Mr. Hawking Swt Mr Bowler IIIA Cou 4 Transit Please attach f 4201/3 HEALTH REPORT For 1936 FOR THE COULSDON AND PURLEY URBAN DISTRICT Survey BY THE MEDICAL OFFICER OF HEALTH S. C. JENNINGS & SONS, LTD. Redhill, Surrey. HEALTH REPORT FOR 1936 FOR THE COULSDON AND PURLEY URBAN DISTRICT BY THE MEDICAL OFFICER OF HEALTH S. C. JENNINGS & SONS, LTD. Redhill, Surrey. URBAN DISTRICT COUNCIL OF COULSDON AND PURLEY. Public Health Committee. Chairman: Councillor Mrs. G. M. bluett. Councillor J. Anderson. Councillor F. Jobbins. „ W. H. S. Aplin, A.F.C., „ A. L. Mitchell. A.M.I.C.E., A.I.P.C. „ J. H. Nelson. „ Mrs. Bartleet. „ H. A. Ross. „ J.I. Conway. „ W. J. Tiller. „ E. O. Hughes. Maternity and Child Welfare Committee. Coun. Mrs. bartleet. Mrs. M. Davison. Mrs. M. G. Pillow. „ Mrs. Bluett. Mrs. R. J. Everett. Mrs. M. J. Read. „ Mrs. Ransome, M.A. Mrs. E. B. Farrow. Mrs. J. Saunders. Mrs. M. G. Adams. Mrs. W. H. Finn. Mrs. D. E. Tierney. Mrs. E. L. Clark. Mrs. H. K. Freeman. Mrs. P. Towes. Mrs. L. B. Clark. Mrs. A. Morse. Mrs. L. M. Turner. Mrs. E. Davie. Mrs. G. Phillips. Representatives on the Wandle Valley Joint Hospital Board. Councillor S. B. Gillespie. Councillor F. Jobbins. Councillor T. A. Harrison, J.P. Councillor F. White. Representatives on the Purley War Memorial Hospital Committee. Councillor Mrs. Hipwell. Councillor W. J. Tiller. STAFF: Medical Officer of Health: F. R. Edbrooke, M.B., Ch.B., D.P.H. *Assistant Medical Officer of Health: E. C. Loudon, M.B., Ch.B., D.P.H. *Medical Officer of Ante-natal Clinics: Winifred M. Small, M.B., Ch.B. *Assistant Medical Officers for Child Welfare Centres: Constance Hildred, M.B., Ch.B. Janet D. E. Michael, M.D., M.R.C.P., M.R.C.S. *Consulting Obstetric Specialists: Leslie Williams, M.D., M.S., F.R.C.S. A. Joseph Wrigley, M.D., F.R.C.S. Sanitary Inspector: H. Buxton, M.R.S.I. Additional Sanitary Inspectors: *S. E. Crisp, C.S.R.I. L. E. Snelling, A.R.S.I. Health Visitors: Miss E. T. White, S.R.N., S.C.M., I.S.T.M., H.V.C, Miss D. E. Letts, S.R.N., S.C.M., H.V.C. Miss S. g. Paddle, S.R.N., S.C.M., H.V.C Clerks: *S. E. Crisp, G. A. Lee. * Part-time Official. 3 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 11,182 Registrar-General's estimate of population, 1936 51,460 Population, Census, 1931 37,666 Number of occupied houses, December, 1936 13,969 Number of occupied houses, 1931 9,533 Rateable Value, December, 1936 £669,284 Sum represented by a penny rate, December, 1936 £2,604 VITAL STATISTICS. Birth Rate per 1,000 of the estimated resident population. Total. M. F. Live Births—Legitimate 622 326 296 do. —Illegitimate 19 8 11 12.5 641 334 307 Rate per 1,000 (live and still) births. Still Births 27 16 11 40 Death Rate per 1,000 of the estimated resident population. Deaths 439 211 228 8.5 Rate per 1,000 (live and still) births. Deaths from Puerperal causes:— Puerperal Sepsis 1 1.49 Other puerperal causes 1 1.49 Total 2 2.99 Death Rates of Infants under one year of age:- All infants per 1,000 live births 33 Legitimate infants per 1,000 legitimate live births 31 Illegitimate infants per 1,000 illegitimate live births 105 Deaths from Cancer (all ages) 70 Deaths from Measles (all ages) 1 Deaths from Whooping Cough (all ages) Nil Deaths from Diarrhoea (under 2 years) 1 4 URBAN DISTRICT COUNCIL OF COULSDON AND PURLEY. HEALTH REPORT FOR 1936. Ladies and Gentlemen, I beg to present to you my Annual Report for 1936, this being the fifth Report as your Medical Officer of Health. In general it will be found to resemble its predecessors, the arrangement being the same, while the impression gathered will probably be one of gradual improvement in the health of the District. The year under review saw a further increase in both the Birth and Death Rates, the former probably due in part to the increasing number of young couples who are settling in the District. The increase in the Death Rate is in part fictitious, being chiefly attributable to the rather surprising number of non-residents who died in one of the Mental Hospitals in the District, and who had no previous permanent abode. The rise would otherwise have been very slight. The Infantile Mortality Rate remained at the usual low level, while the Maternal Mortality Rate only slightly increased. Undue emphasis should not, however, be placed upon this slight rise as this Rate is liable to marked fluctuations from the small numbers concerned. From the point of view of Infectious Disease, the year may be considered to have been a fairly satisfactory one. The waves of Scarlet Fever and Diphtheria subsided during the first half of the year, and it is hoped that these, and other Infectious Diseases, will now remain at a low level for a time. Probably preparation for the launching of a Scheme for the immunisation of children against Diphtheria was the most conspicuous of the activities of the Department during the year, but this was only one of the many new or extended forms of service which are undertaken annually. New legislation has to be absorbed and applied each year, the Housing Acts 1935 and 1936, being the most noteworthy in the past year. These have entailed considerable activity in the Sanitary Department, but the most outstanding achievement of this Department has been securing the abolition of no less than 119 cesspools during the year. Other extensions of note were the taking over of responsibility for the disinfection of houses from the Wandle Valley Joint Hospital Board, and duties under the Rats and Mice Destruction Act from the Surrey County Council. 5 Meanwhile the Maternity and Child Welfare services continue to grow, and during the year a new Centre was established at Sanderstead. In addition, a considerable amount of time has been given to the possibility of increasing the maternity accommodation available for the District, and to the provision of an adequate service of midwives. By contrast, and symbolical of the outstanding anachronism of the modern world, considerable attention has again been given to the application of "Air Raid Precautions". Thanks to the sane example of quiet and unobtrusive preparation which the Council has set the District, the disturbance of the minds of residents, which is liable to be caused by the over-enthusiastic application of such schemes, has been minimised. It is hoped, however, that mental lethargy will not result. The urgent necessity for the abolition of the root cause of this potential danger to the Public Health, as being the only completely effective means of its removal, should remain a constant stimulus to further effort. Only by preventing the possibility of the misuse of aircraft for the settlement of international disputes can absolute safety from the air be secured. A National Campaign to stimulate interest in Physical Fitness is being launched in the current year, and it may be opportune in concluding these introductory remarks to reiterate that ultimately the responsibility for the health of the District rests on each individual resident. Only by the recognition and acceptance of the laws of health can the concerted action recorded in this Report culminate in a healthier District, in the experience of the joy of robust health by the individual, and in better service to mankind, which must surely be the ultimate aim of such a Campaign, if success is to be achieved. My thanks are due to the Members of the Public Health Committee, my colleagues and staff for their co-operation during the year which has increased the pleasure in my work. Special thanks are due to the Sanitary Inspector for his aid in reporting upon certain sections of the work in which we have closely collaborated. I am, Ladies and Gentlemen, Your obedient servant, F. R. EDBROOKE, Medical Officer of Health. Public Health Department, 69, Brighton Road, Purley. 6 HEALTH REPORT FOR 1936. The Urban District of Coulsdon and Purley was constituted by an Order of the Local Government Board, dated the 1st November, 1914, and came into existence on the 7th April, 1915. Situated some 12-18 miles from the centre, and to the South of London, on a portion of the North Downs, it is one of the most beautiful districts within easy reach of London. Chiefly residential in character, and with a population that has increased in a remarkable manner since 1921, it still contains large rural areas. No large manufacturing concerns exist, the chief occupations being building and the retailing of the necessities of life to the residents. Unemployment is comparatively low, and in fact a steady influx of labour from more distressed areas has taken place. AREA AND POPULATION. The District has an area of 11,182 acres, this being 2,547 acres more than before the last revision of boundaries in 1933. The acreage of each Ward is:— Coulsdon East 2,812 Coulsdon West 1,253 Selsdon and Farleigh 1,963 Kenley 1,292 Sanderstead 2,312 Woodcote 865 Purley 685 Twenty-one years ago when the Urban District came into existence the population was estimated to be 17,920, and this had increased to 21,493 by the time of the Census in 1921. By the 1931 Census this figure had become 37,666, while in mid-1936 the Registrar-General estimated the population to be 51,460, this representing an increase of 2,890 in the last twelve months. Only about 3,000 of this total can be attributed to the area added in 1933, which is still chiefly rural. The number of inmates in the Institutions in the District in 1936 was:— Males. Females. Total. Cane Hill Mental Hospital 860 1338 2198 Netherne Mental Hospital 552 933 1485 Russell Hill Schools 60 191 251 Reedham Orphanage 194 127 321 Totals 1666 2589 4255 7 In 1915 there were 4,141 occupied houses, chiefly in Purley and Woodcote, whereas in 1936 there were 13,969 houses, distributed amongst the Wards as follows:— Coulsdon Bast 1,466 Coulsdon West 2,612 Kenley 1,144 Purley 2,404 Sanderstead 3,292 Selsdon and Parleigh 1,554 Woodcote 1,497 There were thus 3.7 persons per house in 1936, as compared with 4.3 in 1915. VITAL STATISTICS. BIRTHS. During the year 641 Births were registered as belonging to the District, of which 334 were males and 307 were females, as compared with 593 in 1935. This is equal to an Annual Birth Rate of 12.5 per thousand of population, as compared with 12.2 last year, and 11.8 and 11.1 in the preceding two years. The average Birth Rate for this District declined during the four quinquenniel periods 1915-1934, viz., 13.9, 13.5, 12.9 and 11.6, but slight rises occurred in this District and in the Country as a whole in 1934, suggesting that a turning point had been reached. Locally this has proved correct, as increases in the Birth Rate have now been experienced in three successive years. Nationally, however, the rate has remained fairly stationary, the Birth Rates for England and Wales being 14.8 in 1936, 14.7 in 1935, and 14.8 in 1934. The local increase probably reflects in part the number of young married couples who are settling in this District, being attracted by the amenities and the type of development which has taken place in recent years. There were 19 illegitimate births (8 males and 11 females) registered, this being 6 less than in the preceding year. Expressed as a percentage of total births, 2.9 were illegitimate. The proportion of illegitimate births showed a marked decline from 1915 to 1934, the averages for the five yearly periods being 5.7, 3.4, 3.7 and 2.8. The number of still births has only been recorded during the last six years. In 1936 there were 27 registered (16 males and 11 females) this being 1 less than last year but 18 more than in 1934. 8 DEATHS. The number of Deaths registered during the year as belonging to this District was 439 (211 males and 228 females), as compared with 388 in 1935, and 355 in 1934. This number excludes deaths which, although occurring within the District, belonged to other districts, but includes deaths of residents who died outside the District, and also non-residents dying in the District who have previously had no permanent place of abode. The Death Rate for the year was equal to 8.5 per thousand of population, as compared with 7.9, 7.6, 7.1 and 8.5 in the preceding four years. A slight modification is, however, necessary if the number is to be compared with that of England and Wales, the age and sex distribution not being quite typical of the Country as a whole. The corrected crude Death Rate for 1936 thus becomes 8.4 per thousand of population. The Death Rates for England and Wales were 12.1 in 1936, 11.7 in 1935, and 11.8, 12.3 and 12.0 in the preceding three years. During the first fifteen years of the existence of this Urban District there was a tendency for the Death Rate to decline, as in the country as a whole, the average for the three quinquennial periods being 8.5, 7.4 and 7.0. During the five years, 1929-34, there was a slight rise to an average of 7.4, while in the last three years there has been a steady increase. In part the most recent increase can be accounted for, as 21 persons died in a local Institution who had had no permanent abode prior to their admission. Their deaths were thus registered as belonging to this District. In 1935 there was only one similar case, and in 1934 only six. Of the 439 Deaths which occurred in Coulsdon and Purley in 1936 54 per cent. were over 65 years of age. This is about the same percentage as in the last three years, and compares very favourably with the average of 45 per cent. for the five years 1926-30. The principal causes of Death, together with the rates per cent, of total deaths, are shown in the following Table. For the full list of causes of death, and the ages at which the deaths occurred, see Table IV in the Appendix. Cause. Number of Deaths. Rate per cent. of Total Deaths. Bronchitis 11 2.6 Tuberculosis of respiratory system 23 5.2 Cancer, malignant disease 70 15.9 Heart Disease 111 25.3 Cerebral Hæmorrhage 15 3.4 Other circulatory diseases 35 7.9 Pneumonia 18 4.1 Nephritis 17 3.9 Violence (including Suicide) 14 3.2 9 It will be seen that the chief causes of death in the District were Heart and other circulatory diseases (including Cerebral Haemorrhage) 161, and Cancer 70, followed by Pulmonary Tuberculosis 23, Pneumonia (all forms) 18, Nephritis 17 and Violence (including Suicide), 14. HEART DISEASE, etc. The percentage of deaths due to heart and other circulatory disease was approximately the same as in 1935, constituting just over one-third of all deaths. As has been previously stated, in so far as this group includes deaths from what is virtually senility, it is hoped that the proportion coming under this heading will increase. The proportion over 65 years of age was 72 per cent., that being the same as in the last two years, while 40 per cent. were over 75 years of age at the time of death. Of the remaining 28 per cent. under 65 years of age only about 4 per cent. were connected with Rheumatism, the chief cause of heart disease in the young, or were congenital in origin. It is probable, however, that Rheumatism was responsible for the original damage in a much larger proportion, although not mentioned in the Death Certificate. Once again, about one-fifth of this group of deaths was in respect of persons under 65 years of age, in whom the postponement of death might reasonably have been expected had undue strain or excess been avoided. CANCER. As in 1935, cancer produced 15.9 per cent. of the total deaths, as compared with 19.4 per cent. in 1934 and 18.8 per cent. in 1933. Considered in relation to the population, the Cancer Death Rate was 1.36 per thousand of population in 1936, and 1.28, 1.49 and 1.30 in the preceding three years, corresponding figures for England and Wales being 1.61 for 1936, 1.58, 1.56, and 1.52. As the average annual Cancer Death Rate locally was 1.13 per thousand of population from 1915-24 and 1.26 from 1925-34, while that for England and Wales was 1.21 and 1.44, it will be seen that an increasing proportion of deaths is being attributed to this disease. While in part this is due to better notification and diagnosis, this proportion is such that increasing effort is required to reduce this too common cause of death. The following table gives the age, sex and distribution of the disease in the 70 deaths which occurred during 1936:— 10  Under 30 30-40 40-50 50-60 60-70 70-80 Over 80 Total. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Cheek - - - - - - 2 - - - - - - - 2 - Mouth - - - - - - 1 - - - - - - - 1 - Tongue - - - - - - - - - - - 1 - - - 1 Oesophagus - - - - - - - 1 - - - - - 1 - Stomach 1 - - - - - 3 1 1 - 2 1 - - 7 2 Large Intestine - - - - - - - - 2 2 2 - - 1 4 3 Gall Bladder - - - - - - - - - - 1 1 - - 1 1 Liver - - - - - - 1 1 - 2 - - - - 1 3 Pancreas - - - - - - - - - - 1 1 1 - 2 1 Lungs - - - - - - 2 - 1 - 1 - - - 4 - Uterus - - - - - 2 - 1 - 1 - 1 - - - 5 Ovary - - - - - 1 - 1 - 3 - 1 - - - 6 Breast - - - - - 2 - 2 - 3 - 3 - 1 - 11 Prostate - - - - - - 2 - 1 - 2 - 1 - 6 - Bladder - - - - - - - - - - 1 1 - - 1 1 Bone - - - - - 1 1 1 - - 1 1 - 1 2 4 Totals 1 - - - - 6 12 7 6 11 11 11 2 3 32 38 The usual features will again be noted, viz.—the increasing frequency with advancing age, and the high proportion in which the stomach, intestines or breast are affected. Two small steps have been taken locally during the year towards reducing the cancer mortality. The Department has co-operated with the Surrey County Health Department in an investigation into the course of the disease in the fatal cases which have occurred, with a view to seeing what treatment has been secured, etc. On the other hand, the Medical Officer of Health has undertaken the duties of local Medical Secretary to the British Empire Cancer Campaign through which qualified speakers can be secured for suitable local meetings at which the subject of cancer is to be considered. It is hoped that more use will be made of this and similar facilities by local Societies, etc., in the future. While much further effort is required, and is being given along the line of research into the cause, prevention and treatment of cancer, it should be more generally recognised that at the present time cancer can very frequently be cured, if only recognised early enough, and the best available treatment secured. The responsibility for obtaining early examination rests with the individual resident. The symptoms which call for most attention are persistent and repeated pain, bleeding, swelling, early morning diarrhoea, increasing constipation, and difficulty in passing water. 11 In view of the numbers this year attributed primarily to prostate and breast, the importance of the last symptom should be emphasized, and special stress again laid on the need for the investigation of any lump in the breasts of females, especially over 30 years of age, which does not subside in a very short time. Apart from the danger of delay, much ill-health frequently results from the mental agony caused by postponing examination. The reassurance of a negative finding is almost as important as an early positive result. TUBERCULOSIS AND PNEUMONIA. Deaths from Tuberculosis and Pneumonia are referred to in other sections of this Report. VIOLENCE. Deaths from Violence, including Suicide, were less frequent in 1936 than in 1935, when they accounted for nearly 6.0 per cent. of the total deaths. In 1936 there were 11 deaths from violence, other than suicide, this being 2 less each year since 1934, which saw the highest number of deaths from this cause that had been experienced since the formation of the District. Of the 11 deaths, 5 were from road accidents (3 less than in 1935), 3 were due to falls, mostly in elderly people, 2 from aeroplane accidents, and 1 was post-operative. Deaths from Suicide also decreased in number, there being only 3 as compared with 9, 6 and 3 in the preceding three years. The Death Rate from this cause was thus 6.0 per 100,000 of population, as compared with averages of 11 and 12 in the two preceding decades. Two of the deaths were in males, while in all three, death was due to coal gas poisoning. MATERNAL MORTALITY. There were 2 deaths associated with childbirth during 1936, the Maternal Mortality Rate being 2.99 per thousand total births, as compared with 3.81 in England and Wales. 12 When dealing with such small numbers, the resultant rate is liable to fluctuate rather markedly from year to year, hence too much stress should not be placed on the local figure for 1936. Thus the average rates for the four quinquennial periods 1915-24 remained fairly stationary at 3.20, 2.08, 2.66 and 3.21, although in one year (1932) the rate rose as high as 10.2. The national rate has shown a further reduction this year, which is very pleasing. Of the two deaths which occurred locally, one was attributed to puerperal sepsis, and could probably have been avoided had the mother concerned secured early attention by the midwife already booked, but not sent for in time. More than one case during the last year has emphasised this primary and, it would be thought, obvious necessity for making early arrangements for expected confinements and securing prompt treatment at the onset of labour. The other case received skilled ante-natal and natal attendance and must therefore be classified as unavoidable in the present state of our knowledge. The prevention of pregnancy would have been the only way to have avoided the fatal issue. While considerable attention has been focussed on the risks of childbirth, and constant attention is being given locally and nationally to the reduction of these risks, it should be again emphasised that undue alarm on the part of expectant mothers is undesirable and increasingly unjustifiable. The attendant risks are much less than they were and are decreasing annually. With reasonable forethought and co-operation with the medical services available to all, irrespective of social position or financial resources, childbirth should resume its place as the natural phase in life which it fundamentally is. INFANT MORTALITY. The number of deaths occurring in children under one year of age was 21, as compared with 19 last year, and 14 and 10 in the preceding two years, all except 2 being in legitimate children. The Infantile Mortality Rate was thus 33, as compared with 32, 26 and 30 in the last three years. As previously pointed out, this Rate is liable to marked fluctuations owing to the small numbers concerned. Even five-yearly grouping does not abolish this, as the average figures for the four quinquennial periods, 1915-34, demonstrate, viz., 44, 28, 38 and 32. During the last four years, however, it has steadied at about 30. 13 The Infantile Mortality Rate for England and Wales was 59 in 1936, and 57, 59 and 64 in the three preceding years, the figure for 1935 being the lowest on record. The averages for 1915-24 and 1924-35 were approximately 83 and 67. The causes of death in the 21 infants under one year of age who died in 1936 were:— Peritonitis—idiopathic purulent 1 Enteritis-infective 1 Birth injuries 2 Congenital defects (heart or spinal) 5 Atelectasis, prematurity or marasmus 8 Ditto with Broncho-pneumonia 2 Post operative (intussusception) 1 Measles 1 Of these children, 18 were under three months, 15 under one month and 13 not more than one week old at death. The neo-natal mortality rate (i.e., deaths within the first month per thousand live births) was thus 23. While only a small number, and the same as last year, the group due to birth injury, together with some of the deaths classified as due to prematurity, etc., are those which it is hoped skilled ante-natal and natal attention will prevent. The infective group should be those most easily prevented and hence those most deplored in the above list. The following Table shows the Populations, Births, Birth Rates, Deaths, Death Rates and Infantile Mortality Rates for each of the past ten years:— 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 Population 29,370 31,520 32,490 40,000 37,300 40,050 44,390 46,340 48,750 51,460 Births 371 393 436 433 472 474 486 547 593 641 Birth Rate 12.6 12.4 13.4 10.8 12.6 11.8 11.1 11.8 12.2 12.5 Deaths 198 208 278 259 288 342 313 355 388 439 Death Rate 6.7 6.6 8.5 6.4 7.7 8.5 7.1 7.6 7.9 8.5 Infant Deaths 10 15 22 19 11 22 10 14 19 21 Infantile Mortality Rate 26 38 50 43 23 46 20 26 32 33 14 COMPARATIVE CRUDE BIRTH-RATES, DEATH-RATES, ANALYSIS OF MORTALITY, MATERNAL DEATH-RATES, AND CASE-RATES for certain Infectious Diseases in the year 1936. England and Wales. 122 County Boroughs and Great Towns including London. 143 Smaller Towns (Resident Populations 25,000 to 50,000 at 1931 Census). London Administrative County. Coulsdon and Purley Urban District. Rates per 1,000 Population. Births:— Live 14.8 14.9 15.0 13.6 12.5 Still 0.61 0.67 0.64 0.53 0.52 Deaths:— All Causes 12.1 12.3 11.5 12.5 8.5 Typhoid and Paratyphoid fevers 0.01 0.01 0.00 0.01 0.00 Smallpox — — — — — Measles 0.07 0.09 0.04 0.14 0.02 Scarlet fever 0.01 0.01 0.01 0.01 — Whooping Cough 0.05 0.06 0.04 0.06 — Diphtheria 0.07 0.08 0.05 0.05 0.03 Influenza 0.14 0.14 0.15 0.14 0.11 Violence 0.52 0.45 0.39 0.52 0.27 Notifications:— Smallpox 0.00 0.00 — — — Scarlet Fever 2.53 2.18 2.48 2.57 2.27 Diphtheria 1.39 1.31 1.26 1.69 0.68 Enteric Fever 0.06 0.05 0.06 0.06 0.05 Erysipelas 0.40 0.38 0.35 0.44 0.23 Pneumonia 1.11 1.10 0.96 0.99 0.25 Deaths under 1 yr. of age Rates per 1,000 Live Births. 59 63 55 66 33 Deaths from Diarrhœa and Enteritis under 2 years of age 5.9 8.2 3.4 14.4 1.56 Maternal Mortality: Puerperal Sepsis 1.40 Not available. 1.56 Others 2.41 1.56 Total 3.81 3.12 Maternal Mortality: Rates per 1,000 Total Births (i.e., Live and Still). Puerperal Sepsis 1.34 Not available. 1.49 Others 2.31 1.49 Total 3.65 2.99 Notifications:— Puerperal Fever 3.27 3.46 2.80 3.03 1.49 Puerperal Pyrexia 9.64 9.52 7.57 11.15 — INFECTIOUS DISEASE. The year 1936 compared favourably with its predecessors from the point of view of notifiable Infectious Disease, with a total of 183 notified cases, other than Tuberculosis, compared with 230 in 1935 and 190 in 1934. Had the waves of Scarlet Fever and Diphtheria, which 15 menced in 1934, not continued in the first half of 1936 an even better record could have been reported. In both these diseases a return to a more normal incidence was experienced in the latter half of the year. As it was, the incidence of Infectious Disease per thousand of population fell from 4.7 in 1935 to 3.6 in 1936, thus comparing favourably with the average rates of 6.7 for 1915-24, and 3.9 for 1925-34, while even in the cases of scarlet fever and diphtheria the rates were well below those for the country as a whole. The following Table shows the number of cases notified, together with the number removed to Hospital, and the total deaths:— Disease. Number Notified. Removed to Hospital. Total Deaths. Scarlet Fever 117 102 — Diphtheria 35 35 2 Typhoid Fever 3 2 — Erysipelas 12 3 — Cerebro-spinal Meningitis 1 1 1 Puerperal Fever 1 1 1 Ophthalmia Neonatorum 1 — — Pneumonia 13 — *18 Totals 183 144 22 * Includes deaths from all forms of Pneumonia. Further Tables (I and II) will be found in the Appendix showing the ages at which the infection occurred, the municipal wards in which the cases were resident, and the monthly incidence of the disease. DIPHTHERIA. The wave of Diphtheria which lasted throughout 1935, and resulted in 52 cases, gradually subsided during 1936, there being 35 notified cases, which were chiefly associated with one Ward of the District, and confined to the first half of the year. In addition, 4 cases were admitted to Hospital suspected of having the disease in which the diagnosis was not confirmed, while one case was re-admitted after discharge, having been found to be still carrying virulent Diphtheria bacilli. Of the 35 notified cases, 3 were only "carriers" who were not themselves suffering ill-health when admitted. In 3 instances two members of a family were affected, in one case 3 members and in another case 4 members suffered from the disease. All cases were removed to Hospital, and unfortunately two children died. The nature and extent of the main outbreak was commented upon fully in the Annual Report for 1935, hence further comments would be superfluous. 16 In the second half of the year there were only 10 cases, and these were scattered over the District, while more than half of them probably contracted the disease outside the Urban District. This number corresponds approximately with the average incidence of the disease in this Urban District, and it is hoped that 1937 will present not more than the normal number of cases for the whole year. Meanwhile consideration has been given to the establishment of a Diphtheria Immunisation Scheme in the Urban District, the local demand for such a facility having increased. While it is realised that the recent wave of Diphtheria has now subsided, and that a small demand for immunisation may be experienced at first owing to the comparatively few cases of the disease failing to stimulate public interest, it has been decided that a start should be made. The Council decided early in 1937 to establish a Clinic at 89, Brighton Road, Purley, where children from 1 to 5 years of age could be immunised free of charge, and children over 5 years of age at a small charge to cover the cost of materials. The reason for this differentiation is that it is highly desirable from the point of view of the health of the District, as opposed to that of the individual, for a good percentage of toddlers to be immunised rather than the older children. While more cases are apt to occur among school children, partly owing to there being more of them than of children under school age, and partly to their more intimate contact with other children, it is the toddlers who suffer more severely when infected. Persons immunised may still carry virulent germs, and if, as is apt to happen, a much larger proportion of older children are first immunised they may well carry the disease to the younger children. On the other hand, the toddler is less likely to spread disease owing to its comparative immobility. It is hoped that the general practitioners of the District will also co-operate in the work of immunisation, and that the foundation of a Scheme may be wisely laid, capable of extension as and when required. While it is unlikely that the response, and numbers which can be immunised, will influence the incidence of the disease in the District for some time, and a rise may be experienced in the interval, the means will be available for those who desire to protect their children, and ultimately it is hoped that few cases will result. From the point of view of the individual who accepts the full course of treatment, at least 9 out of 10 can expect to be immune within six months, and remain immune for some years, while almost all can feel assured that death from Diphtheria will be avoided after the initial period. The fact that immunity does take several weeks or months to develop is, of course, an additional reason for not delaying treatment, but having it done early although there may be but little of the disease about, 17 What the ultimate results of mass immunisation will be it is probably unwise to forecast, but the generally accepted view at the present time is that it is reasonable to provide facilities for immunisation for those who desire to avail themselves, thereby aiming at producing safely and quickly an immunity which the fortunate would develop naturally in the course of years, in order to protect those who would otherwise be unfortunate and succumb to this disease before gaining the required immunity. ENTERIC FEVER. Three cases of Enteric Fever were notified as compared with one last year and an average of 5 for the preceding five years. The first case was one of Typhoid diagnosed and treated in a London Hospital. The other cases, which occurred in July and August, were of Paratyphoid, one being treated at home and the other in hospital. In no case was the origin of the disease traced and all the cases recovered. A further case suspected of being Typhoid Fever proved to be one of Undulant Fever. SCARLET FEVER. The wave of Scarlet Fever which began in 1934 and continued throughout 1935 did not diminish as rapidly as was expected. A further 117 cases occurred during 1936, as compared with 124 in 1935, and 119, 69, and 29 in the preceding three years. As, however, 90 per cent. of the cases occurred in the first six months of the year, it is probable that 1937 will see a distinct improvement in the incidence of this disease. More than half the cases in 1936 occurred in the Coulsdon West Ward, which was the Ward most affected in 1934, although Woodcote had the highest percentage in 1935. As a result of this distribution, as might be expected, a higher proportion were treated in hospital, there being 102 cases so treated. The number of cases occurring in Institutions was less than in 1935, only 2 cases occurring in a Mental Hospital and 1 in the Orphanage. About half of the cases were in persons not in attendance at schools, while of those of school age more than one-quarter originated in one public elementary school. It should not, however, be assumed that infection necessarily occurred during school hours, although this was probable in a few cases. Six cases were "Return Cases" following discharge of convalescents from hospital. The disease remained mild in type, no deaths having resulted in the last four years, while only 5 deaths from Scarlet Fever occurred in the preceding ten years 1923-32. 18 There were 8 instances during 1936 in which a secondary case occurred in the same house as a primary case, and 2 in which a third case occurred. As only one of the secondary cases occurred in a house where the primary case was treated at home, and in this instance the infection was contracted before the original case had been diagnosed, the policy of treating cases of Scarlet Fever at home when the patient can be reasonably isolated is further justified. ERYSIPELAS. There were 12 cases of Erysipelas notified as compared with 11, 23 and 17 in the last three years. Of these, 5 were patients in the Mental Hospitals, the remaining 7 being unconnected cases scattered over the District. Three of the cases were removed to hospital, and one death occurred in which this disease was the terminal condition. PUERPERAL FEVER. One case was notified and removed to Epsom Hospital, where she subsequently died. This case is referred to in the section on Maternal Mortality. CEREBRO-SPINAL MENINGITIS. One case of Cerebro-spinal Meningitis occurred in the early part of the year in a child who was removed to the Isolation Hospital, where unfortunately the disease proved fatal. PNEUMONIA. There were only 13 cases of Acute Primary or Influenzal Pneumonia notified, as compared with 32, 30 and 28 cases in the last three years. As, however, 6 of these cases occurred in one of the Mental Homes, the number of cases notified in the remainder of the District was 7, as compared with 14, 6 and 7 in the preceding three years. No case was removed to hospital. OPHTHALMIA NEONATORUM. There was only one case of this disease notified during the year which proved to be streptococcal in origin. The child was removed to hospital, and recovered without impairment of vision. It will be seen by the Table at the beginning of this section that the case-rates for Infectious Disease have remained low compared with the country as a whole. As pointed out in previous Reports, it is difficult to prevent these diseases in a District such as this, having very frequent contact with London, Croydon, and the surrounding districts, especially 19 with the mild and often Unrecognised form of Scarlet Fever now prevalent. The fact that during the year in only 20 instances did secondary cases follow primary ones in the home (three of these being swab positive only) suggests that the limitation of cases has continued satisfactorily. NON-NOTIFIABLE INFECTIOUS DISEASE. The group of non-notifiable Infectious Diseases, with the exceptions of Influenza and Measles, caused no deaths during 1936, which was a fairly mild year as far as these diseases were concerned. Influenza accounted for 6 deaths in adults, three of whom were over 80 years of age, while one newly-born infant died of measles. Apart from the death returns, the only source of information as to the presence of outbreaks of non-notifiable Infectious Diseases are the returns received from the public elementary schools. As judged by these, the only outbreaks of note were:— CHICKEN POX.—There were isolated cases scattered over the District in January and February, but in the next four months there was quite a sharp outbreak all over the area and especially at Selsdon. A number of cases also occurred in the Autumn, chiefly in Coulsdon. MEASLES.—From January to March there was an epidemic affecting all parts of the area. Selsdon was chiefly affected in January and February, and Coulsdon in February and March. MUMPS.—There were a few cases in Coulsdon West and Smithambottom in March which increased in numbers in May and June, spreading to Coulsdon East. The numbers continued to increase in Smithambottom from October to December, while a number of cases occurred in Purley in the last two months of the year. WHOOPING COUGH.—Comparatively few cases occurred, chiefly in Sanderstead in March and April, and in the other parts of the area from May to July. Home visitation and exclusion from school are the two chief measures relied on to postpone the onset until a more favourable age is reached to stand the disease. Treatment in Hospital is provided for a limited number of cases, and 2 cases of Measles were admitted to the Isolation Hospital during the year under this arrangement, social or physical complications being present. Arrangements with the Immunisation Centre of Great Ormond Street Hospital exist, whereby cases in which there are special reasons for immunisation against Measles or Whooping Cough may be referred to this Clinic by the Medical Officer of Health. The Council, however, reserve the right to recover all, or part, of the cost of treatment. Similar facilities have also been arranged for immunisation against Scarlet Fever. To date no use has been made of this facility, immunisation being undertaken by the patient's own doctor in the few cases which 20 have arisen. Difficulty has, however, been experienced in obtaining serum for the prevention of Measles. TUBERCULOSIS. During the year 30 new cases were notified, as compared with 35, 45 and 54 in the last three years. The 30 cases comprised:— Localisation. Males. Females. Total. Pulmonary 17 10 27 Non-Pulmonary 2 1 3 Totals 19 11 30 The number of deaths registered as occurring from Tuberculosis was 24, viz.:— Localisation. Males. Females. Total. Pulmonary 13 10 23 Non-Pulmonary 1 — 1 Totals 14 10 24 With regard to Pulmonary Tuberculosis, the number of new cases notified in 1936 again fell as compared with the preceding year. The case rate per 100,000 of population was 54, which compared very favourably with the average rates of 115 for 1915-24, and 88 for 1925-34. It is satisfactory to note a further fall this year in the number of new cases of non-pulmonary Tuberculosis, viz.:—3 as compared with 5, 17 and 10 in the preceding three years. The incidence per 100,000 of population was very low, being 6, the average for the previous decades being 15 and 18. There was one more death from Pulmonary Tuberculosis than last year, but the death rate from this disease remained the same, viz.:— 45 per 100,000 of population, as compared with the average death rates of 72, 57, 36 and 38 for the four quinquennial periods 1915-34. On the other hand, the number of deaths from non-pulmonary Tuberculosis diminished in 1936, there being only 1 death, providing a corresponding death rate of slightly less than 2 per 100,000 of population, thus continuing the downward tendency of this rate which gave averages of 20, 9, 7 and 8 in the quinquennial periods 1915-34. The following Table shows the number of new cases of Tuberculosis notified during the year, together with the deaths at various age periods: 21 Age Periods. New Cases. Deaths. Pulmonary NonPulmonary Pulmonary NonPulmonary M. F. M. F. M. F. M. F. Under 1 year — — — — — — — — 1 and under 5 — — 1 — — — — — 5 and under 10 — — — — — — — — 10 and under 15 — 1 — — — — — — 15 and under 20 — — — 1 1 1 1 — 20 and under 25 5 3 1 — 1 2 — — 25 and under 35 5 2 — — 1 2 — - 35 and under 45 4 3 - — 3 3 - - 45 and under 56 2 1 — — 3 — — — 55 and under 65 1 — — — 4 1 — — 65 and upwards — — — — — 1 — — Totals 17 10 2 1 13 10 1 — The new cases were distributed amongst the Wards as follows:— Localisation. Coulsdon East Coulsdon West Kenley Purley Sanderstead Selsdon & Parley Woodcote Pulmonary 5 5 4 2 4 4 3 NonPulmonary 1 — 1 — — — 1 Of the deaths which occurred from Tuberculosis in 1936, 79 per cent. were in previously notified cases. Of the remainder, 2 cases were diagnosed after death, two cases had been notified to a neighbouring Authority and not transferred, and one case occurred in an old standing case thought to have been previously notified. The attention of medical practitioners has been drawn to the necessity for early notification, and all cases of failure to comply are followed up, appropriate action being taken in each case. The Council has made arrangements for the examination, free of charge, of sputa from cases or suspected cases of Tuberculosis, and during the year 72 such examinations were made. Visitation is also provided to prevent the spread of the disease where possible, by disinfection, removal of unhygienic conditions, etc. Treatment for cases of Tuberculosis is under the control of the Surrey County Council, which provides both Dispensary and Sanatorium treatment. A Dispensary, available for this District, has been established at Whytecliffe Road, Purley, where sessions are held on the 2nd, 3rd, 4th and 5th Mondays at 2.0 p.m., the 1st Monday at 5.30 p.m. and the 2nd and 4th Tuesday at 10.0 a.m. A Voluntary After-care Committee serving the whole Dispensary area, on which this Council is represented by the Medical Officer of 22 Health, also assists in the Tuberculosis Scheme by helping individual cases and their dependents. PUBLIC HEALTH ACT, 1925, SECTION 62. No occasion arose during the year necessitating the taking of steps by the Council to secure an Order for the compulsory removal to hospital of a person suffering from Pulmonary Tuberculosis. PUBLIC HEALTH (PREVENTION OF TUBERCULOSIS) REGULATIONS, 1925. No action was required during the year, under the powers conferred by the above Regulations, in respect of tuberculous employees in the milk trade. AMBULANCES. For Infectious Disease Cases.—Two motor ambulances have been provided by the Wandle Valley Joint Hospital Board for the removal of Infectious Disease cases to Hospital. For Accident and General Cases.—The Council has provided three motor ambulances for the removal of accident and general cases. These ambulances are under the control of the Fire Superintendent. Special facilities are provided for the conveyance of maternity cases to the Purley Memorial Hospital, which were extended in 1936 to include cases going to any Hospital under the Council's Maternity Scheme, but their application is always conditional upon the hospital fee being paid before the patient's discharge from hospital. HOSPITALS. Infectious Diseases.—This Council is one of the constituent Authorities forming the Wandle Valley Joint Hospital Board, and cases of Infectious Disease (other than Small Pox) occurring in this District are admitted to the Board's Hospital at Beddington Corner. Building extensions commenced during 1936, and the provision of additional cubicle blocks for observation purposes will be specially welcomed in this District. Small Pox.—Under an arrangement with the Surrey County Council cases of Small Pox from this area are admitted to the Small Pox Hospital at Clandon. General Hospitals.—The Croydon General Hospital and the Purley War Memorial Hospital receive patients from this area, but a number of residents receive treatment at London Hospitals. 23 Public Assistance Hospitals.—Patients from this area are admitted to the Public Assistance Hospitals at Epsom, Redhill and Kingston. Maternity Hospital Accommodation.—The Council has an arrangement with the Purley Memorial Hospital whereby the Council has the call on three beds. If accommodation permits, additional cases can be admitted. While under this scheme 87 cases were confined at this Hospital during the year 1936, an additional 17 cases were admitted to Queen Charlotte's Hospital, London. A number of maternity cases from this area are confined at the Public Assistance Hospital at Epsom. Reference is made in the section on Maternity and Child Welfare to the possibility of extending this accommodation. BACTERIOLOGICAL WORK. The bacteriological work in connection with this District was carried out by the Medical Superintendent at the Wandle Valley Joint Isolation Hospital until the end of June, 1936. Since then her work has been limited to the examination of sputa for tubercle and swabs for Diphtheria, the following number of specimens being examined by her during the year:— Swabs for Diphtheria 366 Sputa for Tubercle 72 An arrangement was made during the year whereby other specimens, the examination of which is of importance to the public health, can be examined by the Pathologist to the Croydon General Hospital. DISINFECTION. The disinfection of bedding and premises was undertaken by the Wandle Valley Joint Hospital Board until July, 1936, since when they have agreed to undertake the disinfection of bedding only. The Council has made arrangements for the disinfection of premises since July, 1936, which is carried out by the Sanitary Department. For the convenience of ratepayers, this Council has decided to provide for disinfection even when this is not essential in the interests of public health, but in these cases a charge will be made of 10s. 0d. per load of bedding, etc., 5s. 0d. for the first room, and 2s. 6d. for each additional room disinfected at the same time. MATERNITY AND CHILD WELFARE. The Council is responsible for the Maternity and Child Welfare work in this District, and in its endeavour to minimise the risks of childbirth, and to secure the healthy development of all children born, or residing in the area, the following measures are taken:— 24 Ante-Natal Clinics. An Ante-natal Clinic was established by the Council in 1931, the first session being held on the 24th June in that year. In 1932 the number of sessions had to be increased owing to the great appreciation of this facility, while in 1933 Clinics were established at Purley and Coulsdon. Sessions are now being held from 2.30 to 4.0 p.m. at:— (a) The Methodist Church, Brighton Road, Coulsdon, on the first, second and fourth Monday in each month. (b) The Methodist Church, Sylverdale Road, Purley, on the first and third Wednesday in each month. (c) The Baptist Church, Addington Road, Selsdon, on the second Wednesday in each month. The Clinic at Brighton Road, Coulsdon, will be transferred to 69, Brighton Road, Purley, in July, 1937. It will be seen from the following tabular statement of attendances that 243 new ante-natal cases presented themselves during 1936, as compared with 180, 143 and 114 in the preceding three years. This suggests that in approximately 36 per cent. of the total births (live and still) registered as belonging to the Urban District the mothers had previously been examined under the Council's scheme, the corresponding figures for the preceding years being 29, 26, 23 and 22 per cent. The majority attending are subsequently confined by midwives or at the Purley War Memorial and Queen Charlotte's Hospitals, but a number are referred to the Clinic by local doctors for a second opinion or for observation during the early months of pregnancy, where this would not otherwise be forthcoming. ANTE-NATAL CLINICS. Attendances. Brighton Road, Coulsdon. Month. Sessions. New Cases. Total. Ante-Natal Post-Natal Ante-Natal Post-Natal January 2 11 - 40 2 February 2 14 - 42 4 March 2 9 - 38 1 April 2 11 1 55 3 May 2 14 - 46 3 June 2 3 - 35 2 July 2 6 - 35 3 August 2 8 - 37 1 September 2 14 - 43 5 October 2 16 — 53 4 November 2 9 — 58 1 December 2 4 — 34 1 Totals 24 119 1 516 30 25 Sylverdale Road, Purley. Month Sessions. New Cases. Total. Ante-Natal Post-Natal Ante-Natal Post-Natal January 2 6 — 21 2 February 2 14 — 36 1 March 2 10 — 34 1 April 2 11 1 55 3 May 2 10 — 43 3 June 2 5 1 39 1 July 2 4 — 40 — August 2 6 — 37 — September 2 3 — 36 1 October 2 8 — 37 4 November 2 5 — 29 4 December 2 4 — 27 5 Totals 24 86 2 434 25 Baptist Hall, Selsdon. Month Sessions. New Cases. Total. Ante-Natal Post-Natal Ante-Natal Post-Natal January 1 4 — 17 — February 1 3 1 18 1 March 1 8 — 23 — April 1 2 — 21 — May 1 2 — 18 2 June 1 3 1 18 1 July 1 3 — 17 — August 1 — — 12 — September 1 2 — 10 3 October 1 5 — 13 2 November 1 5 — 17 1 December 1 3 — 13 1 Totals 12 40 2 197 11 Totals at all Clinics. New cases. Total Attendances, Old and New. Ante-natal 243 1,139 Post-natal 5 66 Gynaecolological 2 8 250 1,213 Dr. Winifred Small is the Medical Officer of the Ante-natal Clinics, and is to be congratulated upon the success of the Ante-natal work. All cases attending are seen by her personally. Post-natal Clinic. During the year 60 Ante-natal cases seen at the Clinic presented themselves for post-natal examination. As this is desirable in all cases, and comparatively little time can be given to the work at the Ante-natal sessions, arrangements have been made for a special post-natal session 26 which will be held at 69, Brighton Road, Purley, on the third Monday in each month, commencing in July, 1937. It is hoped that in future all mothers attending the Clinics as antenatal cases will re-attend at least once after their confinement, as many may thereby be saved unnecessary inconvenience and ill-health. Obstetric Specialists. In November, 1934, the Council appointed as Obstetric Specialists to the Council Mr. Leslie Williams and Mr. Joseph Wrigley, both of whom are Specialists in this work attached to London Hospitals. Their services are available for advice, and, if necessary, treatment in any case in which obstetrical difficulty is anticipated or realised, or Puerperal Pyrexia or Fever develops, in any ratepayer in the District. The Council reserves the right to recover part, or all of the cost involved from the family. During 1936, only one case required the services of one of these Specialists. Maternity Cases. During the year arrangements were made for the admission of 87 cases to the Purley War Memorial Hospital for their confinement under the Council's scheme, as compared with 80, 86 and 68 in the preceding three years. The Hospital is situated just within the boundary of the County Borough of Croydon, and hence its supervision as a Maternity Home is the responsibility of the Medical Officer of Health for that area. The Council has now the call on three beds in this Hospital, although for a time this was increased to four beds. As has been stated in previous reports, with the growing need of the District consideration has been given to the question of enlarging the Maternity Block or building a new Maternity Hospital. In view of the fact that a number of applications from all sources have had to be refused owing to lack of accommodation, and 17 residents had to be admitted to Queen Charlotte's Hospital during the year in addition to those admitted to Epsom Hospital, a good deal of attention was paid to this question during 1936. As it appeared impossible to provide more accommodation at Purley Memorial Hospital, the provision of a joint Maternity Home with the Urban District of Beddington and Wallington was considered, but owing to the fact that the Surrey County Council are providing 68 maternity beds in the proposed Public Health Hospital at St. Helier's, the Ministry of Health considered that such a Maternity Home would be superfluous. Unfortunately the Hospital at St. Helier's will not be completed for several years. 27 Meanwhile arrangements will continue, it is hoped, with Queen Charlotte's Hospital, London, and St. Mary's Hospital, London, which will take any emergency cases which cannot be accommodated at other Hospitals. Improved facilities for transport to all these Hospitals have been made available by the Council during the year. There are in addition six private Maternity Homes at present in the Urban District. Midwives Acts. The Surrey County Council are at present the Supervising Authority under the Midwives Acts. At the end of the year this Council decided to apply again for these powers. Negotiations also took place with the Surrey County Council as to the provision of midwives for the District, this Council representing its willingness to appoint a sufficient number of full-time midwives for the needs of the District. Home Helps. The Council has made arrangements for the supply of Home Helps in necessitous maternity cases since 1920, and during the year 25 cases were assisted in this way, which is the same number as in 1935. Birth Control. Cases, in which advice on Birth Control is considered desirable on medical grounds by the Doctors at the Clinics, are referred to the Croydon Mothers' and Infants' Welfare Association Clinic in Croydon. Arrangements were made during the year by which this Council makes an annual grant to this Association, in return for which any necessitous residents so referred are provided with advice, etc., at reduced charges. Health Visitation. Since May, 1935, the Council has employed the services of three whole-time Health Visitors, who work under the supervision of the Medical Officer of Health. It will be seen from the following detailed list of visits paid by the Health Visitors during 1936 that a total of 7,695 visits were paid, this being 970 more than in 1935, and 2,527 more than in 1934 when the staff consisted of two Health Visitors. It is satisfactory to be able to report again that adequate home visitation has been possible, in spite of the fact that additional Maternity and Child Welfare and Ante-natal sessions have been arranged. With the commencement of immunisation 28 Work, the opening of a new Centre at Old Coulsdon and a Post-natal Clinic, it must be realised that the Health Visitors will have a considerable increase in their duties, and will consequently have less time for home visitation. It is possible, therefore, that this may have to be slightly below the standard desired for the interim period which inevitably precedes an increase in staff. Care will, however, be taken to see that visitation is reduced in those cases in which it is least required. At present nearly all houses at which births are notified in this District are visited at least once, and in the vast majority of cases the advice given then, and at subsequent visits, or at the Maternity and Child Welfare Centres, has been much appreciated. Visits paid by Health Visitors. 600 first visits to babies 1,978 visits to babies under one year 4,268 visits to children from one to five years 247 Ante-natal visits— 148 first visits 99 re-visits 70 visits to cases of tuberculosis— 51 first visits 19 re-visits 81 visits to cases of measles— 58 first visits 23 re-visits 22 visits to cases of chicken-pox— 21 first visits 1 re-visit 50 visits to cases of whooping cough.— 39 first visits 11 re-visits 12 investigations of infant deaths 20 investigations of still-births 1 investigation of a case of ophthalmia neonatorum 346 miscellaneous visits 7,695 Total. Child Welfare Centres. Five Maternity and Child Welfare Centres have been established by the Council, of which details are tabulated on the following pages. The most recently established Centre is the one at Sanderstead, at which the first session was held in November, 1936. The increasing development in that part of the area, together with the very high attendance at Selsdon, which needed relief, supported by requests from residents, decided the Council in commencing this new Centre. The experiment has been amply justified by the attendances to date. 29 The claims of Old Coulsdon residents have not, however, been forgotten, and it is proposed that a Centre be established there in October, 1937. Reviewing the figures for the year, it will be seen that 502 new cases attended, while the total attendance of old and new cases was 12,519. These figures represent increases of 75 and 1,787 on the preceding year, and increases of 248 and 5,817 on the year 1931 ; that is to say, the attendance at the Centres has almost doubled itself in the last five years. The increase in new cases this year was most marked at the Brighton Road Centre, there being 29 more than in 1935, as compared with 17 at Selsdon and 9 at Kenley, while the new cases at Rickman Hill decreased by one. On the other hand, the average and total attendances increased at Selsdon far more than at the other Centres. The average attendance there increased from 61 to 81 per session, while Brighton Road increased from 58 to 70 per session, and Kenley from 49 to 53. The slight drop in the average attendance at Rickman Hill from 58 to 56 was probably associated with the epidemics which have chiefly affected the area served by that Centre. There can be no doubt of the importance and appreciation of this work, for which there is no provision by any other agency in the District. If additional proof is required, the fact that approximately 62 per cent. of the newly-born babies notified as being born in the District attended one or other of the Centres during 1936 should be conclusive evidence. This figure of 62 per cent. represents an increase of 3 per cent. on 1935. No alteration in the Consultants at the Centres has occurred during the year. Dr. Janet Michael has continued at the Brighton Road Centre, and Dr. Constance Hildred has extended her work at Selsdon by taking over the new Sanderstead Centre in order to ensure co-operation between these two Centres. The Medical Officer of Health attends the Kenley and Rickman Hill Centres. Each of the Centres shows a slight increase in the number of consultations per session visited by a Doctor, but it is undesirable for the efficiency of the work that the average number seen should exceed 25 per session. In the two Centres at which this has occurred it is hoped that relief will be forthcoming by the opening of new Centres. If, however, this does not result, additional attendance by the doctors concerned will probably be desirable. 30 BRIGHTON ROAD INFANT WELFARE CENTRE (Established 1916). Held at the Methodist Schoolroom, Brighton Road, Coulsdon, every Thursday afternoon from 2.30 to 4.0 p.m. Doctor attends second and fourth Thursday in each month. Month. Sessions. Attendances. Consultations. Referred to Hospital. New Cases Old Cases. Total New & Old January 5 10 289 299 59 2 February 4 17 278 295 65 5 March 4 10 266 276 58 — April 4 11 289 300 46 — May 4 6 273 279 64 — June 4 12 261 273 52 — July 5 13 291 304 42 1 August 2 9 146 155 27 2 September 4 15 318 333 86 1 October 5 23 379 402 73 — November 4 12 243 255 46 — December 4 6 237 243 64 — Totals 49 144 3,270 3,414 682 11 RICKMAN HILL INFANT WELFARE CENTRE (Established 1929). Held at the Church of St. Francis, Rickman Hill, Coulsdon, on every Tuesday afternoon from 2.30 to 4.0 p.m. Doctor attends second and fourth Tuesday in each month. Month. Sessions Attendances. Consultations. Referred to Hospital. New Cases. Old Cases. Total New & Old January 3 7 181 188 25 — February 4 6 221 227 56 — March 5 6 283 289 56 — April 3 3 152 155 31 1 May 4 8 240 248 64 — June 4 5 204 209 64 1 July 4 7 233 240 51 — August 2 8 110 118 29 — September 5 10 315 325 62 — October 4 6 240 246 47 1 November 4 9 184 193 55 — December 5 10 199 209 44 — Totals 47 85 2,562 2,647 584 3 31 SELSDON INFANT WELFARE CENTRE (Established 1928). Sessions held at the Baptist Hall, Addington Road, Selsdon, on each Monday afternoon from 2.30 to 4.0 p.m. Doctors attend first and third Monday in each month. Month. Sessions. Attendances. Consultations. Referred to Hospital. New Cases. Old Cases. Total New & Old January 4 16 303 319 57 — February 4 6 248 254 45 — March 5 12 322 334 46 — April 3 16 237 253 46 — May 4 13 333 346 50 — June 4 12 364 376 52 — July 4 9 366 375 57 — August 3 13 243 256 47 — September 4 10 362 372 51 — October 4 12 325 337 48 1 November 5 6 395 401 52 — December 3 5 163 168 56 — Totals 47 130 3,661 3,791 607 1 KENLEY INFANT WELFARE CENTRE (Established 1917). Held at the Methodist Schoolroom, Sylverdale Road, Purley, on every Friday afternoon from 2.30 to 4.0 p.m. Doctor attends second and fourth Friday in each month. Month. Sessions. Attendances. Consultations. Referred to Hospital. New Cases. Old Cases. Total New & Old January 5 6 207 213 47 — February 4 5 177 182 43 — March 4 15 195 210 35 — April 3 4 150 154 29 — May 5 13 216 229 42 — June 4 15 180 195 43 1 July 5 10 257 267 44 — August 2 7 109 116 28 — September 4 16 217 233 48 — October 5 12 315 327 40 — November 4 6 229 235 41 — December 3 9 158 167 28 — Totals 48 118 2,410 2,528 468 1 32 SANDERSTEAD INFANT WELFARE CENTRE (Established 1936). Held at the Congregational Church, Sanderstead Road, on the first and third Thursdays in each month. The Doctor attends each session. Month. Sessions. Attendances. Consultations. Referred to Hospital. New Cases. Old Cases. Total New & Old November 2 16 44* 60 30 — December 2 9 70 79 32 — Totals 4 25 114 139 62 — * Transfers. Provision of Milk and Specialist Treatment. During the year 90 cases in which the parents were known to be in necessitous circumstances, and the children in need of milk, were provided with a supply of milk delivered to their homes, free or at a reduced price, the expense being borne by the Council. This was an increase of 19 cases on 1935. Whilst throughout the District the children are, generally speaking, well nourished, and in many cases above the average development, there are in attendance at each Centre children who bear witness to the impoverished condition of their homes. In the majority of these cases the child has shown great improvement as the result of this provision of extra nourishment. A few cases, however, have shown that the provision of milk is not the only need. During the year 16 cases were referred to hospitals from the Centres, 15 being to Purley Hospital for Ultra Violet Ray treatment, massage or minor operations, and 1 to Croydon General Hospital for orthopaedic treatment. A number of cases have also been referred to their own Doctors for treatment. These numbers remain low, however, thanks to the appreciation of the fact that the Child Welfare Centres are not for the treatment of the sick, but for periodical examination and observation of the apparently healthy child in order to detect any minor defects, or detrimental tendencies, and for instruction on how to rear children along sound lines. On the other hand, the number of children circumcised at Purley Hospital prior to the mother's discharge after her confinement has remained very high, 57 per cent. of the male babies born in 1936 being so treated. 33 While the agreement with the Croydon General Hospital for the treatment of cases suffering from, or liable to develop deafness, has remained in force, no cases have had to be referred for such treatment for the second year in succession. This would appear to be due to the securing of prompt and efficient treatment in the early stages through the family doctor or some other agency. The scheme for the dental treatment of ante-natal and nursing mothers and children under 5 years of age, which was launched in 1934, again increased both in efficiency and popularity. During the year 45 cases were treated by those Dental Surgeons in the District who had signified their willingness to serve under the Scheme, as compared with 33 cases in 1935. While the Scheme still remains slightly ponderous and rather more expensive for the individual than could be desired, it has been improved during the year by the fixing of an income scale by which agreements can be entered into and treatment commenced at a much earlier date than hitherto. The numbers treated hardly justify other arrangements as yet, the present Scheme appearing to be the best that can be evolved to deal with the demand experienced to date in this District. DAY NURSERIES. There are two Day Nurseries maintained in the District, towards each of which the Council makes an annual grant. For the population of the District such accommodation is relatively high as compared with the country as a whole, but both do very useful work which, it is hoped, will be extended to meet what genuine demand is found to exist, as and when the need arises, especially in Coulsdon, where new and attractive premises have been provided. An attempt has been made during the year to link up this work more closely with the Maternity and Child Welfare work of the Council. CHILDREN ACTS, 1908-32. The Health Visitors are all recognised Infant Life Protection Officers. During the year 25 foster mothers have been under supervision, 39 children being distributed amongst the Homes, two of which Homes were entered on the register for the first time during the year. During the same period one child was adopted by foster parents, 3 were removed to Homes under Voluntary Organisations, 1 foster parent removed from the District, and 1 foster parent resided in the District temporarily before returning to Croydon. 34 The Homes, which include 5 Boarding Schools accommodating children under 9 years of age, were distributed as follows:— Coulsdon 10 Kenley 3 Selsdon 1 Sanderstead 3 Purley 8 25 HOUSING. As will be appreciated by a perusal of the Table at the end of this section, and a comparison with the same Table in the 1935 Report, a considerable amount of time has been given to the question of Housing during the year. The number of houses inspected increased from 331 in 1935, to 924 in 1936. The chief reason for this increase is the number of houses which had to be visited to detect overcrowding, or to ascertain the maximum number of persons who could reside in the working class houses of the District in order that the ascertained figure could be inserted in the rent book, as required by the Housing Act, 1936. It will be appreciated that, in view of the fact that the majority of houses in the District are good class dwellings in very good condition, about 60 per cent. having been built in the last 16 years, the position before this Council is a much lighter one than in many parts of the country. The only important need has been for the re-housing of individual cases of overcrowding detected, there being no slums or congestion of property with which to deal. As stated in the 1935 report, the original Housing Survey revealed 21 cases of overcrowding. In addition 3 new cases were detected during 1936, but all except 4 of the total had been relieved before the end of the year. Only 2 of the 24 houses concerned were Council houses. HOUSING STATISTICS. 1. Inspection of Dwelling Houses during the Year:— (1) (a) Total number of houses inspected for housing defects (under Public Health or Housing Acts) 924 (b) Number of inspections made for the purpose 936 (2) (a) Number of dwelling houses (included under sub-head (1) above inspected and recorded under the housing Consolidated Regulations, 1925 30 (b) Number of inspections made for the purpose 30 (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 35 (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 279 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 the Local Authority or their Officers 414 3. Action under Statutory Powers during the Year:— (a) Proceedings under sections 17, 18 and 23 of the Housing Act, 1930:— (1) Number of dwelling houses in respect of which notices were served requiring repairs 11 (2) Number of dwelling houses which were rendered fit after service of formal notices:— By owners 12 By Local Authority in default of owners — (b) Proceedings under the Public Health Acts:— (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 91 (2) Number of dwelling houses in which defects were remedied after service of formal notice:— (a) By owners 89 (b) By Local Authority in default of owners — (c) Proceedings under sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling houses in respect of which Demolition Orders were made — (2) Number of dwelling houses demolished in pursuance of Demolition Orders — (d) Proceedings under section 20 of the Housing Act, 1930:— (1) Number of separate or underground rooms in respect of which Closing Orders were made — (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit — 4. Housing Act, 1935—Overcrowding:— (a) (i) Number of dwelling houses overcrowded at the end of the year 4 (ii) Number of families dwelling therein 7 (iii) Number of persons dwelling therein 36 36 (b) Number of new cases of overcrowding reported during the year 3 (c) (i) Number of cases of overcrowding relieved during the year 19 (ii) Number of persons concerned in such cases 166 (d) Particulars of any cases in which dwelling houses have again become overcrowded after the Local Authority have taken steps for the abatement of the overcrowding:— One family consisting of two adults and 6 children was removed to a Council house, and another family consisting of two adults and two children occupied the house they vacated. Later two more children, each over ten years of age came to dwell in the house, thereby causing overcrowding. This family has obtained other accommodation since the end of the year. Another family abated the overcrowding by obtaining other accommodation for the older members, but owing to another child reaching the age of ten years it has again become over crowded. (e) Any other particulars in respect to overcrowding conditions it is desirable to report Nil. Number of Houses erected during the Year:— By the Council Nil By other persons 977 WATER SUPPLY. The District is chiefly supplied with water by the Sutton and District Water Company, whose mains supply that part of the District on the north-west side of Brighton Road and Chipstead Valley Road, and by the East Surrey Water Company, who supply the remainder of the area. There are in addition a comparatively small private supply to premises on the Old Coulsdon Estate, Coulsdon, and a private supply to the Cane Hill Hospital, which latter is augmented as the need arises from the East Surrey Water Company's mains. The mains of each Company were extended during the year to replace old mains, and to meet the housing developments in various parts of the District. The reports upon the bacteriological examinations of the East Surrey Water Company's and the Sutton and District Water Company's supplies showed that these softened waters had maintained their usual good quality for drinking and domestic purposes. Two samples of water were taken from each, and were all found to be satisfactory. It is understood that the water supplied by the Sutton Water Company in this area is obtained from the Woodmansterne wells, which water can be 37 used to supplement the supply from the Sutton and Cheam Wells, but that the reverse process cannot take place at present. During the year the rainfall was considerable, 32.70 inches being registered by the rain gauge under the observation of the Surveyor's Department. Consequently there has been no shortage of water for domestic purposes, and it was not necessary for the Water Companies which supply the District to issue warnings with regard to the exercise of care in the use of water. During the year eighteen samples of water were submitted for bacteriological examination from the private supply of the Old Coulsdon Estates, Ltd. With one exception all the samples were reported upon satisfactorily. In the case of the less satisfactory sample, which was taken in July, the slight bacteriological abnormality detected was not of importance from the point of view of public health. The liability of this water to fluctuation in quality, and the fact that reliance for its safety depends solely upon satisfactory chlorination gives rise, however, to continual apprehension, and a constant repetition of samples is taken throughout the year. The risk to the health of the District and the recurring expense to the ratepayers of sampling will continue until this supply is placed upon a satisfactory basis. It will be seen that a total of 22 samples of water was thus submitted for examination throughout the year. In addition 47 samples of the East Surrey Water Company's and the Sutton and District Water Company's supplies were examined for hardness by the Medical Officer of Health. The statutory limit for hardness in these waters is 9 degrees, and in only one case was this found to be exceeded. The private supply has about 26 degrees of hardness. The source of the water supply is from deep wells sunk into the chalk in various parts of this and adjoining Districts. CLOSET ACCOMMODATION. The major portion of the district is on the water carriage system connected to the public sewers. In the more rural parts of the district a number of houses are drained into cesspools, but these are being abolished as new sewers are provided. In most of these cases the houses are already provided with water closets. During the year 4 pail closets were converted to water closets, and at four cottages which had been void for a time and in which the pail closets had meanwhile been demolished, four new water closets were provided and the drains connected to the sewer. One earth closet was also converted to a water closet. In addition during the year 119 cesspools were abolished and the drains of 125 houses connected to the public sewer. 38 The approximate number of each type remaining at the end of the year were:— Premises with water closets drained to sewer 13,727 „ „ „ „ „ „ cesspools 253 „ „ earth closets 1 „ „ pail closets 47 The total number of cesspools throughout the district is approximately 229. PUBLIC CLEANSING. The collection of house refuse and trade refuse has proceeded on similar lines to those of the previous year. In most parts of the district there is a weekly collection and in some cases twice weekly where for special reasons the circumstances require it. Trade refuse is removed at a charge of 6d. per bin. There has been no alteration in the charges for the emptying of cesspools by Council tanks, and an increasing use has been made of this method of removing the contents which are disposed of in the public sewers. The increased volume of refuse for destruction has necessitated the provision of two additional cells at the Refuse Destructor. SMOKE ABATEMENT. During the year the chimneys of small factories and workshops have given little trouble and no complaint has been received regarding the few large stacks in the District. Such complaints as were received were duly dealt with and were chiefly concerning domestic boilers. Nine complaints were received about the burning of trade and garden refuse in close proximity to dwelling houses. The Council has made special arrangements for the disposal of trade and garden refuse at the rate of 6d. per bin, and to avoid the unnecessary pollution of the atmosphere in proximity to dwelling houses, residents are urged in future to take fuller advantage of the facilities offered, or alternatively, to dry garden refuse properly before burning, if it cannot be buried. Books of twenty 6d. tickets can be obtained from the Accountant, Council Offices, Purley, or single 6d. tickets can be had from the foreman scavenger. The Council also undertakes, free of charge, the collection of waste paper, which if kept clean and parcelled up will be collected apart from the house refuse. RIVERS AND STREAMS. All watercourses receive careful supervision, and during the year it was not found necessary to take any action for nuisances arising therefrom. 39 DRAINAGE AND SEWERAGE. The following extensions of the public sewers took place during the year:— Kingswood Way 1,018 yards 9 in. diameter. Keston Avenue, Coulsdon 166 „ 9 in. „ Cullesden Road, Kenley 272 „ 9 in. „ Foxley Road, Kenley 588 „ 9 in. „ Church Lane Avenue, Hooley 370 „ 7 in. „ Church Lane Drive, Hooley 370 „ 7 in. „ Estate developers continued to lay sewers on private estates and some of these were taken advantage of by the owners of existing premises. The disposal of the sewage of the District is dealt with by the County Borough of Croydon and the West Kent Main Drainage Board. shops. The various shops in the District have been re-visited and special attention paid to sanitary conveniences, lighting, temperature, washing facilities and accommodation for meals. Sanitary accommodation has been provided or improved in 7 premises; at one shop provision has been made for the heating of the premises, while ventilation has been improved in 2 shops. SWIMMING POOLS. There are no public swimming baths or pools in the District, but the private swimming bath at Reedham Orphanage, Old Lodge Lane, Purley, is used by the children of the Home, by scholars of local elementary schools, and occasionally by scholars of secondary schools. Towards the end of the swimming season one sample of water was taken from the swimming bath and submitted to bacteriological examination. The bath is covered in, and the water supply, which is obtained from the mains, is heated before discharge into the bath. A method of purification was being installed after the bath had closed down, which it is hoped will result in more satisfactory samples during 1937. The water was changed as frequently as was found necessary by the Owners. SANITARY INSPECTIONS, Etc. The following is a statement of the complaints received, inspections paid, defects remedied, etc. Compared with 1935, there were 13 more complaints received, and 557 more defects remedied, while the number of visits paid increased by 2,399. The last-mentioned increase was chiefly due to 1936 being 40 the first year in which the services of a full-time additional Sanitary Inspector were available. The increase in the work undertaken by the Sanitary Department may be deduced from the following Table:— Years. Number of complaints received, Number of visits paid. Number of preliminary notices served. Average 1921-23 97 1919 129 Average 1926-30 133 2720 292 Average 1932-35 198 3737 381 1936 316 6864 665 The additional work undertaken by the Sanitary Department during the year chiefly related to work under the Housing Acts, 1935 and 1936. Not only have inspections had to be made to detect overcrowding, but to provide all owners of working class property within the District with figures stating the maximum accommodation of these dwellings. This has entailed a great deal of work additional to the normal increase owing to the growth of the District, which included the abolition of 119 cesspools during the year. Further additions have been required by the Shops Acts, and by the Council undertaking both the disinfection of premises and the carrying out of duties under the Rats and Mice Destruction Act. The Staff employed in this Department during 1936 consisted of two full-time and one half-time Sanitary Inspectors, with one clerk, and the assistance of a workman who is chiefly engaged in disinfection, rat destruction, drain testing, etc. Their work has been most satisfactorily carried out, and credit is due to the Chief Sanitary Inspector for his energy and the smoothness with which expansion has taken place to cope with the additional duties. COMPLAINTS. Overcrowding 1 Defective copper 1 Non-collection of house refuse 15 Dampness 41 Accumulation of refuse 15 Defective sink 1 Insanitary condition of premises 33 General repairs required Offensive smells 21 Choked or defective drains 35 Rats and mice 65 Verminous condition of premises 12 Nuisance through improper keeping of animals 3 41 Flooding by rain-water 3 Insufficient/improper sanitary accommodation 2 Smoke from chimneys 4 Defective water supply 4 Defective W.C. 2 Insufficient heating 1 Insanitary condition of land 3 Lighting and ventilation 3 Dustbins 9 Bonfires, etc. 9 No washing facilities 1 Insects, rabbits, etc. 11 Weeds 5 Miscellaneous 3 Improper soakaway 6 Builders' latrines 1 Total 310 Inspections. Houses inspected 894 Re-inspections and calls made 2,586 Inspections under the Housing Acts 30 Inspections of workshops and factories 156 Inspections of bakehouses 34 Inspections of cowsheds 26 Inspections of milkshops and dairies 31 Inspections of slaughterhouses 108 Inspections of meat and other foods 240 Inspections of stables and stable yards 19 Inspections of yards, outbuildings, drains, etc. 1,623 Inspections of piggeries, fowls and other animals 24 Inspections re Rats and Mice Destruction Act 185 „ „ Shops Act 361 Number of drains tested with water 262 Number of drains tested with colour 6 Number of drains tested with smoke 9 Infectious disease investigations 150 Disinfections carried out 73 Miscellaneous 30 6,847 42 Notices Served. Preliminary Notices 665 Statutory Notices 111 Letters and Final Circulars 303 Defects Reported. Insufficient or defective drainage 36 houses Improperly drained yards 9 „ Cesspools requiring emptying 97 „ Defective cesspools 19 „ Choked drains 51 „ Defective fresh air inlet 59 „ Defective ventilation shafts 3 „ No wire cages to vent shafts 7 „ Unclean walls and ceiling 179 „ Defective plaster 84 „ „ floors 31 „ „ firegrates and washboilers 53 „ „ sashcords 35 „ „ or, choked rainwater pipes 43 „ „ woodwork 71 „ „ paving 52 „ „ dustbins 146 „ „ sinks and sink waste pipes 24 „ „ kerbs around gullies 24 „ Dampness through defective roofs 92 „ Dampness through other causes 128 „ Defective W.C. fittings 37 „ Accumulations 17 „ Animals kept so as to be a nuisance 2 „ Verminous conditions 2 „ Lack of domestic cleansing 2 „ Overcrowding 24 „ Insufficient lighting and ventilation 16 „ Defective outbuildings 9 „ Brickwork and pointing defective 51 „ Paintwork defective 15 „ Glazing defective 5 „ Unclean outdoor premises 10 „ No proper sanitary accommodation 10 „ Without water supply 1 house 43 Rats 49 premises Insufficient W.C.'s 5 „ Cowsheds requiring cleansing 1 „ Burning of refuse 7 „ Miscellaneous 47 „ 1,553 Defects Remedied. Drainage repaired or provided 110 houses Yard drainage provided or improved 9 „ Cesspools emptied 80 „ „ repaired 1 house „ abolished 114 houses Drains cleansed 43 „ Fresh air inlets provided 72 „ Vent shafts provided or repaired 9 „ Wire cages to vent shafts provided 13 „ Pail closets converted to water closets 4 „ Privy abolished 1 house Drains connected to sewer 112 houses New water closets 10 „ Gully traps, etc., provided 45 „ Inspection chambers provided 82 „ Walls and ceilings cleansed 153 „ Plaster repaired 80 „ Floors repaired 40 „ Firegrates and washboilers repaired 46 „ Sashcords repaired 34 „ Rainwater pipes and eaves guttering repaired 43 „ Woodwork repaired 69 „ Paving repaired 64 „ Dustbins provided 144 „ Sinks and sink waste pipes replaced or repaired 26 „ Kerbs around gullies repaired 35 „ Dampness remedied due to defective roofs 93 „ Dampness remedied due to other causes 80 „ W.C. fittings repaired 43 „ Accumulations removed 12 „ Nuisances from improper keeping of animals abated 1 house 44 Verminous conditions abated 2 houses Improved domestic cleanliness 2 „ Overcrowding abated 19 „ Fighting and ventilation provided or improved 17 „ Outbuildings repaired 5 „ Defective brickwork repaired or re-pointed 58 „ Paintwork renewed 14 „ Glazing of windows 19 „ Outdoor premises cleansed 6 „ Sanitary accommodation provided 4 „ Rat infestations abated 45 premises Water supply laid on 8 „ Burning of refuse abated 8 „ Miscellaneous 30 „ 1,905 ERADICATION OF BED BUGS. The total number of Council houses found to be infested with bugs during the year was seven, while one other house was found to be infested. These houses have all been disinfected. The work is carried out usually by the Public Health or Surveyor's Departments, various methods being adopted according to the degree of infestation. In most cases all mouldings, skirtings, picture rails and other wooden fixtures, such as cupboards, are removed, and all surfaces and crevices are treated with the blow lamp, or are sprayed with an insecticide, after which the rooms affected are treated by fumigation with sulphur. Further similar treatment is carried out 10 days or so after the first disinfestation. Occupiers sometimes complain of the appearance of isolated bugs and are allowed liquid insecticide with a spray for use if the necessity arises. The co-operation of the tenant is an important factor in the final disappearance of the vermin. Special fumigants have been tried, but the most effective methods are those set out above. On a few occasions the work was carried out by a Firm of Contractors who used their own materials, which did not include hydrogen cyanide gas, but the result was not a marked success, it being found necessary to spray with insecticide on several occasions after the Contractors had completed their work. The homes of applicants for Council houses are inspected with a view to obtaining some knowledge as to their suitability as tenants, 45 and careful examination is made on these occasions for any indication of the presence of vermin. Suitable steps are taken, when required, to prevent the introduction of vermin into clean houses by this means. RATS AND MICE DESTRUCTION. During the year 65 complaints of the presence of rats were received, and all were given attention, necessitating 185 inspections. The premises infested were chiefly embankments, private houses, shops, and premises where sheds and refuse heaps formed suitable harbouring places. The steps taken to exterminate the pests are the giving of advice as to laying of poisoned baits or traps, and the rendering of the sheds rat proof. The necessary work may be undertaken, on request, by the Public Health Department at a charge of 2s. 6d. per hour with a minimum charge of 5s. 0d. It has only been necessary to serve two statutory notices during the year, the occupiers of infested premises being only too eager to take advantage of the advice given. Many residents, however, do not yet realise that occupiers themselves are responsible for the elimination of these pests, although they are welcome to the advice which the Department can give as to the best means to adopt. SCHOOLS. School Closure.—It was not necessary during the year to close any public elementary school on account of the prevalence of Infectious Disease amongst the scholars. Infectious Disease contacts of school age are excluded from school for a period of time which varies with the nature of the disease. The Head Teachers of secondary schools, public elementary and private schools are notified immediately any scholar attending their schools develops or is in contact with an Infectious Disease. The advice of the Medical Officer of Health as to further action is available should this be requested, and disinfection is provided when required. Medical Inspection.—The medical inspection of school children is carried out by the Education Department of the Surrey County Council. Sanitary Services.—The water supply, drainage and sanitary accommodation in all public elementary schools were inspected from time to time, and found to be satisfactory. LEGAL PROCEEDINGS. It was not found necessary to institute legal proceedings during the year to enforce the abatement of nuisances. 46 REGULATED TRADES. Dairies and Cowsheds. During the year one farm ceased to be occupied as a dairy farm, although it was not removed from the register. The registered dairy farms in the district are as set out below:— Hooley Farm, Woodplace Lane, Coulsdon. Dean Farm, Brighton Road, Hooley. Elm Farm, Farleigh. Moorcroft Farm, Farleigh. Farleigh House Farm, Farleigh Farleigh Court Farm, Farleigh Not producing milk for sale. There are, in addition, two other farms which supply milk to private Institutions by which they are owned, viz.:—Woodplace Farm, Woodplace Lane, Coulsdon, which supplies milk to Netherne Mental Hospital, and the Farm, Cane Hill, Coulsdon, which supplies milk to Cane Hill Mental Hospital. There are also a small number of persons who own two or more cows and use the milk for their own consumption. Frequent inspections of cowsheds and dairies are made with a view to requiring compliance with the provisions of the Milk and Dairies Order, 1926. A quarterly veterinary inspection of all cows in the District is undertaken by the Surrey County Council, but in addition the local Council secures a further quarterly examination by a local Veterinary Officer. At the end of the year there were 10 registered dairies, one dairy having been removed from the register through disuse. The number of registered retailers was 46, of whom 17 reside outside the district. SLAUGHTER-HOUSES. There are two slaughter-houses within the District, both of which are licensed annually. The number of sheep, pigs and calves slaughtered in them during the year was approximately 851. Section 1 of the Slaughter of Animals Act, 1933, came into operation on the 1st January, 1934, and superseded the byelaws with regard to the stunning of all animals with a mechanically operated instrument. No alteration in the stunning of animals was involved thereby in this District. The Cash Captive Bolt Killer and the Greener Safety Killer are the instruments used. 47 Licences to slaughter animals were issued to four slaughtermen. Notifications of intention to slaughter are forwarded regularly by the occupiers of the licensed slaughter-houses, and the Sanitary Inspectors make an inspection of all carcasses before they are placed upon the market. BAKEHOUSES. There are sixteen bakehouses within the District, seven of which are used for baking bread, the remainder being chiefly used for making confectionery. One bakehouse was closed during the year and one new bakehouse registered. All the premises were inspected periodically and are generally well kept. OTHER FOOD PREMISES. There has been no alteration in the number of fish friers during the year, and their businesses have been generally well conducted. No complaints have been received regarding them, and routine inspections have revealed little to which exception could be taken. This occupation is not scheduled as an offensive trade in the District. All shops, kitchens of restaurants, tea rooms and other places where food is prepared or sold were inspected and appropriate action taken where necessary. FACTORIES AND WORKSHOPS. There are 148 Factories and Workshops within the District, of which 49 are Factories and 99 are Workshops. In addition there are 18 Workplaces. INSPECTION OF FACTORIES, WORKSHOPS AND workplaces. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. Number of Inspections. Written Notices. Occupiers prosecuted. (1) (2) (3) (4) Factories (Including Factory Laundries) 41 - - Workshops (Including Workshop Laundries) 112 - - Workplaces (Other than Outworkers' premises) 8 - - Total 161 - - 48 DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Number of offences in respect of which Prosecutions were instituted. Found. Remedied. Referred to H.M. Inspector. (1) (2) (3) (4) (5) Nuisances under the Public Health Acts:—* Want of cleanliness 11 12 - - Want of ventilation - - - - Overcrowding - - - - Want of drainage of floors -- - - — Other nuisances 10 7 — — Sanitary insufficient 4 7 - - unsuitable or defective 4 4 - - modation not separate for sexes - - -- — Offences under the Factory and Workshop Acts:— Illegal occupation of underground bakehouse (s. 101) - - - - Other offences — - — - (Excluding offences relating to outwork and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921.) Total 29 30 - - * Including those specified in sections 2, 3, 7 and 8 of the Factory and Workshop Act, 1901, as remediable under the Public Health Acts. INSPECTION AND SUPERVISION OF FOOD. Milk. During the year 66 samples of milk were submitted for examination, and of these 24 samples were submitted to biological, in addition to bacteriological and microscopical examination. In March, the Council's Veterinary Officer requested that a sample of milk should be taken from one named cow at a farm within the District. The bacteriological examination failed to detect Tuberculosis, but the biological examination showed that the cow was excreting Tubercle bacilli. Meanwhile the animal concerned had been condemned, within a week of the sample being taken, by the County Veterinary Officer on clinical evidence. In August seven samples were taken from the same farm as the result of the Council's Veterinary Officer's inspection, and Acid-fast bacilli— probably B. tuberculosis—were reported as being present in four of the samples. 49 The results were communicated to the Chief County Veterinary Officer, and as a result the animals were examined by the County Officials, two cows were removed and others isolated. One bulk sample of milk was taken in October from the same herd of about 37 cows and showed no abnormalities bacteriologically, but the biological examination revealed Tubercle bacilli to be present. In the meantime the herd had been disposed of, and at the end of the year the cowshed was still unoccupied. Eight samples from other retailers were taken during the year which proved to be bacteriologically unsatisfactory, and letters were sent informing them of the results. Three of these unsatisfactory samples were from one retailer who eventually changed his source of supply, while another ceased to retail milk before a repeat sample could be taken. In all other cases repeat samples proved to be satisfactory. The following is a summary of the results of the 66 samples examined bacteriologically:— TOTAL COUNT. Under 30,000 39 30,000—200,000 19 200,000—400,000 4 Over 400,000 4 COLIFORM BACILLUS. Absent in 1 c.c. 3 „ 0.1 c.c. 33 Present in 1 c.c. 2 „ 0.1 c.c. 14 „ 0.01 c.c. 7 ,, ,, 0.001 c.c. 6 „ 0.0001 c.c. 1 These results may be compared with the standard formerly required tor "Grade A." milk, which had not to contain more than 200,000 organisms per c.c., nor any coliform bacillus in 0.01 c.c. It will be seen that 79 percent. comformed to the former "Grade A." standard. This percentage does, however, vary so much with the proportion taken from doubtful sources, or which have been previously subjected to commercial pasteurisation, the former tending to reduce, and the latter to increase the proportion up to "Grade A." standard, that it is unwise to compare the condition of the milk supply from year to year on these figures. No samples of graded milk were taken under the special instructions of the Ministry of Health, but the 66 samples examined bacteriologically included two samples of Pasteurised milk, both of which complied with the prescribed standard. There is no producer of Pasteurised milk licensed in the District. 50 ' During the year the Council granted the following licences to sell milk under the Milk (Special Designations) Order, 1923. Ordinary. Supplementary. Grade A (T.T.) 8 6 Grade A. 1 2 Certified 6 6 Grade A. Pasteurised 2 1 Pasteurised 10 5 ICE CREAM. Seven samples of ice cream were taken with the following results:— Sample. No. of bacteria per 1 c.c. on agar at 37° C. in 48 hours. Coliform Bacillus Present in Absent in 1. 23,000 - 0.1 c.c. 2. 6,500 — 0.1 c.c. 3. 530 — 0.1 c.c. 4. 136,000 — 0.1 c.c. 5. 120,000 — 0.1 c.c. 6. 27,600 — 0.1 c.c. 7. 146,000 — 0.1 c.c. As these were considered to be reasonably satisfactory, and a marked improvement on 1935, no further action was taken. MEAT. The carcases of all animals slaughtered in the licensed slaughter houses of the district are inspected before being placed on the market. Ante-mortem inspection is made as frequently as circumstances permit. The animals do not remain in lairage for more than a few minutes and killing commences immediately. The animals slaughtered were as follows:— Calves 34 Sheep and Lambs 721 Pigs 96 all of which were inspected. The number of condemnations was as follows:— Entire carcases (a)Tuberculosis Nil. (b) Other diseases Nil. Parts of carcases (a)Tuberculosis Nil. or organs. (b) Other diseases 7 The following unsound meat and food was destroyed during the year:— Meat 33 lbs. Other foodstuffs 385 lbs. Vegetables 168 lbs. Total 586 lbs. 51 FOOD AND DRUGS (ADULTERATION) ACT, 1928. The duties under the abovenamed Act are carried out by the Surrey County Council. The following samples were collected from this area during the year. The total number shows an increase on 1935, and a return to the average for the preceding years. This increase is chiefly due to the number of other articles examined, the proportion of milk samples being rather less than hitherto. Articles. Analysed. Adulterated or Deteriorated. Prosecutions. Convictions . Formal. formal. Total. Formal. Informal. Total. Milk 34 1 35 5 - 5 2 2 Cream - - - - - - - _ Butter 2 - 2 - - - - Cheese 1 - 1 - - - — - Margarine - - - - - - - - Lard 1 - 1 — - — — - Meat 2 - 2 - - - - - Flour 4 - 4 - — - — - Tea — - - - — - — - Coffee - 1 1 - - - — - Cocoa - - - - - - — - Sugar 1 - 1 - - - - - Sausages 1 - 1 - - - - - Confectionery and J am - - - - - - - - Sausage Meat - - - - - - - - Wine - - - - - - - - Beer - - - - — - - - Spirits 2 - 2 - - - - - Drugs - - - - - - - - * Other articles 13 1 14 2 - 2 - - Totals 61 3 64 7 - 7 2 2 *Details of other articles Milk bar 1 _ 1 _ _ _ _ _ Rich Cream 2 _ 2 2 _ 2 _ _ Shredded Beef Suet 1 - 1 - - - - - Orange Squash 1 - 1 - - - - - Lemon Curd - 1 1 - - - -- - Bacon 1 - 1 - - - - - Tomato Ketchup 1 - 1 - - - - - Mint Sauce 1 — 1 — — - - - Steak and Kidney Pie 1 - 1 - - - - - Raisins 1 — 1 — - - - - Ground Almonds 3 - 3 - - - - - 52 COMICAL AND BACTERIOLOGICAL EXAMINATION OF FOOD. Samples of food and water for analysis are sent to the following Laboratories:— WATER SAMPLES:— Messrs. Rideal, Rideal & Sciver, 28 Victoria Street, S.W.I. Counties Public Health Laboratories, Queen Victoria Street, E.C.4. MILK:— Counties Public Health Laboratories, Queen Victoria Street, E.C.4. Royal Surrey County Hospital, Guildford. ICE CREAM:— Messrs. Rideal, Rideal & Sciver. ADOPTIVE ACTS AND BYELAWS IN FORCE WITHIN THE URBAN DISTRICT. ACTS. Investing Authority. Statute. Date of Order. Croydon Union Section 160, P.H.A. 1875 (ruinous and dangerous bridges) 15th Aug., 1887 Croydon Union P.H.A. 1875:— Sec. 153. ,, 157 (so far as it is not already in force) ,, 160 (so far as it relates to the Towns Improvement Clauses Act, 1847, with respect to naming of streets and numbering the houses) 20th Jan., 189S P.H.A.A. Act, 1890 Sections 20, 22, 24, 26 (1), 27, 34, 36 and 23. Croydon Union P.H.A.A. Act, 1890, adopted Part III. Croydon R.D.C. P.H.A. 1875, Sec. 39, 44, 45, 49, 50. P.H.A.A. Act, 1890, Sec. 39 .. 1875 (Coulsdon only), 42 1875 (Sanderstead) 42 and 161 4th May, 1896. (1st par.) 1875 (Purley) 155 P.H. (Buildings in Streets) Act, 1888, Sec. 3 (Purley) Croydon R.D.C. P.H.A. 1875, Section 66 28th Dec., 1896 Croydon R.D.C- P.H.A. 1875, Section 47 28th Sept., 1902 53 4 Croydon R.D.C. P.H.A. 1875, Sec. 112,113, 114, 115 30th May, 1906 Croydon R.D.C. P.H.A. 1875, Sec. 169 (second par. and third par.) 26th Dec., 1907 P.H.A. 1875, Sec. 170 P.H.A.A. Act, 1890, Sec 29, 30 and 31 Croydon R.D.C. P.H.A.A. Act, 1907, Sec. 15, 16, 17,18, 20, 21,22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 and 3.3 in Part 28th Apr., 1909 Part II, Part III (but 35 and 38 as amended by Order). Part IV (but 59 as amended by Order). Part VI Coulsdon & Purley P.H.A. 1925. Parts II, III, IV, V. 1st Dec., 1925 U.D.C. BYELAWS. 1921—Byelaws with respect to Slaughter-houses. 1925—Byelaws with respect to Registries for Female Domestic Servants. 1926—Byelaws with respect to New Streets and Buildings. 1928—Byelaws with respect to Pleasure Grounds. 1931—Byelaws with respect to Nuisances. 1931—Byelaws with respect to Tents, Vans, Sheds and Similar Structures. 1931—Byelaws with respect to Houses let in Lodgings. 1932 - Byelaws with respect to Ventilation of Buildings. 1932—Byelaws relating to Great Farleigh Green and Little Farleigh Green. 1.934—Byelaws with respect to Alderstead Heath. 1934—Byelaws with respect to Elevations of Buildings. 54 TABLE I.—CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1936. | Disease. Number of Cases Notified. Total Cases notified in each Ward. Total Cases removed to Hospital. Deaths. At Ages—Years. 1 At all Ages. Under 1 Year. 1 and under 2 2 and under 3. 3 and under 4. 4 and under 5. 5 and under 10. 10 and under 15 15 and under 20. 20 and under 35. 35 and under 45. 45 and under 65. 65 and over. Coulsdon East. Coulsdon West. Kenley. Purley. j Sanderstead. Selsdon and Farleigh Woodcote. Scarlet Fever 117 - 1 7 7 39 9,4 15 17 3 4 - 13 64 6 9 17 2 6 102 Diphtheria 35 - 2 1 2 3 14 10 2 1 - - - 4 24 1 - 2 4 - 35 2 Typhoid Fever 3 - - - - - - 2 1 - - - - - - - - 1 - - 2 - Erysipelas 12 - - - - - 1 - - 3 - 6 2 3 5 - - 3 - 1 3 - Puerperal Fever 1 - - - - - - - - - - - - - 1 - - - - - 1 1 Cerebro-spinal Meningitis 1 - - - - - - - - - - - - 1 - - - - - - 1 1 Ophthalmia Neonatorum 1 1 — - — - - - - - - - 1 - - - - - - - - Pneumonia 13 - - - - - 1 1 4 2 2 3 2 5 1 - 1 2 2 - *18 Totals 183 1 2 2 9 11 55 36 19 25 6 12 5 24 101 8 9 24 8 9 144 22 * All forms. The above figures include:— Cane Hill Mental Hospital.—Scarlet Fever 2, Erysipelas 2, Pneumonia 6. Netherne Mental Hospital.—Erysipelas 3. 55 TABLE II.—THE MONTHLY INCIDENCE OF INFECTIOUS DISEASE. Disease. Jan. Feb. March. April. May. June July. August. Sept. Oct. Nov. Dec. Total. Scarlet Fever 16 21 21 16 10 11 2 2 5 4 5 4 117 Diphtheria 5 6 6 3 3 2 2 1 3 1 1 2 35 Typhoid Fever 1 - - - - - - 1 1 - - — 3 Erysipelas 1 2 1 1 - - 1 - 1 - 3 2 12 Cerebrospinal Meningitis 1 - - - - - - - - - - - 1 Puerperal Fever - - - - - - - 1 - - — — 1 Ophthalmia Neonotorum - — - — — — - — - — - 1 1 Pneumonia — 2 2 1 — — — 3 2 3 13 Totals 24 31 30 21 13 13 5 5 10 8 11 12 183 56 TABLE III.—INFECTIOUS DISEASE NOTIFIED EACH YEAR SINCE 1916. ^ Disease. 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 Small Pox - - - - - - - - - - - - - 2 2 3 4 - - - - Scarlet Fever 16 20 10 55 129 136 59 40 58 35 48 74 94 125 69 45 29 69 119 124 117 Diphtheria 38 17 4 26 44 62 70 27 101 14 17 11 23 26 17 8 21 16 24 52 35 Erysipelas 11 12 8 12 5 8 9 2 12 10 4 13 8 3 11 8 11 23 17 11 12 Typhoid & typhoid Fever 7 18 73 31 15 5 16 11 5 24 9 9 9 6 4 4 7 5 5 1 3 Cerebro-spiual Fever - 3 1 - - 1 - - - - - - - 1 - - - - - 1 1 Puerperal Fever 2 1 1 - - 2 - - - - 1 - - 1 - 1 1 - 1 1 1 Puerperal Pyrexia - - — - — - - - — - - 1 1 1 1 3 5 1 2 1 - Poliomyelitis 1 - — 1 1 - 1 - 1 - - 1 1 - 1 - 2 - 1 1 - Encephalitis Dethargica - _ - - 1 1 1 1 1 1 - 1 1 - - - 1 - - - - Ophthalmia Neonatorum 2 1 1 - 1 - - 1 - - 12 - 3 - 1 1 2 - 1 - 1 Pneumonia - — - 18 8 9 21 6 16 11 - 9 7 38 11 14 29 28 20 32 13 Malaria - — — 5 - - - - - - - - - - - - - - - - - Measles 151 468 33 12 - — _ - - - - - - - - - - - - - - Dysentery - - - 4 7 7 7 17 - - 1 - - 5 - - - - - 6 - Chicken Pox — — — — — — - 5 11 - - - - - - - - - - — — Tuberculosis—Pulmonary 25 17 25 28 24 12 29 16 24 14 19 25 23 22 38 44 36 44 28 30 27 Other Forms 2 4 2 2 2 3 5 3 6 5 2 9 4 2 7 4 6 10 17 5 3 Totals 255 561 158 194 237 246 218 129 235 114 113 153 174 232 162 135 154 196 235 265 213 57 TABLE IV.—DEATHS OCCURRING DURING THE YEAR 1936. Cause of Death. Males. Females. Total. Under 1 year. 1 and under 2. 2 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and over. Typhoid Fever,etc. - - - - - - - - - - - Measles 1 - 1 1 - - - - - - - Scarlet Fever - - - - - - - - - - - Whooping Cough - - - - - - - - - - - Diphtheria 1 1 2 - 1 — 1 - — — — Influenza 2 4 6 - - - - -- — 3 3 Encephalitis Lethargica - - - - — — — - - - - Cerebro-spinal Fever - 1 1 - - 1 - - - - - Respiratory Tuberculosis 13 10 23 - - - — 5 9 8 1 Other Tuberculous Diseases 1 - 1 - - - - 1 - - - Syphilis 1 - 1 - - - - — - 1 - General Paralysis of Insane,etc. 1 - 1 1 Cancer 32 38 70 - - - - 3 30 37 Diabetes 3 4 7 — — — — — 1 1 5 Cerebral Hemorrhage 8 7 15 - - - - - - 5 10 Heart Disease 47 64 111 1 - 1 2 - 7 22 78 Aneurysm 1 1 2 - - - - - - 1 1 Other Circulatory Diseases 14 19 33 - - ~ - - - 7 26 Bronchitis 6 5 11 — — — — — 1 2 8 Pneumonia 10 8 18 - - 1 - - 1 3 13 Other respiratory Diseases 3 1 4 - - — - — 1 2 1 Peptic Ulcer 1 2 3 - - - — - - 2 1 Diarrhoea, etc. (under 2 years) 1 - 1 1 - - - - - - - Appendicitis 1 4 5 - - - - 1 3 1 - Cirrhosis of Liver 1 — 1 — — — — — — 1 - Other Diseases of the Liver 2 4 6 - - - - - - - 6 Other Digestive Diseases 6 7 13 1 1 ~ — — 2 2 7 Nephritis 13 4 17 — — - - — 2 3 12 Puerperal sepsis - 1 1 - - - - - 1 - - Other Puerperal Causes - 1 1 — — — — — 1 — — Congenital Debility, etc. 5 12 17 17 - - - - - - - Senility 2 3 5 - - - - - - - 5 Suicide 2 1 3 — — — — 1 2 — — Other Violence 8 3 11 - - - 2 3 3 1 2 Other Defined Causes 23 23 46 - — — 3 — 7 15 21 Causes Ill-defined or unknown 2 - 2 - - - 1 1 - Totals 211 228 439 21 2 3 8 11 45 111 238 58 Table v.—wandle valley joint hospital board. Cases admitted to the Hospital during Year ended 31st December, 1936. Disease. Beddington and Wallington. Coulsdon and Purley. Merton and Morden. Mitcham. cases deaths cases deaths cases deaths cases deaths Diphtheria 11 - 38 1 27 - 103 4 Scarlet Fever 47 1* 96 — 111 — 149 — Typhoid Fever 1 - 1 - 5 - 4 1† Erysipelas — - 3 - 2 1‡ 7 1§ Tonsillitis 4 — 6 - 1 - 5 - Measles 3 - 2 - 11 1$ 6 - Other Diseases. Chicken Pox - - - - 1 - - - C.S.M.—Mastoidectomy— Septicaemia - - 1 1 - _ 2 - Ulcerated Stomatitis 1 — — — — — 1 — Tubercular Meningitis - - - - - - 1 1 Enteritis 1 - 1 - - — — - Whooping Cough - - - - 2 - 3 3 Babies—admitted with mother - - 1 - - - - - Rubella - - 3 - 1 — - - Rheumatic Fever.. - - — - - - 1 - Pemphigus - - 1 - - - - - Mother—no disease - - 1 - - - - - Pneumonia - -- - -- 1 -- - - Totals 68 1 154 2 162 2 282 10 * Streptococcal Meningitis following Scarlet Fever. † Typhoid with Para Typhoid, ‡ Erysipilas with Nephritis. § Erysipelas with Cerebral Embolus. $ Convulsions from Measles. 1 1 1