Cou5 LIBRARY HEALTH REPORT FOR 19 3 7 FOR THE COULSDON AND PURLEY URBAN DISTRICT BY THE MEDICAL OFFICER OF HEALTH S. C. JENNINGS & SONS, LTD., Redhill, Surrey. 1 HEALTH REPORT FOR 19 3 7 FOR THE COULSDON AND PURLEY URBAN DISTRICT BY THE MEDICAL OFFICER OF HEALTH S. C. JENNINGS & SONS, LTD., Redhill, Surrey. 1 URBAN DISTRICT COUNCIL OF COULSDON AND PURLEY. Public Health Committee. Chairman: Councillor Mrs. G. M. Bluett. Councillor Mrs. e. Barti.ef.t. Councillor F. Jobbins. ,, J.I. Conway. ,, A. L. Mitchell. H. J. Deacon, A.C.G.I., ,, J.H. Nei.son. B.Sc.', A.M.I.Mech.E., ,, Mrs. H. M. Ransoms, M.A. M.W.M.A. ,, H. A. Ross. ,, T.A.Harrison. ,, W. J. TILLER. Maternity and Child Welfare Committee. Coun. Mrs. Bartleet. Mrs. E. Davie. Mrs. A. Morse. ,, Mrs. Bluett. Mrs. A. E. Eburne. Mrs. G. Phillips. ,, Mrs. Ransome, M.A. Mrs. R. J. Everett. Mrs. M. G. Pillow. F. Jobbins. Mrs. L. G. Clibbens. Mrs. M. J. Read. Mrs. M. G. Adams. Mrs. E. B. Farrow. Mrs. J. Saunders. Mrs. E. G. Beard. Mrs. W. H. Finn. Mrs. W. F. StowER. Mrs. L. B. Clark. Mrs. H. K. Freeman. Mrs. D. E. Tierney. Representatives on the Wandle Valley Joint Hospital Board. Councillor Arridge. Councillor F. Jobbins. ,, S. B. Gillespie. ,, F. G. L. Moir, M.M.I.Struct.E., I.Mar.E. Representatives on the Purley War Memorial Hospital Committee. Councillor Mrs. Ransome, M.A. Councillor W. J. Tiller. Representative on the Coulsdon and District Day Nursery. Councillor Mrs. Bartleet. Representative on the Pnrley and District Day Nursery. Councillor Mrs. Bluett. 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. (until 31st March, 1937). *Medical Officer of Ante-natal and Post-natal Clinics: Winifred M. Small, M.B., Ch.B. * Assistant Medical Officers for Child Welfare CentresP: Constance Hildred, M.b., Ch.b. Janet E. D. Michael, M.D., M.R.C.P., M.R.C.S. Grace M. Archer, M.R.C.S., L.R.C.P. *Consulting Obstetric Specialists: Douglas Lindsay, M.D., Ch.B., F.R.F.P.S. 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.R.S.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. Midwives: Miss A. E. G. Neighbour, S.R.N., S.C.M. Mrs. C. Noakes, S.R.N., S.C.M. Clerks *S. E. Crisp. G. A. Lee. G. V. Engwell. * Part-time Officials. 3 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 11,182 Registrar-General's estimate of population, 1937 53,920 Population, Census, 193137,666 Number of occupied houses, December, 1937 14,624 Number of occupied houses, 1931 9,533 Rateable Value, December, 1937 £695,262 Sum represented by a penny rate, December, 1937 £2,740 VITAL STATISTICS. Birth Rate per 1,000 of the estimated resident population. T otal. M. F. 12.8 Live Births—Legitimate 666 355 311 do. —Illegitimate 26 17 9 692 372 320 Rate per 1,000 (live and still) births. Still Births 15 8 7 21.7 Deaths 458 223 Death Rate per 1,000 of the estimated resident population. 235 8.5 Deaths from Puerperal causes:— Rate per 1,000 (live and still) births. Puerperal Sepsis 1 1.42 Other Puerperal causes 1 1.42 Total 2 2.83 Death Rates of Infants under one year of age :— All infants per 1,000 live births 35 Legitimate infants per 1,000 legitimate live births 34 Illegitimate infants per 1,000 illegitimate live births 38 Deaths from Cancer (all ages) 87 Deaths from Measles (all ages) Nil Deaths from Whooping Cough (all ages) Nil Deaths from Diarrhoea (under 2 years) 3 4 URBAN DISTRICT COUNCIL OF COULSDON AND PURLEY. HEALTH REPORT FOR 1937. Ladies and Gentlemen, I beg to present to you my Annual Report for 1937, this being my sixth Report as your Medical Officer of Health. It will be found that the arrangement adopted in preceding Reports has been retained to facilitate reference, but with the development of the services several new sections have had to be added, and others extended. I am pleased to be able to report that in general the year under review was a very satisfactory one as judged by the recognised standards. The Birth Rate increased for the fourth year in succession; the Death Rate remained steady and at a low level; the Infantile Mortality Rate very slightly increased, and the Maternal Mortality Rate slightly decreased, but both compared very favourably with other districts and the Country as a whole. In spite of the outbreak of typhoid fever, in which 20 residents were affected, the incidence of infectious disease was one of the lowest experienced by the District. The diminution in Diphtheria to a new low level record was particularly satisfactory. Although it has no connection therewith, one of the outstanding events of the year was the inauguration of a scheme for immunisation against diphtheria. It is most noteworthy for the fact that not since the days when vaccination against small pox was introduced has a corporate effort been made to stamp out a disease by specific treatment calculated to enhance the immunity of the group. Unlike the introduction of vaccination, however, diphtheria immunisation has been made a matter for voluntay co-operation from the first. This freedom of choice has increased the responsibility upon parents of carefully considering whether this form of treatment is not advisable for their children. Certainly the present absence of severe diphtheria should not be made an excuse for procrastination. Further waves of the disease will undoubtedly occur unless a high degree of immunity is present in the District. Another feature of 1937 was the coming into force of the Midwives Act which aims at an improved midwifery service for ah, together with a higher status for, and better standard among midwives. The Council appointed two midwives at the end of the year, and it is hoped that residents, especially in the Sanderstead and Selsdon areas, will avail themselves of their services. 5 The other outstanding event was the place given both nationally and locally to health propaganda. The National Campaigns for the wider use of the Health Services, and the encouragement of physical fitness were emphasised within the District. While strong suspicions have frequently been voiced both as to the objects underlying the Campaigns, and their inadequacy in that they indicate only one or two lines along which health may be improved or secured, it is surely folly if doubt and criticisms such as these are made the excuse for non-co-operation in an effort towards personal and national fitness. Whatever the original motive may have been it can surely be agreed that the better our health the greater the possibility of our enjoyment of life and of our individual and corporate service to mankind. The word 'possibility' needs emphasis, as, of course, the achievement of health, though a laudable ideal, does not of itself necessarily imply greater resultant happiness. The latter is undoubtedly what we all wish to attain ultimately, though it is not an essential corollary to improved health. It is suggested, however, that, if the aim of greater happiness for all is recognised, and that clear thinking is given to the methods by which it may be secured, better health may not only be achieved en route, but in its turn assist in the attainment of the ideal. The necessity not only for a high motive but for clear thinking requires stressing, as in a world in which only a limited amount of our resources are available annually for the "social services," these require directing wisely if the pain and ill-health which tend to hamper our individual and collective progress are to be removed. At a time when large sums are being spent and additional expenditure is anticipated on the achievement of health and fitness, the relative importance of different methods needs careful balancing, and the part which individual thought and effort can play must be borne in mind. As small examples, of which many might be given, my attention has again been drawn this year to the numerous comparatively small defects prejudicing the health of a large number of residents, e.g., widely spread dental caries, post-natal defects, hernias, varicose veins, indigestion and the like remaining untreated when a relatively small amount of individual effort and expense are required for their rectification. The increase in the deaths from cancer and road accidents locally this year, both influenced by the personal factor to a very appreciable extent, are other examples, and the attention of local organisations might well be given to these and similar subjects without necessitating municipal outlay. The part played by social and economic factors is also of great importance, but it is hoped that sufficient has been said to stimulate thought and the recognition of the fact that much can be 6 done by, and most in fact depends upon, our individual acceptance of responsibility for our own, and our neighbour's health and well being. In conclusion I would again desire to express my appreciation of the sympathetic co-operation of your Committee and my gratitude for the loyal assistance of my colleagues and staff. The help of the Sanitary Inspector and Senior Health Visitor in preparing the sections of the Report dealing with their work has been of great value. I am, Ladies and Gentlemen, Your obedient servant, F. R. EDBROOKE, Medical Officer of Health. Council Offices, Brighton Road, PURLEY. HEALTH REPORT FOR 1937. 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. The inauguration of the Green Belt Scheme in October, 1937, by the Lord Mayor of London was the consummation of years of endeavour to reserve a large part of these areas, and approximately one-fifth of the Urban District is now reserved as permanent open spaces. No large manufacturing concern 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 Purley 685 Woodcote 865 Twenty-two 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 Census of 1931 this figure had become 37,666, while in mid-1937 the Registrar-General estimated the population to be 53,920, this representing an increase of 2,460 in the last twelve months. Only about 3,000 of this total can be attributed to the area added in 1933, which is still chieflv rural. The number of inmates in the Institutions in the District in 1937 was:— Males. Females. Total. Cane Hill Mental Hospital 900 1540 2440 Netherne Mental Hospital 598 1147 1745 Reedham Orphanage 180 126 306 Russell Hill Schools 60 188 248 TOTALS 1738 3001 4739 8 In 1915 there were 4,141 occupied houses, chiefly in Purley and Woodcote, whereas in 1937 there were 14,624 houses, distributed amongst the Wards as follows :— Coulsdon East 1,783 Coulsdon West 2,638 Kenley 1,154 Purley 2,433 Sanderstead 3,516 Selsdon and Farleigh 1,576 Woodcote 1,524 There was thus an average of 3.7 persons per occupied house in 1937, as compared with 4.3 in 1915. VITAL STATISTICS. BIRTHS. During the year 692 Births were registered as belonging to the District, of which 372 were males and 320 were females, as compared with 641 in 1936. This is equal to an Annual Birth Rate of 12.8 per thousand of population, as compared with 12.5 last year, and 12.2, 11.8 and 11.1 in the preceding three years. The average Birth Rate for this District declined during the four quinquennial periods 1915-1934, viz., 13.9, 13.5, 12.9 and 11.6, but slight rises occurred in the 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 four successive years. Nationally, however, the rate has only slightly increased, the Birth Rates for England and Wales being 14.9 in 1937, 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 continue to settle in this District, being attracted by the amenities and the type of development which has taken place in recent years. There were 26 illegitimate births (17 males and 9 females) registered, this being 7 more than in the preceding year. Expressed as a percentage of total births, 3.8 were illegitimate. The proportion of illegitimate births showed a marked decline from 1915 to 1934, the average 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 seven years. In 1937, there were 15 registered (8 males and 7 females), this being 12 less than last year, and 13 less than in 1935. One female still-birth was illegitimate. The local Still-birth Rate was thus 0.28 per thousand of population, as compared with 0.60 for England and Wales. 9 DEATHS. The number of Deaths registered during the year as belonging to this District was 458 (223 males and 235 females), as compared with 439 in 1936. 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 8.5, 7.9, 7.6, 7.1 and 8.5 in the preceding five years. A slight modification, however, is 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 1937 thus becomes 8.3 per thousand of population. The Death Rates in England and Wales were 12.4 in 1937, 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 1929-1934, there was a slight rise to an average of 7.4, followed in the next three years by a steady increase, but this year the rate is the same as in 1936. In part the most recent increases are due to the number of persons dying in local Institutions who had no permanent abode prior to their admission, their deaths being registered as belonging to this District. In 1936 and 1937 there were 21 and 17 such cases, whereas in 1935 there was only 1 similar case and in 1934 only 6. The increased number of deaths from Violence is also a contributory factor this year. Of the 458 deaths which occurred in Coulsdon and Purley in 1937, 54 percent. were over 65 years of age, which compares favourably with the average of 53 percent. for the last four years, and 45 percent. 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. Cause. Number of Deaths. Rate percent. of Total Deaths. Bronchitis 12 2.6 Influenza 20 4.3 Tuberculosis of respiratory system 21 4.5 Cancer, malignant disease 87 18.9 Heart Disease 107 23.3 Cerebral Haemorrhage 17 3.7 Other circulatory diseases 25 5.4 Pneumonia 16 3.9 Violence (including Suicide) 33 7.2 10 For the full list of causes of Death, and the ages at which the deaths occurred, see Table IV in the Appendix. It will be seen that the chief causes of death in the District were Heart and other circulatory diseases (including Cerebral Haemorrhage) 149, and Cancer 87, followed by Violence (including Suicide) 33, Pulmonary Tuberculosis 21, Influenza 20, and Pneumonia (all forms) 16. HEART DISEASE, etc. The percentage of deaths due to heart and other circulatory diseases was rather less than in the two previous years, although constituting approximately one-third of all deaths. As has been previously stated, in so far as this group includes deaths in elderly persons from what is really old age, it is hoped that the proportion of deaths coming under this heading will increase. This year 73 percent. were over 65 years of age at the time of death, while 45 percent. were over 75 years of age, these figures representing increases of 1 percent. and 5 percent. over the corresponding figures for 1936. Of the 27 percent. which were under 65 years of age, only about 4 percent. 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. In 1937, Cancer produced 18.9 percent. of the total deaths as compared with an average of 17.5 for the preceding four years. Considered in relation to population, the Cancer Death Rate was 1.61 per thousand of population in 1937, and 1.36, 1.28, 1.49 and 1.30 in the preceding four years, corresponding figures for England and Wales being 1.63 for 1937, 1.61, 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. 11 The following Table gives the age, sex and distribution of the disease in the 87 deaths which occurred during 1937:— 20-30 30-40 40-50 50-60 60-70 70-80 Over 80 Totals. M. F. M. F. M. F. M.. F. M. F. M F. M. F. M. F. Tongue Cervical - - - - - - - - 1 - - - - - 1 - Glands - - - - - - 1 - - - - - - - 1 - Lip - - - - - - - - - - - - - 1 - 1 Parotid - - — - - — - - - - — - - 1 - 1 Larynx - - - - 1 - - - - - - - - - 1 - Oesophagus — — — — — — — 1 — — — 1 — - — 2 Stomach - - - - - - 1 - 3 2 2 - - 1 6 3 Intestine - - - - - 1 2 1 3 6 3 3 - 4 8 15 Gall Bladder _ - - - - 1 - - - - - - - - - 1 Liver - - - - - 1 - - - 2 - - - - - 3 Pancreas - - - - - - - - - 1 1 - - - 1 1 Lungs Uterus - — — •— 1 1 1 3 3 2 2 1 —• — 7 2 5 Ovary - 2 - - - - - - - 2 - - - - - 4 Breast - - - 1 - 3 - 2 - 2 - 1 - 2 - 11 Prostate - - - - - - - - 2 — 2 - - . - 4 - Testes - - - - 1 - - - - - - - - - 1 - Urinary Bladder - - - - - - 1 - 1 - 1 1 - - 3 1 Jaw Bone - - 1 - - - - - - - - - - - 1 - Brain - - - - - 1 - - - 1 - - - - - 2 Abdominal Muscles - - - 1 - - - - - - - - - - - 1 Totals - 2 1 2 3 8 6 7 13 18 11 7 - 9 34 53 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. This year the chief increase is in the number of cases connected with the intestines and lungs, the latter again chiefly in males, thus reflecting tendencies which can be noted in the national death rates from this disease. The Medical Officer of Health continues to act as local Medical Secretary to the British Empire Cancer Campaign, but no applications for speakers on this subject were received during the year. Local societies might well consider including speakers on the subject of Cancer when preparing their programmes for the coming year. 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 or repeated pain, bleeding, swelling, early morning diarrhoea, increasing constipation, or difficulty in passing water. 12 As each year about one-sixth of these deaths are attributable to Cancer of the breast, the necessity for the investigation of any lump in the breasts of women, especially over 30 years of age, which does not subside in a very short time, must be repeated. In all cases, not only is there danger in delay, but 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. VIOLENCE. Deaths from Violence, including Suicide, increased considerably during 1937, the Death Rate of 0.61 per thousand population being the highest recorded in the Urban District since its formation, while this is the third time in the last five years in which the local rate has exceeded the National Rate, which was 0.54 in 1937. The average for the last fifteen years, however, was 0.37 locally and 0.51 nationally. In 1937 there were 25 deaths from Violence other than Suicide, this being 10 more than occurred in 1934, which previously held the record for deaths from this cause since the formation of the District. The increase was chiefly due to road accidents. Of the 25 deaths, 14 were from this cause (9 more than in 1936), of which 8 were pedestrians, including 2 toddlers, 3 motorists, 2 cyclists and 1 motor cyclist. Three deaths were from aeroplane accidents, 2 were due to falls in elderly people, and 2 from drowning. Deaths from Suicide increased in number, there being 8 as compared with 3, 9, 6 and 3 in the preceding four years. The Death Rate from this cause was thus 15 per 100,000 of population as compared with 6 last year and averages of 11 and 12 in the preceding two decades. Five of the deaths were in males, 3 being from bullet wounds, 1 from burning and 1 from coal gas poisoning, the latter also being the cause of death in 2 females, strangulation being resorted to in the remaining case. With the exception of two, the deaths from Suicide occurred between the ages of 40 and 60 years. TUBERCULOSIS AND PNEUMONIA. Deaths from Tuberculosis and Pneumonia are referred to in other sections of this Report. 13 MATERNAL MORTALITY. There were 2 deaths associated with childbirth during 1937, the Maternal Mortality Rate being 2.83 per thousand total births, as compared with 3.11 in England and Wales. Both rates have fallen this year, the corresponding figures for 1936 being 2.99 locally and 3.81 nationally. Of the 2 deaths which occurred locally, one was attributed to puerperal sepsis, and the other to an unfortunate sequel to Caesarian section. In both cases the confinements, for which private arrangements had been made, occurred outside the District. 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 again be emphasized 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. By reasonable forethought and acceptance of the medical services which are 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 24, as compared with 20 last year, and 19, 14 and 10 in the preceding three years, all except 1 being in legitimate children. The Infantile Mortality Rate was thus 35 as compared with 33, 32, 26 and 30 in the last four 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 five years, however, it has steadied at about 31. The Infantile Mortality Rate for England and Wales was 58 in 1937, and 59, 57, 59 and 64 in the four 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 24 infants under one year of age who died in 1937 is shown in the following Table 14 Infantile Mortality during the Year 1937. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total Deaths under 1 yr. Scarlet Fever - - - - - - - - - - Measles - - - - - - - - - - Whooping Cough -- - - - - - - - - — Diphtheria - - - - - - - - - - Diarrhoea and Enteritis - - - - - 2 1 - - 3 Bronchitis - - - 1 1 - - - - 1 Pneumonia (all forms) - 1 - - 1 1 1 - - 3 Rickets - - - - - - - - - - Suffocation (overlying, etc.) - - - - - - 1 - - 1 Want of attention at birth 1 - - - 1 - - - - 1 Birth injury 1 - - - 1 - - - - 1 Atelectasis 3 - -- — 3 — - - - 3 Congenital malformation - 1 - 2 3 - - - - 3 Premature Birth Atrophy, debility 4 — — - 4 — — - - 4 and marasmus 1 — 2 - 3 1 - - - 4 Totals 10 2 2 3 17 4 3 - - 24 The neo-natal mortality rate (i.e., deaths within the first month per thousand live births) was thus 25, as compared with 23 last year. 15 COMPARATIVE CRUDE BIRTH-RATES, DEATH-RATES, ANALYSIS OF MORTALITY, MATERNAL DEATH-RATES, AND CASE-RATES for certain Infectious Diseases in the year 1937. England and Wales. 125 County Boroughs and Great Towns including London. 148 Smaller Towns (Resident Populations 25,000 to 50,000 at 1931 Census). London A dministrative County. Coulsdon and Purley Urban District. Rates per 1,000 Population. Births:— Live 14.9 14.9 15.3 13.3 12.8 Still 0.60 0.67 0.64 0.54 0.28 Deaths:— All Causes 12.4 12.5 11.9 12.3 8.5 Typhoid and Paratyphoid fevers 0.00 0.01 0.00 0.00 0.06 Smallpox — — — — — Measles 0.02 0.03 0.02 0.01 - Scarlet fever 0.01 0.01 0.01 0.01 - Whooping Cough 0.04 0.04 0.03 0.06 - Diphtheria 0.07 0.08 0.05 0.05 - Influenza 0.45 0.39 0.42 0.38 0.36 Violence 0.54 0.45 0.42 0.51 0.61 Notifications:— Smallpox 0.00 — 0.00 — — Scarlet Fever 2.33 2.56 2.42 2.09 1.15 Diphtheria 1.49 1.81 1.38 1.93 0.15 Enteric Fever 0.05 0.06 0.04 0.05 0.49 Erysipelas 0.37 0.43 0.34 0.44 0.26 Pneumonia 1.36 1.58 1.20 1.18 0.55 Rates per 1,000 Live Births. Deaths under 1 yr. of age Deaths from Diarrhoea and Enteritis under 2 years of age 58 62 55 60 35 5.8 7.9 3.2 12.0 4 3 Maternal Mortality Puerperal Sepsis 0.97 Not available. 1.45 Others 2.26 1.45 Total 3.23 2.89 Rates per 1,000 Total Births (i.e., Live and .Still). Maternal Mortality : Puerperal Sepsis 0.94 Not available. 1 42 Others 2.17 1.42 Total 3.11 2.83 Notifications:— Puerperal Fever 13.93 17.59 11.52 4.15 7 07 Puerperal Pyrexia 1434 2.82 INFECTIOUS DISEASE. The year 1937 compared very favourably with preceding years from the point of view of notifiable infectious disease, with a total of 154 notified cases, other than tuberculosis, compared with 183, 230 and 190 in the three preceding years. Had it not been for the outbreak 16 of typhoid, this comparison would have been even more favourable. Even so, when the increasing population is taken into consideration, it will be found that the incidence of infectious disease was very low, thus the number of cases per thousand of population fell from an average of 6.7 in 1915-24 to an average of 3.9 in 1925-34; in 1935 it was 4.7, in 1936 it fell to 3.6, while in 1937 it was as low as 2.8. 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 62 50 Diphtheria 8 8 - Enteric Fever 26 15 3 Erysipelas 14 2 - Pneumonia 30 — *16 Puerperal Fever 5 5 1 Puerperal Pyrexia 2 1 — Ophthalmia Neonatorum 1 — — Polio-encephalitis 2 2 2 Polio-myelitis 3 3 — Dysentery l 1 — Totals 154 87 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 incidence of this disease remained at a very low level throughout 1937, following a wave which lasted from the Autumn of 1934 until the early summer of 1936. Only 8 cases were notified during the year compared with 35, 52 and 24 in the preceding three years. This is the lowest number recorded since 1931, and represents, in view of the increasing population, by far the lowest incidence experienced in the District since its constitution in 1915. It is further interesting to note that of the 8 notified cases one case was swab positive only, while another showed clinical signs of diphtheria although all swabs proved negative. Only one of the 8 cases had received any form of immunisation treatment, and this had only received the "one shot" method of treatment, without being tested afterwards to ascertain its efficacy. The onset of the disease a year after treatment proved that in this case insufficient immunity had developed. In addition to the 8 notified cases, 5 cases were admitted to Hospital as suspicious clinically, but proved negative bacteriologically, while two 17 residents contracted the disease when staying outside the District. No deaths from this disease occurred during the year. The sudden fall in the number of cases should not, of course, be attributed in any way to the practice of diphtheria immunisation in the Urban District. While a number of children had previously received injections from their own doctors, and a report on those immunised at the Clinics during the year will be found later in this Report, the total number of children so treated is insufficient as yet to influence the incidence of diphtheria in the District. Inspection of Table III at the end of this Report will reveal that waves of diphtheria have been experienced locally in 1921-2, 1924, a slight one in 1929, and again in 1934-6. At present a trough, similar to those intervening between previous waves, is being passed through, and while this may last for a year or more, an increased number of cases will undoubtedly be experienced in the future unless a much greater response to the offer of immunisation is forthcoming. It is folly to postpone treatment solely because the disease is now at a low ebb. TYPHOID FEVER. The outbreak of typhoid fever which occurred in the neighbouring County Borough of Croydon, and affected this District received unparalleled publicity, hence only a few notes are necessary on the disease within the boundaries of this Urban District. A total of 24 notifications was received, but of these 4 were not confirmed, 3 notifications proving to relate to cases of paratyphoid fever, while in the other case the diagnosis was doubtful owing to the very acute course run by the disease and the lack of bacteriological evidence. Preceding and unconnected with the epidemic, a case of definite typhoid fever which had contracted the disease in France was diagnosed in a Nursing Home in this District. As it had been taken ill in Croydon, notification was accepted by them and the case treated in the Croydon Borough Isolation Hospital. All the remaining 19 definite cases of typhoid fever occurred during November or early December, and were thus connected in time with the main epidemic. Of these, 14 were connected with Croydon schools (9 being in two schools), which received the contaminated water supply. In the remaining 5 adult cases, 1 was readily traceable to the water supply, 2 were, after very close enquiry, shown to have had the opportunity of being affected by the supply, the fourth worked in Croydon and might possibly have been so affected, but in the fifth case no connection with the supply or contact with cases could be traced. The 19 cases were distributed as follows :—- Selsdon 3 Sanderstead 12 Purley 3 Coulsdon 1 18 With this distribution of cases and with the great difficulty often experienced in tracing any connection between the supply, with its intricate ramifications, and the sufferers, it is difficult to see what useful purpose could have been served by circulating information on the source of infection at the time when this was first suspected. In 13 cases the patients were admitted to Hospital (10 to the Wandle Valley Isolation Hospital), while 6 were treated at home. Unfortunately, in addition to the doubtful case, 2 deaths occurred, these being the cases first notified, and presumably those most heavily infected. Four of the local cases had been treated by inoculation during the incubation period, but subsequently developed the disease. The steps taken during the outbreak followed almost exactly those adopted in Croydon, and very close co-operation was maintained between the two Public Health Departments. While the numbers affected in this District were much smaller than in Croydon, the staff available was correspondingly small. Enquiries were first directed to discovering the source of infection at the houses in which the cases occurred, and then, when the Addington Well water was suspected, to tracing possible sources of pollution including any from that part of the gathering ground situated in this District, or among those persons who were known to have worked at or near the Well, but who reside on this side of the boundary. Numerous consultations were provided and advice on desirable preventive measures was given to the very many residents, including head teachers, who enquired of the Department. The isolation of cases and disinfection of premises, etc., followed the recognised lines, with the exception that more attention was given to the disinfection of the laundry of cases nursed at home, before its dispatch to the public laundries, than has hitherto been provided. Advice on the preventive inoculation of cases which might have been developing the disease was not easy to give owing to the lack of unanimity both in the opinion expressed by experts and in the practice adopted by the doctors locally. As far as this District is concerned the Doctors residing in the Urban District inoculated altogether approximately 372 persons, all of whom, however, were not resident within these boundaries. Of this number about 237 were so treated because they lived, worked or visited in what was thought to be the area of the contaminated supply. With the exception of 40 who had 3 modified doses, the prescribed doses of the usual T.A.B. vaccine were given in each case, bearing in mind the age of the patient, and subsequently 6 developed typhoid fever, while a seventh is believed to have had an abortive attack. In addition to the latter, one of the definite cases, which was treated at home, 19 was considered to have had a very slight attack, while the remainder are thought to have run the usual course. On the other hand, the Medical Officers at each of the Institutions receiving cases expressed the opinion that some inoculated cases appeared to have been much more severe as a result, while one Croydon case proved fatal. In assessing the value of this form of inoculation for the prevention of cases, it should be remembered that in all probability an appreciable proportion of persons so treated had not actually been exposed to infection, while of the general population who were known to be exposed through residing in the district served by the contaminated supply, less than one per cent. contracted the disease irrespective of inoculation. From these observations it would appear difficult to demonstrate any preventive value in inoculation once the recipients have been exposed to infection, and may be incubating the disease. The remaining 135 persons were treated chiefly on account of their contact with known cases or the possibility of such contact in the future. The usual T.A.B. vaccine was used with the prescribed dose for the age of the recipient except in 40 cases in which a reduced dose was given, and in 10 cases which received an oral vaccine. None of this group contracted the disease, but it should be noted that neither were any secondary cases known to have occurred among the uninoculated residents in the District. From these facts, it would appear that the risk of secondary infection in an urban population of the type residing in this District, with the exception of those persons actually nursing cases, is so low as to negative the general application of this form of preventive treatment even in times of epidemic. The short lived immunity conferred by inoculation, and the comparative rarity of outbreaks at the present time certainly contraindicate its general adoption in this Country in normal times, although when contemplating life abroad the risk is such that this form of treatment should undoubtedly be advocated. Other important features of the epidemic which made it exceptional, and which should be recorded for future reference are:— 1. The undue publicity which it received both on the wireless and in the Press. Apart from the unnecessary strain to the officials who were endeavouring to cope with the outbreak, from the seemingly never ending telephone calls, etc., which resulted and hampered their work, a state bordering very closely on public panic was produced. It is doubtful whether any good whatever resulted from this publicity, whereas not only did local trade suffer adversely, but much needless worry, and in some cases, definite ill-health resulted. It would probably be wiser in the event of any future epidemics for a concerted effort to be made to confine attention to preventive measures, while very serious consideration should be given before any use is made of the wireless. 20 2. Considerable negative and adverse criticism, much of which was ill-informed and unjustified, was forthcoming at a time when those in control were already overburdened by the work produced by the epidemic. How far this resulted from the publicity cannot be estimated, but such criticism as was justifiable and constructive might with advantage have been postponed until the epidemic had abated, although, of course, positive and helpful suggestions on the prevention of disease are always appreciated. 3. As is well known, the outbreak resulted in the first Public Inquiry ever held in this Country under such circumstances, which Inquiry opened before the epidemic had ceased. The proceedings and findings of the Inquiry have been made public, but it will be for the future to judge whether the immense amount of time, work and money involved justified this form of investigation, or whether the results might not have been equally well achieved, much more simply, by other and less costly procedure. PARATYPHOID FEVER. There were two notifications of paratyphoid fever received during the year, in addition to the 3 cases notified as typhoid and subsequently found to be paratyphoid fever. The cases were distributed throughout the year and over the District. Four cases were removed to Hospital, 2 to the Wandle Valley Isolation Hospital where, unfortunately, one case terminated fatally. In no case was the source of the infection discovered. SCARLET FEVER. As was anticipated in the last Report, after three years of increased incidence a distinct fall in the number of cases can be reported, only 62 having been notified, compared with 117, 124 and 119 in the previous three years. As waves of this disease have occurred at intervals of about seven years, it is hoped that even lower figures will be recorded during the next few years. As in 1934 and 1936, Coulsdon West was the Ward most affected, hence the proportion of cases treated in Hospital was again relatively high, a total of 50 cases being admitted during the year. Four cases occurred in the Mental Hospitals. Just over half the cases were in persons not in attendance at school, and a high proportion of these had probably contracted the disease outside the District. The influence of contact at school was negligible, only 3 cases having possibly been infected in this way. Three cases were " Return Cases " following the discharge from Hospital of patients 21 still carrying the disease, while one person developed scarlet fever after nursing a relation with the disease at home. Apart from this case, there were only 3 other instances in which more than one member of the household was affected, one of these being included in the 3 "Return Cases" previously referred to, while the others either contracted the disease from a common source or from the primary case before its removal to hospital. Once again the policy of home treatment in cases in which reasonable isolation can be maintained has proved justifiable, and might be more generally adopted in the District. The disease remained mild in type, no deaths having resulted in the last 5 years, compared with 5 in the preceding ten years. ERYSIPELAS. There were 14 notifications of erysipelas during the year as compared with 12, 11 and 23 in the last three years. Of these, 8 were patients in the Mental Hospitals, the remaining 6 being unconnected cases scattered over the District, of which 2 were admitted to hospital. No deaths occurred. PUERPERAL FEVER. Five cases of puerperal fever and 2 of puerperal pyrexia were notified during the year, as compared with an average of 1 case of each for the past three years. The increase was chiefly due to 4 cases of puerperal fever which occurred in the practice of one midwife, who was found to be harbouring the causal organisms (haemolytic streptococci), in her throat. Her isolation was dealt with by the Surrey County Council as Supervising Authority under the Midwives Act. These 4 cases were transferred to Queen Charlotte's Hospital Isolation Block, where they all recovered. The other case of puerperal fever, which developed phlebitis, was treated satisfactorily at the Wandle Valley Isolation Hospital. Unfortunately, in addition, a resident contracted puerperal fever, which terminated fatally, during her confinement outside the District. The two cases of puerperal pyrexia, each due to pyelitis (one also having pleurisy), both recovered satisfactorily, one being treated at home and the other at Redhill County Hospital. OPHTHALMIA NEONATORUM. Only one case was notified, which did not require removal to Hospital, the child recovering without impairment of vision. 22 POLIO-ENCEPHALITIS AND POLIO-MYELITIS. Two cases of polio-encephalitis and 3 of polio-myelitis were notified during the year, this being the highest number experienced in any one year since the formation of the District, the previous highest being 2 in 1932. The first case with cerebral symptoms, occurred in April in an adult resident who was in a London Hospital, following an abdominal operation, and unfortunately ended fatally. As the patient had been in Hospital three weeks before developing symptoms, the disease may have been contracted outside the Urban District. The other cerebral case in a young adult unfortunately followed a very rapid course and proved fatal in another London Hospital. Strangely enough a case of polio-myelitis had occurred in the same household less than three years previously. The 3 cases of polio-myelitis occurred in August and September, 2 being in the Coulsdon West Ward. Of these cases, 2 were treated at a London Hospital, and 1 at the Wandle Valley Isolation Hospital. Both of the former developed paralysis, and are still receiving treatment. These cases coincided with a wave of the disease which occurred chiefly in South-East England and, as is usual in such outbreaks, it is probable that a number of mild cases were not recognised. One such case, also in the Coulsdon West Ward, presented itself at a Child Welfare Centre having received no treatment during the acute stage, which was considered to be due to a cold. The resultant paralysis is still receiving treatment through the Child Welfare Scheme. PNEUMONIA. There were 30 notifications of acute primary or influenzal pneumonia during the year, as compared with 13, 32 and 30 in the past three years, but 20 of these related to inmates of the Mental Hospitals. The remaining 10 cases were chiefly in the Sanderstead Ward. No cases were removed to the Isolation Hospital. The number of deaths registered as occurring from all forms of pneumonia was 16 as compared with 18 in the preceding year. DYSENTERY, Etc. Although several waves of gastro-enteritis were experienced in the District during the year, including two in the Autumn in which a number of children had quite sharp attacks with pyrexia, and blood and mucus in the stools, only one case of dysentery was notified. Unfortunately, the baby in question died in hospital without confirmation of the diagnosis by bacteriological examination. 23 One of the waves of gastro-enteritis preceded and another coincided with the outbreak of typhoid, but clinical diagnosis was facilitated as almost all cases of the latter commenced with constipation, diarrhoea developing at a much later stage. An investigation into a comparatively mild, though fairly widespread outbreak of gastro-enteritis in a large private school in the District earlier in the year suggested that the infection was probably air-borne, being from boy to boy rather than from a common source, a feature which repeated itself in later outbreaks. Unfortunately no bacteriological findings are available, and owing to the short length of illness in most cases, specimens were not easily obtainable. In view of the number of cases of dysentery found in surrounding Districts, however, it is probable that a number of cases of unrecognised dysentery due to Sonne's dysentery bacillus were included in the local outbreaks. THE CONTROL OF INFECTIOUS DISEASE. While a perusal of the foregoing will illustrate the place of isolation, disinfection, etc., in the limitation of infectious disease, only 4 secondary cases having occurred in the same houses as primary cases during the year, it is increasingly appreciated how inadequate these measures invariably are. With diseases such as diphtheria, in which a definite proportion of the general population are carrying virulent germs, although apparently healthy, segregation of those suffering from the disease can only be partially successful in preventing its spread. It is this factor which has made the recent wave of scarlet fever so difficult to control, mild and missed cases with inconclusive symptoms, e.g., streptococcal infections causing no rash, being potential sources of infection. One of the measures in which most hope for the future lies is artificial immunisation. Unfortunately in a number of diseases the immunising agent has yet to be discovered; in others the number of different strains of the causal organism increases the difficulty of immunising; in yet others the immunity which can be created artificially is so short lived as to make the question of the general use of such measures doubtful or unwise. Diphtheria immunisation has now been widely used for years, is very effective, and usually lasts for a considerable time, hence, especially as the disease which is thus prevented or reduced in severity is normally a very serious infection, the question of accepting the free treatment offered to all pre-school children should be very carefully considered by all parents. IMMUNISATION. At the present time the facilities at the local Immunisation Clinics are limited to inoculation for the prevention of diphtheria. Arrangements are still in force whereby cases in which there are special reasons 24 for immunisation against measles, whooping cough, or scarlet fever may be referred to the Centre at Great Ormond Street Hospital by the Medical Officer of Health, but no applications were received during the year for cases wishing to avail themselves of these arrangements. The local Diphtheria Immunisation Clinics commenced activity in April, 1937, sessions being held at 69, Brighton Road, Purley, and at the Baptist Hall, Selsdon, as and when required. No attempts whatever have been made to persuade parents to have their children immunised, propaganda being limited to the circulation during health visitation or attendance at the Centres, of a pamphlet briefly stating the case for diphtheria immunisation and the local arrangements. To date it has been possible to give definite appointments to all cases and the arrangements have been much appreciated by those who have attended. Treatment is provided free of charge to all children who on application are under 5 years of age, but in the case of older children a charge of 6d. is made for the initial test, and if further treatment is required, a total charge of 5s. 0d. is made, which covers the cost of the materials if a sufficient number of children can be treated at a time. The only prophylactic used has been Toxoid-Antitoxin Floccules (T.A.F.), which has the great advantage not only of producing a high defree of immunity with a low relapse rate, but the minimum of reaction in the recipient. None of the cases treated in 1937 complained of any thing which could be associated with the injection worse than a slight local soreness on the day of treatment, while the vast majority noticed nothing more than the slight prick of the needle. Injections are given at intervals of from two to four weeks, and the result is tested by the Schick Test at least three months after the final injection. The following Table shows the numbers treated from April to December, 1937:— Number of sessions 42 Number subjected to primary Schick Test 32 Number found positive 32 Total number of cases treated 97 Number who had received the full course bv December 31st. 1937:— Aged 1 to 5 years 38 Aged 5 years and over 13 Number subseauentlv tested bv Schick Test 51 Number found positive 1 Number found negative 50 Number awaiting Schick Test 46 It will be noted that all cases subjected to the primary Schick Test were found positive. These included 2 children who had previously received the "one shot" form of inoculation, the after effects of which should always be tested. It is considered that the numbers so far tested are too small to justify the abandonment of the primary test in children over 5 years of age. 25 Only one child was definitely positive three months or more after treatment. This child had only been given two injections of T.A.F. as he had received the " ne shot" treatment twenty-one months before presenting himself at the Clinic. A further dose has since been given, the result of which will be tested later. There were in addition a few infants in whom the subsequent test was not too satisfactory owing to their youthful energy at the time of injection. In these cases the parents have been advised to return for a further test before the children commence school. The 97 children receiving treatment came from various parts of the District as indicated by the following Table:— Coulsdon East 4 Coulsdon West 9 Kenley and Whyteleafe 21 Purley 5 Sanderstead 11 Selsdon 47 To date but little appreciation of this facility has been exhibited in Coulsdon, Purley and Woodcote. The doctors practising in the District have been asked to co-operate by forwarding information of cases immunised privately, and in return have been offered serum at reduced rates. No records have been received, however, since the establishment of the Clinics, nor have applications been made for serum, probably due to the fact that very little immunisation has been done in this way during the year. NON-NOTIFIABLE INFECTIOUS DISEASE. The group of non-notifiable Infectious Diseases, with the exception of influenza, caused no deaths during 1937, which was a very mild year as far as these diseases were concerned. Apart from the death-returns, the only information as to the presence of outbreaks of non-notifiable Infectious Disease are the returns received from the public elementary schools. As judged by these, the incidence of these diseases were as follows:— MEASLES.—Only occasional cases occurred until June and July, when there was an outbreak in Sanderstead and Smithambottom, 49 cases being notified. In the remaining months of the year only 2 cases were notified. GERMAN MEASLES.—Very few cases were notified. WHOOPING COUGH.—No cases were noted in the first three months of the year; the following three months produced 20 cases, the majority in Sanderstead, while in the last four months 16 cases were notified, chiefly in Coulsdon and Old Coulsdon. MUMPS.—Altogether 23 cases were notified, 12 of which occurred in January, chiefly in Coulsdon. The remainder were scattered over the District and throughout the year. CHICKEN POX.—Only 30 cases were notified, of which 14 occurred at Kenley in June. The others were well distributed over the District, and throughout the year. 26 Home visitation and exclusion from school are still the two chief methods relied upon to postpone the onset until the most favourable age is reached to stand the disease, but the possibility of modifying measles on a wider scale by an injection shortly after exposure to infection is becoming more practicable each year. Treatment in hospital is provided for a limited number of cases, and 1 case of measles, 1 of rubella and 2 of mumps were admitted to the Isolation Hospital during the year under this arrangement, social or physical complications being present. Occasionally in addition cases are admitted to the County Hospitals. TUBERCULOSIS. The following Table presents concisely the position with regard to tuberculosis in this District during 1937. Pulmonary. NonPulmonary. Total. M. F. M. F. M. F. Number on register, 1st January, 1937 72 83 17 22 89 105 Additions, 1937:— New cases notified 17 19 1 6 18 25 Cases removed into District 12 - 3 - 15 11 Restored to register 3 2 1 - 4 2 Total additions 32 32 5 6 37 38 Removals, 1937:— Deaths 11 6 - - 11 6 Removed from District 12 18 1 2 13 20 Recovered 6 10 5 7 11 17 Total removed from register 29 34 6 9 35 43 Number on register, 31st Dec., 1937. . 75 81 | 16 19 91 100 It will be noted that there were 43 new cases of tuberculosis notified during the year, as compared with 30, 35, 45 and 54 in the preceding 4 years. The following Table shows the age-periods at which the notifications and deaths occurred. 27 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 - - - - - 1 - 5 and under 10 - - - - - - - - 10 and under 15 - - - - - - - - 15 and under 20 2 2 - - 1 - - - 20 and under 25 1 6 1 4 3 2 - - 25 and under 35 3 6 - 2 1 3 - - 35 and under 45 4 3 - - 3 1 - - 45 and under 55 3 2 - - 1 1 - - 55 and under 65 2 - - - 2 - - - 65 and over 1 - - - 3 . - - 1 Totals 17 19 1 6 14 7 1 1 The new cases were distributed amongst the Wards as follows:— Localisation. Coulsdon East Coulsdon West Kenley Purley Sanderstead Selsdon & Farley Woodcote Pulmonary 6 8 2 7 7 3 3 Non- Pulmonary 1 - 2 - 3 1 - While there was a slight increase in the new cases of pulmonary tuberculosis, the case rate of 65 per 100,000 of population compares very favourably with the average rates of 115 for 1915-24 and 88 for 1925-34. A similar tendency is exhibited in the non-pulmonary tuberculosis case rate, which was 13 as compared with 15 and 18 in the previous decades. There were 2 fewer deaths from pulmonary tuberculosis than last year, and the death rate fell to 39 per 100,000 of population, as compared with 45 last year and averages of 72, 57, 36 and 38 for the four quinquennial periods 1915-34. Similarly as only 2 deaths occurred from the non-pulmonary forms of this disease the corresponding death rate was slightly less than 4 per 100,000 of population compared with 20, 9, 7 and 8 in the quinquennial periods. Of the deaths which occurred from tuberculosis in 1937, 74 per cent. were in previously notified cases. Of the remainder 3 were thought to have been previously notified, 1 case was only confirmed after death, 1 case was notified in another district and not transferred, and in the remaining case the doctor forgot to notify. 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. 28 The Council has made arrangements for the examination, free of charge, of sputa from cases, or suspected cases of tuberculosis, and during the year 51 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 in each month at 2.0 p.m., on the 1st Monday at 5.30 p.m., and the 2nd and 4th Tuesdays at 10.0 a.m. A Voluntary After-care Committee, towards which the Surrey County Council makes a pro-rata contribution, serves the Purley Dispensary area which extends beyond the Urban District boundary. The Committee does very useful work in helping individual cases and their dependants. The Council is represented thereon by the Medical Officer of Health. PUBLIC HEALTH ACT, 1936, SECTION 172. Proceedings to secure the compulsory removal to hospital of a person suffering from pulmonary tuberculosis and living under circumstances likely to cause serious risk of infection, were authorised by the Council on one occasion during the year, but the person removed from the District before further action could be taken. 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, and these are likely to be replaced by new models during 1938. Use is made of ambulances provided by 29 the London County Council for the removal of puerperal fever cases to Queen Charlotte's Isolation Block. 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 resident in this Urban District, (other than Public Assistance cases), whose confinements have been dealt with under the Council's Maternity and Child Welfare Scheme, to any hospital approved by the Medical Officer of Health. 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) in this District are admitted to the Board's Hospital at Beddington Corner. Building extensions commenced in 1936, but fortunately these have not yet been required, as to date no additional accommodation is available. 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 large number of residents receive treatment at London Hospitals. County Hospitals.—Patients from this area are chiefly admitted to the County Hospitals at Redhill, Kingston and Epsom. Maternity Hospital Accommodation.—The Council has an arrangement with the Purley War Memorial Hospital whereby the Council has the call on three beds. If accommodation permits additional cases can be admitted. While under this Scheme 61 cases were confined at this Hospital during the year 1937, an additional 21 cases were admitted to Queen Charlotte's Hospital, London. A number of cases from this area are confined at the County Hospital, Redhill. Reference is made in the section on Maternity and Child Welfare to the need for extending the maternity accommodation available to the District. 30 bacteriological work. The examination of swabs for diphtheria and sputa for tuberculosis is carried out by the Medical. Superintendent at the Wandle Valley Isolation Hospital, and during the year the following number of specimens were examined:— Swabs for diphtheria 161 Sputa for tuberculosis 51 In addition an arrangement exists whereby other specimens, the examination of which is of importance to the Public Health, are examined by the Pathologist to the Croydon General Hospital. Under this arrangement the following numbers of specimens were examined during 1937:— Cerebro-spinal fluid 1 Blood—Widal test 10 Urine and faeces for Typhoid 10 DISINFECTION. The disinfection of bedding, etc., is undertaken by the Wandle Valley Isolation Hospital Board, while the disinfection of premises is carried out by the Officers of the Public Health 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. Od. per load of bedding, etc., 5s. Od. for the first room, and 2s. 6d. for each additional room disinfected at the same time. During the year the following disinfections were carried out:— Free of cost. Charged for. Loads of bedding, etc. 165 9 Houses disinfected 170 4 HEALTH PROPAGANDA. During the year several forms of Health propaganda were introduced, the Council co-operating with the National and Surrey County Health Campaigns which were launched in the Autumn. As it is very difficult to attract an audience to public meetings in this District, the campaign was limited to approaching school children, mothers at Infant Welfare Centres, and such voluntary organisations as desired speakers on health topics. The children over 11 years of age attending most of the public elementary and secondary schools in the District attended two displays of health films at one of the local Cinemas during the closing months of the year. Unfortunately none of the private schools availed themselves of the opportunity to attend. While these displays were successful 31 in many ways, the routine use of the cinematograph in schools, with the inclusion of suitable health films, would probably prove of greater value and less costly, with less disorganisation and risk of infection. Similarly, displays at the Infant Welfare Centres such as were given at all Centres during the winter months, would probably prove more acceptable if introduced as a regular part of the programme at the Centres. Undoubtedly there are great possibilities in the use of the film for health education, and such money as is available could well be spent on the production of more films dealing with specific health questions in a modern and attractive manner. The posters and other printed matter produced for the National Campaign to encourage the wider use of the Health Services were not appreciated in this District. A local edition of "Better Health," a monthly magazine containing a foreword written or arranged by the Medical Officer of Health, the inset of which is produced by the Central Council for Health Education, has been distributed throughout the District since November, 1937. Some 2,000 copies are issued locally each month, but the value of this form of propaganda in the District has yet to be estimated. Several voluntary societies included health topics in their Winter programmes, and it is hoped that this practice will continue. 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:— Ante-Natal Clinics. The first Ante-natal Clinic was established by the Council in June, 1931. Since then an increasing number of sessions has been required, and these are now held from 2.30 to 4.0 p.m. at:— (a) 69, Brighton Road, Purley, 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. It will be seen from the following tabular statement of attendances that 214 new ante-natal cases presented themselves during 1937, as compared with 243, 180, 143 and 114 in the preceding four years. This suggests that in approximately 30 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 figures for the preceding years being 36, 29, 23 and 22 per cent. 32 Attendances at Ante-Natal Clinics, 1937. clinics. Number on register. Attendances. Sessions. Average attendance per session. New cases. Total. 69, Brighton Road, Purley (prior to 12.7.37 at the Methodist Ch., Coulsdon). Ante-natal 157 108 593 Post-natal 43 — 50 Gynaecological 4 1 4 Individuals 160 109 647 32 20.8 Methodist Hall, Sylverdale Road, Purley Ante-natal 79 62 351 Post-natal 36 4 51 Gynaecological 6 5 6 Individuals 88 71 408 24 17.0 Baptist Hall, Addington Rd., selsdon Ante-natal 47 34 138 Post-natal 23 — 32 Gynaecological — — — Individuals 47 34 170 12 14.2 All Centres Ante-natal 283 204 1082 Post-natal 102 4 133 Gynaecological 10 6 10 Individuals 295 214 1225 68 18.0 The chief purpose of these Clinics is to ensure that those prospective mothers who would not otherwise obtain supervision during the Antenatal period by a qualified medical practitioner can secure this service. The result is that almost all cases which attend are subsequently confined by midwives in their own homes or at Purley Hospital, or are admitted to Queen Charlotte's or the County Hospital, Redhill. In the latter cases much closer supervision is possible, and at less inconvenience than would occur if the patient had to travel to London or Redhill for antenatal treatment. Efforts were made during the year to secure much closer cooperation between the various agencies concerned, and with the advent of a recognised midwifery service covering the whole district, the Clinics will continue to provide a most useful service, although the numbers attending may not greatly increase. Complicated cases are referred to their own doctors or to the Council's Obstetric Specialists when this is desirable in the interests of the patient. 33 Ante-natal mothers continue to be supplied with free cow's milk if the financial circumstances warrant this action, while dental treatment is also arranged, if necessary at reduced cost. The supply of sterilised dressings on similar terms was introduced during the year. Post-Natal Clinic. In July the first session of what has been termed the Post-natal Clinic was held at 69, Brighton Road, Purley. The purpose underlying the establishment of this Clinic is to encourage all mothers who would not otherwise secure a post-natal examination by a doctor to do so. One examination is desirable at the end of the lying-in period by the doctor attending at the confinement, and another at about six weeks after the birth has occurred. If all the mothers who attend the Ante-natal Clinics re-attend after their confinements, the Ante-natal Clinics would become overcrowded, hence the special Post-natal Clinic was started. The numbers expected only justified one session per month, viz., the third Monday in each month. In practice, while the majority of post-natal cases arrive on that day, as is desirable, others can attend only at the normal ante-natal sessions. This is counterbalanced by some ante-natal mothers attending at the Post-natal Clinic. Fundamentally, the anomaly which appears to exist in the following Table of attendances relates only to the nomenclature of the Clinics. The chief thing is to see that all cases are properly examined post-natally, and thus avoid the inconvenience and suffering which has often in the past resulted from neglect following childbirth. During the year a total of 107 cases who had previously attended the Ante-natal Clinics attended post-natally, i.e., 41 per cent. of the average number of new Ante-natal cases in 1936-7. Where necessary, appliances are supplied to post-natal mothers, a reduced charge being made if this is indicated. Cases requiring special treatment are referred either to their own doctors, or to the Specialists at Croydon or at one of the London Hospitals. Post-Natal, Clinic. (Established 19th July, 1937). Attendances. Sessions. Average attendance per session. New cases. T otal. Post-natal 1 22 Ante-natal 11 53 Gynaecological 1 5 Individuals 13 80 6 13.3 34 Obstetric Specialists. In March, 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. In November, 1937, a third name was added, viz., Mr. Douglas Lindsay. The services of these Specialists are available for advice, and, if necessary, treatment in any case in which obstetrical difficulty is anticipated or realised, or puerperal fever or pyrexia develops, in any ratepayer in the District. In practice they are only called in to cases in which the full normal fee of a Specialist cannot be afforded. Except in the case of persons admitted to Purley Hospital, the Council reserves the right to recover from the family part, or all, of the cost involved. During the year one or other of the Specialists was called in for consultation on 5 occasions, and subsequently required to operate on 2 cases. Maternity Cases. During the year the number of maternity cases admitted for their confinement to Purley Hospital under the Council's Scheme fell from an average of 84 in the three preceding years to 61. This reduction was due to outbreaks of "pemphigus neonatorum," which necessitated the closure of the ward on more than one occasion. 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 the call on 3 of the 6 maternity beds in this Hospital, but for several years this accommodation has been recognised as being inadequate, and during the year 21 cases were sent to Queen Charlotte's, while 18 cases were admitted to the County Hospital, Redhill. A uniform charge is made for conveyance by ambulance to any of these hospitals of maternity cases whose confinements are arranged through the Council's Scheme, and, on and after the 1st April, 1938, this will be 5s. 0d. per case. Similarly a uniform charge is made for maintenance and treatment in both Purley Hospital and Queen Charlotte's Hospital, while the County Council's charge for treatment in Redhill varies with the means of the patient's family. Unfortunately it has proved impossible to provide further accommodation locally owing to the contemplated provision by the Surrey County Council of 68 maternity beds at the St. Helier's Public Health Hospital, the foundation stone of which was laid in March, 1938. Meanwhile the Purley Hospital Committee are appealing for £45,000 for extensions at the Hospital to include a new Maternity Block containing 12 beds. 35 In addition to the abovementioned accommodation there are 3 private Maternity Homes at present in the Urban District. Midwives Acts. It is probable that the pressure on the maternity accommodation available for the District will be relieved to some extent by the application of the Midwives Act, 1936. Following prolonged negotiation, it was eventually decided that the Council, acting as Agents for the County Council, should appoint two Midwives to serve the Sanderstead/Selsdon and Purley/Kenley areas. In addition, the Coulsdon Nursing Association has appointed one of its nurses specifically for midwifery. The Council's Midwives were appointed in December, 1937, and it is hoped that, working in close co-operation with each other, and the other branches of the Maternity and Child Welfare scheme, the present team of three midwives approved by the County Council will increase the co-ordination and usefulness of the scheme. There are, in addition, 10 midwives practising privately in the Urban District. Unfortunately the application made by the Council at the end of 1936 for supervisory powers under the Midwives Acts was again refused. The anomaly of the position is increased now that two-thirds of the approved Midwives are directly employed by this Council. Home Helps. The Council has made arrangements for the supply of Home Helps in necessitous cases, and during the year 35 cases were assisted in this way, this being 10 more than in either of the preceding two years. 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. An annual grant is made by the Council 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 three Health Visitors, who work under the supervision of the Medical Officer of Health. As was anticipated in the Annual Report for 1936, the total number of visits paid by the Health Visitors decreased from 7,695 in 1936, to 36 6,954 in 1937. This fall is partly due to fewer visits being required to cases of infectious disease, other than tuberculosis. The chief cause, however, and the one which will continue to influence the number of visits in the future, is the increased number of fixed appointments which the Health Visitors have to keep. As compared with mid-1936, the Sanderstead and Old Coulsdon Centres, together with the Postnatal and Immunisation Clinics, absorb no less than 9 extra sessions a month, hence the time available for visitation has been greatly reduced. This year the effect has been to reduce the average number of re-visits to children under one year of age from 3.3 re-visits per child to 2.5 revisits, while children from 1 to 5 years have received 1.8 visits as compared with 2.1 visits in 1936. The percentage of births visited has also been reduced from 93 per cent. in 1935 and 1936, to 90 per cent. in 1937. These reductions are not in themselves of vital importance provided that fewer visits are only paid to those families least needing visitation. They reveal an inevitable interim stage in a rapidly developing district such as this. As, however, the number of births each year steadily increases, while there is a tendency for more rather than fewer fixed appointments, the time is rapidly approaching when the services of a fourth Health Visitor will be required if the standard of work is not to fall below that desirable for this District. Visits paid by Health Visitors. 633 first visits to babies 1,607 visits to babies under one year 3,905 visits to children from one to five years 241 Ante-natal visits 137 first visits 104 re-visits 115 visits to cases of tuberculosis— 69 first visits 46 re-visits 1 visit to a case of mumps 7 first visits to cases of chicken pox 41 visits to cases of whooping cough— 30 first visits 11 re-visits 8 visits to cases of measles— 7 first visits 1 re-visit 2 investigations of cases of ophthalmia neonatorum 5 investigations of cases of puerperal fever 2 investigations of cases of puerperal pyrexia 16 investigations of infant deaths 14 investigations of cases of stillbirths 357 miscellaneous visits 6,954 Total 37 Infant Welfare Centres. Six Infant Welfare Centres have been established by the Council, which are held from 2.30—4 p.m. at the following places:— Methodist Church, Brighton Road, Coulsdon Every Thursday. Church of St. Francis, Rickman Hill, Coulsdon Every Tuesday. Church Hall, Bradmore Green, Old Coulsdon 2nd and 4th Wednesdays in each month. Methodist Church, Sylverdale Road, Purley Every Friday. Baptist Church, Addington Road, Selsdon Every Monday. Congregational Church, Sanderstead Hill, Sander- 1st and 3rd Thursdays stead in each month. This is the first complete year for the Sanderstead Centre, while the Old Coulsdon Centre was established in October, 1937. Both have amply justified their existence as judged by the attendances to date. It is unlikely that further Centres will be required for some time, although the popularity of the Selsdon and Brighton Road Centres is resulting in average attendances which will have to be watched. The average number of children attending at Selsdon is still the highest, although it has fallen slightly from 81 to 79 per session, whereas Brighton Road has increased from 69 to 75. The Rickman Hill average has also increased from 56 to 64, and the Kenley Centre from 53 to 59. Each of these four Centres is held weekly, the doctor attending twice a month. In the next financial year it is anticipated that more frequent attendances by the doctor will be arranged at Brighton Road and Selsdon. The Old Coulsdon and Sanderstead Centres are only held twice a month, a doctor being present on each occasion, and these had an average attendance of 42 and 49 respectively. The total attendance for all Centres increased from 12,519 to 14,658, this being exactly double the total for 1932; similarly there were 92 more new cases in 1937 than in 1936. The increase in new cases was most marked at Brighton Road with 26 additional new cases, whereas Selsdon had 12 fewer new cases than in 1936, suggesting that the maximum effect of the new building in that part of the District has already been experienced. 38 39 Attendances of Children at Infant Welfare Centres, 1937. Brighton Road, Coulsdon. Rickman Hill, Coulsdon. Bradmore Green, Old Coulsdon. Sylverdalc Road, Purley. Sanderstead Hill, Sanderstead. A ddington Road, Selsdon. Totals. 1937. Totals 1936. 1935. 1934. 1933. 1932. New cases 170 86 28 123 69 118 594 502 423 368 329 288 Other cases 3,451 2,869 224 2,777 1,127 3,616 14,064 12,017 10,309 8,710 7,490 7,131 Total attendances 3,621 2,955 252 2,900 1,196 3,734 14,658 12,519 11,732 9,078 7,819 7,419 Consultations with Doctor 724 588 120 493 406 535 2,866 2,403 2,099 2,013 1,876 1,977 Referred to Hospital 15 3 - 2 1 - 21 16 17 - 21 27 Number of sessions 48 46 6 49 24 47 220 195 191 192 177 170 Average attendance per session 1937 75 64 42 59 49 79 *66 — — — — - 1936 69 56 —. 53 69 81 -- *64 — — — — 1935 58 57 —. 49 — 61 — — *61 — — 1934 49 46 — 42 — 52 - — —. *47 — 1933 45 46 — 42 — 49 — — — — *44 — 1932 45 47 — 40 — 37 - — — — — *44 * Average attendance per session for all Centres. A review of the work of the Infant Welfare Centres was made during the year for the purpose of assessing the degree of success achieved in furthering the objects of the Centres, i.e., firstly medical supervision of the children from birth to school age, and secondly, the education of the parents. The numerical results are as follows:— Approximately two-thirds of the children under school age in the Urban District attend one of the Centres at least once before reaching the age of 5 years, but upon analysis of several hundred cases, it is found that of the two-thirds who do attend 12% do not attend when 0-1 years old. 28% „ „ „ „ 1-2 „ „ 41% „ „ „ „ 2-3 „ „ 46% ,, ,, ,, ,, 3-4 „ „ 53% „ „ „ „ 4-5 „ „ Of those who continue to attend, on the average those 0-1 years old attend 19 times per annum and see the Doctor 4.6 times. „ 1-2 „ „ „ 13.5 2.4 „ „ 2.3 „ ,, „ 10 ,, ,, „ „ „ „ 2.0 „ „ 3-4 „ „ „ 9.6 „ „ „ „ „ „ 2.0 „ „ 4-5 „ „ „ 9.1 „ „ „ „ „ 1.7 „ It will be noted that whereas nearly two-thirds of the children attend as babies, after the age of three years only about one-third of the group are still attending. In other words, about half the attenders drop off after the age of 3 years, or are absent for a whole year at a time, and the Doctor is often not seen even when they are attending. In view of this tendency, which is not peculiar to this District, it is possible that in the next financial year new methods will be used to encourage the attendance of toddlers, or, at least, to assess the importance of their regular attendance. With regard to the educational side of the Infant Welfare work, attempts have been made to render this more effective, especially as applied to group education. The less expensive forms of propaganda such as posters and literature will continue to be used. A previous impression that Talks to Mothers are comparatively valueless, unless the children can be accommodated in another room, has rather been confirmed than otherwise. The use of the Cinematograph has been experimented with in connection with the Health Campaign reported upon elsewhere. The results were definitely promising, especially in certain Centres. If the initial expense of a projector ever becomes justified by reason of its use in other sections of the Council's activities, the institution of regular film displays at the Centres would probably be well worth while, if only to encourage a wider view of the purpose of the Centres. 40 No alteration in the staffing of the existing Centres was made during the year. Dr. G. M. Archer has undertaken the duties of Consultant at the new Centre at Old Coulsdon, The Provision of Milk and Specialist Treatment. During the year 89 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 a decrease of 1 case on 1936. 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 21 cases were referred to hospitals from the Centres, 15 being from Brighton Road Centre. Of these, 18 were referred to Purley Hospital for minor operations (16), Ultra Violet Ray treatment (1), or massage (1); while 3 attended Croydon General Hospital, in 2 cases for orthopaedic treatment and one for the treatment of nævi. A number of cases were also 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. 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 third 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 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 69 cases were treated by those Dental Surgeons in the District who had signified their willingness to serve under the scheme, as compared with 45 and 33 in the preceding years. While the scheme remains slightly ponderous and rather more expensive for the individual than could be desired, treatment is now 41 commenced much more expeditiously than hitherto owing to the application of an income scale permitting agreements being entered into immediately the estimates of the Dental Surgeons are received. The numbers treated to date hardly justify other arrangements as yet, the present scheme appearing to be the best that can be evolved to deal with the demand so far experienced in this District. DAY NURSERIES. There are two Day Nurseries maintained in this District chiefly by voluntary subscriptions, but towards each of which the Council makes an annual grant equivalent to approximately one-third of the total cost of the Day Nurseries. The Purley Day Nursery has now accommodation for an average of 33 children, while the Coulsdon Day Nursery can take an average of 23. The total attendances during 1937 were 5,391 and 6,471 respectively. For the population of the District, such accommodation is relatively high as compared with the Country as a whole, but both Nurseries do very useful work. It is recognised, however, that compared with other forms of Infant Welfare work, apart from residential treatment, the provision of Nurseries is much the most expensive type of work undertaken or subsidised by the Council. There is also a divergence of opinion as to how far mothers should be encouraged to leave their homes in order, usually, to supplement the family income. Undoubtedly there are few, if any, of those now using the Nurseries who do not definitely need to provide or augment their incomes. At the same time there are approximately 138 mothers resident in the Urban District with children under 5 years of age now going out to work, hence the necessity for providing more accommodation requires consideration, but would not appear to be extremely urgent. In view of the fact that the Surrey County Council as Educational Authority has had under consideration the provision of Nursery Classes at the schools in the District, it has not been considered advisable to vary the grants made by the Council during the current year. CHILD LIFE PROTECTION. The Health Visitors are all recognised Infant Life Protection Officers. During the year 23 foster mothers have been under supervision, 37 children being distributed amongst the Homes, 7 of which Homes were entered on the register for the first time during the year. During the same period, 2 foster mothers removed from the District, while 4 registrations were cancelled, 3 by request, and 1 owing to the unsuitability of the Home. 42 These Homes, which include 2 Boarding Schools accommodating children under 9 years of age, were distributed as follows Coulsdon 7 Old Coulsdon 1 Kenley 4 Purley 6 Selsdon 4 Purley Oaks 1 23 HOUSING. If this Report is compared with its predecessors it will be noted that, while the number of houses inspected during the year is not quite so high as last year, it is far in excess of that for 1935. In the latter year 331 inspections were made, compared with 924 in 1936 and 824 in 1937. The chief reasons for these increases were the additional visits required, originally to detect any overcrowding which existed, as required by the Housing Act, 1935, and latterly to ascertain the maximum numbers of persons which could reside in the houses suitable for accommodating members of the working classes in the District, in order that the ascertained figures could be inserted in the rent books, as required by the Housing Act, 1936, sec. 62. This information has now been supplied as affecting approximately one-half of such houses, and as a good proportion of the remainder are owner occupied houses in which there is little desire to ascertain the maximum figures, less time will be required in future in dealing with this aspect of the work. There is, however, a reluctance on the part of a number of owners to insert the maximum number on account of the permitted standard being lower than that generally accepted and desirable in a District such as this. It is feared that tenants will thereby be encouraged to increase the number of occupants to that permitted by the Act. In view of the fact that the majority of the 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 task of relieving overcrowding has been a light one locally, while no slums or undue congestion of property exist with which to deal. In the original survey for overcrowding 21 cases were detected, and by the end of 1936 only 6 of these, or others found subsequently, remained for attention. During 1937, an additional 4 cases were discovered and 5 relieved, hence there were still 5 remaining cases in 4 premises at the end of the year requiring attention, none of which related to property owned by the Council. Two of these cases were the remnants of the original cases, but one of them is a case which, after relief, became again 43 overcrowded owing to a child attaining the age of 10 years. The owner occupier has since been granted a licence permitting the present number of occupants to continue in residence for one year. The other original case remains unrelieved at present. 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) 824 (b) Number of inspections made for the purpose 844 (2) (a) Number of dwelling houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 59 (b) Number of inspections made for the purpose 60 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation — (4) Number of dwelling houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 254 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 244 3. Action under Statutory Powers during the Year:— (a). Proceedings under sections 9, 10 and 16 of the Housing Act, 1936:— (1) Number of dwelling houses in respect of which notices were served requiring repairs 1 (2) Number of dwelling houses which were rendered fit after service of formal notices (a) By owners 1 (b) 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 80 (2) Number of dwelling houses in which defects were remedied after service of formal notices:— (a) By owners 63 (b) By Local Authority in default of owners — 44 (c) Proceedings under sections 11 and 13 of the Housing Act, 1936:— (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 12 of the Housing Act, 1936:— (1) Number of separate tenements 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, 1936, Part IV—Overcrowding:— (a) (i) Number of dwelling houses overcrowded at end of year 4 (ii) Number of families dwelling therein 7 (iii) Number of persons dwelling therein 32 (b) Number of new cases of overcrowding reported during the year 4 (c) (i) Number of cases of overcrowding relieved during year 5 (ii) Number of persons concerned in such cases 35 (d) Particulars of any cases in which dwelling houses have again become overcrowded after the Local Authority has taken steps for the abatement of overcrowding. Case (1) Overcrowding was abated by parents voluntarily obtaining other accommodation for a number of their children. Later all the children returned and the Council decided to provide them with a suitable house so soon as one became available, but at the end of the year no such house had become available. The family has since removed from the district. Case (2) Occupier abated overcrowding by similar means to those set out above, but the house again became overcrowded by reason of one child attaining the age of 10 years. This case was receiving the attention of the Council at the end of the year, and a licence has since been granted. Number of New Houses erected during the Year:— By the Local Authority Nil By other persons 735 45 WATER SUPPLY. The District is chiefly supplied with water by the Sutton 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 District. 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 from the East Surrey Water Company's mains as the need arises. The source of the water supply in all cases is from deep wells sunk into the chalk in various parts of this and neighbouring districts. 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. Six samples of water were taken from these sources, and were all found to be satisfactory. It is understood that the water supplied by the Sutton and District Water Company in this area is obtained from the Woodmansterne wells, and a rota has been in existence for some time whereby monthly samples for full examination are taken by the Local Authorities in the districts supplied with water from these wells. The number of these samples has now been further increased. The Company, in addition, examines samples daily from each source. A similar rota has been agreed upon by the Local Authorities supplied by the East Surrey Water Company, and owing to the greater area covered, at least three or four samples per month will be examined, in addition to the periodical samples taken by the Company. Sampling is, however, only one form of control, and can not be relied upon solely to secure the protection of consumers, irrespective of the frequency with which samples are examined. Undoubtedly in builtup areas such as those from which the greater part of the water supplied in this District originates, the most important factor is continuous and adequate treatment at the source, the responsibility for which rests upon the water undertakers. The method of treatment of the water by the statutory companies has been carefully reviewed. In each case the employment of a form of lime treatment, together with chlorination, presents a double line of protection of the water at the source of supply. If fully maintained and supervised these methods should limit the risk of water borne disease to contamination occurring after the water has left the works. 46 Efforts are also being made to reduce the possibility of the pollution of the water in reservoirs or mains. During the early part of the year the water supply to the Old Coulsdon Estate was found to be inadequate owing to the increased number of houses drawing on the supply which is from a private well in Caterham Drive. The capacity of the pump to supply the necessary water proved insufficient, and the loss of head entailed thereby caused certain houses on the highest part of the Estate to be for a time without water. The Company then entered into an arrangement with the East Surrey Water Company whereby for a period of three months the private supply was supplemented. The uneven pressures and alteration of the flow in the mains on the Estate which ensued caused the deposit in the pipes to be seriously disturbed, resulting in discolouration of the water when it was drawn off, and 16 complaints of this condition were received. Towards the end of the year a new well was sunk 400 feet deep having a bore of 12 in. with 4 in. galvanized steel rising main, situated about 50 feet to the rear of the Pumping Station in Caterham Drive. The water level is 160 feet below the surface with a pump 35 feet below the water level. This new pump of 12.5 b.h.p. is worked automatically and is regulated by a float in the water tower, the rate of delivery being approximately 5,000 gallons per hour. A new chlorinating plant was also installed, and for the first few weeks it was found that the water was over-chlorinated, resulting in a series of complaints regarding its unfitness for drinking purposes. During the year 22 samples of this water were submitted for bacteriological examination, and one sample was taken from the rising main before chlorination which confirmed that the intermittent contamination of this supply previously known to occur, still existed. Another sample taken from a draw-off tap was later reported upon adversely, Coliform organisms being present in 20 c.c., but the following sample proved satisfactory. One chemical examination was also made of this water. In view of the uncertain purity of the source of supply in this case, and the reliance placed upon chlorination for the protection of consumers, daily examinations by the Medical Officer of Health for excess chlorine were commenced at the end of the year, while the East Surrey Water Company were again approached by the Council on the subject of taking over distribution in this area. An extension of soil sewers on the Estate is also being put in hand. 47 During the year the rainfall was 37.83 inches, being 5.13 inches higher than the previous year, and occurred as follows:— Inches. January 5.92 February 5.06 March 4.12 April 2.63 May 2.43 June 1.81 July 1.12 August 2.82 September 1.96 October 2.79 November 2.18 December 4.99 Total 37.83 These measurements were registered by the rain guage under the observation of the Surveyor's Department, to which Department I am indebted for this information. No shortage of water for domestic purposes occurred during the year. The statutory maximum limit for hardness in the water supplied by the East Surrey, and Sutton and District Water Companies is 9 degrees, and 53 samples have been examined by the Department during 1937 to ascertain that this was not exceeded. In no case was this found to occur, but an examination of the water supplied on the Old Coulsdon Estate, where there is no statutory maximum in force, resulted in 25 degrees of hardness. CLOSET ACCOMMODATION. Public sewers are provided for the whole of the area except for the outlying portions in which most of the houses are drained to cesspools. The vast majority of premises are provided with water closets, but isolated buildings in public and private recreation grounds, together with a relatively small number of private dwellings have recourse to other forms of sanitary accommodation. During the year five pail closets were converted to water closets, seven cesspools were abolished and the house drains connected to public sewers, and at four premises (previously without proper drainage) two new cesspools were provided. The approximate number of each type remaining at the end of the year were:— Premises with water closets drained to sewers 14,463 „ „ „ „ „ „ cesspools 255 „ „ earth closets 1 „ „ pail closets 56 The total number of cesspools throughout the district is approximately 229. 48 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, after the first 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. I am indebted to the Surveyor for the information that the provision of the two additional cells at the Refuse Destructor during 1936 has permitted his department to cope adequately with the quantity of refuse collected. SMOKE ABATEMENT. During the year the chimneys of small factories and workshops gave little trouble and no complaint was received regarding the few large stacks in the District. Such complaints as were received were duly dealt with, and were chiefly concerning domestic boilers. Twelve complaints about the burning of trade and garden refuse in close proximity to dwelling houses were received. The Council has made special arrangements for the disposal not only of trade refuse, but of 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, if it cannot be buried, to dry the garden refuse properly before burning. Books of twenty 6d. tickets can be obtained from the Treasurer, 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 is 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. DRAINAGE AND SEWERAGE. There were no extensions of the public sewers during the year. Estate developers, however, continued to lay sewers on private estates and some of these were utilised by the owners of existing premises. The disposal of the sewage of the District is undertaken by the County Borough of Croydon and the West Kent Main Drainage Board. 49 SHOPS. Attention has been given to the requirements of the Shops Act, 1934, with regard to sanitary conveniences, lighting, temperature, washing facilities and accommodation for meals, 624 inspections being made for this purpose during the year. Additional sanitary accommodation has been installed in nine premises and washing facilities provided in two other premises. SWIMMING POOLS. There are no public swimming baths or pools in the District, but there is one private swimming bath at the Reedham Orphanage, Old Lodge Lane, Purley, which is used by the children of the Home, scholars of local elementary schools, and occasionally by scholars of secondary schools. The bath is covered in and the water supply, which is from the public mains, is heated before discharge into the bath. After the closing down of the bath in September, 1936, a chlorinating plant was installed and in May, 1937, a sample of water was reported upon as being satisfactory bacteriologically. SANITARY INSPECTIONS, Etc. The following is a statement of the complaints received, inspections paid, defects remedied, etc. Compared with 1936, there were 135 more complaints received, and 1,224 more inspections made, from which it may be concluded that a steady increase in the work of the Sanitary Department has occurred. No particularly spectacular achievements have to be reported for the year, but a satisfactory uniform standard of efficiency was maintained throughout. COMPLAINTS. Dampnes 47 Choked and defective Drains 41 Insanitary conditions, general repairs, etc. 38 Insects, moles, etc. 28 Rats and mice 95 Accumulations of refuse 34 Inadequate soakaways 3 Defective water service pipes 2 Nuisances caused by keeping of animals 7 Smoke nuisance, burning of refuse, etc. 13 Overcrowding 7 Non-collection of refuse 9 Defective, or discoloured water supply 8 50 Inadequate or no water supply 11 Hooding 4 Dustbins 11 Offensive smells 36 Defective water closets 4 Domestic uncleanliness 1 Vermin 16 Defective gully 1 Inadequate hot water 2 Choked rain water pipe 1 Unsound food 2 Caravans 2 Weeds 2 Insufficient light 4 Noise 4 Want of paving 1 Insufficient heating of shop 1 Miscellaneous 10 Total 445 Inspections. House inspections 824 Re-inspections and calls 2,835 Workshops and factories 177 Bakehouses 43 Cowsheds and dairies 74 Slaughterhouses 113 Meat and other foods 469 Stables, piggeries, etc. 54 Drains, outbuildings, etc. 1,684 Rats and mice inspections 745 Shops Acts inspections 624 Drains tested 61 Infectious disease enquiries 106 Disinfections carried out 230 Smoke inspections 5 Houses let in lodgings 1 Miscellaneous 26 Total 8,071 51 Notices Served. Preliminary Notices 664 Statutory Notices 86 Letters and Final Circulars 192 Defects Reported. Insufficient or defective drainage 31 Improperly drained yards 6 Cesspools requiring emptying 124 Defective cesspools 34 Choked drains 42 Defective fresh air inlet 26 Defective ventilation shafts 3 No wire cages to vent shafts 3 Unclean walls and ceiling 124 Defective plaster 54 „ floors 31 „ firegrates and wash-boilers 42 „ sashcords 25 „ or, choked rainwater pipes 45 „ woodwork 37 paving 32 „ dustbins 177 „ sinks and sink waste pipes 17 „ kerbs around gullies 11 Dampness through defective roofs 56 Dampness through other causes 88 Defective W.C. fittings 24 Accumulations 14 Animals kept so as to be a nuisance 2 Verminous conditions 15 Lack of domestic cleansing 5 Overcrowding 5 Insufficient lighting and ventilation 20 Defective air-bricks 6 Defective outbuildings 8 Brickwork and pointing defective 56 Paintwork defective 2 Glazing defective 12 Unclean outdoor premises 10 No proper sanitary accommodation 5 Insufficient sanitary accommodation 9 Absence of water supply 2 Rats 99 52 Insufficient W.C.'s 5 Burning of Refuse 4 Insufficient soakaways 6 Defective roofs 10 Miscellaneous 32 Total 1,359 Defects Remedied. Pail closets abolished 3 Cesspool provided 1 Drainage repaired or provided 37 Cesspools emptied 85 „ repaired 1 „ abolished 8 Soakaway provided 1 Drains cleansed 45 Fresh air inlets provided 36 Vent shafts provided or repaired 5 Wire cages to vent shafts provided 3 Drains connected to sewer 9 New water closets 8 Gully traps, etc., provided 22 Inspection chambers provided 23 Walls and ceilings cleansed 156 Plaster repaired 71 Floors repaired 33 Firegrates and wash-boilers repaired 46 Sashcords repaired 32 Rainwater pipes and eaves guttering repaired 42 Woodwork repaired 49 Paving repaired 39 Dustbins provided 186 Sinks and sink waste pipes replaced or repaired 22 Kerbs around gullies repaired 14 Dampness remedied due to defective roofs 54 Dampness remedied due to other causes 107 W.C. fittings repaired or provided 23 Accumulations removed 21 Nuisances from improper keeping of animals abated 2 Verminous conditions abated 15 Domestic cleanliness improved 5 Overcrowding abated 4 53 Lighting and ventilation provided or improved 19 Outbuildings repaired 3 Defective brickwork repaired or re-pointed 49 Paintwork renewed 17 Windows glazed 15 Outdoor premises cleansed 4 Sanitary accommodation provided 5 Rat infestations abated 97 Water supply laid on 14 Burning of refuse abated 2 Roofs repaired 12 Soakaway provided 4 Washing facilities provided 2 Miscellaneous 28 Total 1,479 ERADICATION OF BED BUGS. The methods adopted for the eradication of bed bugs during the year were similar to those which had been found most successful during the preceding years. The numbers of houses dealt with were as follows:— Council Houses infested 10 „ disinfested 10 Other „ infested 9 „ „ disinfested 9 The work in Council houses and private houses is usually carried out under the supervision of a representative of the Public Health Department and the methods adopted are in proportion 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. Much depends on the time of the year when the bugs make their appearance, and at all times the tenant is advised to raise the temperature as much as possible and to maintain it in order that the application of a strong concentration of sulphur may be effective. In normal rooms of 90-120 square feet 6 lbs. of sulphur is used. Further examination is made at the expiration of about 10 days and, if necessary, further treatment is given. It is rarely found necessary, however, to apply a second fumigation with sulphur. 54 Occasionally occupiers complain of the appearance of isolated bugs and are supplied with liquid insecticide together with a spray for their private use. A careful and diligent application of the insecticide has proved effective after one or two weeks and no further trouble has been found to arise in these houses. The officers of the Council carried out all disinfestations during the year and no special firm of contractors was engaged. The homes of applicants for Council houses are inspected with a view to obtaining some knowledge of their suitability as tenants, and if the houses and furniture are found to be infested steps are taken as set out above before removal is effected. It has been necessary occasionally to submit the bedding to steam disinfection. RATS AND MICE DESTRUCTION. During the year there was an increase in the number of complaints received and also a large increase in the number of inspections and reinspections made. The complaints numbered 95 and the total number of inspections 745, representing increases of 30 and 560 on the previous year. The premises inspected were chiefly private houses, shops, garages with concrete floors, premises where sheds had been erected, and sites on which large heaps of vegetable refuse had remained undisturbed for considerable periods. The very numerous railway embankments throughout the district form an ideal harbouring place, especially where shops and similar premises are in close proximity. Residents are advised on the laying of poisoned baits or traps, or on the demolition or ratproofing of sheds. The necessary work may be undertaken, on request, by the Public Health Department at a charge of 2/6d. per hour with a minimum charge of 5/-, the cost of poisons being extra. It was found necessary to serve six statutory notices during the year, this being an increase of four on the previous year. Many residents do not yet realise that the occupiers of premises are themselves responsible for the destruction of the rats, although the department is always willing to give advice as to the best means to adopt in any particular case. SCHOOLS. School Closure.—No public elementary school was closed during the year on account of the prevalence of infectious disease amongst the scholars. 55 The periods of exclusion from school which are set out in the Surrey County Council Memorandum on Communicable Diseases are the periods usually applied. The Head Teachers of all schools are notified immediately any scholar develops or is in contact with any notifiable 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. Under the Coulsdon and Purley Act, 1937, it is now compulsory for the parent or guardian of a child suffering, or suspected to be suffering from an infectious disease to notify the Head Teacher, and, in addition, to notify the Superintendent of any Sunday School attended by the patient. Similarly no children excluded from school on account of infectious disease are permitted to attend Sunday School or places of public entertainment or assembly, while the Council has power to secure the closing of any of these premises on the advice of the Medical Officer of Health, if thought necessary in order to prevent the spread of infectious disease. Medical Inspection.—The Medical Inspection of school children attending the public elementary or secondary schools is carried out by the Education Department of the Surrey County Council. School Clinics.—The Surrey County Council provide Clinics for the treatment of school children, as follows:— General Medical Clinic: Surrey County Dispensary, Whytecliffe Road, Mondays, 9.30 to 12 noon. Purley Thursdays, 9.30 to 11 a.m. School Dental Clinic: do. do. do. Thursdays, 9.30 to 11 a.m. 2 p.m. Fridays, 9.30 to 11 a.m. 2 p.m. Saturdays, 9.30 to 12 noon. School Eye Clinic: do. do. do. 1st Friday, 2.30 to 4 p.m. Sanitary Services.—The water supply, drainage and sanitary accommodation in the public elementary schools have been 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. 56 REGULATED TRADES. Daisies and Cowsheds. The following is a list of the dairy farms which were in existence in the District at the end of the year:— Hooley Farm, Woodplace Dane, Coulsdon. Dean Farm, Brighton Road, Hooley. Elm Farm, Farleigh. Moorcraft Farm, Farleigh. Farleigh House Farm, Farleigh. Welcomes Farm, Farthing Downs, Coulsdon. Owing to the length of time which had elapsed since Farleigh Court Farm had previously been used as a dairy farm it was removed from the register, but Welcomes Farm, Farthing Downs, was re-registered during the year. In addition there are two other farms which supply private institutions with milk, viz.: Woodplace Farm, Woodplace Dane, Coulsdon, which supplies Netherne Hospital and is owned by the Surrey County Council, and the Farm at Cane Hill Hospital, which supplies that Hospital, and is owned by the London County Council. There are also a number of persons who own a few cows and use the milk solely for their own consumption. The requirements of the Milk and Dairies Order, 1926, have been rigidly applied and frequent inspections of cowsheds and dairies were made for this purpose. A quarterly veterinary inspection of all cows in the District is undertaken by the Surrey County Council, but in addition the local Council has secured 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 and another disused dairy re-registered. The number of registered retailers was 43, 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 animals slaughtered during the year was 920. As required by the Slaughter of Animals Act, 1933, all animals are slaughtered with a mechanically operated instrument, the Cash Captive Bolt Killer and the Greener Safety Killer being the instruments used. 57 Licences to slaughter animals were issued to four slaughtermen. Notifications of intention to slaughter are forwarded regularly by the occupier of one of the licensed slaughter-houses, a regulation slaughter notice being supplied by the other licensee. The Sanitary Inspectors make an inspection of all carcases before they are placed upon the market. BAKEHOUSES. There are sixteen bakehouses within the District, eight of which are used for baking bread, the remainder being chiefly used for making confectionery. All the premises were inspected periodically and are generally well kept. OTHER FOOD PREMISES. There was no alteration in the number of fish friers during the year, and their businesses were generally well conducted. Few complaints were received regarding them, and routine inspections 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. WORKSHOPS AND FACTORIES. There are 159 Factories and Workshops within the District, of which 62 are Factories and 97 are Workshops. In addition there are 12 Workplaces. INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. (1) Number of Inspections. (2) Written Notices. (3) Occupiers prosecuted. (4) Factories (Including Factory Laundries) 55 - - Workshops (Including Workshop Laundries). 122 _ _ Workplaces (Other than Outworkers' premises) 12 - - Total 189 - - 58 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 Pubi.ic Health Acts:– Want of cleanliness 13 12 - - Want of ventilation - - - - Overcrowding - - - - Want of drainage of floors - - - - Other nuisances 11 10 — — Sanitary accommodation insufficient 4 2 - - unsuitable or defective 4 2 - - 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 32 26 _ _ * 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 OI- FOOD. Mii,k. During the year 62 samples of milk were submitted for bacteriological and microscopical examinations, and of these 10 were submitted also for biological examination. Eleven of the samples proved bacteriologically or microscopically unsatisfactory and the retailers concerned were duly informed by letter. Repeat samples were taken and showed considerable improvement. The following is a summary of the results of the 62 samples examined bacteriologically, which show an improvement on last year's figures : - TOTAL COUNT. Under 30,000 bacteria per c.c. 36 30,000—200,000 23 200,000—400,000 0 Over 400,000 3 COLIFORM BACILLUS. Absent in 1 c.c. 6 ,, 0.1 c.c. 28 ,, 0.01 c.c. 17 ,, ,, 0.001 c.c. 8 ,, ,, 0.0001 c.c. 3 59 No samples of graded milk were taken under the special instructions of the Ministry of Health, but two samples of " Tuberculin Tested " milk were submitted, one of which did not conform to the prescribed standard as judged by the methylene blue test. The second sample, which was a repeat sample, proved satisfactory. During the year the Council granted the following licences to sell milk under the Milk (Special Designations) Order, 1936:— Ordinary. Supplementary. " Tuberculin Tested " 9 8 "Accredited" 2 1 " Pasteurised " 10 5 ICE CREAM. During the year 20 samples of ice-cream were taken with the following results :— Sample. No. of Bacteria 1 c.c. on ager at 37° 6. in 48 hours. Coliform Bacilli. Present in Absent in 1. 39,600 .1 c.c. .01 c.c. 2. 9,900,000.. .001 c.c. — 3. 2,100 yJp. .1 c.c. 4. 66,000 — .1 c.c. 5. 330,000 — .1 c.c. 6. 4,686,000 — .1 c.c. 7 2,376,000 (repeat of No. 2) .01 c.c. .001 c.c. 8 448,000 .0001 c.c. — 9. 19,200 — .1 c.c. 10. 5,400 (repeat of No. 5) — .1 c.c. 11. 496,000 (repeat of No. 6) .1 c.c. .01 c.c. 12. 54,330 (repeat of No. 8) — .1 c.c. 13. 72,330 — .1 c.c. 14. 605,000 .01 c.c. —- 15. 725,000 (repeat of No. 11) .001 c.c. — 16. 194,000 .01 c.c. — 17. 2,200 (repeat of No. 14) — .1 c.c. 18. 19,000 (repeat of No. 12) .01 c.c. — 19. 1,848,000 (repeat of No. 15) .001 c.c. —- 20. 3,630,000 (repeat of No. 16) .001 c.c. – The following notes illustrate the procedure adopted, and the degree of success achieved. Sample No. 2.—Letter sent to manufacturer and method of manufacture investigated. Further sample (No. 7) taken later showed considerable improvement, but was not satisfactory.. The producer thereupon discontinued its manufacture. Sample No. 5.—Manufacturer notified of the result of this sample and the method of manufacture examined. A further sample (No. 10) was satisfactory. 60 Sample No. 6.—The report of this sample was forwarded to the manufacturer and investigation made into his method of production. A further sample (No. 11) was taken and showed marked improvement, which unfortunately was not maintained, as shown in the third and fourth samples (Nos. 15 and 19). Sample No. 8.—The producers were informed of this result and a special visit made regarding the process of manufacture. A repeat sample (No. 12) was taken later and the result was satisfactory, which result was maintained as shown in a later sample (No. 18). Sample No. 14.—The result of the sample was communicated to the producer and the repeat sample (No. 17) was satisfactory. Sample No. 10.—This was. a sample of ice-cream produced outside the district and retailed from street barrows. The report was forwarded to the producer who informed the Department by interview and by letter that steps were being taken to discover the cause of the trouble. A further sample (No. 20) was taken later, but was still unsatisfactory. The results of this sample were forwarded to the producer and to the Local Authority in whose district the ice-cream was manufactured. Owing to the lateness of the season, no further sample was taken. It should be explained that attention was concentrated during the year on local producers, the examination of the products of the larger firms having proved satisfactory in previous years.. It will be noted that the ice cream from 5 producers was reasonably satisfactory, and that the action taken by the Department resulted in an improvement in 3 cases, while one producer ceased to manufacture ice cream. In 2 cases no improvement was noted during the year. It is hoped that powers obtained under the Coulsdon and Purley Urban District Council Act, 1937, will strengthen the Council's position in its endeavour to improve the standard of this product locally, but unfortunately there are loopholes in the Act, e.g., the exclusion of clubs, hotels and restaurants, which will tend to limit its effectiveness. MEAT. The carcases of animals slaughtered in the licensed slaughter houses of the district are inspected before being placed on the market. 61 Ante-mortem inspection is made as frequently as circumstances permit, but the animals do not usually remain in lairage for more than a few minutes as killing commences immediately. The following unsound meat and fish was destroyed during the year :— Meat 339¼ lbs. Fish 41¼ lbs. Total 380½ lbs. The following table shows the number of animals killed and carcases inspected together with details of the parts affected with disease :— Cattle, excluding Cows. Cows. Calves. Sheep and Lambs. Pigs. Number killed — — 44 743 133 Number inspected — — 44 729 133 All Diseases except Tuberculosis :— Whole carcases condemned – – – – – Carcases of which some part or organ was condemned 6 _ Percentage of the number inspected affected with disease other than tuberculosis – – – 82 – Tuberculosis only— Whole carcases condemned 1 – – Carcases of which some part or organ was condemned 3 – 12 Percentage of the number inspected affected with tuberculosis – – 9.0 – 9.0 FOOD AND DRUGS (ADULTERATION) ACT, 1928. The duties under the above named 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 1936, and on the average for the preceding years. This increase is chiefly due to the number of milk samples being rather more than hitherto. 62 Articles. Analysed. Adulterated or Deteriorated. Prosecutions. Convictions . Formal. Informal. Total. Formal. Informal. Total. Milk 50 2 52 5 — 5 1 1 Cream 3 _ 3 - - - - _ Butter 3 _ 3 - - - - _ Cheese - _ - - - - - — Margarine - - - - - - - - Lard - - - - - - - - Meat 2 - 2 - — - — _ Flour - _ - - - _ - _ Tea - _ _ - - _ - . _ Coffee — _ _ - - _ - - Cocoa - _ - - - - Sugar - - - - - - - - Sausages 9 - 9 1 - 1 - - Confectionery and Jam 1 1 2 1 1 2 _ - Sausage Meat - - - - - - - - Wine — — — - — — — — Beer - _ _ - - _ _ _ Spirits - - - - - - - - Drugs - - - - - - - - *Other articles 5 2 7 - - - - - TOTAI.S 73 5 78 7 1 8 i i Details of other articles Figs 1 - 1 - - - - - Natural Lemon Squash I - 1 - - - - - Cream filled Chocolate roll - 1 1 - 1 1 _ _ Ground Almonds 1 1 - - - - - Raisins 1 _ 1 - - - - - Sultanas 1 _ 1 - - - - - Ground Almonds Substitute. . 1 1 - - - - - CHEMICAL 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 :— Messrs. Rideal, Rideal & Sciver. Counties Public Health Laboratories, Queen Victoria Street, E.C.4. Royal Surrey County Hospital, Guildford. ICE CREAM:— Messrs. Rideal, Rideal & Sciver. 63 ADOPTIVE ACTS AND BYELAWS IN FORCE WITHIN THE URBAN DIvSTRICT. ACTS. Public Health Acts Amendment Act, 1890. Parts I, II and II, so far as the provisions thereof have not been repealed. Private Street Works Act, 1892. Public libraries Acts, 1892/1919. Public Health Acts Amendment Act, 1907. Sections 15, 10, 17, 18, 19, 20, 21, 22, 28, 29, 30, 31, 32, and 33 in Part II so far as the provisions thereof have not been repealed. Part IV so far as the provisions thereof have not been repealed. Public Health Act, 1925. Part VI. Section 85 in Part VII. Part II so far as the provisions thereof have not been repealed. The Coulsdon and Purley Urban District Council Act, 1937. BYE-LAWS. Byelaws with respect to Slaughterhouses. Tents, Vans, Sheds and Similar Structures. Houses let in Lodgings. Ventilation of buildings. Elevations of Buildings. New Streets and Buildings. Nuisances. Registries for Female Domestic Servants. Pleasure Grounds. Alderstead Heath. Little Farleigh Green. Great Farleigh Green. 64 TABLE I.—CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1937. Disease. Number of Cases Notified. Total Cases notified in each Ward. Total Cases removed to Hospital. Deaths. At all Ages. At Ages—Years. Coulsdon East. Coulsdon West. Kenley. Purley. 1 Sanderstead. Selsdon and Farleigh. Woodcote. Under X 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 3nd under 20. 20 and under 35. 35 and under 45. 45 and under 65. 65 and over. Scarlet Fever 62 2 3 1 4 19 9 6 12 5 1 — 7 21 3 12 13 1 5 50 — Diphtheria 8 _ 1 1 - - 3 3 _ _ - _ — 1 1 1 1 2 2 - 8 — Enteric Fever 26 _ — _ _ _ 5 5 3 6 2 3 2 2 2 _ 2 14 3 3 15 3 Erysipelas 14 — — — — — 1 _ _ 1 2 7 3 2 8 1 _ 1 1 1 2 _ Pneumonia 30 — — — — — — 3 _ 5 4 11 7 16 6 — 1 6 _ 1 _ *16 Puerperal Fever. . 5 - - - - - — _ - 4 - 1 - 1 3 1 _ - - - 5 1 Puerperal Pyrexia 2 _ — _ _ _ _ _ _ 2 _ _ _ _ 1 1 - _ _ 1 _ Ophthalmia Neonatorum 1 1 — — — — — — — — — — — — — — — 1 — — — — Polio-encephalitis 2 — — — — — — — — 1 1 — _ - 1 - - 1 - - 2 2 Polio-myelitis 3 — - 1 1 - _ 1 - _ - _ - - 2 1 _ - _ — 3 _ Dysentery 1 1 — — — — — — — — — — — — — — — 1 — — 1 - Totals 154 2 3 5 2 4 28 21 9 31 14 23 12 29 45 7 17 39 7 10 87 22 * All forms. 65 TABLE II.—THE MONTHLY INCIDENCE OF INFECTIOUS DISEASE. Disease. Jan. Feb. March. April. May. J une July. August. Sept. Oct. Nov. Dec. Total. Scarlet Fever 8 4 6 7 4 6 3 3 5 1 11 4 62 Diphtheria - - - - - 1 _ 2 1 - 4 - 8 Enteric Fever - 1 - - - _ - 2 _ _ 18 5 26 Erysipelas 5 2 3 2 - - - - - - 1 1 14 Pneumonia 17 8 — 2 _ - 1 1 _ _ 1 _ 30 Puerperal Fever - 2 - 1 - 2 _ - _ — _ – 5 Puerperal Pyrexia — — - - - 1 - - _ 1 — – 2 Polio-encephalitis - - - 1 - - 1 - - - - - 2 Polio-myelitis – — - - - - - 2 1 — — - 3 Ophthalmia – – – – – - – – – – – – – Neonatorum - - - 1 - - - - _ _ - - 1 Dysentery - - - - - – – - - - 1 - 1 Totai.s 30 17 9 14 4 10 5 10 7 2 36 10 154 60 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 1937 Small Pox _ _ – _ _ _ _ _ _ – – _ _ 2 2 3 4 _ – _ _ _ Scarlet Fever 16 20 10 55 129 136 59 40 58 48 74 94 125 69 45 29 69 119 124 117 62 Diphtheria 38 17 4 26 44 62 .70 27 101 14 17 11 23 26 17 8 21 16 24 52 35 8 Erysipelas 11 12 8 12 5 8 9 2 12 10 4 13 8 3 11 8 11 23 17 11 12 14 Typhoid & Para typhoid Fever 7 18 73 31 15 5 16 11 5 24 9 9 9 6 4 4 7 5 5 1 3 26 Cerebro-spinalFever – 3 1 - - 1 - - - — - - - 1 - - - - - 1 1 — Puerperal Fever 2 1 1 - - 2 - - - - 1 - – 1 - 1 1 - 1 1 1 5 Puerperal Pyrexia - - - - - - - - - - - – 1 1 1 3 5 1 2 1 - 2 Poliomyelitis 1 — - 1 1 - 1 - 1 - - 1 1 - 1 - 2 - 1 1 - 3 Polio-encephalitis – – – – – – – – – – – – – – – – – – – – – 2 Encephalitis Lethargica - - — - 1 1 1 1 1 1 — 1 1 - - - 1 - - - — — Ophthalmia Neonatorum 2 1 1 — 1 — — 1 — — 12 — 3 — 1 1 2 — 1 — 1 1 Pneumonia — — - 18 8 9 21 6 16 11 - 9 7 38 11 14 29 28 20 32 13 30 Malaria - - _ 5 - - - - - - - - - _ _ _ - _ - - - - Measles 151 468 33 12 – – – – – – – – – – – – – – – – – – Dysentery - - - 4 7 7 7 17 - - 1 - - 5 - - - - - 6 - 1 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 36 Other Forms 2 4 2 2 2 3 5 3 6 5 2 9 4 2 7 4 6 10 17 5 3 7 Totals 255 561 158 194 237 246 218 129 235 114 113 153 174 232 162 135 154 196 235 265 213 197 67 TABLE IV —DEATHS OCCURRING DURING THE YEAR 1937. 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. 3 - 3 _ — — _ — 2 _ 1 Measles — — — - — — — — — — — Scarlet Fever – – – – – – – – – – - Whooping Ccugh. – – – – – – – – – – – Diphtheria - - - - - — - - - - - Influenza 10 10 20 — — — — 2 2 4 12 Encephalitis Lethargica 1 1 2 - - - - - - 1 1 Cerebro-spinal Fever - - - - — - - - - - - Respiratory Tuberculosis 14 7 21 - - - - 6 8 4 3 Other Tuberculous Diseases 1 1 2 - - 1 — - - - 1 Syphilis 1 2 3 - - - - - 2 1 - General Paralysis of Insane,etc. 1 - 1 – – – – – – – 1 Cancer 34 53 87 — - - — 1 11 31 44 Diabetes 3 4 7 - - - _ - 1 2 4 Cerebral Haemorrhage G 11 17 – – – – – – 5 12 Heart Disease 49 58 107 - 1 - 1 - 4 22 79 Aneurysm - i - - - - - - - - - - Other Circulatory Diseases 9 16 25 - - - - - 3 5 17 Bronchitis 4 8 12 1 - - - - - 2 9 Pneumonia 10 6 16 3 - - 1 - - 6 6 Other respiratory Diseases 2 1 3 – – – – – – 1 2 Peptic Ulcer 5 3 8 - - - - - - 3 5 Diarrhoea, etc. (under 2 years) 1 2 3 3 - - - - - — - Appendicitis 3 3 6 - - - 2 - 2 - 2 Cirrhosis of Liver 2 - 2 - - - - - - 1 1 Other Diseases of the Liver _ 2 2 - - - - - - 1 1 Other Digestive Diseases 3 7 10 - - - - - - 3 7 Nephritis 4 5 9 - - - - - 2 4 3 Puerperal sepsis - 1 1 - - - - - 1 - - Other Puerperal Causes - 1 1 - - - - — 1 - - Congenital Debility) etc. 11 5 16 16 – – – – – – – Senility 5 3 8 – – – – – – — 8 Suicide 5 3 8 - — — — 1 1 5 1 Other Violence 18 7 25 1 1 2 1 3 8 5 4 Other Defined Causes 18 15 33 — - - 2 2 3 6 20 Causes Ill-defined or unknown - - - - - - - - - - Totals 223 235 458 24 2 3 7 15 51 112 244 68 TABLE V.—WANDLE VALLEY JOINT HOSPITAL BOARD. Cases admitted to the Hospital during Year ended 31st December, 1937. Disease. Beddington and Wallington. Coulsdon and Purley. Merton and Morden. Mitcham. cases deaths cases deaths cases deaths cases deaths Diphtheria 4 - 8 - 28 4 98 2 Scarlet Fever 59 - 50 - 115 - 181 - Enteric Fever 1 - 13 1 1 1 - - Erysipelas 1 - 2 - 1 - 8 - Tonsillitis 1 - 5 - 2 - 7 - Measles 2 - 1 - 3 _ 3 - Whooping Cough 1 - - - 3 - 6 - Rubella - – 1 - 2 - 5 - Other Diseases. Influenza _ — - - _ _ 1 - Impetigo - - - - 2 - 1 - Cerebro-spinal Meningitis - - - - 1 1 — - Pneumonia — — — - - _ 2 - Meningitis—Tubercular - - - - - - 1 1 Mumps - - 2 - 2 - 2 - Furunculosis with Anaemia - - 1 - - — - - Puerperal Fever - - 1 - - - - - Nephritis 1 - - - — - — - liver Abcess from Amoebic Dysentery – – – – – – 1 1 Rhinitis and Bronchitis _ _ _ _ _ _ 5 Adenitis _ _ _ _ 1 _ 1 - Cellulitis of Ankle _ _ _ _ 1 _ _ _ Otitis Media _ _ _ _ 1 _ 1 _ Chicken Pox _ _ _ _ 3 _ 1 _ Poliomyelitis - - 2 - 1 _ 1 - Septic Burn of Foot _ - _ _ - - 1 - Septicaemia - - - - - - 1 - Totals 70 - 86 1 167 6 327 4 INDEX. Page Ambulances 29, 30 Analysis of Mortality 10 Ante-natal Clinics 32 Area 4, 8 Bacteriological Work 31 Bakehouses 58 Bed Bugs, Eradication of 54 Birth Control 36 Birth Rates 4, 9 Births, Live, Illegitimate and Still 4, 9 Cancer 11 Causes of Deaths 10, 68 Chicken Pox 26 Child Life Protection 42 Clinics : Ante-natal 32 Birth Control 36 Diphtheria Immunisation 25 Infant Welfare 38 Post-natal 34 School 56 Tuberculosis 29 Closet Accommodation 48 Control of Infectious Disease 24 Dairies and Cowsheds 57 Day Nurseries 42 Deaths and Death Rates 4, 10 Dental Treatment 41 Diarrhoea and Enteritis 23 Diphtheria 17 Diphtheria Immunisation 24 Disinfection 31 Drainage and Sewerage 49 Dysentery 23 Enteric Fever 18,21 Erysipelas 22 Factories and Workshops 34, 35 Food and Drugs Act 62 Food Supply : Milk 59, 60 Meat 61, 62 Food Preparing Places 58 Health Visitation 36 Health Visitors, Visits by 37 Health Propaganda 31 Heart Disease, etc 11 Home Helps 36 Hospitals 30 Houses, Inspection of 44, 45 Houses, Inhabited 4 Housing 43 Housing Statistics 44, 45 Ice Cream 60 Immunisation 21 Infantile Mortality 14 Infant Life Protection 42 Infectious Disease : Cases notified 16,17,65,67 Monthly Incidence of 66 Control of 24, 56 School Notifications 26 Inspection and Supervision of Food 59 Page Laboratory Facilities 31, 63 Legal Proceedings 56 Maternal Mortality 14 Maternity Cases 35 Maternity and Child Welfare : Services 32 Committee 3 Hospital Accommodation 30 Measles 26 Meat 61 Midwives 36 Milk, Provision of 41 Milk (Special Designations) Order 60 Milk, Sampling of 59 Mortality : Analysis of 10 Infant 14 Maternal 14 Mumps 26 Non-notifiable Infectious Disease 26 Obstetric Specialists 3, 35 Ophthalmia Neonatorum 22 Orthopaedic Treatment 41 Paratyphoid Fever 21 Pneumonia 23 Polio-myelitis and Polio-encephalitis 23 Population 4, 8 Post-natal Clinic 34 Public Cleansing 49 Public Health Committee 3 Puerperal Fever 22 Puerperal Pyrexia 22 Rainfall 48 Rateable Value 4 Rats and Mice Destruction 55 Rivers and Streams 49 Sanitary Inspections, etc. 50 Scarlet Fever 21 Schools 55 School Clinics 56 Sewerage 49 Shops Acts 50 Slaughterhouses 57, 61 Small Pox 16 Smoke Abatement 49 Social Conditions 4, 8 Staff 3 Statistics : Housing 44 Vital 4 Still Births 4, 9 Swimming Baths 50 Tuberculosis 27 Tuberculosis Care Committee 29 Typhoid Fever 18 Violence, Deaths from 13 Vital Statistics 4 Wandle Valley Isolation Plospital 30, 69 Water Supply 46 Whooping Cough 26 Workshops and Factories 58