was .907; on the 1911 population it was 1.039; for comparative purposes the death rates, as recorded for this District in recent years, should therefore be decreased, and in earlier years should be increased to this extent. The crude death-rate for the District for 1925, based on the figures of the Registrar-General, was 8.9 per 1,000 of the population, and the corrected or standardized death-rate was 8.l. The rate for England and Wales for 1925 was 12.2. The deaths of infants under one year of age, in 1925, numbered 22, viz., 13 males and 9 females. Nine of the deaths occurred within a fortnight of birth. The mortality rate was 47 per 1,000 births; that for England and Wales was 75. 7 Eight children died between the ages of one year and five years, viz., 3 from violence, 2 from pneumonia, and 1 each from influenza, whooping cough and appendicitis. The number of deaths from various causes in the two periods, 1916— 1920 and 1921—1925, are shown in the following Table:— Cause of Death. 1916 — 1920. 1921—1925. Male. Female. Male. Female. Enteric Fever 1 2 1 1 Small-pox — — — — Measles 5 9 8 6 Scarlet Fever 1 1 — 2 Whooping Cough 2 5 4 3 Diphtheria 7 15 3 9 Influenza 47 66 26 31 Encephalitis Lethargica — 2 2 Meningococcal Meningitis 1 1 — 1 Respiratory Tuberculosis 62 54 56 31 Other Tuberculous Diseases 17 16 5 13 Cancer 82 95 116 123 Rheumatic Fever — — 1 — Diabetes 10 10 8 8 Cerebral Haemorrhage, etc. 62 67 37 43 Heart Disease 77 75 104 128 Arterio-sclerosis 43 29 79 43 Bronchitis 35 37 46 29 Pneumonia (all forms) 49 41 51 53 Other Respiratory Diseases 7 6 14 4 Ulcer of Stomach or Duodenum 12 1 10 4 Diarrhoea, etc. (under 2 years) 5 5 4 3 Appendicitis and Typhlitis 10 7 6 6 Cirrhosis of Liver .. 4 1 2 2 Nephritis 12 18 17 23 Puerperal Sepsis — 3 — 7 Other Accidents, etc., of Pregnancy — 3 — 11 Congenital Debility, etc. 37 26 24 18 Suicide 8 6 15 5 Other Violence 18 11 33 20 Other Defined Diseases 122 152 134 139 Causes I11-Defined. 1 1 1 1 All Causes 737 763 802 769 The following Table shows for the District the average annual birthrate, death-rate, infant mortality rate, and number of deaths of children between the ages of one and five years, for each of the last ten quinquennial period, and for the year 1925:- Birthrate. Deathrate. Infant Mortality. Average Deaths, 1—5 years. 1876—1880 29.4 14.8 94 21 1881—1885 27.3 13.1 84 20 1886—1890 25.3 12.6 97 20 1891—1895 23.9 12.9 99 18 1896—1900 22.9 12.2 95 15 1901—1905 22.4 10.2 88 14 1906—1910 21.1 9.6 65 14 1911—1915 18.8 9.4 60 16 1916—1920 16.5 10.8 55 12 1921—1925 13.9 9.9 41 9 1925 12.6 8.9 47 8 8 Poor Law Relief.—The amount expended in outdoor relief in the District, exclusive o! the Parish of Woodmansterne, was £2,373 15s. 3d. in the year 1925. II.-GENERAL PROVISION OF HEALTH SERVICES IN THE AREA. Hospitals Provided or Subsidised by the Local Authority or County Council.—Hospitals for Tuberculosis and Small Pox are available for the District under the schemes of the Surrey County Council. The St. Anthony's Hospital, North Cheam, and the Croydon Borough Sanatorium, Cheam, are situated in the District. The Isolation Hospital for the District is the Cuddington Joint Isolation Hospital, which provides accommodation for the Epsom Rural District, and the Carshalton, Leatherhead, and Sutton Urban Districts, and is situated in the parish of Cuddington, in the Epsom Rural District. The Hospital consists of two Ward Blocks, each containing two wards for 6 and 8 beds respectively (capacity 12,000 and l6,000 cubic feet), a third Ward Block, containing two wards for 4 and 6 beds (capacity 8,000 and 12,000 cubic feet), and a fourth Block, containing four wards for 3 beds each (capacity 5,500 cubic feet); a Discharging Block, containing 2 beds; Administrative Block, Disinfector, Laundry, Mortuary, etc. Ambulance Facilities.—Cases of infectious disease are removed to the Isolation Hospital in the motor ambulance of the Joint Hospital Board. There is no ambulance in the District for non-infectious cases, but the motor ambulance stationed at Epsom is available. Clinics and Treatment Centrrs. Centre. Situation. Accommodation. By whom provided. Banstead Welfare Centre. Church Institute, Banstead. Meeting room & Doctor's room. Surrey County Council. Tadworth do. Parochial Hall, Tadworth. do. do. Cheam do. Parochial Hall, Cheam. do. do. Bookham do. The Barn Hall, Gt. Bookham. do. do. Cobham do. Boys' Club, Spencer Road. do. do. Ashtead School Clinic. Ashtead Council School. — do. Cobham School Clinic. Infants' Council School. — do. Cobham Dispensary Boys' Club. — do. 9 Public Health Officers.— Medical Officer of Health, Dr. J. Williamson, M.D. (Lond.). D.P.H.; whole time, combined district; salary contribution made. Senior Sanitary Inspector, Mr. W. T. Wooldridge; whole time to District Council; salary contribution made. Also Surveyor for sanitary purposes. Sanitary Inspector for Western District, Mr. F. A. Pratley, M. Inst. M. & Cy.E., A.R.S.I.; whole time to District Council; salary contribution made. Also Surveyor for sanitary purposes. Assistant Sanitary Inspectors and Surveyors, Mr. R. E. Wallace, A.R.S.I.; holds Meat Certificate; no contribution made. Mr. J. W. Gale, A.R.S.I. ; no contribution made. Assistant Sanitary Inspectors, Mr. John Frederick Armstrong, M.S.I.A., for Eastern District; Mr. Arthur Jump, M.S.I.A., for Western District; both hold Certificates of Royal Sanitary Institute, and for Meat and Foods. Veterinary Inspectors, Mr. G. M. Vincent, M.R.C.V.S., and Mr. N. S. King, M.R.C.V.S.; part time; no contribution made. Mr. Wooldridge has charge of the Eastern District, and Mr. Pratley of the Western District. Each is provided with a clerk, and, at the beginning of the period, Mr. Wallace was acting as Assistant in both Districts. From time to time I drew attention to the fact that the large amount of work in connection with new buildings rendered it impossible to carry out systematic inspections, and early in 1924 the District Council appointed Mr. Gale as Assistant for the Western District, and transferred Mr. Wallace entirely to the Eastern District, and they also granted additional travelling facilities. In May, 1925, I again reported that the staff was insufficient for the work, and suggested that the duties of Sanitary Inspectors should be assigned to officers appointed for that purpose alone. After due consideration, the Council felt that there were difficulties in carrying out this suggestion, and decided to appoint an additional well-qualified Assistant in each Division to give his time wholly to the work of Inspector, and engaged Mr. Armstrong and Mr. Jump, who commenced duties in December. Professional Nursing in the Home.—General nursing in the District is carried out by the nurses of the following Associations:— Bookham and Fetcham Nursing Association. Cobham Nursing Home. Banstead District Nursing Association. Cheam District Nursing Association. Ewell District Nursing Association. There are no arrangements for the nursing of cases of Measles or other infectious diseases. Midwives.—None of the midwives are employed or subsidised by the District Council. 10 Adoptive Acts, Bye-Laws and Regulations.—The following Adoptive Acts, etc., relating to the Public Health, are in force in the District:— Adoptive Acts, etc. Date of Adoption Infectious Disease (Prevention) Act, 1890 Dec. 3rd, 1890 Public Health Acts Amendment Act, 1890: Sees. 16—19, 21, 23, 25, 26, 28, 32 and 33 Oct. 28th, 1896 Public Health Acts Amendment Act, 1907: Sees. 15—18, 20—24, 27—38, 44—46, 49, 52— 60, and 62—65 Sept. 28th, 1915 Public Health Act, 1875: Sec. 25 Sept. 26th, 1908 Sac. 26 (1), Ashtead, Cheam, Cobham, Cuddington, Ewell, Fetchaua, and Stoke d'Abernon Feb. 10th, 1903 Sec. 44, Ashtead, Clieam, Cuddington and Ewell Mar. 2nd, 1893 Remaining Parishes Dec. lltb, 1916 Public Health Act, 1875: Sees. 112, 113 and 114, Clieam, Chessington, Cuddington and Ewell Mar. 7th, 1918 Ashtead Jan. 9th, 1917 Public Health Act, 1875: Sees. 157 and 158: Cbeam Dec. 24th, 1879 Ewell Oct. 27th, 1880 Ashtead and Cuddington Nov. 9th, 1892 Remaining Parishes Oct. 24th, 1899 Public Health Act, 1875: Sec. 169: Ashtead, Cheam, Cuddington and Ewell Nov. 9th 1892 Public Health Act, 187: Sees. 169 and 170: Remaining Parishes May 2nd, 1902 Bye-laws relating to Common Lodging Houses May 22nd, 1895 ,, ,, Tents, Vans, Sheds, etc. June 20th, 1900 ,, ,, Removal of House Refuse and cleansing of Earth- closets, &c. Sept. 12th, 1900 ,, ,, Nuisances: Ashtead, Cheam, Cuddington and Ewell Apl. 12th, 1911 ,, ,, Cesspools Jan. 17th, 1912 ,, ,, New Streets and Buildings July 1st, 1914 ,, ,, Drainage of Existing Buildings July 1st, 1914 „ ,, Slaughter Houses Jan. 31st, 1923 Regulations as to Dairies, Cowsheds and Milkshops Aug. 16th, 1889 III.—SANITARY CIRCUMSTANCES OF THE AREA. Water.—The whole District is provided with supplies from Water Companies. The Parishes of Banstead, Ewell, Woodmansterne, and the greater part of Cheam and Cuddington, are supplied by the Sutton District Water Company ; Ashtead, Great and Little Bookham, Cobham, Fetcham, 11 Stoke d'Abernon, and part of Chessington are supplied by the Leatherhead Water Company; and Headley is supplied by the East Surrey Water Company. The supply in each instance is derived from wells in the chalk, and that of the Sutton Company is softened. There is a constant supply, except in the case of a small part of the district of the Leatherhead Water Company, which is at too high a level to permit of the maintenance of a constant supply. A number of houses at Worcester Park and the northern part of Cliessington are supplied by the Metropolitan Water Board. The District Council receive from the Sutton Water Company copies of the reports upon the monthly analysis of the water. With the exception of a very few outlying houses, the supply throughout the Distriot is obtained from the mains of the Companies. Rivers ane Streams.—With the exception of complaints received from a neighbouring Authority that an unsatisfactory effluent was being discharged at times from the District Council's Outfall Works at Worcester Park into the Beverley Brook, no instance of pollution came to the Council's notice. The effluent appeared to be at all times within the standard of the Port of London Authority. Drainage and Sewerage.—The Parishes of Aslitead, Cheam, Cobham and Ewell, the northern part of the Parish of Cuddington, and Eastwick, in the Parish of Great Bookham, are sewered, sewers being available throughout these districts, except for a small part of Ewell, and for Fairmile, Hatchford and Little Heath, in the Parish of Cobham. In all cases the sewers are on the separate system. The sewage from Ashtead is treated in combination with that from Leatherhead at the Leatherhead Outfall Works. The treatment at the Worcester Park Works, to which the Cheam and Cuddington sewers discharge, at the Cobham Works and Ewell Works, is by "double-contact" beds; part of the Cobham sewage is treated by means of sprinklers. In 1914, Messrs. John Taylor and Son presented a scheme for the drainage of Banstead and Woodmansterne. The matter was shelved in consequence of the War, but again came under the consideration of the District Council, who decided to proceed with the scheme, in 1922; the Ministry of Health then suggested that the Parish of Walton-on-the-Hill, in the Reigate Rural District, should be included in the scheme, and a conference was held at the end of that year between representatives of the Ministry and the District and Parish Councils concerned, and Messrs. Taylor subsequently prepared a scheme, amended to allow of the proposed extension. After further negotiations, a second conference was held in February, 1924, when it was found that the estimated cost was in excess of the amount for which a loan, based upon the rateable value of Banstead, was permissible. It was therefore decided that the outlying parts of the Parish must be for the time excluded from the scheme, and it was also decided not to proceed with the portion of the scheme relating to Woodmansterne. 12 The extensive development of the Nork Park Estate, in the northwestern part of the Parish of Banstead, rendered it necessary that this portion should be sewered without delay, and the Council applied to the Ministry for sanction to a loan. At an Inquiry which was held in June, 1924, into the application, it was agreed to extend this section to include a somewhat congested part of the Village of Banstead. The work of laying the sewers was begun in January, 1925, and was nearing completion at the end of the year, some connections having already been made. In November, 1925, an Inquiry was held into the application of the District Council for sanction to borrow £88,845 for the whole scheme, and at the end of the year negotiations were in progress with the Beigate Rural District Council as to the terms on which the sewage of Walton would be received, if that Council should decide to proceed with the scheme for that Parish. The sewers will discharge into those of the Cheam and Cuddington system for treatment at the Worcester Park Outfall Works. This addition, together with the large increase of population already served by these works, will necessitate the reconstruction of the system of disposal. The new sewers will permit of the reception of the drainage of the Kensington, Chelsea and St. Marylebone Schools in the Parish of Ewell, and of other parts of that Parish, and of the Parishes of Cheam and Cuddington. In 1923, Mr. Pratley submitted a scheme for the drainage of Fairmile, Cobham, and of the Parish of Stoke d'Abernon. The scheme was placed in the following year in the hands of Messrs. John Taylor and Son for report, and estimates and drawings were presented to the Council in September. Messrs. Taylor also prepared a scheme for the drainage of Great and Little Bookham and Fetcham, and another for the Elmbrook Estate, Cheam. The appropriate steps are being taken to proceed with these three schemes. Sewers have been extended to take the drainage of newly developed areas in the Parishes of Ashtead, Cheam, Cobham and Ewell, and Mr. Wooldridge has prepared a scheme for the extension of sewers in West Ewell. The District Council were negotiating at the end of the year for the reception of the drainage of an estate in Woodmansterne Parish into the sewers of the Coulsdon and Parley Urban District Council. Closet Accommodation.—In all places in which sewers are available the houses are provided with water-closets with flushing apparatus, and the drains are intercepted from the sewers and are ventilated. The parts of the District in which there is no water-carriage system are for the most part provided with moveable pails or tub-closets. The numbers of premises provided with water-closets, pail-closets and privies in the Eastern District (Banstead, Cheam, Cuddington, Ewell, Headley and Woodmansterne) and the Western District (remaining Parishes) are:— Eastern District. Western District. Whole District. Water-Closets 5028 2667 7695 Earth- or Pail-Closets 383 446 829 Privies 35 112 147 13 Scavenging.—House refuse is collected weekly in the Parishes of Ashtead, Banstead, Cheam, Cobham, Cuddington and Ewell. The work is done in each Parish by a contractor, and the refuse is deposited in tips. Complaints were received in 1923 of nuisance arising from the site on which the Cheam house refuse was being deposited, and the contractor eventually ngreed to erect a pulveriser on another site, provided that he was given the contract for the collection of the Banstead and Cheam house refuse for a term of years. Aftar considerable delay the plant was erected, but the method of disposal continued to be unsatisfactory, and the Council have under consideration the question of adopting some other method. The houses generally are provided with covered movable ash-bins. The District Council empty the cesspools and cleanse the tub-closets in the Parish of Banstead, under the supervision of Mr. Wooldridge, the Banitary Inspector. Numerous complaints were received from time to time of nuisances from overflow of cesspools, as many of them fill very rapidly and the pumping plant was unable to cope with the work at times of heavy rain. This trouble has been to a great extent relieved by the purchase of a Dennis Vacuum Cesspool Emptier, of 750 gallons capacity, in March, 1925. Great difficulty is also experienced in disposing of the sewage, owing to the opposition raised to the use of any of the sites selected by the Council. The District Council also empty the cesspools in the parts of the Parish of Cuddington for which sewers are not available. Sanitary Inspection.—The Sanitary Inspectors make the following Reports:- Eastern District. Western District. Number of inspections of dwelling-houses 484 619 Number of dwelling-houses at which nuisances were discovered 134 92 Number of nuisances discovered on other premises 30 24 Number of informal notices served 148 148 Number of statutory notices served 2 5 Number of nuisances a,bated or defects remedied 276 217 Inspections of other premises:— Premises Number on register. Number of visits. Defects discovered. Notices served. Slaughter-houses 9 89 3 — Places where food is prepared — 6 1 1 Bakehouses 19 42 1 — Other Workshops 167 239 25 14 Factories 24 41 1 1 Dairies, Cowsheds and Milkshops 101 170 15 7 Schools — 7 5 5 Bye-laws.—On several occasions action was taken under the Bye-laws with respect to tents, vans, sheds, etc., to procure the removal of encampments of gipsies, which were without proper water supply and sanitary 14 accommodation, and, in particular, a large encampment near Banstead Mental Hospital gave much trouble before it was eventually broken up under threat of prosecution. Schools.—Each of the 21 Elementary Schools is provided with water from a public supply except Ranmore, in the Parish of Great Bookham, which obtains water from a private well. The Schools in the Parishes of Ashtead, Cheam, Cobham and Ewell are provided with water-closets draining to the sewers. Banstead, Burgh Heath Church of England, Tadworth, Bookham, Chessington and Woodmansterne Schools have water-closets draining to cesspools. Burgh Heath Wesleyan, Fetcham, Headley, Oxshott and Eanmore Schools have earth-closets, and drains discharging into cesspools. Notices are sent to the Head Teachers when a child is notified to be suffering from infectious disease, both as to the patient and other children living in the infected house, and a notice is sent subsequently on the discharge of the patient from hospital. The schools and homes of the patients are visited by the Health Visitors of the County Council, on receipt of notifications from the teachers, and I also visited the schools at times of outbreaks of infectious disease. Each school was visited by me during the year, and was found to be in a satisfactory condition. IV.—HOUSING. General Housing Conditions.—The figures relating to housing at the Census, 1921, will be found on page 5. At the Census, 1911, there were 5,819 private families, with a population of 25,465, in approximately 5,560 houses ; in 1921 there were 6,994 families, with a population of 29,099, in 6,605 houses. The number of persons per house had, therefore, fallen from 4.84 to 4.47, but the number of families per house had risen by about one per cent. The survey of the District in 1919 revealed a considerable shortage of houses in practically all of the Parishes, and numerous applications for houses were then, and have since continued to be, received. The District Council nrepared a scheme under the Act of 1919 for the erection of 350 houses, of which 126 were erected before the operations under that Act were brought to an end. In December, 1923, the Council formulated a further scheme under the Act of that year, and made application to the Ministry of Health for permission to erect 300 houses and for payment of subsidy thereon. There was considerable delay in proceeding with this scheme, mainly owing to the inability of the Council to obtain tenders sufficiently low to receive the approval of the Ministry, and they were unable to enter into any contracts until the beginning of 1925. In the meantime they prepared schemes for the land already in their possession and purchased other sites, and good progress had been made by the end of the year. 15 The following Table shows, for the various Parishes, the number of houses erected under the 1919 scheme, and the number erected, in course of erection, or for which tenders had been received in 1925 and have since been accepted, under the later scheme:— 1919 1923 1919 1923 Palish. Scheme. Scheme. Parish. Scheme. Scheme. Ashtead — 34 Fetch am — 10 Banstead 10 56 Headley 12 — Cheam 50 46 Stoke d'Abernon 16 — Cobham 24 30 Woodmansterne 16 — Ewell — 34 Included in the first batch in Cheam Parish are two houses which had been begun by a private builder, and were purchased and completed by the Council. In the two years 1924 and 1925 the District Council paid 223 subsidies of £75 each to private persons or societies, with the sanction of the Ministry of Health. They also received the sanction of the Ministry from time to time to grant loans under the Housing Act, 1923, for assistance in the erection of houses, in all up to the amount of £150,000, and by the end of 1925 they had advanced £101,946 under this Act, in addition to £5,015 under the Small Dwellings Acquisition Act. Iam indebted to the Surveyors for the following figures showing the number of new houses erected in each Parish in each of the past five years:— Parish. 1921. 1922. 1923. 1924. 1925. 1921—25. Banstead 57 22 25 53 102 259 Cheam 47 60 141 162 222 632 Cuddington 7 10 13 14 17 61 Ewell 15 24 64 123 162 388 Headley 12 — — — 1 13 Woodmansterne 33 8 12 10 12 75 Ashtead 15 26 25 33 51 150 Great Bookham 2 28 55 78 78 241 Little Bookham — — 4 11 3 18 Chessington — — 1 2 2 5 Cobham 32 11 18 17 48 126 Fetcham 2 8 29 16 23 78 Stoke d'Abernon.. 20 8 4 3 3 38 Whole District 242 205 391 522 724 2084 Overcrowding.—The Census returns for 1921, quoted on page 5, showed that 150 families, representing 3.4 per cent. of the population, were then living under conditions of more than two persons per room, as against 79 families, representing 2.8 per cent. of the population, in 1911; the percentage of the population living under these conditions in 1921 in the County generally was 4.3. These figures indicate that overcrowding increased in the intercensal period, and cases frequently come to notice in the course of inspections, but a considerable proportion of them are of a minor character, and a comparison of the results of recent inquiries with those of five or six years ago shows that bad cases of overcrowding are decreasing in number. 16 At the Census, 1921, the number of rooms per person, in houses containing not more than 9 rooms, was 1.22 for the District, approximately the same figure as that for the whole County. In 1925, the most serious cases of overcrowding were two, at Ewell and Tadworth, in which three families were found to be occupying one cottage, and a third at Great Bookham, in which two families were overcrowding a small cottage. The condition was remedied in the first two cases by the allotment of new cottages erected by the Council to two of the Ewell families and one of the Tadworth families, and in the third case by the removal of one of the families, on the service of a notice. In December the District Council allocated 15 of their new cottages to families in the Parish of Clieam who were living in overcrowded conditions. Fitness of Houses.—The general standard of housing is very fair, but in each Parish there are a number of old houses which are structurally in such a condition that they are not worth the outlay required to make them fit habitations, involving as it would in some cases almost complete reconstruction. The proportion of such cases is probably highest at Bookham and Ewell. The demand for houses does not permit of the application of Closing Orders except in the worst cases, and it is the practice of the Council to call upon the owners to do sufficient repair and cleansing to mitigate the conditions pending the provision of suitable accommodation. The main defects that are found are dampness from defective roofs and gutters, from want of general repair, and, in the older cottages, from absence of a damp-course, want of internal cleansing, and in a comparatively few cases, low-pitched and sloping ceilings and inadequate window space, and lack of ground at the back of the houses. Remedial defects are in most cases made good by the owners without recourse to the service of statutory notice. In one instance the owner of a group of cottages, which were in a bad state of repair, agreed with the Council to devote the whole of the rent to the carrying out of the necessary work. Bye-laws relating to Houses, etc.—The District Council on many occasions summoned before them persons who had erected buildings without the deposit of plans, or had converted other buildings or structures into dwellings, or were so using them. In other cases orders were issued to remove unsuitable material which had been used in the construction of houses. Housing Statistics for the Year 1925. Number of new houses erected during the year:— (а) Total 724 (b) With State assistance under the Housing Acts: (i.) By the Local Authority 32 (ii.) By other bodies or persons 163 17 1.— Unfit Dwelling-Houses. Inspection. (1) Total number of dwelling-houses inspected for bousing defects (under Public Health or Housing Acts) 645 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910, or the Housing Consolidated Regulations, 1925 213 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 3 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub heading) found not to be in all respects reasonably fit for human habitation ... ... ... ... 63 II.—Remedy of Defects without Service of Formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers ... 84 III.—Action wider Statutory Powers. A.—Proceedings under section 3 of the Housing Act, 1925. (1) Number of dwelling-houses in brespect of which notices were served requiring repairs 5 (2) Number of dwelling-houses which were rendered fit:— (a) by owners 1 (b) by Local Authority in default of owners — (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close — B.—Proceedings under Public Health Acts. (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 2 (2) Number of dwelling-houses in which defects were remedied:— (a) by owners 2 (b) by Local Authority in default of owners — 0.—Proceedingt under Sections 11, 14 and 15 of the Housing Act, 1925. (1) Number of representations made with a view to the making of Closing Orders 1 (2) Number of dwelling-houses in respect of which Closing Orders were made 1 (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit 1 (4) Number of dwelling-houses in respect of which Demolition Orders were made — (5) Number of dwelling-houses demolished in pursuance of Demolition Orders — 18 V.— INSPECTION AND SUPERVISION OF FOOD. Milk Supply.—At the end of the year there were 101 entries upon the Register, and 66 of these were in respect of premises upon which cows were kept. The Veterinary Inspectors made quarterly examinations of the cows, usually between 1,200 and 1,250 in number, belonging to the registered cowkeepers. No undoubted cases of tuberculosis were reported, although several suspected animals were subjected to the tuberculin test. In the few cases in which emaciation or other symptoms of tuberculosis were discovered, the animal was separated from the herd, and was either slaughtered at once or after the conditions showed no improvement under treatment. It was reported, after the examination in the third quarter of the year, that a number of animals which were in a poor condition had been slaughtered, in view of the coming into force of the new Regulations in September. A number of cases of simple mastitis were reported, and in such cases the milk was not used for human consumption. The premises were visited by the Sanitary Inspectors, who reported the discovery of defects, mainly in respect of want of cleanliness, on 15 occasions. Four licences for Certified Milk, two for Grade A (Tuberculin tested) Milk, and one for Grade A Milk were issued during the year. One cowkeeper was summoned before the Council to show cause why he should not be removed from the Register, with the result that he laid on a proper water supply and carried out works of general improvement. At the end of December, 1924, and in 1925, one sample of milk which had been pasteurised and 26 samples of ordinary milk were examined for the number of bacteria per cubic centimetre and the presence of bacillus coli. The pasteurised milk contained 21,000 bacteria per c.c. and showed the presence of bacillus coli in 1 c.c., but not in smaller quantities. A sample of rail-borne milk contained 445,000 bacteria per c.c., and bacillus coli in .01 c.c. The number of bacteria in the other 25 samples varied from 2,050 to 120,500 per c.c. ; in 10 samples the number was less than 30,000, the standard for certified milk, in 12 others it was less than 100,000, and in the remaining 3 samples it was slightly above that number. Two samples showed the presence of bacillus coli in 001 c.c., 8 in 01 c.c., 10 in .1 c.c., and in 6 samples the bacillus was not found in .1 c.c. Five of the samples came within the standard of certified milk, 8 others within that of Grade A milk, and the remainder, with the exception of the sample first mentioned, were within the standard of Grade A milk in respect of the number of bacteria, but showed an excess of bacillus coli. In cases in which the results of the examinations were not satisfactory, the cowkeepers were informed that the analyses indicated a lack of cleanliness in the production of the milk. Meat.—The occupiers of the slaughter-houses were circularised and their attention called to the provisions of the Public Health (Meat) Regulations, and the slaughter-houses and butchers shops were visited and inspected, and the requirements of the Regulations were explained. 19 Notices of the time of slaughter are received by the Sanitary Inspectors, who have paid occasional visits and examined carcases, but in no instance were these found to be diseased. All the slaughter-houses are privately occupied, and the numbers in use at the undermentioned dates were:— In 1920. In Jan., 1925. In Dec., 1925. Registered 10 10 10 Licensed — — — OTHER Foods.—The bakehouses were periodically inspected, and were found to be in a satisfactory condition. Sale of Food and Drugs Acts.— The County Medical Officer of Health informs me that 87 samples of milk, 12 of cream, 4 of preserved cream, 4 of butter, and 4 of other articles were analysed under these Acts, that 8 samples of milk and 1 sample of cream were found to be adulterated, and that there were 4 prosecutions with 2 convictions. VI.—PREVALENCE OF AND CONTROL OVER INFECTIOUS DISEASES. The following Table shows, for each of the past five years, the number of cases of certain diseases notified in the District, including those among the staff, but excluding those among the patients, at the Banstead Mental Hospital:— 1921. 1922. 1923. 1924. 1925. Scarlet Fever 103 48 33 13 32 Diphtheria 12 10 8 23 27 Enteric Fever 5 — 7 2 6 Puerperal Fever 1 1 2 — 3 Pneumonia 10 14 11 7 14 Encephalitis Lethargica — — — 2 3 Pulmonary Tuberculosis 35 27 27 21 39 Non-Pulmonary Tuberculosis 2 10 4 7 12 Ophthalmia Neonatorum 1 2 3 1 3 In private houses, 32 cases of Scarlet Fever occurred in 26 houses, and 16 cases of Diphtheria in 12 houses, in 1925. In the five years there were 215 cases of Scarlet Fever in 161 houses, and 60 cases of Diphtheria in 48 houses ; of these cases, 55 of Scarlet Fever and 16 of Diphtheria were notified in the Parish of Banstead, 41 of Scarlet Fever and 25 of Diphtheria in Cheam, 42 of Scarlet Fever and 2 of Diphtheria in Ewell, 33 of Scarlet Fever and 6 of Diphtheria in Ashtead, and the remaining cases in the other nine Parishes. There were 8 instances of return cases of Scarlet Fever in 1921 and 3 in 1922 ; 3 secondary cases occurred in 1 instance, 2 in another, and 1 in each of the other 4 instances. Nine of the 18 cases of Enteric Fever were notified as Paratyphoid B. Fever; 2 of these cases at Ashtead and 3 at Cheam, in 1923, formed part of a series of cases in this and neighbouring Districts in which the infection was apparently conveyed by contaminated confectionery. In 1925, 4 cases 20 of Paratyphoid B. Fever and 2 of Typhoid Fever were notified; it was ascertained, from the date of onset, that the infection in 4 of these was certainly, and in another case probably, contracted away from the District. Of the 5 cases of Encephalitis Lethargica, 2 occurred at Cobham and 1 each at Ewell, Fetcham and Worcester Park; another patient from Cobham was also found to be suffering from the disease after admission to the Epsom Union Hospital, in September, 1925. Five of the patients died of the disease, and the sixth patient died of Pneumonia about two years after the onset of his illness. Bacteriological examinations are made at the Lister Institute of Preventive Medicine at the expense of the District Council. During the year 72 examinations were made for the diphtheria bacillus, with 8 positive results, and 15 for the tubercle bacillus, with 3 positive results. The District Council provide diphtheria antitoxin for suitable cases, and 24,000 units were issued during 1925 for the use of patients who were suspected, but could not be definitely declared, to be suffering from Diphtheria. In all other cases the patients were at once removed to the Isolation Hospital for treatment. No applications of the Schick or Dick tests in Diphtheria and Scarlet Fever were made. Under the Public Health (Pneumonia, etc.) Regulations, 1919, 56 cases of Pneumonia, other than those occurring among the patients in the Banstead Mental Hospital, and 7 cases of Malaria were notified; no cases of Dysentery were notified except in the Mental Hospital. The notified cases of Pneumonia bear but little relationship to the deaths ; e.g., in 1925 there were notified 7 cases of Lobar Pneumonia, of which 3 ended fatally, 3 unspecified cases with one death, 2 cases of Influenzal Pneumonia, both fatal, and 2 cases of Broncho-pneumonia, but there were registered in addition, in the District, 3 deaths from unspecified Pneumonia, 2 from Influenzal Pneumonia, and 9 from Bronchopneumonia. The deaths from Influenza in the five years numbered 9 in 1921, 22 in 1922, 1 in 1923, 8 in 1924, and 17 in 1925, or 57 in all, representing an annual death-rate of 0.32 per 1,000 of the population, as against a rate of 0.37 for England and Wales ; 26 were males and 31 were females ; 5 of the deaths occurred among children under 5 years of age, 3 among persons between the ages of 5 and 25 years, 13 between the ages of 25 and 45 years, 13 between the ages of 45 and 65 years, and 23 among persons over 65 years of age. The deaths were distributed fairly evenly over the whole District; 13 occurred in the Parish of Cheam, 10 in Banstead, 8 in Ewell, and 6 each in Ashtead and Cobham. Outbreaks of Measles and Whooping Cough occurred in practically all parts of the District at some time during the five years; the outbreaks were for the most part of a mild type, but there were 9 deaths from Measles and 7 from Whooping Cough. In 1925 there was only 1 death from Measles and none from Whooping Cough. 21 The homes of the children who are reported by the School Teachers to be suffering from these diseases are visited by the Health Visitors of the County Council, and I visited the schools at times of outbreak and advised as to precautions. There are no facilities in the District for the cleansing of verminous persons or their belongings. Notifiable Diseases during the Year 1925.— Disease. Total cases notified. Cases admitted to Hospital. Deaths. Scarlet Fever 32 24 — Diphtheria 27 — 3 Enteric Fever 6 2 — Puerperal Fever 2 — 2 Pneumonia 14 1 24 Erysipelas 5 — — Encephalitis Lethargica 3 1 3 Ophthalmia Neonatorum 3 1 — Ten of the cases of Diphtheria occurred at the Boys' Surgical Home, Banstead, and one at the Kensington, Chelsea and St. Marylebone Schools. In addition, 18 cases of Erysipelas, 10 of Pneumonia, and 5 of Dysentery were notified in the Banstead Mental Hospital. Total cases and deaths at various ages:— Cases. Under 1-yr. 1 2 3 4 5 10 15 20 35 45 65 Scarlet Fever — — 1 — 5 13 6 3 3 1 — — Diphtheria — 1 2 2 2 11 6 — 2 — 1 — Enteric Fever — — — — — — — — 2 3 1 — Deaths. Diphtheria — — — — — 2 1 — — — — — Encephalitis — — — — — — — 1 — — 2 — Tuberculosis. New cases and mortality during 1925. Age Periods. New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M F M F M F M F 0 — — 1 1 1 — — 1 1 — — 1 — — — — — 5 — — 2 1 — — — — 10 1 1 — — — — — — 15 1 2 — 1 — — — — 20 3 3 1 — 2 1 — — 25 2 7 1 1 3 3 — 1 35 6 2 — 1 4 — — — 45 2 3 — — 3 — — — 55 2 2 — — 1 1 — — 65 & above 2 — — 1 2 —- — 1 19 20 6 6 16 5 — 3 22 The 21 deaths from Pulmonary Tuberculosis represent an annual death-rate of 0.60 per 1,000 of the estimated population. The average rate for the ten years, 1916 to 1925, was 0 68. There was one death from General Tuberculosis, one from Tuberculous Meningitis, and one from Tuberculous Peritonitis. The following Table shows the mean population, the number of cases notified, and the number of deaths from certain infectious diseases in each quinquennium during the 50 years from 1876 to 1925:— Period. Mean Population. Cases. Deaths. Scarlet Fever. Diphtheria. Enteric Fever. Scarlet Fever. Diphtheria. Enteric Fever. Measles. Whooping Cough. Pulmonary Tuberculosis. 1876— 13200 — — — 17 10 5 14 24 114 1881— 14300 257 102 37 13 29 5 a 25 91 1886— 15500 88 100 21 4 20 4 8 25 83 1891— 17000 214 96 21 8 38 5 12 17 88 1896— 18600 348 80 19 6 12 3 11 22 92 1901— 21500 266 118 21 4 14 2 6 32 76 1906— 25000 318 153 19 1 14 2 5 13 74 1911— 28300 337 106 12 3 12 — 11 12 88 1916— 27700 157 169 14 2 22 3 14 7 116 1925— 32500 229 80 20 2 12 2 9 7 88 Notification of infectious disease was voluntary until 1889, and the figures representing the number of cases up to that year are, therefore, incomplete. VII.—MATERNITY AND CHILD WELFARE. In the five years 6 casus of Puerperal Fever were notified, and 8 other persons belonging to the District died of the disease elsewhere ; there were, in all, 7 deaths, 5 of which occurred in hospitals. Ten cases of Ophthalmia were notified, of which several were in a mild form ; one patient was removed to Moorfields Hospital and another to St. Margaret's Hospital; all made good recovery. Among young children, Measles caused 8 deaths, "Whooping Cough 7, and Epidemic Diarrhoea 7 ; 4 of the deaths from Measles, 2 from Whooping Cough, and all from Diarrhoea occurred among children under one year of age ; 3 of the other deaths from Measles and 3 from Whooping Cough, among children between the ages of 1 and 2 years ; the remaining 3 deaths occurring between the ages of 2 and 5 years. A child of 4 years of age was notified to be suffering from Poliomyelitis, and was treated in the acute stage at St. Thomas's Hospital, and continued to attend for after treatment. 23 Ophthalmia Neonatorum, 1925. Cases Notified. Treated at Home. Treated in Hospital. Vision Unimpaired. 3 2 1 3 The work of Maternity and Child Welfare throughout the District is carried out under the Scheme of the Surrey County Council. Epsom, J. WILLIAMSON, May, 1926. Medical Officer of Health. WILLIAM PILE. Ltd Printers, 26, High Street, Sutton.