AC 4413(3) CARSHALTON CAR 14 Carshalton Urban District Annual Report OF THE Medical Officer of Health FOR THE YEAR 1949 Printed by the "Croydon Times," Ltd., 104, High 8treet, Croydon. CARSHALTON URBAN DISTRICT ANNUAL REPORT OF THE Medical Officer of Health FOR THE YEAR 1949 1 PREFACE To the Chairman and Members of the Carshalton Urban District Council. Mr. Chairman, Ladies and Gentlemen, I have the honour to present my Report on the health of the district for the year 1949. The period under review was the first complete year of the operation of the National Health Service Act, 1946. As you are aware, many functions which the Council previously exercised passed with the Act to other authorities and, in consequence, there is now no published review of the transferred services including that devoted to the care of mothers and young children which previously formed a large part of this Annual Report. The vital statistics which are the main indices to the state of public health are generally satisfactory. The death rate is again less than that for the country as a whole and is still lower after allowance is made for the more favourable composition as to age and sex of the local population. There was for the fifth year in succession no maternal death, but the infant mortality rate was twice that of the year before. It should, however, be remembered that the infant death rate of 29 per thousand live births is still less than the national figure and that the mortality for 1948 was a phenomenally low one. There was a welcome fall in mortality from cancer and that from tuberculosis was the lowest for 26 years. The incidence of infectious disease was much in accord with expectation and there was no major visitation of this type of illness. Measles, following a year of high prevalence, was markedly less common in 1949. Diphtheria gave rise to one case only and thus provides a record low incidence for this infection which is shared with the year before. Infantile paralysis was contracted by three persons as in the previous year, but was not fatal in any. Only one death was caused by infectious disease and that by whooping cough. 3 Of the preventable diseases, that which is assuming greater significance is food poisoning. The occurrence of illness of this nature has increased steadily throughout the country since the war and it is likely to continue to present a serious health problem so long as economic circumstances require the maximum use of whatever sources of food are available and until a marked improvement in our standards of food hygiene has been achieved. Sanitary supervision in the hands of your Chief Sanitary Inspector continued to be exercised at a high level of efficiency. The greatest obstacle to progress in this important field of hygiene is, here as elsewhere, still the lack of housing accommodation, and we have suffered so long from this sanitary sore that there is a risk of familiarity breeding the proverbial contempt and inducing a sense of fatalistic resignation. Much of the present expenditure on sanatoria, hospitals and other forms of medical treatment would be unnecessary if the housing problem were solved. I would make my customary acknowledgment of the valuable service rendered by the staff of my department who, as in the past, not only worked with efficiency, but with a keen sense of personal responsibility. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, F. LAWRENCE SMITH, Medical Officer of Health. July, 1950. 4 PUBLIC HEALTH STAFF. Medical Officer of Health: †F. Lawrence Smith, M.B., Ch.B., D.P.H. Chief Sanitary Inspector: *H. J. Spicer, M.R.S.I. Deputy Chief Sanitary Inspector: *H. G. Cripps, C.R.S.I. Sanitary Inspectors: *L. G. Lydiatt, C.R.S.I. *H. C. E. Gatehouse, C.R.S.I. *G. R. Surfleet, C.R.S.I. Public Health Nurse: Mrs. D. E. Baldock, S.R.N. Chief Clerk: Miss V. Hotten *Meat and Food Certificate of the Royal Sanitary Institute. †Also Divisional Medical Officer, Surrey County Council. 5 Section A—Natural and Social Conditions of the District. Area (in acres) 3,346 Number of inhabited houses (end of 1949) according to Rate Books 16,638 Rateable Value at 31st December, 1949 £502,720 Sum represented by 1d. rate £2,046 THE Sanitary District, situated about midway between the Thames and the North Downs, is roughly rectangular in shape. It is approximately one mile in width and, commencing at a datum level of 72 at the northern boundary, it extends for some five miles in a southerly direction up the slope of the North Downs to a height of 450 feet above sea level. The subsoil, which is clay in the northern part, changes to a sandy gravel as one proceeds southwards, and then merges into chalk, which covers the southern half of the district. The River Wandle forms the eastern boundary in the northern part and arises from several springs at the outcropping of the chalk near the centre of the district. Reference has been made in recent reports to the progressive decrease in the flow from these springs resulting from depletion of the underground supplies of the London Basin. Both ponds in the centre of the district, which have provided a valuable amenity, were completely dried up for a considerable part of the year except for the temporary accumulation of surface water with its attendant risks from stagnation. The greater part of the urban district is of comparatively recent growth, providing a dormitory area for workers in the metropolis. As a result, like other districts similarly developed in the outer ring, it has a young population as will be seen from the Registrar-General's statistics of the age structure of the population referred to later in this report. With the exception of the southern portion, the district is highly urbanised, the housing density increasing as one approaches the northern boundary. Housing is mostly of the working class type and the rateable value per head of population is among the lowest in the county. 6 SUMMARY OF VITAL STATISTICS FOR 1949. (Based on the Registrar-General's Figures.) Population. Registrar-General's Estimate Total 62,310 Civilian 62,260 Births. Males. Females. Total. Live (Legitimate) 436 357 793 (Illegitimate) 15 17 32 451 374 825 Birth Rate (per 1,000 population) 13.2 Stillbirths (Legitimate) 9 6 15 (Illegitimate) — 1 1 9 7 16 Stillbirth Rate per 1,000 total birth 19.0 Deaths 250 271 521 Death Rate (crude) per 1,000 population 8.3 Infant Mortality. All deaths under 1 year 15 9 24 Infant Mortality Rate (per 1,000 live births) 29.0 Deaths of leg. infts. under 1 year Rate per 1,000 legitimate births 15 9 24 30.2 Deaths of illeg. infts. under 1 year Rate per 1,000 illegitimate births - - - — Maternal Mortality. Death from Sepsis Rate per 1,000 births - - - - Deaths from other causes Rate per 1,000 total births - - - - Maternal Death Rate - Zymotic Deaths. 7 Principal Zymotic Diseases — 1 1 Deaths from Measles — — — Deaths from Whooping Cough — 1 1 Deaths from Diarrhoea (under 2 years) - - - Zymotic Death Rate 0.01 Deaths from Tuberculosis. All Forms Rate per 1,000 of population 9 13 22 0.35 Phthisis Rate per 1,000 of population 9 10 19 0.30 Deaths from Cancer 48 35 83 Rate per 1,000 of population 1.33 7 The Registrar-General's statistics relating to population and deaths differ slightly from those compiled from local records. The total figures in respect of the district as a whole, which are supplied by the RegistrarGeneral, are set out in this report, but where classification has been made, e.g., by age groups, sex, wards, etc., it has necessarily been based on our own records, which may, in the aggregate, show slight discrepancies compared with the Registrar-General's totals. UNEMPLOYMENT. The number of Carshalton men and women registered as unemployed at the Sutton Employment Exchange and the boys and girls similarly lecorded by the Local Youth Employment Bureau shortly after the turn of the year was as follows:— Men 105 Women 56 Boys 45 Girls 33 The boys and girls include 52 who left school at Christmas, 1949, and had not yet taken up employment. POPULATION. The civilian population at mid-year as estimated by the RegistrarGeneral rose by 140 to 62,260. The total population, including non-civilians, was estimated at 62,310, of which 14,269 were under 15 years of age. Distribution of population by wards at June 30th, 1949, was estimated as follows:— TABLE 1. ESTIMATED RESIDENT POPULATION, MID-1949, BY WARDS. Ward. Houses at Mid-1949. Estimated population Mid-1949. St. Helier North 2,166 8.630 St. Helier South 1,699 7,050 St. Helier West 2,022 8,380 North-East 2,690 9,380 North-West 2,156 7,300 Central 1,698 6,060 South-East 2,188 7,730 (Queen Mary's Hospital) 1,100 South-West 2,012 6,680 Whole District 16,631 62,310 8 An examination of the Registrar-Generals statistics relating to the sex and age distribution of the civilian population in the administrative areas of England and Wales at 31st December, 1947, provides the following information:— Age. Surrey Administrative County. Carshalton U.D. Males. Females. Males. Females. All ages 599,580 711,120 28,380 32,980 0-4 53,105 50,486 2,381 2,263 5-14 86,001 81,040 4,701 4,628 15-17 25,218 25,925 1,821 1,944 18-19 6,860 17,701 453 1,293 20-24 30,511 43,181 1,729 2,495 25-34 84,084 100,475 3,317 3,945 35-44 107,542 120,543 4,990 5,708 45-54 85,057 101,637 4,777 5,208 55-64 62,431 79,970 2,479 2,845 55-59 — 41,961 — 1,609 60-64 — 38,009 — 1,236 65-74 40,998 57,647 1,193 1,700 75-84 15,597 27,185 475 788 85 and over 2,176 5,330 64 163 These figures show that the average age of Carshalton's population is 33.9 years and that of Surrey as a whole, 36.9 years. Children under 15 in Carshalton represent 22.7% of the total, whilst in the whole county they represent 20.6%. Old people over 65 years of age form 7% of the total population of the urban district and 11.3% of the county as a whole. Women of reproductive age represent 46.6% of the total females in Carshalton and 43.2% of those in the whole of Surrey. BIRTHS. The number of live births in 1949 fell to 825 from 962 in the year before, providing a birth rate of 13.2 per thousand population compared with 15.5 in 1948. Of the total, 451 were males and 374 females. Information available from the registration of births is not complete as to the home addresses of the parents. For computation of ward birth rates, therefore, use is made of the notifications of birth received under the Public Health Act, supplemented by the Registrar's weekly returns of registrations. From these sources it is known that 841 9 live births and 17 stillbirths occurred in 1949. They were distributed as shown in the following table:— Ward. Live Births. Birth Rate per 1,000 Population. Stillbirths. Stillbirth Rate per 1,000 total births. St. Helier North 125 14.4 1 7.9 St. Helier South 86 12.2 2 22.7 St. Helier West 128 15.2 4 30.3 North-East 177 18.9 4 22.1 North-West 103 14.1 4 37.3 Central 88 14.5 — — South-East (excluding Queen Mary's Hospital) 82 10.6 1 12.0 South-West 52 7.8 1 18.8 Two-thirds of all births occurred in hospitals and nursing homes. The percentages of such births for the individual wards were as follows:— St. Helier North 58 St. Helier South 61 St. Helier West 70 North-East 63 North-West 72 Central 69 South-East 70 South-West 71 Out of 858 total births, 570 took place in the following hospitals and nursing homes:— Live. Still. Total. Carshalton, Beddington and Wallington District (War Memorial) Hospital 61 1 62 St. Helier Hospital 408 14 422 Other Surrey Hospitals 54 1 55 Other Hospitals 12 — 12 Private Nursing Homes 19 — 19 Totals 554 16 570 10 TABLE 2. BIRTHS, 1949, DOMICILIARY AND OTHERS — BY WARDS. Ward. Born in District. Born Outside District. Grand Total. In Hospitals and Nursing Homes. In Private Houses. Total. In Hospitals and Nursing Homes. In Private Houses. Total. St. Helier North 71(1) 53 124(1) 2 2 126(1) St. Helier South 52(2) 34 86(2) 2 — 2 88(2) St. Helier West 89(4) 39 128(4) 4 — 4 132(4) North-East 102(4) 66 168(4) 13 — 13 181(4) North-West 62(3) 29(1) 91(4) 16 — 16 107(4) Central 55 27 82 6 — 6 88 South-East 37(1) 25 62(1) 21 — 21 83(1) South-West 16 15 31 22(1) — 22(1) 53(1) Totals 484(15) 288(1) 772(16) 86(1) — 86(1) 858(17) (Figures in brackets indicate stillbirths included in totals.) TABLE 3. BIRTH AND DEATH RATES FOR CARSHALTON, 1922-1949. Year. Population (RegistrarGeneral's) Birth Rate. Death Rate. Infant Mortality Rate. Maternal Mortality Rate. 1922 14,240 19.7 8.8 50 10.6 1923 14,610 18.8 8.6 36 3.6 1924 15,050 18.5 10.1 58 7.1 1925 15,660 20.0 10.0 42 3.2 1926 17,040 17.0 9.3 31 0.0 1927 18,450 16.5 9.1 72 9.8 1928 21,910 15.5 9.0 65 14.7 1929 23,420 18.8 9.4 61 0.0 1930 25,500 17.0 7.6 46 0.0 1931 28,620 16.7 7.5 43.8 8.1 1932 32,280 15.0 7.9 47.3 3.89 1933 35,260 14.9 8.8 64.4 4.23 1934 38,110 16.5 8.6 53.5 4.60 1935 51,000 15.7 6.6 46.0 4.80 1936 57,000 15.7 7.1 46.7 7.57 1937 58,030 15.0 6.6 40.0 0.0 1938 58,730 14.7 7.6 46.1 2.3 1939 59,510 13.2 7.1 35.4 3.7 1940 58,340 13.3 8.7 43.8 5.1 1941 56,840 12.2 8.4 40.5 1.4 1942 57,120 14.0 7.5 27.5 2.4 1943 56,600 13.9 8.2 39 4.9 1944 52,300 17.0 9.5 39 1.1 1945 54,230 15.0 8.2 23.2 0.0 1946 60,040 17.8 7.2 18.6 0.0 1947 61,270 17.0 7.8 22.8 0.0 1948 62,030 15.5 7.4 14.5 0.0 1949 62,310 13.2 8.3 29.0 0.0 11 TABLE 4. COMPARATIVE STATISTICS—1949. England and Wales. 126 County Boroughs and Great Towns including London 148 smaller Towns (Resident Populations 25,000 to 50,000 at 1931 Census). London Administrative County. Carshalton. *Rates per 1,000 Civilian Population. Births— Live 16.7† 18.7 18.0 18.5 13.2 Still 0.39† 0.47 0.40 0.37 0.25 Deaths— All causes 11.7† 12.5 11.6 12.2 8.3 Typhoid and Paratyphoid 0.00 0.00 0.00 0.00 - Whooping Cough 0.01 0.02 0.01 0.01 0.01 Diphtheria 0.00 0.00 0.00 0.00 — Tuberculosis 0.45 0.52 0.42 0.52 0.35 Influenza 0.15 0.15 0.14 0.11 0.06 Smallpox 0.00 0.00 — — — Acute Poliomyelitis and Polioencephalitis 0.01 0.02 0.02 0.01 - Pneumonia 0.51 0.56 0.49 0.59 0.52 Rates per 1,000 Live Births. Deaths under 1 year of age 32‡ 37 30 29 29 Deaths from Diarrhoea and Enteritis under 2 years of age 3.0 3.8 2.4 1.7 - Rates per 1,000 Civilian Population. Notifications— Typhoid fever 0.01 0.01 0.01 0.01 — Paratyphoid fever 0.01 0.02 0.01 0.01 — Cerebro Spinal fever 0.02 0.03 0.02 0.02 0.01 Scarlet fever 1.63 1.72 1.83 1.46 1.74 Whooping Cough 2.39 2.44 2.39 1.70 3.61 Diphtheria 0.04 0.05 0.04 0.07 0.01 Erysipelas 0.19 0.20 0.19 0.17 0.09 Smallpox 0.00 0.00 0.00 0.00 — Measles 8.95 8.91 9.18 8.54 7.60 Pneumonia 0.80 0.91 0.65 0.55 0.67 Acute Poliomyelitis 0.13 0.13 0.12 0.18 0.03 Acute Polioencephalitis 0.01 0.01 0.02 0.01 0.01 Food poisoning 0.14 0.16 0.14 0.19 4.80 Rates per 1,000 Total Births (Live and Still). Puerperal Fever and Pyrexia 6.31 8.14 5.30 6.82 46.37 Maternal Mortality— Abortion with Sepsis 0.11 Not available - Abortion without Sepsis 0.05 - Puerperal Infections 0.11 - Other Puerperal causes 0.71 - *A dash (—) signifies that there was none. †Rates per 1,000 total population. ‡Per 1,000 related live births. 12 COMPARATIVE HEALTH STATISTICS, 1934/49. 1 Death Rate (Civilian) per 1,000 population. Infant Mortality per 1,000 live births. Maternal Mortality (excluding abortion) per 1,000 total births. Year. England and Wales Carshalton. England and Wales Carshalton. England and Wales Carshalton. 1934 11.8 8.6 59.3 53.5 3.8 3.0 1935 11.7 6.6 57.0 46.0 3.4 2.4 1936 12.1 7.1 58.7 46.7 3.1 5.4 1937 12.4 6.6 57.7 40.0 2.7 0 1938 11.6 7.6 52.8 46.1 2.7 1.1 1939 12.1 7.1 50.6 35.4 2.5 2.0 1940 14.4 8.7 56.8 43.8 2.1 3.8 1941 13.5 8.4 60.0 40.5 2.2 0 1942 12.3 7.5 50.6 27.5 2.0 2.4 1943 12.1 8.2 49.1 39.3 1.8 4.9 1944 11.6 9.5 45.4 39.2 1.5 1.1 1945 11.4 8.2 46.0 23.2 1.4 0 1946 11.5 7.2 43.0 18.6 1.2 0 1947 12.0 7.8 41.0 22.8 1.0 0 1948 10.8 7.4 34.0 14.5 0.86 0 1949 11.7 8.3 32.0 29.0 0.82 0 DEATHS. The number of deaths allocated to the district by the RegistrarGeneral for 1949 was 521, of which 250 were males and 271 females. The crude death rate was accordingly 8.3 per thousand population compared with 7.4 in the year before. The "comparable" death rate arrived at by the application of the Registrar-General's comparability factor of 1.26 to allow for differences in the age and sex composition of the population was 10.4 per thousand population. This is the figure to be compared with the death rate for England and Wales of 11.7. The distribution of the deaths by wards was as follows:— WARD DEATH RATES AND MEAN AGE AT DEATH 1949. Ward. Deaths. Death Rate (crude). Mean Age at death. St. Helier North 55 6.3 58.1 yrs. St. Helier South 45 6.3 58.0 „ St. Helier West 50 5.9 59.5 „ North-East 83 8.8 56.3 „ North-West 75 10.2 64.8 „ Central 74 12.2 63.5 „ South-East (excluding Queen Mary's Hospital) 81 10.5 68.0 „ South-West 63 9.4 71.9 „ Whole District 526 8.5 62.8 yrs. 13 Mortality from cancer was lower, 84 deaths being attributable to this disease as against 98 in the year before. This provides a death rate for this cause of 1.33 per thousand population. CANCER DEATHS—WARD DISTRIBUTION, 1949. Ward. Cancer Deaths. Rate per 1,000 Estimated Population. St. Helier North 12 1.39 St. Helier South 8 1.13 St. Helier West 10 1.19 North-East 16 1.70 North-West 7 0.95 Central 12 1.97 South-East 11 1.42 South-West 8 1.19 The classification of the cancer deaths by sites affected is given in Table 5. TABLE 5. Group. Site Affected. Male. Female. Total. 46 Digestive Organs— Stomach 9 1 10 Liver and Biliary Passages 3 3 6 Intestines 6 4 10 Rectum 9 4 13 Pancreas — 2 2 Peritoneum 1 — 1 47 Respiratory Organs— Larynx 1 — 1 Lungs and Bronch 10 2 12 48 Uterus — 1 1 49 Other female genital organs — 4 4 50 Breast — 9 9 51 Male genital organs 3 — 3 52 Urinary Organs 4 2 6 54 Brain 1 1 2 55 Other organs— Glands 1 - 1 Carcinomatosis — 1 1 Thyroid — 1 1 Scapula — 1 1 48 36 84 Average age at death Males 65.9 yrs. Females 63.3 yrs. All persons 64.8 yrs. 14 Tuberculosis accounted for 22 deaths as against 25 in 1948, the death rate for this disease thereby fell to 0.35 per thousand population. The death rates from tuberculosis for the last twenty years were as follows:— Year. Death Rate per 1,000 Population. Year. Death Rate per 1,000 Population. 1930 0.51 1940 0.56 1931 0.66 1941 0.71 1932 0.52 1942 0.46 1933 1.10 1943 0.81 1934 0.60 1944 0.63 1935 0.96 1945 0.51 1936 0.64 1946 0.41 1937 0.63 1947 0.40 1938 0.63 1948 0.40 1939 0.77 1949 0.35 The distribution of tuberculosis mortality by wards and other details are given in Section F of this Report. The common infectious diseases were responsible for one death, that from whooping cough. There were no deaths from infantile paralysis or any of the other infectious diseases. Violence in one form or another caused the death of 24 residents in the following ways:— Suicide 4 Drowning 1 Road Traffic Accidents 4 Accidents in the Home 12 Accidents at Work 1 War Injuries 2 Inquests. Inquests were held on 42 persons who died in the district. The following verdicts were returned:— Accidental Death 28 Suicide 7 Open Verdict 1 Misadventure 2 Natural Causes 2 War Injuries 1 Indictment for Manslaughter 1 Nineteen of the total were residents of the district. Two deaths were due to road accidents. 15 INFANT MORTALITY. The deaths of 24 children who died under the age of one year were registered, of which 15 were males and 9 females. These provide an infant mortality rate of 29.0 per thousand live births compared with 14.5 in the year before. The comparable rate for England and Wales was 32. All infant deaths were of legitimate children. Fifteen of the 24 deaths occurred in the first month of life, 14 of them in the first week. Congenital malformations, prematurity and diseases peculiar to infancy accounted for 14, infections for 6, and accident for 2. The ward distribution of infant mortality and the causes of death are shown in Tables 6 and 7. TABLE 6. INFANT MORTALITY—WARD DISTRIBUTION. Ward. Infant Deaths. Rate per 1,000 Live Births. St. Helier North 4 32 St. Helier South 1 11 St. Helier West 1 8 North-East 8 45 North-West 2 19 Central 5 56 South-East 3 36 South-West - - MATERNAL MORTALITY. There was no death attributable to maternal causes. This is the fifth successive year with no maternal death. 16 TABLE 7. INFANT MORTALITY DURING THE YEAR 1949. Deaths Classified as to Cause and Age at Death. Cause of Death. Under 1 week. 1—2 weeks. 2—3 weeks. 3-4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total deaths under 1 year. Pneumonia 1 - - - 1 - 3 1 - 5 Erythroblastosis 2 — - — 2 — — — — 2 Prematurity 8 — — — 8 — — — — 8 Meningitis — — — — — — — — 1 1 Congenital Malformation 1 1 — — 2 2 — — 1 5 Atelectasis 1 — — — 1 — - — - 1 Accidental Inhalation of Material 1 - - — 1 1 - — — 2 Totals 14 1 — — 15 3 3 1 2 24 17 TABLE 8.—CAUSES OF DEATH DURING THE YEAR 1949. By Age and Sex. No. Causes of Death. 0 — 1 — 5 — 15 — 25 — 35 — 45 — 55 65 — 75 — All Ages. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Psns. All Causes 15 10 4 3 1 2 4 8 5 5 3 14 41 29 39 29 67 42 73 132 252 274 526 1 Typhoid and Paratyphoid Fevers — — — — — — — — — — — — — — — — — — — — — — — 2 Cerebro-Spinal Fever — — — — — — — — — — — — — — — — — — — — — — — 3 Scarlet Fever — — — — — — — — — — — — — — — — — — — — — — — 4 Whooping Cough — — — 1 — — — — — — — — — — — — — — — — — 1 1 5 Diphtheria — — — — — — — — — — — — — — — — — — — — — — — 6 Tuberculosis of Respiratory System — — — — — — 1 2 1 3 1 3 3 1 2 — 1 1 — — 9 10 19 7 Other Forms of Tuberculosis — — — — — 2 — — — — — — — — — — — — — 3 3 8 Syphilitic Diseases — — — — — — — — — — — — 1 1 — — 1 — — — 2 1 3 9 Influenza — — — — — — — — 1 — — — — — — — 1 — — 2 2 2 4 10 Measles — — — — — — — — — — — — — — — — — — — — — — — 11 Ac. Poliomyelitis and Polioencephalitis — — — — — — — — — — — — — — — — — — — — — — — 12 Ac. Infectious Encephalitis — — — — — — — — — — — — — — — — — — — — — — — 13 Cancer of Buc. Cav and Oesophagus (M) Uterus (F) — — — — — — — — — — — — — 1 — — — — — — — 1 1 14 Cancer of Stomach and Duodenum — — — — — — — — — — — — 1 — 1 — 4 1 3 — 9 1 10 15 Cancer of Breast — — — — — — — — — — — 2 — 2 — — — — — 5 — 9 9 16 Cancer of all Other Sites — — — — — — — 2 1 — — 2 6 2 8 6 16 4 8 9 39 25 64 17 Diabetes — — — — — — — — — — — — — — — — — — — — — — — 18 Intra-cranial Vascular Lesions — — — — — — — — — — — — 1 2 2 5 2 9 5 17 10 33 43 19 Heart Disease — — — — 1 — — — — 1 — 2 13 6 16 5 22 16 31 57 83 87 170 20 Other Diseases of Circulatory System — — — — —-— — — — — — — 1 2 1 — 1 1 5 6 12 9 20 29 21 Bronchitis — — — — — — — — — — — — — 2 1 3 4 — 3 9 8 14 22 22 Pneumonia 2 3 2 — — — — — — — — — 3 1 1 — 6 2 5 1 19 13 32 23 Other Respiratory Diseases — — — — — — — —-— — — — — 1 — 2 — — 1 — 2 3 3 6 24 Ulcer of Stomach or Duodenum — — — — — — — — — — — — 1 — 1 2 1 — 2 — 5 2 7 25 Diarrhoea, under 2 years — — — — — — — — — — — — — — — — — — — — — — — 26 Appendicitis — — — — — 1 — — — — — — 1 — — — — — — — 1 1 2 27 Other Digestive Diseases — — — — — 1 1 — 1 1 1 1 2 2 — — — — — — 5 5 10 28 Nephritis — — — — — — — 1 — — 1 — — 2 — 2 2 1 1 — 4 6 10 29 Puerperal and Post Abort. Sepsis — — — — — — — — — — — — — — — — — — — — — — — 30 Other Maternal Causes — — — — — — — — — — — — — — — — — — — — — — — 31 Premature Birth 5 2 — — — — — — — — — — — — — — — — — — 5 2 7 32 Congenital Malformation, Birth Injury, Infant Diseases 6 4 — — — — — — — — — 1 1 — — 1 — — — — 7 6 13 33 Suicide — — — — — — — — — — — 1 — 2 1 — — — — — 1 3 4 34 Road Traffic Accidents — — — — — — 1 — — — — — — — — — 1 — — 1 2 2 4 35 Other Violent Causes 1 1 — 1 — — 1 — 1 — — — 1 1 1 1 — 1 3 3 8 8 16 36 All Other Causes 1 — 2 — — — — 1 — — — 1 4 3 3 3 5 — 6 8 21 16 37 18 Section B—Health Services. Nursing in the Home. Home nursing is now the responsibility of the County Council as the local health authority under Section 24 of the National Health Service Act, 1946. Under the County scheme an agreement has been entered into with the Surrey County Nursing Association to which the majority of the voluntary District Nursing Associations are affiliated. Laboratory Facilities. Clinical material in connection with infectious disease, food poisoning, puerperal pyrexia and tuberculosis was submitted for examination to the Emergency Public Health Laboratory, St. Helier Hospital, the Sutton and Cheam Hospital Laboratory, and in special circumstances to the Epsom Public Health Laboratory. The facilities provided by the Public Health Laboratory Service at Epsom are restricted by the inadequacy of the premises in which the Laboratory is accommodated. In consequence the biological testing of milk for tuberculosis cannot be undertaken. Food and Drugs and water samples were examined by Mr. D. D. Moir, the Council's Public Analyst, whose laboratory is at 16, Southwark Street, London, S.E.1. The following examinations were made during the year:— Throat and Nose Swabs 45 Faeces examination 11 Rectal Swabs 60 Water:— For chemical analysis 2 For bacteriological examination 5 Food and Drugs:— Analysis 307 Bacteriological examination of milk 202 Bacteriological examination of ice-cream 139 Bacteriological examination of other foods 26 19 TABLE 9. Admissions to Isolation Hospitals, 1949. Disease. Cuddington. Croydon. Bletchingley. West Kent. Bromley and Beckenham. Wimbledon. Wandle Valley. The Grove. Park. Brook. South Middlesex. Queen Mary's. Tolworth. St. Helier. Scarlet Fever 33 4 — — — 2 23 5 — — 1 — — 1 69 Scarlet Fever and Chicken-pox — — 2 — — — — — — — — — — — 2 Diphtheria 1 — — — — — — — — — — — — — 1 Meningococcal Meningitis — — — — — — — — — — — — — 1 1 Poliomyelitis 1 — — — — — — — — — — 1 — — 2 Polioencephalitis — — — — — — — — — — — — — 1 1 Erysipelas — — — — — — 2 1 — — — — — — 3 Whooping Cough 14 — — 1 — — 3 — 1 — — — — — 19 Measles 31 — — — 1 — 12 — — — — — — — 44 Dysentery — — — 1 1 — — — — — — — — — 2 Rubella 2 — — — — — — — — — — — — — 2 Chicken-pox 4 1 — — 1 — — — — — 2 — — — 8 Mumps 4 — — — — — 6 — — 2 — — — — 12 Pneumonia 2 1 — — — — 1 — — — — — — — 4 Food Poisoning 1 — — — — — — 1 — — — — — 2 Tonsilitis 4 — — — — — 2 — — — — — — — 6 Gastro-enteritis 2 — — — — — — — — — — — — — 2 Others 9 — — — — — 3 3 — — — — 2 — 17 108 6 2 2 3 2 52 10 1 2 3 1 2 3 197 20 Hospitals. All the hospitals in the district are now administered by the SouthWest Metropolitan Regional Hospital Board. The isolation hospital facilities which previously were controlled by the local sanitary authorites through their Joint Board played a predominant part in the control of infectious disease. The authority which the Medical Officer of Health had to admit cases to such hospitals was one of his chief weapons in this field of preventive medicine. Its loss is a handicap which should not have been imposed upon him. He now finds that the local bed accommodation for this type of illness has been seriously reduced, that some other authority decides whether a case of infectious disease shall be admitted or not, and that such cases have, on an increasing scale, to be conveyed greater distances to the nearest available bed with greater prejudice to recovery. The transmission of information as to admissions and discharges of patients now takes much longer than in the days when we had daily telephone contact with the Joint Board's own local fever hospital where, almost without exception, all infectious cases could be accommodated. This is a significant disadvantage when it is remembered that time is of the essence of infectious disease control. Table 9 shows the cases admitted to isolation hospital during the year. Vaccination and Immunisation. The Council agreed with the County Council that their Medical Officer of Health should continue to direct the arrangements in the district for diphtheria immunisation and for vaccination against smallpox, the provision of which services was a function placed upon the County Council by Section 26 of the National Health Service Act, 1946. Details of the operations of these schemes are given in Section F of this Report dealing with infectious disease. Byelaws. In November the Council approved " Byelaws as to the handling, wrapping and delivery of food and sale of food in the open air " and in December " Byelaws as to the business of hairdresser or barber." Both received ministerial confirmation in January, 1950. Clinics and Treatment Centres. The following programme of clinics is provided by the County Council and the Hospital Board and are available to residents of the district. 21 Care of Mothers and Young Children. Rochester Road Centre:— Infant Welfare Clinic Tues. and Thurs. 2—4 p.m. Maternity Clinic Mondays 10 —12 a.m. Toddler Clinic Wednesdays 2—4 p.m. Dental Clinic Mons. and Thurs. 10—12 a.m. Fourth Saturday 10—12 a.m. Massage Clinic Mons., Tues., Weds., Thurs., Fri. 10-a.m.—1 p.m. Mons., Tues., Thurs. Friday 2—5 p.m. Wry the Lane Centre:— Infant Welfare Clinic Weds, and Fridays 2—4 p.m. Maternity Clinic Tues. and Fridays 10—12 a.m. Toddler Clinic Tuesdays 2—4 p.m. Stanley Road Centre:— Infant Welfare Clinic Fridays 2—4 p.m. Maternity Clinic Tuesdays 10—12 a.m. Toddler Clinic 1st and 3rd Thurs. 2—4 p.m. St. Helier Centre—Green Lane:— Infant Welfare Clinic Mondays 2—4 p.m. Maternity Clinic Thursdays 10—12 a.m. The Mount Centre:— Infant Welfare and Maternity Clinic Wednesdays 2—4 p.m. School Health Service—General Medical Clinics. Rochester Road Centre Weds, and Fridays 9.30—12 a.m. Stanley Road Centre Mondays 9.30—12 a.m. Middleton Road Centre, Morden Mons. and Weds. 9.30—12 a.m. Dental, eye and special clinics for child guidance, speech therapy, etc., are provided, attendance at which is by appointment. Diphtheria Immunisation and, Vaccination. Treatment is available for children under 5 at infant welfare clinics and for school children at school clinics. Tuberculosis Clinics. St. Helier Hospital Mondays and Fridays Wednesdays 4th Monday (for old cases only) 2 p.m. 9.30 a.m. 5 p.m. Venereal Disease Clinics. St. Helier Hospital Mondays (Males) Wednes. (Females) Fri. (Females) 1.3 5—7 p.m. 4.30—7 p.m. 0—3.30 p.m. 22 Section C—Sanitary Circumstances. Water Supply. With the exception of 170 dwellings in the extreme north the district is supplied by the Sutton and District Water Company with water derived normally from chalk wells situated at Sutton, Cheam, and Woodmansterne. The supply can, if necessary, be augmented by the Metropolitan Water Board, the Epsom and Ewell Corporation and the East Surrey Water Company. The Company is under statutory obligation to soften to 9 of hardness. The supply throughout the year was satisfactory both in quality and quantity and no significant contamination was detected. A comprehensive programme of testing of the raw and finished waters is carried out by the Company's resident chemist supplemented by periodical sampling by the Counties Public Health Laboratory. The following analysis of the examinations carried out in the Company s Laboratory is supplied by courtesy of the Engineer and Works Manager. Sample. No. of Bacteriological Examina tions. No. of Full Chemical Analyses. Coli Aerogen Organisms present in 100 ml. of Samples (excluding B. Coli 1 & 2). B. coli present in 100 ml. Types 1 & 2. Total Coli Aerogen Organisms. No. % No. % Sutton Raw 308 21 24 7.8 20 6.5 44 Sutton Finished 310 19 22 7.1 17 5.5 39 Woodmansterne Raw 302 18 Nil Nil Nil Nil Nil Woodmansterne Finished 305 17 1 0.33 Nil Nil 1 Cheam Raw 310 21 22 7.1 5 0.97 27 Reservoir 217 Nil 2 0.96 Nil Nil 2 District (excluding new Mains) 284 5 3 1.06 3 1.06 6 23 Water as it reaches the consumer is sampled as a routine by the health departments of the sanitary districts supplied by the Company on an agreed rota. The following is a representative report :— Chemical analysis in parts per million. Total solid matter in solution (dried at 180° C.) 2.11 Combined chlorine 17.5 Nitric nitrogen 8.4 Nitrous nitrogen 0.048 Ammonia, free and saline 0.012 Ammonia, albuminoid 0.017 Oxygen absorbed from permanganate in 4 hours at 26.7° C. 0.065 Hardness—by acidimetric titration—Temporary 78 Permanen 50 Total 128 Reaction for free chlorine 0.07 pH 7.8 The water was bright and clear and was slightly bluish in colour. Bacteriological examination. Action by free chlorine during transit of the sample was prevented at the time of sampling. Number of colonies per ml. developing upon agar in 2 days at 37° C. 0 Number of colonies per ml. developing upon agar in 3 days at 22° C. 0 Organisms of the coliform group absent in 100 ml. Streptococci do. C1. welchii do. This water is of high organic purity and is similar in chemical composition to previous samples from this source. The residual chlorine indicates that treatment is being maintained. The bacteriological condition is excellent and the water is suitable for the public supply. The waters are not plumbo-solvent. The whole of the population of the district is supplied directly from the mains and there are no stand pipes. Drainage and Sewerage. No extensions or replacements of the main sewerage system took place in 1949. Arrangements have been made for the Council to adopt all the main sewer runs on the Woodcote Smallholdings, but adoption has not yet taken place. One of these sewers is being extended for a length of approximately 360 yards to Woodcote Grove House and work commenced in December. The whole of the developed area is soil sewered except for a small part containing 17 properties in the southern end of the district. 24 Sewage is pumped to the disposal works of the Croydon Corporation in Beddington, except at various points on the fringes of the district, where it is more conveniently drained to the sewage systems of neighbouring authorities. Surface drainage in the south is mainly by soakaways in the chalk; elsewhere it is by surface sewers to the River Wandle. Rivers and Streams. Maintenance of the branch of the River Wandle which flows through Carshalton was taken over by the County Council in April, 1947. The length from Hackbridge to the junction with the main stream by Mitcham Works was dredged and cleared of weeds early in the year. No complaints were received by the Health Department during the year. Closet Accommodation. All premises have W.C.s connected to the sewers except seventeen in an unsewered area connected to cesspools. Public Cleansing. The arrangements for refuse collection were improved by the acquisition of two new collecting vehicles of 12 cu. yd. capacity and a secondhand freighter of 15 cu. yd. capacity. A regular weekly collection from all houses was maintained except at Public Holiday periods. Disposal of refuse is by incineration at the Ccuncil's destructor. Alterations and improvements were made to the plant in 1949 to provide an increase in the rate of feed of refuse to the main conveyor, to increase the amount of screenings by the installation of larger mesh screen plates and so enable the rate of burning and consequently the daily tonnage handled to be increased. Screenings and clinker were disposed of to depots in Merstham, Tolworth, and Beddington. These and other improvements now enable the works to handle 300 tons per week without overtime. Kitchen waste is still collected as pig food, the bins for which are cleansed by steam. Sanitary Inspection. The following information supplied by the Chief Sanitary Inspector, under Article 27 of the Sanitary Officers' Regulations, 1935, indicates the action taken in sanitary inspection during the year. 25 Investigations were made with regard to 1,647 complaints as follows:— Accumulations 32 Animals 9 Ants 4 Beetles 3 Burst Pipes 5 Dampness 35 Drainage defects 59 Drains obstructed 278 Dustbins 189 Flies 3 Food, contaminated 10 General defective conditions 170 Insects, various 4 Milk, contaminated 8 Milk, dirty bottles 1 Milk, sour 2 Miscellaneous 53 Obnoxious effluvia 31 Overcrowding 71 Pig bins 9 Rats and mice 281 Refuse collection 27 Roofs, gutters, etc. 26 Sewers obstructed 8 Shops 2 Sink waste pipes 6 Smoke nuisance 6 Unsound food 155 Verminous premises 24 Wasps 132 Water supplies 4 1,647 Twelve thousand, one hundred and ten visits of inspection and re-inspection were made for the purposes set out below :— Animals, slaughter of 3 Bakehouses 28 Cowsheds 47 Dairies 43 Employment Agencies 3 Factories 549 Food and Drugs and other samples 699 Food poisoning enquiries 10 Food shops and business premises 2,177 House drains tested 39 Housing Act 159 Housing Enquiries 843 Infectious disease contacts 263 Infectious disease premises 148 Offices 16 Carried forward 26 Brought forward Outworkers premises 82 Overcrowding 260 Piggeries 13 Premises re cesspools Public Health Act (Houses) 3,078 Public Health Act re inspections 3,281 Schools 18 Smoke observations 38 Suspected rat infested premises 220 Urinals 76 Water sampling 6 12,110 One thousand and twenty-three informal notices were served concerning the following matters:— Accumulations and deposits 10 Animals 3 Burst pipes 3 Drainage defects 95 Dustbins 42 Factory Acts 3 Food and Drugs 92 Food contamination 25 General defective conditions 371 Housing Act, 1936, Notices to inspect 192 Miscellaneous 2 Obstructed drains 10 Overcrowding 81 Rats and Mice 5 Rivers 3 Shops Acts 60 Smoke nuisance 2 Unsatisfactory food premises 1 Verminous premises 12 Water supply 5 1,023 One hundred and two formal notices were served by authority of the Council under the following Acts :— Section 24, Public Health Act, 1936 12 Section 39, „ „ 3 Section 45, „ „ 3 Section 75, „ „ 5 Section 93, „ „ 69 Section 277, „ „ 4 Section 13, Food & Drugs Act, 1938 5 Section 7, Factories Act, 1937 1 102 27 As a result of investigations made and notices served, the following work was carried out:— Accumulations removed 16 Brickwork, repaired and/or repointed 13 Ceilings cleansed and purified 103 Ceilings, new provided 31 Ceiling plaster repaired and/or made good (including plaster board) 101 Chimney pots repaired and/or made good 3 stacks repaired and/or made good 4 flues repaired 36 Coppers repaired or renewed 1 Damp conditions remedied 96 Damp course provided 1 renewed 6 Disinfestation 60 Door cills repaired 3 Door frames repaired and/or made good 10 Doors repaired, including locks and fasteners 7 Drainage repaired and/or reconstructed 10 inspection chamber repaired and/or made good 6 inspection chamber covers renewed 13 stoppers or caps refixed and/or renewed 1 fresh air inlet repaired and/or renewed 7 soil vent repaired and/or renewed 11 drains tested 27 drains cleared (affecting 658 houses) 230 drains sealed off 3 waste gullies repaired, renewed or cleared 15 waste gullies provided 1 waste pipes, repaired, renewed or provided 21 Dustbins provided 91 Fences repaired or renewed 1 Fire grates repaired and/or renewed 10 Fireplaces repaired and/or made good 12 Floor boards repaired and/or made good 32 concrete repaired, renewed and/or made level 4 ventilation provided 1 Food storage provided 2 ventilated 2 Glazing panes and putty renewed 18 Other matters 19 Paving repaired and/or made level 10 provided 2 drained 4 Ranges, stoves repaired and/or renewed 10 provided 2 Roofs repaired and made weatherproof 79 stripped and recovered 5 flashings repaired and/or renewed 3 Downpipe, guttering repaired and/or renewed 35 provided 2 cleared out and made to work properly 15 Shops, forms provided 42 temperature maintained 5 seats provided 5 light, more provided 3 hot water, means of supply provided 40 28 Sinks renewed or repaired 7 provided 1 Soakaway made to work properly 6 Stair treads repaired, renewed or made level 4 handrails and/or balusters repaired 3 Steps repaired and/or renewed 5 Surface water drainage repaired and made to work properly 4 drainage provided 1 Ventilation, more provided 5 Walls, cement rendered 3 rendering repaired 5 replastered and/or repaired 112 cleansed and redecorated 97 rebuilt 4 Wash basins, baths renewed 1 provided 9 Water cisterns repaired 2 Water Supply repaired 9 provided 1 W.C. accommodation repaired 3 pans renewed 14 pan joints renewed 4 seats repaired, renewed or provided 9 flushing apparatus repaired or renewed 32 W.C.s provided 1 Windows made to open 2 Window frames repaired and/or renewed 13 Windows made to work properly 11 provided with catches or fasteners 1 sash cords renewed 28 Windows repaired and/or renewed 22 Window cills (external) repaired 6 stopping to reveals 2 Woodwork repaired and/or renewed 13 Disinfection. In connection with cases of infectious disease, 142 rooms and 180 library books were disinfected. Twenty-nine lots of bedding were steam disinfected and six lots destroyed. Vermin Control. Persons. For the cleansing of verminous persons and their personal clothing the Council have established a Cleansing Station, equipped with a Thresh Steam Disinfector in Rochester Road. A trained nurse is in attendance to deal with women and children, and a male operator for the men. Financial arrangements have been made with the Education Authority for the treatment of school children. The nurse-in-charge undertakes the following up of the families affected to ensure that treatment is carried to a successful conclusion. The homes are also visited by the Sanitary Inspectors when necessary, and appropriate action in respect of the premises taken as required. 29 The following cases were dealt with at the Council's station during the year:— Families. Persons. Attendances. For scabies 12 32 85 For pediculosis 21 45 91 33 77 170 School children included in these totals were:— For scabies 19 For pediculosis 28 Where possible, the practice of treating all members of affected families is followed. Premises. During the year, four lots of verminous bedding were stoved and two lots were destroyed. Ninety-two premises were treated for the destruction of vermin and insect pests as follows:— Infestation. Sprayed by C.U.D.C. Sprayed by L.C.C. Sprayed by Owners. C.U.D.C. Property L.C.C. Property Privately Owned Property L.C.C. Property Privately Owned Property Beetles 4 1 Bugs 2 — 6 3 1 Fleas — — 1 — — Wasps 11 2 61 - - 17 2 69 3 1 Smoke Abatement. Six complaints were received and dealt with during the year. Rats and Mice (Destruction) Act, 1919. Under the direction of the Ministry of Agriculture and Fisheries rodent destruction was carried out during the year. Five thousand seven hundred and twenty-nine visits were made and 343 rat and mouse infestations found. Of that number 303 were found in private premises, 25 in business premises and 15 in Council premises. 30 With regard to sewers, two maintenance treatments were carried out, one in May and the other in November with the following results :— May Treatment. November Treatment. Manholes baited 228 159 Manholes in which takes of prebait were recorded 64 35 Percentage of manholes showing infestations 28 22 Percentages in relation to total manholes in district 5.6 3 Shops Act, 1912-1938. Seven hundred and fifty-eight inspections of shops were made and informal action was necessary regarding infringements in 60 cases. There were 497 shop premises on the register at the end of the year. Section 10 (Health and Comfort). Three shops had improved lighting provided. Five shops were provided with means of maintaining a reasonable temperature. One shop was provided with sanitary accommodation. Forty shops were provided with washing facilities. Offices. Sixteen inspections of offices were made, but no action was necessary. Swimming Baths. The one privately owned swimming bath was in use during the year, and four samples of water were taken, all of which were satisfactory. Disposal of the Dead. The number of interments in the Carshalton and Merton and Morden Joint Cemetery Board's Cemetery at Morden during the year under review was 358, and of this number 128 were from the Carshalton district. The Churchyard adjoining the Carshalton Parish Church continues to be used for burials, but this is mainly for the re-opening of existing graves. Negotiations for the establishment of a Crematorium to serve the districts of the Battersea Metropolitan Borough Council, Wimbledon Borough, Sutton and Cheam Borough, and that covered by the 31 Carshalton and Merton and Morden Joint Cemetery Board have continued during the year, but whilst a measure of agreement has been reached to provide a Crematorium at Lower Morden, there is, having regard to the prevailing economic conditions, no early prospect of the necessary legal steps being taken to set up a joint Board preparatory to the establishment of the Crematorium. Modern mortuary facilities with provision for post-mortem examinations are provided at the Council's Mill Lane Mortuary. During the year 68 bodies were received into the mortuary, on 67 of which autopsies were performed. National Assistance Act—Section 50. The Council was responsible for one burial under Section 50 of the National Assistance Act, 1948. Establishments for Massage and Special Treatment. Eight establishments for massage or special treatment coming within the scope of Part IV of the Surrey County Council Act, 1931, were visited and inspected. All were found to be satisfactory. Five were used for the practice of chiropody. Employment Agencies. Three employment agencies licensed in accordance with Part V of the Surrey County Council Act, 1925, were visited and found to be satisfactory. 32 Section D—Housing. New Houses. During the year 29 houses of the following types were completed:— "Unity" Permanent Prefabricated Council Houses 22 Privately owned under Licence 4 Rebuilt War Damaged Council Houses 2 Rebuilt War Damaged Privately owned Houses 1 Total 29 Houses in course of erection at the end of the year were as follows:— New Council Houses and Flats 125 Privately owned Houses under licence 1 Rebuilding of War Damaged Privately owned House 1 Total 127 Council's Housing Scheme. The dwellings in the ownership of the Council at the year end totalled 915 houses, flats and temporary bungalows. During the year work continued or was commenced on the undermentioned Contracts:— Site No. Site. Type. No. in Contract. No. completed during year. 3 Clock House Farm Estate (part) "Unity" permanent prefabricated 96 22 3 Clock House Farm Estate (part) Traditional houses 38 — 10 Denmark Road Flats 72 — 11 Alma Road ” 9 — 12 Harrow Road ” 6 — 221 22 33 In addition, the following schemes were in varying stages of preparation with a view to work being commenced during the period of one year beginning on the 1st July, 1949. Site No. Site. Type. No. in Contract. 17 Station Approach ' Flats 30 18 Banstead Road ” 6 23 Lavender Road ” 10 24 Lyndhurst Avenue ” 86 132 The accommodation under requisition by the Council at 31st December, 1949, comprised 151 premises, providing accommodation for 229 families. The number of outstanding approved applications for tenancies at the year end was approximately 1,760. Inspection and Action taken under Statutory Powers. 1. Inspections of Dwelling Houses during the year. (1) (a) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) H.A.—159 P.H.A.—3,078 3,237 (b) No. of inspections made for the purpose 6,518 (2) (a) Number of dwelling houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 to 1932 (b) Number of inspections made for the purpose (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-head) found not to be in all respects reasonably fit for human habitation 533 2. Remedy of defects during the year without service of formal notices. Number of defective dwelling houses rendered fit in consequence of informal action by local authority or their officers (including houses inspected during 1947) 367 34 3. Action under Statutory Powers during the year. (a) Proceedings under Sections 9, 10 and 16 of the Housing Act, 1936. Number of dwelling houses in, respect of which notices were served requiring repairs Number of dwelling houses which were rendered fit after service of formal notices (a) By owners - (b) By local authority in default of owners - (b) Proceedings under Public Health Acts. (1) Number of dwelling houses in respect of which formal notices were served requiring defects to be remedied 89 (2) Number of dwelling houses in which defects were remedied after service of formal notices:— (a) By owners 71 (b) By local authority in default of owners 1 4. Housing Act, 1936. Part IV (Overcrowding). (a) (1) Number of dwelling houses overcrowded at the end of the year 221 (2) Number of families dwelling therein 321 (3) Equivalent number of adults dwelling therein 1,579 (b) Number of new cases reported during the year 94 (c) (1) Number of cases of overcrowding relieved during the year 160 (2) Number of persons concerned in such cases 1,115 ½ (d) Particulars of any cases in which dwelling houses have again become overcrowded after the local authority have taken steps for the abatement of overcrowding — Overcrowding. During the year 94 cases of overcrowding were found to exist and 100 cases were remedied, leaving 221 known to be still overcrowded with 1,579 equivalent adults in occupation at the end of the year. 35 The known position with regard to overcrowding at the beginning and the end of the year was as follows :— Ward. Dwellings overcrowded at 31.12.48 Dwellings decrowded during 1949 Dwellings found overcrowded during 1949 Dwellings remaining overcrowded at 31.12.49 Overcrowded cases remedied during 1949. Formal Action Informal Action Total. St. Helier North 85 48 19 56 25 23 48 St. Helier South 57 34 24 47 17 17 34 St. Helier West 51 23 23 51 13 10 23 North-East 52 29 11 34 10 19 29 North-West 14 11 5 8 4 7 11 Central 10 7 5 8 2 5 7 South-West - - - - - - - South-East 18 8 7 17 1 7 8 287 160 94 221 72 88 160 In 81 of the new instances of overcrowding there was more than one family in occupation, in 75 of which families were sharing accommodation with relatives. Abatement of overcrowding was effected in the following manner:— Provision of alternative accommodation by— C.U.D.C 17 L.C.C 48 Other Local Authorities 7 Left the District 33 Removal of one or more occupants 55 Of the 221 dwellings remaining overcrowded at the end of the year, 152 are owned by the L.C.C., 25 by the Carshalton Urban District Council, and 44 are privately owned. Slum Clearance and Demolition. There still remain some properties which have reached the end of their useful life and which provide accommodation well below an acceptable standard. With the acute shortage of housing accommodation no action with regard to demolition or clearance was undertaken, but it is to be hoped that the rebuilding programme will permit the resumption of this necessary work of rehousing without much longer delay. Tents, Vans, Sheds and Similar Structures. Action was in progress at the end of the year with regard to two movable dwellings. Rent and Mortgage Interest Restrictions (Amendment) Act, 1933. No action was necessary during the year. Factories and Workplaces. There were 122 factories and workplaces on the Register, 83 of them using mechanical power. Employees numbered 1,324, of whom 832 were males and 492 females. Action was necessary with regard to 4 of the factories (3 informal, 1 formal). The following table classifies those employed:— Employees. Premises. Males. Females. Total. Factories— with mechanical power 701 466 1,167 65 without „ „ 95 19 114 20 Workplaces— with mechanical power 18 1 19 18 without „ „ 18 6 24 19 832 492 1,324 122 36 The following table, set out in the manner prescribed by Home Office Form 572 (Revised), indicates the inspections made and action taken under the Factories Act. 1. Inspections for purposes of provisions as to health (including inspections made by Sanitary Inspectors). Premises. (1) Number on Register (2) Number of Inspections. (3) Written Notices. (4) Occupiers Prosecuted. (5) (i) Factories in which Sections 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 20 315 (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 65 234 4 (iii) Other premises in which Section 7 is enforced by the Local Authority* (excluding outworkers' premises) - - - - Total 85 549 4 - * Electrical Stations (Section 103 (1)), Institutions (Section 104) and sites of Building Operations and Works of Engineering Construction (Sections 107 and 108.) 2. Cases in which Defects were found (If defects are discovered at the premises on two, three or more separate occasions they should be reckoned as two, three or more " cases.") Premises. Number of cases in which defects were found. Number of cases in which prosecutions were instituted. Referred Found Remedied. To H.M. Inspector. By H.M. Inspector. (1) (2) (3) (4) (5) (6) Want of cleanliness - - - - - Overcrowding - - - - - Unreasonable temperature - - - - - Inadequate ventilation - - - - - Defective drainage of floors - _ - - - Sanitary Conveniences— (a) Insufficient 2 1 - - - (b) Unsuitable or defective 2 2 - - - (c) Not separate for sexes - - - - - Other offences against the Act (not including offences relating to Outwork) - _ - - - Total 4 3 - - - 37 Outwork (Sections 110 and 111). Nature of Work. Section 110. 1 Section 111. No. of outworkers in Aug. list required by Sect. 110(1) (c) No. of cases of default in sending lists to the Council. No. of prosecutions for failure to supply lists. No. of instances of work in unwhole some premises. Notices served. Prosecutions. (1) (2) (3) (4) (5) (6) (7) Wearing Apparel— Making, etc. 41 — — — — — Cleaning and washing — — — — — — Brass and Brass Articles 7 — — — — — The making of boxes or other receptacles or parts thereof made wholly or partially of paper 2 - - - - - Cosaques, Christmas Crackers, Christmas stockings, etc. 35 — — — — — Total 85 — — — — — 38 Section E—Inspection and Supervision of Food. Milk Supply. On October 1st, registration and supervision of dairy farms and dairy farmers became the responsibility of the Ministry of Agriculture and Fisheries. At that date there were 3 cowkeepers registered in this district, 2 of whom were authorised to use the term " Accredited Milk." Until the functions were transferred regular inspections of these farms were made. Only a very small proportion of the milk consumed in the district is unpasteurised or not heat treated in some other way. Milk Distributors. The Milk and Dairies Regulations, 1949, which replaced the Regulations, 1926-1943, came into force on October 1st. Ten milk retailers who were already registered with the Council re-registered as distributors under the new Regulations. The number so registered increased to 14 by the end of the year. Milk (Special Designation) (Raw Milk) Regulations, 1949. Milk (Special Designation) (Pasteurised and Sterilised Milk) Regulations, 1949. These Regulations, which also came into force on the 1st October, replaced the earlier Special Designation Regulations. "Sterilised Milk" is a new designation and the Raw Milk Regulations provide for the use of the existing designation "Accredited Milk" only until October, 1954. Thereafter the only special designated raw milk will be "T.T. Tested." The Milk (Special Designation) Act, 1949, provides for the obligatory use of a special designation on retailing milk in areas specified by the Minister of Food. Carshalton has not yet been so specified. The effect of such specification after October, 1954, will be that only the following milks can be supplied on retail otherwise than as refreshments— Raw Milk: Tuberculin Tested. Milk Subject to Heat : Pasteurised. Sterilised. Tuberculin Tested (Pasteurised). Tuberculin Tested (Sterilised). 39 The licences issued to distributors to use special designation before the operative date of the new Regulations and at 31st December, 1949, were as follows:— Designation. Licences in Force up to 1/10/49. Licences in Force on 31/12/49. Principal Licences— Sterilised — 7 Pasteurised 5 5 Tuberculin Tested 6 6 Supplementary Licences— Sterilised - 6 Pasteurised 7 7 Tuberculin Tested 8 8 Bacteriological Examination of Milk. Two hundred and two samples of milk were procured and submitted for bacteriological examination. All the milks were sold under the Milk (Special Designations) Regulations and 20 failed to comply with the prescribed Regulations. The test results were as follows :— Designation under which sold. No. of Samples. Methylene Blue Test. Phosphatase Test. Turbidity Test. Satisfactory. Unsatisfactory. Satisfactory. Unsatisfactory. Satisfactory. Unsatisfactory. T.T. Pasteurised 36 35 1 35 1 Pasteurised 118 105 13 115 3 — — Heat Treated 47 43 4 47 — - — Sterilised 1 1 1 — 1 — 202 184 18 198 4 1 — 40 Ice Cream. The sampling of Ice Cream was carried on and the following table gives the results:— No. of Samples. Grade. 1 2 3 4 139 09 33 28 9 Meat and Other Foods. Meat is supplied from the Ministry of Food depots outside the district. There are 21 premises on which pigs are known to be kept. There was no private slaughtering during the year. Twenty-six other foodstuffs were submitted for bacteriological examination in cases of suspected food poisoning. The tests which gave significant results are referred to in the Section of this Report dealing with food poisoning. Food and Drugs Act, 1938. The following 307 samples were procured and submitted for analysis:— Article. No. Adulterated or otherwise irregular. Article. No. Adulterated or otherwise irregular. Butter 6 1 Milk, Condensed 1 Butter, Peanut 1 Olive Oil 1 "Cherryade" 1 Onions, Dried 1 Chocolate Cup 1 Pastry Mixture 1 Chocolate, Drinking 1 Popcorns 1 Cinnamon, Milled 1 Pudding, Christmas 1 Cocoa 2 Pudding, Mixture 1 Coffee & Chicory Essence 2 "Quoffy" 1 "Crunches, Buttered" 1 Saccharine 1 Custard Powder 2 Salad Dressing 2 Extract, Beef 1 Sandwich Spread 1 Fat, Sweetened 1 Sauce 3 1 "Frizzets" 1 Sausage, Beef 3 1 Glycerine & Honey 1 Sausage, Pork 1 "Golden Ruskit" 1 Semolina 2 Groats 1 Sieved Apple with Ice Cream 20 Sugar 1 Jam Tart 1 Soup 3 Jelly 1 Sponge Mixture 2 Jelly Crystals 1 Squash, Grape Fruit 2 Lemonade 1 Squash, Orange 1 Marmalade, Ginger 1 Stuffing, Sage & Onion 1 Marmalade, Orange "Marmalyn" 1 Sugar, Brown 1 1 1 Sweets, Boiled 1 1 Meat, Sausage 3 1 Syrup, Black Currant 1 Meat, Nut 1 Syrup of Figs 1 Milk 208 1 Tea 2 Milk, Malted 1 Vinegar, Malt 1 1 Whisky 5 1 41 The following 9 samples (2.9%) were reported as adulterated or otherwise irregular:— Beef Sausage. Deficiency of meat of 5%. Warning given. Dairy Butter Sweets. These were found to contain 110 parts per million of sulphur dioxide. Manufacturers maintained that sulphur dioxide was necessarily introduced in process of manufacture. No action. Butter (Informal Sample). This sample was certified to be margarine. A subsequent formal sample proved to be genuine. Malt Vinegar. On analysis this contained 0.8% added salt (sodium chloride). Although not a normal constituent it was not injurious and in the absence of a statutory standard for vinegar no action was taken. Sausage Meat. This was certified to be 24% deficient in meat. The case was referred to the Ministry of Food who prosecuted. The vendor was convicted and fined £10 and 5 guineas costs. Milk. This sample had a 1% deficiency of solids not fat. No action taken. Tomato Sauce. Found to contain sulphur dioxide to the extent of 125 parts per million. The manufacturers explained that, in the manufacture of this sauce, sieved apple pulp had been used and that the sulphur dioxide found on analysis was derived solely from that source and that none had been introduced otherwise. Sulphur dioxide in fruit pulp is statutorily permissible. Brown Sugar (Informal Sample). This was certified to contain soda. The matter was taken up with the vendor, but, in view of the circumstances of the case, legal action was unlikely to be successful. Whisky. This was found to be 37.5 degrees under proof against the statutory limit of 35 degrees u.p. The vendor's explanation that the dilution was due to the sample being measured into a wet container was accepted with a warning. 42 Section 9.- Sale of Food Unfit for Human Consumption. Complaints were received in respect of the following foreign matters found in food:— Edible oil in loaf of bread. Edible white oil in loaf of bread. Wholemeal flour of previous mix in loaf of bread. Wasp in loaf of bread. Nail in loaf of bread. Cigarette end in loaf of bread. Maggots in barley. Fly in cheese. Fly in ice lolly. Hairpin in jelly crystals. String in milk. Glass in milk. Sediment in milk Green vegetable matter in milk. Poppy head in peas. Soda in sugar. Metal staple in loaf of bread. Glass in pastry. The evidence in such cases is frequently insufficient clearly to indicate the point in the sequence of events at which the foreign matter was introduced, but, where there was reasonable cause to believe that it occurred before sale, appropriate action was taken including, where warranted, legal proceedings. Arising out of these incidents, the following 4 prosecutions were taken under Section 9 of the Food and Drugs Act, 1938, against the vendors for selling food unfit for human consumption:— Bread containing Metal Staple. The vendors pleaded guilty but the case was dismissed under the Probation of Offenders Act. The vendors were ordered to pay costs of £2 16s. 6d. Apple Pie containing Glass. The vendors were convicted and fined £10 with 4 guineas costs. Iced Lolly containing Fly. Vendors were discharged under the provisions of the Criminal Justice Act, 1948, and ordered to pay 3 guineas costs. Bread containing Cigarette End. The vendor was convicted and fined £25 and 3 guineas costs. Our local experience of numerous instances of contamination of foodstuffs intended for public sale has shown that the fault lies in many cases with the individual food handler. Until he can be educated to a sense of his public responsibility and accepts for himself a high hygienic code of personal conduct, prosecution of the employer is likely to achieve little. 43 Inspection of Food. The following quantities of food found to be unsound, diseased or unwholesome and unfit for human food were surrendered and destroyed or so disposed of as to prevent them from being used for human food :— Bread 5 lbs. Mincemeat 2 lbs. Cereals 95 lbs. Mixture, Pudding, Cake, etc. 20 lb. Cheese 18 lbs. Paste 1 lbs. Confectionery 20 lbs. Pickle 7 lbs. Eggs, Shell 188 Pudding 15 lbs. Egg, Dried 2 lbs. Salad Dressing 11 lbs. Fat 16 lbs. Sauce 1 lb. Fish 2,284 lbs. Semolina 3 lbs. Fruit 364 lbs. Soup 65 lbs. Fruit Drink 45 lbs. Syrup 5 lbs. Jam 125 lbs. Tea 30 lbs. Meat 2,265 lbs. Vegetables 981 lbs. Milk 1,214 lbs. Total Weight : 3 tons, 7 cwts., 3 qrs., C lbs. Inspection of Food Premises. Details of the visits of inspection to food premises and the resulting remedial action taken is shown in Table 10. Food and Drugs Act—Section 13. One prosecution was taken in respect of food premises which failed to comply with the requirements of Section 13 for the prevention of contamination. The Defendant pleaded guilty and was ordered to pay costs of £2 6s. Od. Food Hygiene. With a view to promoting better standards of hygiene in the preparation, storage and sale of food, leaflets of advice on food handling were supplied to all food establishments for distribution to their employees. These were followed by Codes of Practice which were recommended for application to (a) premises, and (b) personnel. 44 TABLE 10. Inspection of Food Premises and Action Taken. Nature of Business. No. of Premises. No. Selling Ice Cream. No. of Inspections. Defective Drainage Remedied. Sinks or wash-basins provided. Means of hot water supply provided. Means of maintaining reasonable temperature provided. Ventilation provided. Food preparation rooms repaired and/or cleansed. Food storage room provided. Refuse bins provided. Other Defective Conditions Remedied. Baker and Confectioner 14 4 52 1 1 1 - - 1 - 1 1 Bakehouses 5 - 28 - - - - - 1 - - 1 Butchers 37 - 247 1 2 4 - 2 1 - 2 4 Canteens 16 - 152 1 - - - - - - - - Chemists 16 - 17 - - - - - - - - - Cinemas 1 1 5 - - - - - - - - - Confectioners (Sweets only) 79 46 130 1 - 7 - - 2 - - 1 Dairies 8 3 43 - - - - - - - - - Fishmonger 20 - 96 1 - 2 1 - 1 - - 2 Food Stalls Variable - 78 - - - - - - - - - Food Vehicles Variable - 152 - - - - - - - - - General Stores 5 2 10 - - - - - - - - - Greengrocer and Fruiterer 45 1 142 2 2 8 1 - 4 - - 7 Grocer 80 11 428 5 5 11 2 1 6 1 3 11 Hotels with Catering Facilities 5 - 17 - - 1 - - - - - 2 Hotels without Catering Facilities 8 - 11 - - - - - - - - - Ice Cream Factories 3 - 55 - - 1 - - - - - 1 Ice Cream Vehicles Variable Variable 31 - - - - - - - - - Off Licences 13 - 23 - - - - - - - - 1 Restaurants and Cafes 25 11 147 1 - 2 - - 1 - 1 2 Tea Packer 1 - 3 - - - - - - - 1 - 1,867 13 10 37 4 3 17 1 8 33 45 Section F—Prevalence of and Control over Infectious and other Diseases. The district has, within its boundaries, three General Hospitals, two of which, namely, Queen Mary's Hospital for Children and the St. Helier Hospital, are particularly large institutions which are part of the hospital services of the South-West Metropolitan Hospital Region. Many of the cases notified from the St. Helier Hospital are admitted there from other districts already suffering from a notifiable disease, but not diagnosed until after admission. In order, therefore, to give a clearer picture of the prevalence of infectious disease in the resident population of the district, separate figures are given in this Section which exclude cases of hospital patients who are not residents of the district. The figures given are after correction for original errors in diagnosis. Notification. The following diseases are notifiable in the district :— Smallpox. Cholera. Diphtheria. Membranous Croup. Erysipelas. Scarlatina or Scarlet Fever. Measles. Whooping Cough Tuberculosis. Dysentery. Acute Influenzal Pneumonia. Acute Polioencephalitis. Typhus Fever. Typhoid Fever. Enteric Fever. Relapsing or Continued Fever. Meningococcal Infection. Acute Poliomyelitis. Ophthalmia Neonatorum. Puerperal Pyrexia. Malaria. Acute Primary Pneumonia. Acute Encephalitis Lethargica. Food Poisoning. Smallpox. No cases of smallpox occurred in the district. Thirty-two contacts of cases of Asiatic Smallpox arising among the passengers of the s.s. Mooltan were vaccinated and kept under surveillance during April. Vaccination. The arrangements for vaccination under the County Council's scheme are directed locally by the district Medical Officers of Health following agreements between the County Council and the Sanitary District Councils. Vaccination is available at the Infant Welfare and School Clinics and may be done by the general practitioners to whom a fee of 5/- per case is payable for notifying details of treatment. 46 The number of persons successfully treated and recorded under these arrangements during 1949 was as follows :— Age at 31st Dec., 1949 Under lyr. 1-4 yrs. 5-14 yrs. 15 yrs. & over. Total. Primary Vaccinations— By Private Practitioners 83 103 27 32 245 At Clinics 127 75 6 14 222 210 178 33 4G 467 Reraccinations— By Private Practitioners - 2 16 60 78 At Clinics — - 1 19 20 — 2 17 79 98 In addition the following unsuccessful attempts at vaccination were made:— Age at 31st December, 1949 Under 1 yr. 1-4 yrs. 5-14 yrs. 15 yrs. & over. Total. Primary 6 5 — — 11 Re-vaccination — — 5 10 15 6 5 5 10 26 The number of children vaccinated in the first year of life at 210 represents 25% of the births which occurred during the year. Information derived from the scheme for the care of mothers and young children indicates that 34% of the children under 5 years of age were vaccinated at 31st December, 1949. Although much lower than is desirable, this proportion compares very favourably with the general experience. The sudden and fatal outbreaks which occur from time to time in this country, usually as the result of importation from abroad, emphasises the necessity for maintaining a high level of general immunity by a greater rate of infant vaccination. Enteric Fever. There were no cases of typhoid and paratyphoid fever. Dysentery. Two cases of dysentery in patients of Queen Mary's Hospital were notified. Both were Sonne infections and both recovered. There were no cases among the resident population. 47 Scarlet Fever. The incidence of scarlet fever was on much the same scale as in the year before, 109 cases being notified, of which 93 were in residents of the district. The incidence rates were accordingly:— All cases 1.77 per 1,000 population. Residents 1.68 per 1,000 population. All were mild cases and there was no death. Thirty-seven, representing 34:% of the total were nursed at home. TABLE 11. SCARLET FEVER—DISTRIBUTION OF CASES, 1949. 1949. Ward. Total. St. Helier North. St. Helier South. St. Helier West. NorthEast NorthWest. Central. SouthEast. SouthWest. January 1 1 - 3 - - - - 5 February — — - 1 1 — — — 2 March — 3 — — — 1 1 1 6 April — 1 2 — — — 1 2 6 May — 1 — — 1 1 — — 3 June 1 3 — — — 1 2 6 13 July 1 2 — 2 — — — 1 6 August — 1 3 4 September — 1 1 — — — 1 3 October - 2 3 1 4 1 — — 11 November 6 2 1 — 1 1 2 4 17 December 7 1 — 1 — 2 3 3 17 Totals 16 17 10 9 7 7 9 18 93 Monthly Mean 1.33 1.41 0.83 0.75 0.58 0.58 0.75 1.50 7.75 Case rate per 1,000 population 1.85 2.41 1.19 0.95 0.95 1.15 1.16 2.69 1.52 TABLE 12. SCARLET FEVER—MULTIPLE CASES, 1949. Ward. No. of houses in which occurred. Total Houses. Total Cases. 1 Case. 2 Cases. 3 Cases. St. Helier North 16 - - 16 16 St. Helier South 17 — — 17 17 St. Helier West 8 1 — 9 10 North-East 9 — — 9 9 North-West 7 — — 7 7 Central 5 1 — 6 7 South-East 7 1 — 8 9 South-West 12 3 — 15 18 Whole District 81 6 — 87 93 48 Diphtheria. Only one case of diphtheria was notified, giving an attack rate of 0.01 per thousand population. The patient, a male adult of 49 years, had a mixed infection of "Gravis" Diphtheria and Vincent's Angina, and recovered after two months' treatment in hospital. The incidence of diphtheria among the resident population since 1934, when the immunisation scheme commenced in the district, was as follows:— Year Cases Incidence per 1,000 Population Year Cases Incidence per 1,000 Population 1934 66 1.73 1942 23 0.40 1935 58 1.13 1943 7 0.12 1936 53 0.95 1944 7 0.12 1937 47 0.80 1945 15 0.27 1938 33 0.57 1946 4 0.06 1939 14 0.23 1947 2 0.03 1940 45 0.77 1948 1 0.01 1941 26 0.45 1949 1 0.01 The number of swabs examined for diphtheria was 45. Diphtheria Immunisation. The scheme for diphtheria immunisation, which is the responsibility of the County Council, is by agreement directed by the Medical Officer of Health of the District Council. The arrangements were as described in the previous Report, namely, facilities at the infant welfare and school clinics and a programme of immunisation sessions held in the infant and junior schools of the district in alternate terms. The object is to secure initial treatment by the age of one year and to reinforce this by further single injections before, or on entry to, school and thereafter at three-year intervals until the child leaves the junior school. Under this procedure the majority of children now receive initial treatment in infancy and two or three reinforcing injections during school life. The technique is to give two doses of 0.5 c.c. A.P.T. at one month's interval for primary treatment and 0.2 c.c. A.P.T. or 1 c.c. T.A.F. for reinforcing injections according to the age of the child. During 1949, 915 residents were immunised as follows:— Age at Year End. Total. Under 1 1 2 3 4 5-9 10-14 At Council Clinics 28 455 56 14 7 3 2 565 In Carshalton Schools — — — — 3 87 29 119 Private Practitioners 17 148 40 5 1 2 2 215 45 603 96 19 11 92 33 899 Less outward transfers 21 17 38 Plus inward transfers — 1 3 1 — 23 26 54 Carshalton Residents 45 604 99 20 11 94 42 915 49 A further 1,588 children received reinforcing injections in the area. After allowing for transfers in and out of the district the figure for Carshalton residents so treated was 1,541. The immunisation state of the child population at the end of year was as follows:— Age at 31.12.49, i.e., Born in Year Under 1 1949. 1 1948. 2 1947. 3 1946. 4 1945. 5 to 9 1940/ 44. 10 to 14 1935/ 39. Total under 15 Number Immunised 46 550 859 885 675 3740 4744 11499 Registrar General's Estimated mid-year population, 1949 4981 9288 14269 Percentage done 60% 91% 81% The following table shows the estimated percentage of children immunised at each year end since 1935, when the Council's scheme was inaugurated and the incidence of diphtheria in the resident population:— Year. Percentage of Children Immunised. Incidence of Diphtheria. 0-5 Years. 5-15 Years. 0-15 Years. Cases. Attack Rate per 1,000 Population. 1935 - - 7 58 1.13 1936 — — 10 53 0.95 1937 — — 15 47 0.80 1938 — — 18 33 0.57 1939 — — 19 14 0.23 1940 — — 21 45 0.77 1941 — 49 26 0.45 1942 40 84 71 23 0.40 1943 57 78 72 7 0.12 1944 54 83 75 7 0.12 1945 58 75 70 15 0.27 1946 64 81 76 4 0.06 1947 63 84 78 2 0.03 1948 67 92 81 1 0.01 1949 60 91 81 1 0.01 Erysipelas. Six cases of erysipelas were notified compared with 16 in the year before. All were residents of the district. Three were admitted to hospital and all recovered. The face was the site of infection in each case. 50 Pneumonia. Of 42 cases of pneumonia which were notified, 9 were stated to be of influenzal origin and occurred during prevalence of that infection in February, March and early April. Sixty-five per cent were adults over 20 years of age. Measles. The number of cases of measles was approximately half that in 1948, the number notified being 474 of which 433 were local children. The previous year had the highest incidence of measles since the disease was first notifiable in 1939. From our knowledge of the periodicity of this infection a fall in the incidence curve in 1949 was to be expected. With a relatively low prevalence the cases were fairly evenly distributed throughout the year. There were no deaths. TABLE 13. MEASLES—WARD INCIDENCE AND MONTHLY DISTRIBUTION, 1949. (Excluding hospital patients non-resident in Carshalton.) 1949. Ward. Total. St. Helier North. St. Helier South. St. Helier West. NorthEast NorthWest. Central. SouthEast. SouthWest. January 3 2 1 2 1 3 12 February 1 — — 3 8 8 5 6 31 March 1 1 1 6 1 5 20 3 38 April — 5 — 3 1 2 9 2 22 May — 3 2 3 — 1 5 1 15 June 1 3 — 3 16 4 2 7 36 July 10 1 — 6 38 9 3 2 69 August 3 — 1 5 25 15 5 3 57 September - - - - - 1 5 1 7 October 2 1 - 4 1 5 7 5 25 November 12 14 11 6 2 2 22 6 75 December 17 8 4 13 - _ 3 1 46 Totals 50 36 21 52 93 54 87 40 433 Monthly Mean 4.16 3.0 1.75 4 33 7.75 4.50 7.25 3.33 36.08 Case rate per 1,000 population 5.79 5 10 2 50 5.54 12.74 8.91 11.25 5 93 7.07 51 Whooping Cough. The incidence of pertussis was two-thirds that of the year before, 225 cases (211 residents) being notified compared with 365. Incidence was rather heavier in the first six months of the year during which period 80% of the cases occurred. There was one death in a child of 2 years. TABLE 14. WHOOPING COUGH—WARD INCIDENCE AND MONTHLY DISTRIBUTION, 1949. (Excluding hospital patients non-resident in Carshalton.) 1949. Ward. Total. St. Helier North. St. Helier South. St. Helier West. NorthEast. NorthWest. Central. SouthEast. SouthWest. January 4 4 13 5 6 3 5 1 41 February 7 4 9 5 7 1 — 8 41 March 6 — 2 11 9 — 1 3 32 April 2 3 3 7 8 — 3 5 31 May 3 1 1 4 5 — 5 — 19 June — 1 1 — — 1 2 — 5 July 2 1 3 — — — 3 — 9 August 2 4 3 1 — — — — 10 September — 3 1 - - - - - 4 October — — 4 — — — — 1 5 November 4 1 1 — 1 — — — 7 December 5 1 1 - - - - - 7 Totals 35 23 42 33 36 5 19 18 211 Monthly Mean 2.92 1.92 3.50 2.75 3.00 0.42 1.58 1.50 17.58 Case rate per 1,000 population 4.05 326 5.01 3.51 4.93 0.82 2.46 2 69 3.44 Cerebro-Spinal Fever. There were no cases of meningo-coccal meningitis. One case was notified in a patient from a neighbouring district admitted to St. Helier Hospital with the disease. Anterior Poliomyelitis and Encephalitis. Three cases of this infection were notified, 2 of which were poliomyelitis and 1 polio-encephalitis. 52 One was a man of 35 years who in September developed some weakness in both legs and the right arm. He was discharged from hospital after five weeks with slight weakness in the left foot which was improving. Another was a child of 5 years who fell ill in November. She was an in-patient for three-and-a-half months and left hospital with slight weakness of both lower limbs and one shoulder to continue treatment as an out-patient. The third case was of a baby of five months who had suffered for some time from "ocular fits." Apart from this there was no evidence of neurological involvement and it was considered that he probably had a mild form of polio-encephalitis. This symptom persisted when he was discharged from hospital otherwise well. Ophthalmia Neonatorum. No cases were notified. The last case of this eye infection of the new born was in 1945. This is due to recent advances in chemotherapy. Puerperal Pyrexia. Notifiable rises of temperature during childbirth numbered 39, compared with 47 in the year before; all in respect of cases confined in the St. Helier Hospital. Five of the total were residents of Carshalton and 25 were first confinements. Food Poisoning. Thirty cases of food poisoning were notified. Two were single cases, one of which was associated with an outbreak of poisoning due to Salmonella typhi-murium at a hospital in London where the patient was on the staff and which was believed to be contracted from a meringue made from duck eggs. The infecting organism was not isolated from the patient, but was isolated from some of the associated cases in other areas. The patient recovered. The other single case was a child in a local hospital who contracted a Salmonella typhi-murium infection and recovered. The vehicle of infection was not identified. An Outbreak of Food Poisoning due to Infected Duck Eggs. History of the Outbreak. On Tuesday, 7th June, 480 scholars of a large combined day and boarding school for girls re-assembled after a long weekend's absence for Whitsuntide. Within the same curtilage as the school was a religious community of 67 persons and a staff of 33. The resident population numbered 161: 80 boarders, 14 staff and 67 community members. The day scholars and non-resident staff totalled 419. The residents and such of the non-residents as took lunch at the school were all served from the one kitchen. The religious community was served 53 in three refectories, the domestic staff in another, mistresses in another, whilst the children took their meals in two dining rooms, one large hall for about 50 older boarders and a smaller one for about 30 junior boarders. On the 10th June the medical officer of the school reported that cases of sickness and diarrhoea were occurring among the girls and investigations were commenced by securing faeces specimens from three of the sufferers. All three revealed the presence of Salmonella typhi-murium. The outbreak had two phases. Phase 1. The first phase began when the first case commenced to be ill at 11.30 a.m. on Thursday, 9th June, and ended on the 14th June, during which time 25 cases occurred on the following dates:— 9th June 9 cases. 10th June 8 cases. 11th June 1 case. 12th June 2 cases. 13th June 1 case. 14th June 3 cases. The symptoms, which varied in severity, were identical in every case: headache, fever, abdominal pain, sickness and diarrhoea and prostration. The duration of acute symptoms varied up to four days, diarrhoea being the most persistent although weakness continued for some days longer. Salmonella typhi-murium was recovered from the faeces in 11 of these 25 cases. Repeat specimens in the positive cases were taken at intervals until negative and although it is not possible to say on which day they became negative the interval between onset of illness and the last positive and first negative result was as follows:— Number of cases Last Positive First Negative 1 1 day 9 days 1 2 days 13 days 1 4 days 19 days 3 5 days 12 days 3 6 days 13 days 1 8 days 18 days 1 23 days 104 days The interval between onset and specimen in the 14 negative cases was as follows :— 2 3 days 1 4 days 1 5 days 5 6 days 3 7 days 2 8 days 54 Of the 25 cases, 23 were boarders and 2 members of the religious community, the last 2 falling ill on the 13th and 14th June respectively. No day scholar suffered in this outbreak and all the child patients were senior boarders who took their meals in the large dining hall. Careful inquiry failed to indicate any particular meal or article of food as the probable vehicle of infection. It was found that a flock of 31 ducks was kept in the grounds and that the eggs formed part of the dietary. The only occasion when duck eggs were served whole to the boarders was on Tuesday, 7th June, the day the school re-assembled, when the 80 of them had poached eggs for the evening meal. Approximately 80% of the eggs served on that occasion were duck eggs from the school's own flock, the remainder being hen eggs. This was at least 40 hours before the onset of the first case and at least 44 hours before the second case. Duck eggs were served to the boarders subsequently, but only hard-boiled as part of salads. Samples were therefore taken from all the available commodities in use which might have been infected. These were custard powder, semolina powder, dried egg, dried milk, lard, oxo, water and six duck eggs. These were all negative for S. typhi-murium as was the culture from the intestine of one mouse caught in the kitchen. Attention to the culinary arrangements and kitchen staff revealed that the kitchen was commodious, well equipped and maintained at a high standard of cleanliness. Food storage facilities were excellent and it was with great difficulty that the one mouse was trapped, evidence of vermin infestation being completely absent. Investigation of the staff who prepared and handled food elicited two significant facts. One member of the kitchen staff, W.D., had suffered from sickness and diarrhoea on the 7th and 8th June, had not reported her illness and had not gone off duty. Faecal specimens were secured from all the catering staff and the person, S.J., in charge of the large dining hall was found to give a positive growth of S. typhi-murium although she was quite well and had been for several months previously. W.D.'s specimen was negative—this on the 14th June, seven days after her onset. In view of the fact that all the cases among the boarders were girls who took their meals in the large dining hall, the probable route of infection appeared to have been demonstrated. W.D. and S.J. were relieved of their food-handliug duties on the 14th June. Strict hygienic precautions in the washing of hands had already been imposed on the whole establishment and no further cases occurred for 14 days. During this interval the use of duck eggs in the dietary of the school children was discontinued, although they continued to be served to the religious community. Phase 2. On the 28th June a member of the religious community, S.R., fell ill with the same symptoms and was followed by two other members of the community, V.B. and S.A.M., on the following day. Faecal examination was positive for S. typhi-murium in two of them and negative in the third. The first negative specimens in the two positive 55 cases were obtained 10 days and 5 days after the date of onset respectively. One of the three, V.B., with a positive specimen was seized with very severe symptoms less than 10 hours after eating a boiled duck egg. The other two had eaten Russian salad containing hard-boiled duck eggs approximately 16 hours before. V.B. fed in a separate dining room from the other two and the onset in her case was so violent that the infecting agent was almost certainly ingested within a matter of hours. In these circumstances investigation was focused more intensely on the domestic supply of duck eggs. The whole of two days' layings, 36 eggs from 31 ducks, were submitted for examination and the laboratory reported that one egg yielded a heavy growth of S. typhimurium. Duck eggs were thereafter excluded completely from the dietary and no further cases occurred. Having established a source of infection the subsequent investigation was devoted to confirming the source by phage-typing and to identifying the infected bird or birds. By a process of segregation, one duck was found to be laying infected eggs after the examination by the Epsom Public Health Laboratory of 142 duck eggs. The last laboratory examination of an infected egg from this duck showed that whilst the yolk was heavily infected the albumen was sterile. Of the first three eggs from this bird, after identification, laid on consecutive days, the first was sterile and the succeeding two infected. Cultures from two of the patients (one from the first group of cases and one from the second group) and from two infected eggs were referred for phage-typing to Dr. Felix at the Central Enteric Reference Laboratory who reported that all four were Vi Strain, Group 2. The question now arose as to what should be done with the domestic flock of ducks, a consideration which depended on the extent to which the flock was infected. Was it safe to eliminate the offending bird only ? To assist in deciding this question, the help of the Ministry of Agriculture and Fisheries Veterinary Laboratory Service at Weybridge was enlisted. Blood from all the 31 ducks and 1 drake was tested for agglutination against S. typhi-murium with the following results:— 6 negative; 6 only slightly doubtful; 20 positive or very doubtful and should be destroyed. (Eight of these positive in very high titre.) The duck which had been found to be laying infected eggs was not one with a high blood titre to S. typhi-murium, but was in the slightly doubtful group. In view of this evidence of extensive infection, 23 of the birds were destroyed and the remaining 9 with the highest titre were transferred to the Ministry of Agriculture and Fisheries Laboratory at Weybridge where routine bacteriological examinations were carried out on faeces and on the eggs laid by the ducks until they went out of production. 56 The ducks were then killed and a post mortem examination performed on each. The findings were as follows:— Salmonella typhi-murium isolated from 5 eggs (3 birds), from faeces of 1 duck, from ovaries of 6 ducks and from the liver of 1 duck. Eleven of these cultures were sent to the Central Reference Laboratory for phage-typing, where they were all shown to belong to the same strain as those from the patients and eggs sent previously, viz., Vi Strain, Group 2. Discussion. This investigation raises interesting considerations as to the route by which infected duck eggs can convey infection and as to the risk from ducks with a positive blood reaction to S. typhi-murium. There can be no doubt that the origin of this outbreak was the flock of ducks kept on the premises. It is generally believed that hard-boiled duck eggs are safe, but that those cooked otherwise are not free from risk, and it would be convenient and satisfying to explain 23 of the first series of 25 cases which occurred in girl boarders by the fact that they all had poached eggs on the evening of the 7th June. The incubation period, however, is generally accepted to be between 8 and 48 hours, possibly up to 72 hours. Whilst, therefore, it is possible that eggs eaten on the 7th June gave rise to cases which occurred on the 9th, or even the 10th June, it is highly improbable that they caused illness up to 7 days afterwards. If those cases which occurred on the 9th and 10th June (17 out of 25) were regarded as primary cases and the remaining 8 spread over 4 further days as secondary, then the incubation period was from 40 to 67 hours with an average of 55 hours. Moreover, examination showed that three weeks later only one duck was laying infected eggs, and those intermittently, and at no time throughout the lengthy investigation of the ducks were more than 3 found to do so. As the eggs served on the 7th June would represent about 4 days' layings which had accumulated over Whitsuntide the number of infected, eggs among the 60 to 70 served on the 7th June could scarcely have been as high as 17. Moreover, it leaves unexplained two of the three patients in the second series who only had hard-boiled duck eggs in salad within 48 hours of onset. It is much more probable that the cases were infected by another route, among which must be considered:— Dishes made with infected duck eggs; A missed case or carrier originally infected from the ducks; Contamination of food by members of the kitchen staff after handling duck eggs soiled with infected excreta. With regard to the first, shell eggs were not used for cooking, dried egg powder being bought for this purpose. Shell eggs were either served whole or hard-boiled in salad. In this connection it is known that the girls and the community ate salad containing hardboiled egg on several occasions between the 7th and 14th June and that the members of the community, three of whom comprised the second series of cases, ate salads during the period preceding the second phase of the outbreak. 57 The second channel of infection is a more probable one. W.D., of the kitchen staff, was ill with diarrhoea on the 7th and 8th June and continued on duty although S. typhi-murium was not recovered from her rectal swab. More significant is the fact that S.J., who was in charge of the large dining hall, had a positive rectal swab when first examined, but swabs on the following three days failed to confirm it. She may in common with the cases have been a non-suffering victim or a cause or both. With regard to the three cases which occurred after an interval of a fortnight, K.B.'s illness was almost certainly due to infection in the duck egg she ate a few hours before, but the mode of infection in the other two, S.R. and S.A.M., is not so obvious. Neither had whole eggs, but did have hard-boiled duck eggs in salad. Strict hygienic precautions had been impressed on everyone in the establishment and there was a resident infirmarian who was a trained nurse with many years of hospital experience. It is extremely unlikely that a missed case in a food handler could have occurred at this stage and, as is known, the outbreak ended completely with elimination of duck eggs from the diet. S.R. and S.A.M. were either infected by supposedly hard-boiled eggs in salad or more likely by the third of the possible routes mentioned above which may also have accounted for the first series of cases. The investigation into the serum reactions of the ducks in this outbreak shows that in the positive reactors the titre is not a reliable guide to the capacity of the duck to lay an infected egg. Blood testing of the 31 ducks (excluding the drake) for S. typhi-murium showed that 5 were negative, 6 slightly doubtful, and 20 positive, 8 of the latter being in high titre. Laboratory investigation carried out at the Epsom Public Health Laboratory and prolonged after the outbreak at Weybridge until the ducks went out of production, detected in all 10 infected eggs from 3 birds out of 192 eggs examined. One of these three ducks, the only one identified before the flock left the school premises, gave only a doubtful serum reaction, but was subsequently found to have infected faeces, to be the only one with intestinal infection and, post mortem, to have infection of the ovary. None of the other 5 ducks with a doubtful serum reaction or the 5 with a negative reaction gave any other evidence of infection. The other 2 ducks which produced infected eggs were among the 8 high-titre reactors, one of which at autopsy had infection of the ovary. The remaining 6 with a positive serum in high titre were not found to lay infected eggs. Three of these at autopsy had infection of the ovary and one infection of the liver. Outbreaks of S. typhi-murium due to a purely local and exclusive supply of duck eggs are not common and this occurrence is of interest in that circumstances made it possible not only to trace the infection to its source, but to secure confirmation by phage-typing of the responsible salmonella. Acknowledgments. Grateful acknowledgment is made to Dr. Stone of the Epsom Public Health Laboratory for her valuable assistance in the examination of no less than 142 duck eggs and many other articles of food ; to Mr. Blaxland of the Ministry of Agriculture and Fisheries Veterinary Laboratory, Weybridge, for his willing co-operation in his investigation of the offending ducks, and to the School Infirmarian and Authorities for their help and ready provision of every facility for prosecuting this investigation. 58 TABLE 15. INFECTIOUS DISEASES—NOTIFICATIONS, DEATHS AND DISTRIBUTION. (Excluding hospital patients non-resident in Carshalton.) Disease. Cases notified. Case rate per 1,000 population. Deaths Distribution by Wards. No. of cases removed to Hospital. Percentage of cases removed to Hospital. St. Helier North. St. Helier South. St. Helier West. NorthEast. NorthWest. Central. SouthEast. SouthWest. Scarlet Fever 93 1.49 16 17 10 9 7 7 9 18 55 59 Diphtheria 1 0.01 — - 1 — — — — — — 1 100 Measles 433 6.94 - 50 33 21 52 93 54 87 40 4 0.92 Whooping Cough 211 3.38 1 35 23 42 33 36 5 19 18 5 2.36 Polioencephalitis 1 0.01 - - - - - - 1 — — 1 100 Poliomyelitis 2 0.02 - - - - - - - 2 - 2 100 Food Poisoning 29 0.46 - - - - — — 28 - 1 - — Erysipelas 6 0.09 — 1 1 — 1 1 1 - 1 3 50 Pneumonia 42 0.67 — 2 5 1 7 11 5 6 5 1 2.38 Puerperal Pyrexia 5 0.08 — — 1 1 - 3 — - - 5 100 59 TABLE 16. INFECTIOUS DISEASES. Notification by Age Groups, 1949. (Excluding hospital patients non-resident in Carshalton.) Disease. Total Cases Notified. Total Cases at all Ages L •..lit" 1 year 1 2 2-3 3-4 4-5 5-10 10-15 15-20 20-35 35—45 45-65 65 and over Scarlet Fever 2 3 14 8 42 15 5 4 93 Diphtheria — — — — — — — — — — 1 — 1 Measles 11 43 65 56 58 184 9 3 3 1 — — 433 Whooping Cough... 16 29 39 28 26 65 2 1 2 1 2 — 211 Polioencepholitis 1 — — — — — — — — — 1 Poliomyelitis — — — — — 1 — . — — 1 — 2 Food Poisoning — — — — — — 12 12 2 2 1 — 29 Erysipelas — — " — — — 1 — — 1 4 6 Pneumonia 2 1 1 1 3 2 1 1 3 6 13 8 42 Peurperal Pyrexia — — — — — — — 5 5 00 TABLE 17. MONTHLY INCIDENCE OF INFECTIOUS DISEASES, 1949. (Excluding hospital patients non-resident in Carshalton.) Disease. Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. Total. Scarlet Fever 5 2 6 6 3 13 6 4 3 11 17 17 93 Diphtheria — — 1 1 Measles 12 31 3 < 22 15 36 69 57 7 25 75 45 433 Whooping Cough... 41 41 3 J 31 19 5 9 10 4 5 7 7 211 Polioencephalitis — — — — — — — — — 1 1 Poliomyelitis — — — — — — — 1 — 1 2 Food Poisoning ... 26 3 29 Erysipelas — ■ 1 — — 1 — — — — 1 1 2 6 Pneumonia 4 11 6 8 3 1 1 1 4 2 1 42 Puerperal Pyrexia ... — — — — 1 — 1 1 2 — 5 Tuberculosis Pulmonary 10 7 6 3 4 7 2 11 9 8 7 2 76 Tuberculosis Non-pulmonary ... 1 1 1 2 — 1 1 1 1 1 10 61 Tuberculosis. The new cases admitted to the tuberculosis register during the year numbered 132, classified as follows:— Males Females Pulmonary 56 Pulmonary 64 Non-pulmonary 5 Non-pulmonary 7 Of the total additions, 86 were primary notifications, 44 were transferred from other districts, and 2 came to notice in other ways. For the same period 105 names were removed from the register for the following reasons:— Recovered 34 Death 23 Otherwise (including removals) 48 TUBERCULOSIS—WARD DISTRIBUTION. Cases on Register at 31st December, 1949. Ward. Pulmonary. Non-Pulmonary. Total Incidence per 1,000 population. Males. Females. Males. Females. St. Helier North 59 76 13 10 158 18.3 St. Helier South 59 60 14 12 145 20.5 St. Helier West 57 54 10 9 130 15.5 North-East 48 48 10 8 114 12.1 North-West 37 27 3 4 71 9.7 Central 31 23 7 — 61 10.0 South-East 24 33 6 6 69 8.8 South-West 27 15 3 4 49 7.3 Totals 342 336 66 53 797 13.2 678 119 The total of 797 is 27 more than at the corresponding date twelve months earlier. The number of patients from Carshalton who received institutional treatment under the arrangements of the South-West Metropolitan Hospital Board during the year was as follows:— At Milford Sanatorium, Surrey 40 At other tubeiculosis institutions 131 171 62 The number of tuberculous persons who died during the year was 23, distributed by age groups as follows:— Age, Years. Pulmonary. Non-Pulmonary. Males. Females. Males. Females. Total. 0 - - - - - 1—5 — — — 1 1 5—15 — — — — — 15—25 1 2 - 1 4 25—35 2 3 — — 5 35—45 1 3 - - 4 45—55 3 1 - - 4 55—65 2 — — — 2 65—75 1 1 1 — 3 Totals 10 10 1 2 23 The deaths attributable to Tuberculosis were 22 as follows:— DEATHS DUE TO TUBERCULOSIS, 1949. Ward. Pulmonary. Non-Pulmonary. Death Rate per 1,000 population. Mean age at Death. Male. Female. Male. Female. St. Helier North 3 1 - - 0.46 41 St. Helier South 1 1 — 1 0.42 31 St. Helier West 1 1 — — 0.23 40 North-East — — — — — — North-West 2 2 0.54 31 Central 1 2 0.49 29 South-East 2 1 — — 0.38 35 South-West 1 2 — — 0.44 59 Totals 9 10 — 3 0.35 36 Two of these deaths were of unnotified cases. No action was taken under the Public Health (Prevention of Tuberculosis) Regulations, 1925, or under Section 172 of the Public Health Act, 1936. The Council adopted a points scheme for deciding the order of priority of applicants for housing accommodation. Special "weighting" is provided under this scheme where the existence of tuberculosis in the household creates a risk of infection. In consequence 9 such families were rehoused out of a total of 57 council tenancies allotted during 1949. 63 TABLE 18. TUBERCULOSIS. New Cases, Age and Sex Distribution and Manner of Admission to Register, 1949. Age Group Years. Primary Notifications "A." Cases transferred from other Districts. Cases brought to notice other than by Notification or Transfer. Total New Cases. Pulmonary. Non-Pulmonary Pulmonary. Non-Pulmonary Pulmonary. Non-Pulmonary M. F. M. F. M. F. M. F. M. F. M. F. 0— 1 - - 1 1 - - - - - - - 2 1— 5 - - - - - 1 - 1 - - - - 2 5—10 1 1 - - - - - - - - - - 2 10—15 1 - 1 1 - - - - - - - - 3 15—20 4 13 - 2 1 - - - - - - - 20 20—25 6 13 2 - 6 3 - - - - - - 30 25—35 5 7 - 1 15 11 - - - 1 - - 40 35-45 4 6 - - 3 - 1 - - - - 14 45—55 3 5 - 1 1 - - - - - - - 10 55—65 5 2 - - 1 - - - - - - - 8 65 up - - - - - - - - - 1 - - 1 Totals 29 47 4 6 27 15 1 1 - 2 - 132 86 44 2 64 INDEX page Acreage 6 Bed Bug—Eradication of 30 Births— Distribution 9 Institutional 10 Rates 9-10-11 Byelaws 21 Cancer 14 Cemeteries 31 Cerebro-Spinal Fever 52 Clinics and Treatment Centres 21 Closet Accommodation 25 Deaths— Classification 18 Distribution 13 Rate 13-11-15 Diphtheria 49 Immunisation 21-49 Dysentery 47 Disinfection 29 Disposal of Dead 31 Drainage and Sewerage 24 Employment Agencies 32 Enteric Fever 47 Erysipelas 50 Establishments for Massage, etc. 32 Factories 36 Food— Poisoning 53 Inspection and Supervision 39-44-45 Food and Drugs Act 41 Hygiene 44 Health Services 19 Hospital 20-21 Housing— Council's Scheme 33 Inhabited Houses 6 Inspection 34 Overcrowding 35 Ward Distribution 35 65 page Ice Cream 41 Industry 8-36 Infant Mortality 16-17 Infectious Diseases 46 Inquests 15 Isolation Hospital 21 Admissions to 20 Laboratory Facilities 19 Maternal Mortality 16 Measles 51 Milk Supply 39 Milk (Special Designations) Order 39 Mortuary 32 Natural and Social Conditions 6 National Assistance Act 32 Nursing Associations 19 Offices 31 Ophthalmia Neonatorum 53 Pneumonia 51 Poliomyelitis 52 Population 8 Public Cleansing 25 Puerperal Pyrexia 53 Rateable Value 6 Rats and Mice Destruction 30 Rent and Mortgage Interest Restrictions (Amendment) Act, 1933 36 Rivers and Streams 25 Sanitary Circumstances 23 Sanitary Inspection 25 Scarlet Fever 48 Shops Acts 31 Slum Clearance and Demolition 36 Smallpox 46 Smoke Abatement 30 Staff 5 Statistics— Comparative 12-13 Vital 7 Swimming Baths 31 66 page Tuberculosis 15-62 Unemployment 8 Vaccination 21-46 Vermin Control 29 Water Supply 23 Whooping Cough 52 Zymotic Diseases 46 Deaths from 7 67