spare copy LIBRARY Cou 6 HEALTH REPORT FOR 1938 FOR THE COULSDON AND PURLEY URBAN DISTRICT BY THE MEDICAL OFFICER OF HEALTH REDHILL: S. C. Jennings & Sons, Ltd., PRINTERS HEALTH REPORT FOR 1938 FOR THE COULSDON AND PURLEY URBAN DISTRICT BY THE MEDICAL OFFICER OF HEALTH REDHILL: S. C. Jennings & Sons, Ltd., Printers, URBAN DISTRICT COUNCIL OF COULSDON AND PURLEY Public Health Committee. Chairman : Councillor T. A. Harrison. Councillor Mrs. Bartleet. Councillor W. H. Glanville. „ Mrs. Bluett. „ F. Jobbins. „ Mrs. Ransome, M.A. „ A. L. Mitchell. „ J.I. Conway. „ J. H. Morton, J.P. „ H. J. Deacon, A.C.G.I., „ J. H. Nelson. B.Sc., A.M.I.Mech.E. ,, H. A. Ross. M.W.M.A. „ W. J. Tille. Maternity and Child Welfare Committee. Councillor Mrs. bartleet. Mrs. R. J. Everitt. Mrs. D. Pascall. „ Mrs. bluett. Mrs. E. B. Farrow. Mrs. M. J. Read. Mrs. Ransome, M.A. Mrs. W. H. Finn. Mrs. J. Saunders. Mrs. M. G. Adams. Mrs. H. K. Freeman. Mrs. W. F. Stower. Mrs. E. G. Beard. Mrs. G. E. Gray. Mrs. D. E. Tierney. Mrs. L. B. Clark. Dr. M. Marsh. Mrs. D. Williams. Mrs. E. Davie. Representatives on the Wandle Valley Joint Hospital Board. Councillor S. B. Gillespie. Councillor F. G. L. Moir, M.M.I. Struct. E., „ F. Jobbins. I. Mar. E. „ J. H. Morton, J.P. Representatives on the Purley War Memorial Hospital Committee. Councillor Mrs. Ransome, M.A. Councillor W. J. Tiller. Representative on the Purley and District Day Nursery. Councillor Mrs. Bluett. Representative on the Coulsdon and District Day Nursery. Councillor Mrs. Bartleet. STAFF: Medical Officer of Health: F. R. Edbrooke, M.B., Ch.B., D.P.H. * Medical Officer of Ante-natal and Post-natal Clinics: Winifred M. Small, M.B., Ch.B. * Assistant Medical Officers for Child Welfare Centres: 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. J. Richardson. * Part-time Officials. 3 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area(in acres) 11,182 Registrar-General's estimate of population, 1938 55,070 Population, Census 1931 37,666 Number of occupied houses, December, 1938 15,431 Number of occupied houses, 1931 9,533 Rateable Value, December, 1938 £711,957 Sum represented by a penny rate £2,860 VITAL STATISTICS. Total. M. F. Birth Rate per 1,000 of the estimated resident population. Live Births—Legitimate 718 351 367 do. —Illegitimate 20 11 9 13.4 738 362 376 Rate per 1,000 (live and still) births. Still Births—Legitimate 21 14 7 27.7 Death Rate per 1,000 of the estimated resident population. Deaths 434 222 212 7.9 Rate per 1,000 (live and still) births. Deaths from Puerperal causes:— . Puerperal Sepsis - — Other Puerperal causes 1 1.32 Death Rates of Infants under one year of age:— All infants per 1,000 live births 51 Legitimate infants per 1,000 legitimate births 46 Illegitimate infants per 1,000 illegitimate births 250 Deaths from Cancer (all ages) 63 Deaths from Measles (all ages) 1 Deaths from Whooping Cough (all ages) Nil Deaths from Diarrhoea (under 2 years) 4 4 URBAN DISTRICT COUNCIL OF COULSDON AND PURLEY. HEALTH REPORT FOR 1938. Ladies and Gentlemen, I beg to present to you my Annual Report for 1938, this being my seventh 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 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 fifth year in succession, while the Death Rate decreased, as also the Maternal Mortality Rate. The incidence of Infectious Disease was the lowest the District has experienced, although the number of cases of scarlet fever increased slightly. Very few cases of diphtheria occurred for the second year in succession, a condition which appears likely to continue throughout 1939. Residents should not, however, be lulled into a false sense of security for about 3,000 deaths occur annually in England and Wales as a result of this disease. Locally waves of diphtheria have occurred with the crests of the waves at varying intervals of from 2 to 6 years. Never previously has such a low trough been experienced for so long a period, hence it is more than likely that there will be an increased number of cases in the relatively near future, especially with the rapid movements of population now taking place. All parents would be well advised to consider the desirability of immunisation for their children, which treatment is offered free of cost to those under 5 years of age, while the charge for those over 5 years is only 5s. 0d. for the full course, this being barely the cost of the serum. The only Rate which did not exhibit a satisfactory trend in 1938 was the Infantile Mortality Rate, which, although slightly below that of the Country as a whole, was the highest experienced in this District. This Rate is, however, liable to marked fluctuations owing to the small numbers involved, hence it is hoped that 1939 will show a definite improvement. The chief causes to which deaths were attributed were prematurity and congenital defects, but as the vast majority of these deaths occurred outside the Urban District, full investigation was difficult, particularly as notification of the deaths are often not transferred to this District until after a lapse of several months. 5 In spite of the interruption of the work of the Department in the Autumn of 1938, this year will stand out as one of great activity in matters relating to the Public Health. In January the Typhoid Inquiry was still being held in the adjoining County Borough, and as a result increased attention was focussed locally on the water supplies, drainage, and on improving the distribution of information on the presence of Infectious Disease. In addition, during the first three months the Surrey County Council and National Health Campaigns were being continued. Further improvements in the Maternity and Child Welfare Service were also decided upon, e.g., the provision of convalescent treatment, of dentures at reduced charges, and of better arrangements for dealing with eye defects. Provision was made for the use of an Emergency Unit for the District and for the establishment of Toddler's Clinics. Special Sub-Committees were involved in formulating plans for better laboratory facilities, in considering the system of payment for maternity treatment at Purley Hospital and similar Institutions, in dealing with one of the private water supplies in the District, and in considering with representatives of the general medical practitioners of the District how the latter could collaborate in improving further the health of the public. Each of these developments has involved an increase in the duties and responsibilities of the Department, which, however, are not limited to those enumerated above or mentioned otherwise in this Report. The medical examination of a changing staff and those employees entering the Superannuation Scheme, together with assisting in the preparation of the Petition for Incorporation and the giving of evidence at the subsequent Inquiry are typical of the various forms of additional work falling upon the Department. Phenomenal progress was made during the crisis of September, 1938, towards establishing a First Aid Service in this District by great exertions on the part of all concerned. Unfortunately the plans then formulated had to be discarded and revised during subsequent months, involving many meetings, extensive correspondence, etc. Moreover, the Home Office having placed upon the Medical Officer of Health the responsibility for enrolment, allocation and training of all first aid volunteers, the majority of his time during the closing months of the year was given to this and similar subjects. No less than 28 courses of training in First Aid, Home Nursing and Antigas measures were organised and held before the end of the year. The story of 1939 will need to record an even greater intensification of effort towards the establishment of the First Aid Service as a result of which, and with great regret, the issue of this Report has been so retarded. It is very satisfactory, however, to be able to record that in 6 spite of these varying demands the Public Health work of the Council extended steadily throughout the year under consideration. In so doing, it is with pleasure that I would record also 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. 7 HEALTH REPORT FOR 1938. 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 Green Belt Scheme, which was inaugurated in 1937, has assisted in the preservation of the rural portions, approximately one-fifth of the Urban District being now reserved as permanent open spaces. No large manufacturing concerns exist, the chief occupations being building, and the retailing of the necessities of life to the residents. Unemployment is comparatively low, and, in fact a steady influx of labour from more distressed areas has taken place. AREA AND POPULATION. The District has an area of 11,182 acres, this being 2,547 more than before the last, revision of boundaries in 1933. The acreage of each Ward is:— Coulsdon East 2,812 Coulsdon West 1,253 Kenley 1,292 Purley 685 Sanderstead 2,312 Selsdon and Farleigh 1,963 Woodcote 865 Twenty-three 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-1938 the Registrar-General estimated the population to be 55,070, representing an increase of 1,150 in the last twelve months. An unique opportunity occurred in September of checking the reliability of the above estimate, and as eight years had elapsed since the last Census it was interesting to determine its accuracy. The issue of gas masks to civilians in the District necessitated a local census being taken from which it was gathered that the population of the District at that time was just under 59,000. It is probable therefore that in mid-1938 the true population was a little more than 58,000. 8 In 1915 there were 4,141 occupied houses, chiefly in Purley and Woodcote, whereas in 1938 there were 15,431 houses, distributed amongst the Wards as follows:— Coulsdon East 1,980 Coulsdon West 2,731 Kenley 1,181 Purley 2,504 Sanderstead 3,793 Selsdon and Farleigh1,631 Woodcote 1,611 There was thus an average of 3.5 persons per occupied house in 1938 as compared with 4.3 in 1915. VITAL STATISTICS. BIRTHS. During the year 738 Births were registered as belonging to the District, of which 362 were males and 376 were females, as compared with 692 in 1937. This is equal to an Annual Birth Rate of 13.4 per thousand of population, as compared with 12.8 last year, and 12.5, 12.2 and 11.8 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 and nationally this proved correct, as increases in the Birth Rate have now been experienced in the District in five successive years, while the Birth Rates for England and Wales have been 15.1 in 1938, 14.9 in 1937, 14.8 in 1936 and 14.7 in 1935. The greater rate of increase locally 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 20 illegitimate births (11 males and 9 females) registered, this being 6 less than the preceding year. Expressed as a percentage of total births, 2.7 were illegitimate. The proportion of illegitimate births showed a marked decline from 1915-1934, the average for the five yearly periods being 5.7, 3.4, 3.7 and 2.8. The number of stillbirths has only been recorded during the last eight years. In 1938 there were 21 registered (14 males and 7 females) this being 6 more than last year. All the stillbirths occurred in legitimate children. The local stillbirth Rate was thus 0.38 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 434, (222 males and 212 females), as compared with 458 in 1937. 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 crude Death Rate for the year was equal to 7.9 per thousand of population, as compared with 8.5 last year, and 8.5, 7.9, 7.6 and 7.1 in the preceding four 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 Death Rate for 1938 thus becomes 7.7 per thousand of population. The crude Death Rates in England and Wales were 11.6 in 1938, 12.4 in 1937, 12.1 in 1936, and 11.7 in 1935. During the first fifteen years of the existence of this Urban Disrtict there was a tendency for the Death Rate to decline, as in the Country as a whole, the average for the three quinquennial periods being 8.5, 7.4 and 7.0. During the five years 1929-34 there was a slight rise to an average of 7.4, followed in the next three years by a steady increase, but this year the rate has declined to 7.9. Of the 434 deaths which occurred in Coulsdon and Purley in 1938, 48 per cent. were over 65 years of age, compared with the average of 53 per cent. for the last five years and 45 per cent. for the five years 1926-30. The principal causes of death, together with the rates per cent, of total deaths, are shown in the following Table:— Cause. Number of Deaths. Rate per cent. of Total Deaths. Bronchitis 3 0.69 Influenza 9 2.07 Tuberculosis of respiratory system 15 3.45 Cancer, malignant disease 63 14.51 Heart Disease 122 28.11 Cerebral Hæmorrhage 15 3.45 Other circulatory diseases 30 6.91 Pneumonia 15 3.45 Violence(including Suicide) 27 6.22 For the full list of causes of deaths, and the ages at which the deaths occurred, see Table IV in the Appendix. 10 It will be seen that the chief causes of death in the District were Heart and other circulatory diseases (including Cerebral Haemorrhage) 167, Cancer 63, followed by Violence (including Suicide) 27, and Respiratory Tuberculosis, Pneumonia and Digestive Diseases each with 15. HEART DISEASE, etc. The percentage of deaths due to heart and other circulatory diseases was rather more than last year, altogether constituting over two-fifths of the total deaths. As has been previously stated, in so far as this group includes deaths in elderly people from what is really old age, it is hoped that the proportion of deaths coming under this heading will increase. This year 72 per cent. were over 65 years of age at the time of death, while 40 per cent. were over 75 years of age, being slightly less than the corresponding figures last year. Of the 28 per cent. which were under 65 years of age, only about 3 per cent. were definitely 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 on the Death Certificate. Once again about a quarter 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 stress been avoided. CANCER. There was a considerable reduction in the number of deaths from cancer during 1938, only 14.5 per cent. of the total deaths being due to this disease as compared with an average of 17.8 for the preceding five years. Considered in relation to population, the Cancer Death Rate was 1.15 per thousand of population in 1938, compared with 1.61 last year and 1.36, 1.28 and 1.49 in the preceding three years, corresponding figures for England and Wales being 1.66 for 1938, 1.63, 1.62, 1.58 and 1.56 Too much should not, however, be deduced from the lower rate experienced locally in 1938. From 1915-24 the average Cancer Death Rate in the District was 1.13 per thousand of population, and 1.26 from 1925-34, the corresponding figures for England and Wales being 1.21 and 1.44. It will thus be seen that on the whole an increasing proportion of deaths is being attributed to this disease. An increasing effort is being made to reduce this too common cause of death, but it would be unwise to suggest that the local decrease signifies anything more than a coincidence at this stage. The following I able gives the age, sex and distribution of the disease in the 63 deaths which occurred during 1938. 11  10-20 20-30 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. #] Jaw - - - - - - - - - - 1 - - - 1 - Tongue - - - - - - - - 1 - - - - - 1 - Larynx - - -. - - - - - 1 - 1 - - - 2 - Oesophagus - - - - - - 1 - - - - - - - 1 - Stomach - - - - - - 1 - 1 - 1 2 - - 3 2 Intestines - - - - - 3 - 3 1 1 2 2 - 2 3 11 Liver - - - - - - - 1 - 2 1 - 1 - 2 3 Pancreas - - - - - - - 1 - - 1 - - - 1 1 Kidney - - - - - - - - - - - - - 1 - 1 Bladder - - - - - - 2 - 1 - - - - - 3 - Prostate - . - - - - - - - 1 - 1 - - - 2 - Lungs - - - - - - - 3 3 - 2 1 - - 5 4 Uterus - - - - - - - 3 - 3 - - - — - 6 Ovary - - - 1 - - - - - 1 - - - - - 2 Breast 1 - - - - - 2 - 3 - 2 - 1 - 9 Totals - 1 - 1 - 3 4 13 9 10 10 7 1 4 24 39 The most marked decreases compared with last year are in deaths from cancer of the stomach and intestines, (19 as compared with 32), otherwise there is very little difference in the corresponding figures. Cancer can very frequently be cured if only recognised early enough and the best treatment available secured. Unfortunately the patient too often delays and does not seek advice until the chance of recovery has been seriously prejudiced. The folly of procrastination should be sufficiently obvious. 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. The symptoms which call for most attention are persistent or repeated pain, bleeding, swelling, early morning diarrhoea, increasing constipation, or difficulty in passing water. As each year about one death in every six or seven from cancer is attributable to cancer of the breast, the necessity for the investigation of any lump in the breast of a woman which does not subside in a very short time must be re-emphasized. VIOLENCE. Deaths from Violence (including Suicide) decreased during 1938, the Death Rate per thousand of population being 0.49 compared with 0.61 last year and 0.55 in England and Wales. In 1938 there were 14 deaths from Violence other than Suicide, as compared with 25 last year. Of the 14 Deaths only 5 were due to road accidents, of which 1 was a pedestrian, 2 were motor car drivers and 2 were motor cyclists. The remaining 9 deaths were due to:—Asphyxia 1, bums 1, run over by train 1, electrocution 1, tree falling upon bus 1, falls 2, and operative shock 2. 12 Deaths from Suicide increased in number, there being 13 as compared with 8, 3, 9 and 6 in the preceding four years. The Death Rate from this cause was thus 23 per 100,000 of population, as compared with 15 last year and averages of 11 and 12 in the preceding two decades. The comparable figure for England and Wales was 12, the proportion of males to females being both nationally and locally about 2 male to 1 female death from this causel. TUBERCULOSIS AND PNEUMONIA. Deaths from tuberculosis and pneumonia are referred to in other sections of the Report. MATERNAL MORTALITY. There was 1 death associated with childbirth during 1938, the Maternal Mortality Rate being 1.31 per thousand total births as compared with 2.97 for England and Wales. Both rates have fallen this year, the corresponding figures for 1937 being 2.83 locally and 3.11 nationally. The death which occurred locally was due to a pulmonary embolism following parturition. Arrangements for the confinement had been made privately. 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. INFANTILE MORTALITY. The number of deaths occurring in children under one year of age was 38, as compared with 24 last year, and 20, 19 and 14 in the preceding three years. Five of the deaths were in illegitimate children. The Infantile Mortality Rate was thus 51 per thousand registered births, which is the highest experienced in this District. Last year it was 35, while in the three preceding years it was 33, 32 and 26. 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. The fact that the Rate was so high in 1938 necessitates further consideration to ascertain whether other factors require to be noted. The Infantile Mortality Rate for England and Wales in 1938 was the lowest experienced to date, viz., 53, compared with 58, 59, 57 and 59 for the four preceding years. The average Rates for 1915-24 and 1924—35 were approximately 83 and 67. The cause of death in the 38 infants under one year of age who died in 1938 is shown in the following Table:— 13 Infantile Mortality during the Year 1938. Under I 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. Influenza - - - - - - - 1 - 1 Broncho- Pneumonia - - 2 - 2 - _ - 1 3 Gastro Enteritis - - - - - 2 - - 1 4 Infective Endocarditis - - - - 1 - - - 1 Meningitis - - - - - - - - 1 1 Asphyxia - - - - - - - 1 - 1 Laryngismus - — - - - 1 - — — 1 Birth injury 1 — - - 1 - - — — 1 Post natal Haemorrhage 1 - - - 1 - - - - 1 Dysentery - - - — - - 1 - - 1 Congenital malformation 3 1 - - 4 2 - - 1 7 Marasmus, atrophy, debility - 1 - - 2 2 - - - 4 Intussusception - - - - - - - 1 - - Premature Birth 11 - - - 11 - - - - 11 Totals 16 2 3 - 21 8 2 3 4 38 • The neo-natal mortality rate (i.e., deaths in the first month per thousand live births) was 27, which is only 2 more than last year. The increase in infantile mortality this year was thus greater proportionately in children who had lived for more than one month. 14 The commonest factor directly or indirectly contributing to the deaths of children under one year of age was "prematurity," this being the primary cause in 11 cases under four weeks, (all of which died outside the District), and the secondary cause in 1 case under and 2 cases over 4 weeks (only 1 of which died in this District). Investigations of this type of death require to be made primarily at the house in which the birth occurred. This is made difficult locally by the high proportion of these deaths occurring outside the District. A further factor which increases the difficulty of investigation in these cases is the considerable time which often elapses before the registration of the death is transferred into this District, and the local Department becomes aware of the death, thus in 1938, no less than 31 of the 38 deaths occurred outside the District, viz., 8 in London Hospitals, 7 at Redhill, 7 in Purley Hospital and 9 in other Croydon Institutions. While congenital malformations are the next commonest cause of death (7 cases in 1938, 3 being over four weeks of age), in the present stage of our knowledge these deaths are usually not preventable. Chief hope of prevention lies in the infectious group of disease, e.g. influenza, broncho-pneumonia, gastric-enteritis, etc., and the importance of protecting young infants from contact with what are often regarded as mild infections, such as the common cold, is constantly emphasized. 15 COMPARATIVE CRUDE BIRTH-RATES, DEATH-RATES, ANALYSIS OF MORTALITY, MATERNAL DEATH-RATES, AND CASE-RATES for certain Infectious Diseases in the year 1938. England and Wales. 126 County Boroughs and Great Towns including London. Rates per 148 Smaller Towns (Resident Populations 25,000 to 50,000 at 1931 Census). 1,000 Population London Administrative County. Coulsdon and Purley Urban District. Births:— Live 15.1 15.0 15.4 13.4 13.4 Still 0.60 0.65 0.60 0.48 0.38 Deaths:— All Causes 11.6 11.7 11.0 11.4 7.9 Typhoid and Paratyphoid fevers 0.00 0.00 0.00 0.00 0.00 Smallpox 0.00 - 0.00 - - Measles 0.04 0.05 0.03 0.06 0.02 Scarlet fever 0.01 0.01 0.01 0.01 0.00 Whooping Cough 0.03 0.03 0.02 0.03 0.00 Diphtheria 0.07 0.07 0.06 0.05 0.00 Influenza 0.11 0.10 0.11 0.06 0.16 Notifications:— Smallpox 0.00 0.00 0.00 - - Scarlet Fever 2.41 2.60 2.58 2.05 1.28 Diphtheria 1.58 1.85 1.53 1.90 0.18 Enteric Fever 0.03 0.03 0.04 0.05 0.09 Erysipelas 0.40 0.46 0.39 0.46 0.23 Pneumonia 1.10 1.28 0.98 0.98 0.21 Rates per 1,000 Live Births. Deaths under 1 yr. of age 53 57 51 57 51 Deaths from Diarrhoea and Enteritis under 2 years of age 5.5 7.8 3.6 13.1 5.42 Maternal Mortality: Puerperal Sepsis 0.89 Not available 0.00 Others 2.19 1.35 Total 3.08 1.35 Rates per 1,000 Total Births (i.e., Live and Still). Maternal Mortality: Puerperal Sepsis 0.86 Not available — Others 2.11 0.32 Total 2.97 0.32 Notifications Puerperal Fever 14.42 18.08 12.51 3.53 6.59 Puerperal Pyrexia 15.46 INFECTIOUS DISEASE. The year 1938 compared very favourably with preceding years from the point of view of notifiable Infectious Disease, with a total of only 120 notified cases, other than tuberculosis, compared with 154, 183 and 230 in the three preceding years. This number represents the lowest number of notifications since 1932, and when the increasing population is taken into consideration, it will be found that the incidence of Infectious Disease was the lowest the District has ever experienced. 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, falling to 3.6 and 2.8 in the following years, while in 1938 it was less than 2.1, representing a very marked reduction. 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 71 59 - Diphtheria 10 10 - Enteric Fever 5 1 - Erysipelas 13 1 - Puerperal Pyrexia 5 5 - Ophthalmia Neonatorum 1 1 - Pneumonia 12 - *15 Dysentery 2 — — Acute Poliomyelitis 1 1 - Totals 120 78 15 * 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. 17 DIPHTHERIA. The incidence of this disease remained at a very low level throughout 1938, following a wave which lasted from the Autumn of 1934 until the early summer of 1936. Only 10 cases were notified during the year compared with 8, 35, 52 and 52 in the preceding four years. This number represents one of the lowest incidences experienced in the District since its constitution in 1915, bearing in the mind the increasing population. Of the 10 cases, three were in adults, two of whom probably contracted the disease whilst working in London, and the other while a patient in a hospital outside the District. One of the juvenile cases followed the visit to the home of a convalescent diphtheria case, while four children who developed the disease within a few days of each other, attended the same school. Only one of the 10 cases had obtained any form of immunisation treatment, and this case had only received two injections without being tested afterwards to ascertain their efficacy. The onset of the disease within a year of treatment proved that in this case insufficient immunity had developed. No deaths from this disease occurred during the year. It is probable that the small number of cases for two years in succession should not be attributed to the practice of diphtheria immunisation in the Urban District. While a number of children have 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 locally. Inspection of Table III at the end of the Report will reveal that waves of diphtheria have been experienced locally in 1921-22, 1924, a slight one in 1929, and again in 1934-36. At present a trough, similar to those intervening between the previous waves, is being passed through, and while this may last 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. Three cases of typhoid fever were notified, two of which occurred amongst the inmates of one of the Mental Hospitals. In the remaining case the infection was thought to have been contracted through eating 18 oysters. The origin of the oysters was traced, but it was found that during this period the oysters were bacteriologically examined and reported upon as being satisfactory. As from time to time oysters give rise to suspicion when investigating sporadic cases of typhoid such as this and it is extremely difficult to definitely fix the responsibility for the origin of the disease, it is desirable that all oysters should be thoroughly cleansed, as they can be, before sale. As in the case of other articles of food it is for the members of the public to demand the hygienic standard they desire. PARA-TYPHOID FEVER. Two unconnected cases of paratyphoid fever were notified, one being an inmate of one of the Mental Hospitals in the District. The other case was removed to hospital. Both cases recovered. The source of infection could not be traced in either case. SCARLET FEVER. The hope expressed in the last Report that after three years of increased incidence, with 119, 124 and 117 cases in the years 1934-36, the fall to 62 cases in 1937 would prelude a further reduction in incidence was not completely realised. Waves of this disease have occurred at intervals of about seven years, and it was hoped that lower figures would be recorded during the next few years. As, however, the rise to 71 cases in 1938 was only slight, a reduction or at least a stabilisation at about this figure in the next few years may be expected. As in 1934 and 1936, Coulsdon West was the Ward most affected. ERYSIPELAS. There were 13 notifications of erysipelas during the year as compared with 14, 12 and 11 in the last three years. Of these 3 were patients in the Mental Hospitals, the remaining 10 being unconnected cases scattered over the District. One case only was admitted to hospital. No deaths occurred. PUERPERAL PYREXIA. Five cases were notified as compared with 7 last year. Four of the cases were admitted to Queen Charlotte's Hospital and 1 to the Wandle Valley Joint Hospital. All the cases recovered. OPHTHALMIA NEONATORUM. Only 1 case was notified and was removed to St. Margaret's Hospital. The child recovered without impairment of vision. 19 ACUTE POLIOMYELITIS. Only 1 case of poliomyelitis occurred in the District. It was removed to the Isolation Hospital and subsequently to an Orthopaedic Hospital for the treatment of the resulting paralysis. PNEUMONIA. There were 12 notifications of acute primary or influenzal pneumonia during the year as compared with 30, 13 and 32 in the past three years. Seven of the cases were inmates of the Mental Hospitals. No cases were removed to the Isolation Hospital. The number of deaths registered as occurring from all forms of Pneumonia was 15 as compared with 16 in the previous year. DYSENTERY. Two cases of Dysentery were notified, both of which were inmates of one of the Mental Hospitals. In addition the death occurred at the County Hospital, Redhill, of a baby under 1 year of age from bacillary dysentery. 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 courses of infection. One of the measures in which most hope for the future lies is artificial immunisation. Unfortuntaely in a number of diseases the immunising agent has yet to be discovered ; in others the number of different strains of the causae 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 20 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. The Council has established two Immunisation Clinics, which commenced activity in April, 1937. These Clinics are held at 69, Brighton Road, Purley, and at the Baptist Church, Addington Road, Selsdon. At the present time the facilities are limited to inoculation for the prevention of diphtheria. Arrangements are, however, in force for immunisation against measles, whooping cough or scarlet fever whereby persons may for special reasons be referred to the Centre at Great Ormond Street Hospital by the Medical Officer of Health. No applications were received during the year for cases wishing to avail themselves of these arrangements. No attempts have been made to persuade persons to have then children immunised, other than 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 for 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. Od. is made, which covers the cost of materials if a sufficient number of children can be treated at a time. A charge of 12/6d. per course for children not resident in the Urban District was decided upon in November, 1938. The only prophylactic used has been Toxoid-Antitoxin Floccules (T.A.F.), which has the great advantage, not only of producing a high degree of immunity with a low relapse rate, but the minimum of reaction in the recipient. None of the cases treated to date have complained of anything which could be associated with the injection more severe 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. 21 The following Table shows the numbers treated during the year 1938:— Number of sessions 48 Number subjected to primary Schick Test 19 Number found positive 18 Number found negative 1 Number who received or completed the full course of treatment during 1938 53 Under 5 years 30 Over 5 years 23 Number tested in 1938 by the Schick Test after receiving treatment 67 Number found negative 64 Number found positive 3 Number awaiting final Schick Test on 31st December, 1938 22 Total number treated or tested during the year 95 It may be noticed that of the 19 cases subjected to the primary Schick Test only 1 was found negative. It is considered, however, that the numbers so far tested are too small to justify the abandonment of the primary test in children over 5 years of age. Of the 3 children who were positive after treatment, one became negative after six months, and one who was still slightly positive after six months has not returned for a further test. The remaining case was very interesting, having received the "one shot" treatment twenty-one months before attending the Clinic. Being Schick positive he received two doses of T.A.F. only, but still being positive six months after the second dose, a third injection was given. He was fairitH' positive four months later, but negative after a further five months had elapsed. Of the children treated only 3 failed to return for the final Schick test having: left the District, but one of these was tested in her new home. The 95 children receiving treatment or tested during the year came from various parts of the District as indicated by the following Table:— Coulsdon East 7 Coulsdon West 16 Purley 15 Kenley 15 Sanderstead 10 Selsdon 31 Out of District 1 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, however, been received since the establishment of the Clinics, nor have applications been made for serum, probably due in part to the fact that very little immunisation has been done in this way. 22 NON-NOTIFIABLE INFECTIOUS DISEASE. The group of non-notifiable Infectious Disease resulted in deaths from measles (1), diarrhoea (4 under 2 years, only 2 of which were probably due to infections), and influenza (9), the latter being less than one-half of the number of deaths from that cause in 1937. Apart from the death returns, the only information as to the presence of outbreaks of non-notifiable Infectious Disease are the returns from the public elementary schools. As judged by these, the incidence of these diseases was as follows:— MEASLES.—A number of cases occurred during the first three months of the year, viz., January, 27, February, 116, and March, 87, the areas most affected being, Chipstead Valley (90), Kenley (57), Old Coulsdon (38), Purley (26) and Sanderstead (16). Only a few cases (17) occurred during the remainder of the year. GERMAN MEASLES.—Very few cases were notified. WHOOPING COUGH.—Nine cases occurred during January and February, 8 of which came from Old Coulsdon; the following three months produced 38 cases, of which 34 occurred in Coulsdon, while during the remainder of the year only 2 cases were notified. MUMPS.—Altogether 187 cases were notified, chiefly during the first seven months of the year, the area chiefly affected being Selsdon with 122 cases, the remainder being scattered throughout the District. CHICKEN POX.—123 cases were notified during the year, of which 48 occurred in Selsdon during March and April, and 53 in Coulsdon during June and July. The remainder of the cases were scattered over the District and throughout the year. 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 4 cases of measles and 1 of rubella 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. Since the beginning of the year the practice of sending a weekly statement of the number of cases of infectious disease to all general practitioners serving the District has been resumed, the statement now including an indication of the Ward in which the disease has occurred, and also including the chief non-notifiable infectious diseases. 23 TUBERCULOSIS. The following Table presents concisely the position with regard to Tuberculosis in this District during 1938:— Pulmonary. NonPulmonary. Total. M. F. M. F. M. F. Number of cases on register, 1st January, 1938 75 81 16 19 91 100 Additions, 1938:— New cases notified 17 15 4 6 21 21 Cases removed into District 6 5 1 3 7 8 Restored to register 2 3 — — 2 3 Total Additions 25 23 5 9 30 32 Removals, 1938:— Deaths 6 9 — — 6 9 Removed from District 6 7 2 1 8 8 Recovered 1 9 1 2 2 11 Non-Tuberculous — — — 1 — 1 Total removed from register 13 25 3 4 16 29 Number on register, 31st Dec., 1938 87 79 18 24 105 103 It will be noted that there were 42 new cases notified during the year as compared with 43 in 1937, and an average of 42 for the four preceding years. The following Table shows the age-groups in which notifications and deaths occurred. Age Periods. New Cases. Deaths. Pulmonary NonPulmonary Pulmonary NonPulmonary M. F. M. F. M. F. M. F. Under 1 year - - - - - - - - 1 and under 5 1 - - - — - - - 5 and under 10 - - 1 2 - — — - 10 and under 15 - 1 - - - - - - 15 and under 20 1 1 1 1 — - - - 20 and under 25 1 - - 1 2 1 - - 25 and under 35 6 7 1 1 2 3 — - 35 and under 45 6 6 - 1 2 2 — 1 45 and under 55 1 - - - - - 1 1 55 and under 65 1 - - - 1 2 - 1 65 and over - - 1 - - - - - Totals 17 15 4 6 7 8 1 3 24 The new cases were distributed amongst the Wards as follows:— Localisation. Coulsdon Bast Coulsdon West Kenley Purley Sanderstead Selsdon and Farleigh Woodcote Pulmonary 5 4 2 3 9 4 5 Non- Pulmonary 1 2 - - 2 3 2 Totals 6 6 2 3 11 7 7 The case rate for new cases of pulmonary tuberculosis notified fell from 65 per 100,000 of population last year to 58 in 1938. (The average case rates for 1915-24 and 1925-34 were 115 and 88 respectively). The non-pulmonary case rate, however, rose from 13 in 1937 to 18 in 1938, the average rates for the two previous decades being 15 and 18. On the other hand, no deaths occurred from non-pulmonary tuberculosis during the year although the average death rates for the quinquennial periods 1915-34 were 20, 9, 7 and 8 per 100,000 of population. The death rate from pulmonary tuberculosis also showed a sharp fall, it being 27 in 1938 as compared with 39 in 1937, 45 in 1936 and averages of 72, 57, 36 and 38 in the quinquennial periods referred to above. Of the deaths which occurred from tuberculosis in 1938, 71 per cent, were in previously notified cases. Of the remainder 1 was thought to have been previously notified, 1 case had been previously notified in another district and not transferred, and in the remaining case the doctor forgot to notify. The Council has made arrangements for the examination, free of charge, of sputa from cases, or suspected cases, of tuberculosis and during the year 48 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 sanatorium and dispensary 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., and on the first Monday at 5.30 p.m. A Voluntary 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 dependents. The Council is represented thereon by the Medical Officer of Health. 25 PUBLIC HEALTH ACT, 1936, SECTION 172. It was not found necessary to institute proceedings under the above Act to enforce the removal to hospital of a case of pulmonary tuberculosis. PUBLIC HEALTH (PREVENTION OF TUBERCULOSIS) REGULATIONS, 1925. No action was required during the year under the powers conferred by the above Regulations in respect of tuberculous employees in the milk trade. AMBULANCES. For Infectious Disease Cases.—The Wandle Valley Joint Hospital Board has provided two motor ambulances for the removal of cases of infectious disease to hospital. Use is also made of an ambulance of the London County Council for the removal of cases of puerperal fever to Queen Charlotte's Isolation Block. 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 unfortunately these were not completed until the 5th November, 1938. 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 Meiporial 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. 26 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 1938 an additional 10 cases were admitted to Queen Charlotte's Hospital, London, and 64 to the County Hospital, Redhill. BACTERIOLOGICAL WORK. The examination of swabs for diphtheria and sputa for tuberculosis is carried out by the Medical Superintendent of the Wandle Valley Isolation Hospital, and during the year the following number of specimens were examined:- Swabs for diphtheria 162 Sputa for tuberculosis 48 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 11 specimens were examined during 1938:— Widal examinations for enteric fever 6 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, the Council has decided to provide for disinfection even when this is not essential in the interests of public health, but in these cases charges will be made of 10s. 0d. 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. L,oads of bedding, etc. 116 1 Houses disinfected 118 1 LABORATORY FACILITIES. During the year the Council considered the possibility of an independent laboratory being set up locally, chiefly for the examination of water and milk samples. The views of adjoining Authorities were sought, and a meeting of their representatives called in October. A Sub-Committee of five of the local Medical Officers of Health was appointed to prepare a detailed scheme for consideration by a further Conference, but no decision had been reached by the end of the year under review. 27 HEALTH PROPAGANDA. The forms of health propaganda introduced during 1937 were continued during 1938. The Council's co-operation with the National and Surrey County Council's Health Campaigns which commenced in the autumn of 1937 was continued during the spring of 1938, the effort being limited to an approach to the school children, and mothers attending the Infant Welfare Centres, owing to the recognised difficulty of attracting audiences to public meetings in this District. The children over 11 years of age from most of the public secondary and elementary schools in the District attended two displays of health films at one of the local Cinemas in the early months of the year. Unfortunately none of the private schools availed themselves of the opportunity to attend. While these displays were successful 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 during the early part of the year 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. 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. Originally 2,000 copies were issued locally each month, but this number was reduced to 1,000 in October, 1938, as meeting more closely the demand. ADVISORY COMMITTEE. During the second half of the year following representations from some of the general practitioners practising in the District, an Advisory Committee was set up consisting of an equal number of representatives of the Council and of the practitioners, such Committee to meet at least three times a year to consider questions of public health as affecting the Urban District, and to report to the Public Health Committee. The first meeting of the Advisory Committee was not held until 1939. 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:— 28 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 Mondays in each month. (b) The Methodist Church, Sylverdale Road, Purley, on the first and third Wednesdays 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 248 new ante-natal cases presented themselves during 1938, as compared with 214, 243, 180, 143 and 114 in the preceding five years. This suggests that in approximately 33 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 30, 36, 29, 23 and 22 per cent. Attendances at Ante-Natal Clinics, 1938. Clinics. Number on register. Attendances. Sessions. Average attendance per session. New cases. Total. 69, Brighton Road, Purley Ante-natal 229 157 771 Post-natal 99 5 56 Gynaecological 5 3 9 Individuals 239 165 836 35 23.8 Methodist Hall, Sylverdale Road, Purley Ante-natal 92 54 387 Post-natal 67 2 78 Gynaecological — 4 6 Individuals 94 60 471 24 19.6 Baptist Hall, Addington Rd., selsdon Ante-natal 70 37 226 Post-natal 30 1 36 Gynaecological - 1 4 Individuals 71 39 266 12 22.2 All Centres Ante-natal 391 248 1384 Post-natal 166 8 170 Gynaecological 5 8 19 Individuals 404 264 1573 71 22.1 29 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 ante-natal treatment. Efforts continue to be made to secure much closer co-operation 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 sendee, 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. Ante-natal mothers continue to be supplied with cow's milk free of charge if the financial circumstances warrant this action, while dental treatment is also arranged if necessary at reduced cost, the latter being extended during the year to include the provision of dentures. Post-Natal Clinic. A Post-natal Clinic has been established by the Council the first session being held in July, 1937, and is held at 69, Brighton Road, Purley, on the 3rd Monday in each month. 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. A minimum of one examination at the end of the lying-in period by the doctor attending the confinement, and another at about six weeks after the birth has occurred are desirable. 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 attending have fully justified the one session per month which is now held. In practice, while the majority of post-natal cases attending the Brighton Road Clinic arrive on that day, as is desirable, others can only attend at the normal ante-natal sessions. This is, however, counterbalanced by some ante-natal mothers attending at the Post-natal Clinic. Fundamentally, the anomaly which appears to exist in the following Table relates only to the nomenclature of the Clinics. 30 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. 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, Clinics. (Established 19th July, 1937). Attendances. Sessions. Average attendance per session. New cases. Total. Post-natal 5 73 Ante-natal 28 143 Gynaecological 4 7 11 20 Individuals 37 223 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 this District. In practice, they are only called in to cases in which the full normal fee of a Specialist cannot be afforded. During the year one or other of the Specialists was called in for consultation on 5 occasions. From September, 1938, it was decided to make no attempt to recover any part of the fees of the Specialists from the patients for a trial period of one year. Emergency Unit. During the year consideration was given to the provision of an Emergency Unit, (commonly known as a "Flying Squad"), which could render assistance in cases of obstetrical emergency of such a nature as to make it necessary for the treatment to be given in the patient's own home. It being anticipated that very few cases would need this 31 Service each year in the Urban District, it was fortunate that, thanks to the generosity of the County Borough of Croydon who provided the necessary equipment and staff, this Service has been made available to residents of this District without participation in the initial expenditure and at a very reasonable charge for its use. The Unit, which consists of a Specialist, certified midwife and the necessary equipment carried in an ambulance, is based upon May Day Hospital, Croydon, and can be summoned by a general practitioner at any hour, a subsequent report being made to the Medical Officer of Health on its use. This arrangement was completed in the autumn but did not need to be utilised locally during the remainder of the year. Maternity Cases. During the year the number of maternity cases admitted to Purley Hospital was 61, this being the same number as last year. 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 10 cases were sent to Queen Charlotte's, while 64 cases were admitted to the County Hospital, Redhill. A uniform charge is made for the conveyance by ambulance to any of these Hospitals of maternity cases whose confinements are arranged through the Council's Scheme, and from the 1st April, 1938, this charge has been 5s. Od. 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. The Public Health Committee through a Sub-Committee gave prolonged consideration during the year to the charges to be made in Purley and Queen Charlotte's Hospitals, and it was decided to increase the charge to that required of cases admitted to the remaining beds in the maternity ward of the Purley Hospital. The charge, however, includes the fees of doctors if called in by a midwife, and those of the Obstetric Specialist should difficulty arise and a consultation or operation prove necessary. 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 ex- 32 tensions at the Hospital to include a new Maternity Block containing 12 beds. In addition to the above there are 3 private maternity homes at present in the Urban District. MIDWIFERY SERVICE. The Council, acting as agents for the Surrey County Council appointed two midwives in December, 1937, to serve the Sanderstead/Selsdon, and Purley/Kenley areas. In addition, the Coulsdon District Nursing Association has appointed one of its nurses solely as a midwife. The Council's midwives commenced duty in areas the majority of which were not previously served by midwives, and during the year attended 56 cases. The Coulsdon nurse attended 105 cases in the same period, her practice being an, established one. In addition, 7 midwives practice privately in the Urban District. At the beginning of the year it was decided that the Surrey County Council's scale should be applied in deciding the charge to be made to necessitous cases attended by the Council's midwives. Unfortunately the supervisory powers under the Midwives Acts have not been delegated to this Council, thus presenting an apparent anomaly which 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 31 cases were assisted in this way. 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. The Council has employed the services of three full-time Health Visitors since May, 1935, who work under the supervision of the Medical Officer of Health. 33 During the year a total of 6,677 visits were paid by the Health Visitors, this representing, as was anticipated, a further decrease in the number of visits which could be made, the totals for 1936 and 1937 being 7,695 and 6,954. Actually the number of first visits to babies under one year of age increased, while an increased number of visits to cases of non-notifiable infectious diseases were paid. The chief reductions were in the number of re-visits to young babies and older children necessitated by the diminution of the time available for such visitation owing to the increased number of fixed appointments the Health Visitors have to keep at the Clinics and Centres. With a growing district requiring extensions of its services, this fall in the number of visits is an inevitable interim feature preceding an increase in staff, the necessity for which has been recognised in 1939. For the purpose of record it may be worth noting that 92 per cent. of the births were visited compared with 90 per cent. in 1937 and 93 per cent. in each of the preceding two years, while an average of 2.3 re-visits were paid to children under one year as compared with 2.5 in 1937 and 3.3 in 1936. Visits paid by Health Visitors. 681 first visits to babies. 1,579 visits to babies under one year of age 3,613 visits to children from one to five years. 211 ante-natal visits:— 127 first visits 84 re-visits 87 visits to cases of tuberculosis 48 first visits 39 re-visits 49 visits to cases of whooping cough 36 first visits 13 re-visits 64 visits to cases of Measles 52 first visits 12 re-visits 12 visits to cases of chicken pox 1 visit to a case of mumps. 22 investigations of infant deaths 13 investigations of still births 2 investigations of cases of ophthalmia neonatorum. 5 visits to cases of puerperal pyrexia 338 miscellaneous visits 6,677 Total. 34 35 Attendances of Children at Infant Welfare Centres, 1938. Brighton Road, Coulsdon. Rickman Hill, Coulsdon. Bradmore Green, Old Coulsdon. Sylverdale Road, Purley. Addington Road, Selsdon. Sanderstead Hill, Sanderstead. Totals, 1938. Totals 1937. 1936. 1935. 1934. 1933. New cases 149 95 89 132 122 80 667 594 502 423 368 329 Other cases 3,839 3,080 1,133 3,268 3,701 1,350 16,371 14,064 12,017 10,309 8,710 7,490 Total attendances 3,988 3,175 1,222 3,400 3,823 1,430 17,038 14,658 12,519 11,732 9,078 7,819 Consultations with Doctor 839 599 508 492 656 428 3,522 2,866 2,403 2,099 2,013 1,876 Referred to Hospital 8 7 13 9 4 3 41 21 16 17 — 21 Number of sessions 49 47 24 49 47 23 239 220 195 191 192 177 Average attendance per session 1938 81 67 51 69 81 62 *71 - - - - - 1937 75 64 42 59 79 49 — *67 — — — — 1936 69 56 — 53 81 69 — — *64 — — — 1935 58 57 — 49 61 — — — — *61 —. — 1934 49 46 — 42 52 - - - - - *47 — 1933 45 46 — 42 49 - - - - - - *44 * Average attendance per session for all Centres. Infant Welfare Centres. Six Infant Welfare Centres have been established by the Council, which are held from 2.30 to 4.0 p.m. at the following places:— Methodist Church, Brighton Road, Coulsdon Every Thursday. Church of St. Francis, Rickman Hill, Coulsdon Every Tuesday. Methodist Church, Sylverdale Road, Purley Every Friday. Church Hall, Bradmore Green, Old Coulsdon Second and fourth Wednesday in each month. Baptist Ham,, Addington Road, Selsdon Every Monday. Congregational Church, Sanderstead Road, Sanderstead First and third Thursdays in each month. The average attendances at the two most recently established Centres both increased satisfactorily during the year. Those for the Brighton Road and Selsdon Centres are now so high that it was decided that after March, 1938, doctors who had previously attended on two sessions a month should be present at each session in the month. It is pleasing also to note further increased average attendances at the well-established Rickman Hill and Kenley Centres. The total attendance at all Centres was no less than 17,038 as compared with 14,658 in 1937, when the total attendance was exactly double that in 1932. The growth of this Service is a feature in civic life which is apt to be overlooked. Child Welfare Centres and health visitation have come to be looked upon as part of the normal service of a Local Authority needing no special consideration or remark. The steady solid work which is given to these annually to make them as successful as they are as agents in improving the health of the youngest residents should not be accepted without comment, and all who assist in these directions are thanked for their continued devotion to this valuable work. Toddler's Clinics. Considerable thought was given during the year to the question of establishing special Toddler's Clinics. It has been generally noted that, especially when increasing attendances are experienced as at the local Centres, the majority of the attention of the Doctors and Health Visitors becomes focussed upon the newly-born babies. Time permits relatively little notice being given to the older children unless these present definitely abnormal features, which are often noted first by the parents. With a view to securing that these older children shall have more adequate supervision hocal Authorities have been encouraged to make special provision for their periodical examination, separate clinics or sessions being set aside for the purpose. 36 The increase in work during and following the September crisis caused the original plans to be varied and the introduction of the scheme to be postponed. Eventually, however, it was decided that early in 1939 the first session in each month at the four largest Centres would be devoted to the supervision of children over 2 years of age, the children being examined at least once a year by the doctor as near the child's birthday as possible. For this purpose the doctors would be required to attend an extra session per month at each Centre. Toddlers attending the Old Coulsdon and Sanderstead Centres would for a time be seen during the normal work of the Centre, special attention, however, being given and records kept of each case. The Provision of Milk and Specialist Treatment. During the year 139 cases in which the parents were known to be in necessitous circumstances and the children in need of milk were provided with a supply of milk, delivered to their homes, free or at a reduced price, the expense being borne by the Council. This was an increase of 50 on 1937. While, throughout the District the children are, generally speaking, well nourished, and in many cases above the average development, there are in addition 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. Orthopaedic Treatment, Etc. During the year 44 cases were referred to hospitals from the Centres, 4 being for orthopaedic treatment, 11 for the removal of tonsils and/or adenoids, 9 for ultra violet ray treatment, 8 for circumcision, 5 for massage, 5 for treatment of naevi, 1 for ear and 1 for skin treatment. 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 the 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. Prevention of Deafness. 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 fourth year in succession. This would appear to be due to the 37 securing of prompt and efficient treatment in the early stages through the family doctor or other agency. Dental Treatment. The Scheme for the dental treatment of ante-natal and nursing mothers and children under 5 years of age, which was launched in 1034, again increased in efficiency and popularity. During the year 90 cases were treated by those Dental Surgeons in the District who had signified their willingness to serve under the Scheme, as compared with 69, 45 and 33 in the preceding three years. While this Scheme remains slightly ponderous and rather more expensive for the individual than could be desired, treatment is commenced 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 application of this scale was extended during the year to include the provision of dentures. The numbers treated to date have not justified any alteration in the present Scheme for utilising the part-time services of a panel of Dental Surgeons, this appearing to be the best arrangement that can be made as yet to deal with the demand so far experienced in this District. Eye Defects. Arrangements were made during the year whereby children suffering from eye defects are referred by appointment to special sessions for young children held at the Surrey County Council's Clinic in Whytecliffe Road, Purley. The merit of this Scheme, apart from the reduction in travelling for most residents, is that continuity of treatment can be obtained, the same Ophthalmic Specialist continuing to see the child if it subsequently enters a public elementary school in the District. Convalescent Treatment. In February, 1938, the Council decided to include an item in the estimates in order to provide that mothers and children under 5 years of age whose physical condition made a period of convalescent treatment desirable, but who would not otherwise be able to secure such treatment owing to the financial circumstances of the family, could in approved cases be assisted in obtaining such treatment. During the remainder of the year one case was assisted in this way. 38 Day Nurseries. Two Day Nurseries have been established in this District, both of which are chiefly maintained by voluntary subscriptions, but towards the cost of which the Council makes an annual grant equivalent to approximately one-third of the total cost of the Nurseries. The Purley Day Nursery has accommodation for an average of 33 children, while the Coulsdon Day Nursery can take an average of 23. The total attendances during 1938 were 6,246 and 6,798 respectively. This accommodation is relatively high for the population of this District when 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 Day Nurseries is much the most expensive branch of such 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, however, there are few, if any, of those who were using the Nurseries during 1938 who did not definitely need to provide or augment the family income, while, had the Nurseries not been in existence, the majority would still have gone out to work, and their children been left probably in less healthy surroundings. The influence on the training and development of the children is also a factor of great importance. Child Life Protection. The Health Visitors are all recognised Infant Life Protection Officers. During the year 17 foster-mothers have been under supervision, 52 children being distributed amongst the homes. During the year 1 registration was cancelled, 1 child died (an inquest being held), 8 children were removed in due course to an Adoption Society, 1 child was similarly removed to a Foundling Home, and 1 child was adopted locally. The locality in which the Homes were situated was as follows:— Coulsdon 9 Kenley 2 Selsdon 1 Sanderstead 1 Purley Oaks 1 Purley 3 HOUSING. During the year 1,135 houses were inspected for housing defects as compared with 824 last year and 924 and 331 in the preceding two years. 39 The chief reasons for the increases in recent years were the additional visits required to be paid under the Housing Act, 1935, to detect overcrowding which existed, and latterly to ascertain the maximum number of persons which could reside in 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. 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 17 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. At the end of 1937 five of these cases and others found subsequently remained for attention. During 1938, three additional cases were discovered and 4 relieved, hence there were 4 cases outstanding at the end of the year. Three of these cases were remnants of the original cases. In one case the owner-occupier has been granted a licence permitting the present number of occupants to continue in residence for one year. The other 2 original cases remained unrelieved at the end of 1938. 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) 1,135 (b) Number of inspections made for the purpose 1,160 (2) (a) Number of dwelling houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 7 (.b) Number of inspections made for the purpose 7 (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 321 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 289 40 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 2 (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 25 (2) Number of dwelling houses in which defects were remedied after service of formal notices:— (a) By owners 24 (b) By Local Authority in default of owners — (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 5 (iii) Number of persons dwelling therein 30 (b) Number of new cases of overcrowding reported during the year. 3 (c) (i) Number of cases of overcrowding relieved during year 4 (ii) Number of persons concerned in such cases 17 (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 Nil Number of New Houses erected during the Year:— By the Local Authority Nil By other persons 594 41 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 by the East Surrey Water Company who supply the remainder of the District. A small private supply serves part of the Old Coulsdon Estate, whilst another private supply serves the Cane Hill Hospital, Coulsdon, the latter being supplemented from the East Surrey Water Company's mains as is found necessary. In all cases the source of the water supply is from deep wells sunk into the chalk in various parts of this and neighbouring districts. During the year the mains of each Company were extended to meet the housing developments in various parts of the District, and no shortage of water was experienced. An increased number of water samples from the chief distributors in the District was taken during the year both for bacteriological and chemical examinations, and the reports showed that the waters maintained their good quality for drinking and domestic purposes. Seven samples were submitted for chemical and eight for bacteriological examination. Seven of the latter were satisfactory, but one sample was reported upon as slightly below the standard desirable for a public water supply, the total number of bacteria being higher than usual although coliform organisms were absent from 50 c.c's. In 1936 a rota was agreed among the local authorities taking the supplies of the Sutton and District and the East Surrey Water Companies for taking samples, and this was continued during 1938. By this arrangement weekly samples of each supply are taken, and any adverse report is immediately communicated to the remaining local authorities and to the Company concerned. It is understood that each Company also collects daily samples for examination. The Companies are informed each week of the cases of Infectious Disease occurring in the District. Sampling is, however, only one form of control, and cannot be relied upon solely to secure the protection of consumers irrespective of the frequency with which samples are taken. Undoubtedly in built-up 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 continued as before. In each case the employment of a form of 42 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 diseases to contamination occurring after the water has left the works. In order to meet the possibility of the pollution of the water in reservoirs or mains one of the statutory companies has liberated the water from the works with a small proportion of free chlorine present therein. (The other Company has taken similar action during 1939). Very few complaints and no ill-health have been noted as a result of the present arrangements. On the Old Coulsdon Estate considerable anxiety has been felt from time to time owing to temporary breakdowns of the plant through broken mains, failure of electric current, and other causes. The new pump installed last year proved equal to the maintenance of the supply under normal conditions, but if for any reason the head of water in the water tower was reduced the system failed to function over certain parts of the area served, and the consumers were left without water. For this reason the Council saw fit at the end of the year, after conferences with the Company, to disapprove further plans for the erection of new houses until a sufficient and satisfactory supply had been laid on, the Company meanwhile being encouraged to make alternative arrangements for the supply of water to the Estate. Many complaints of the discolouration of water were received, and bacteriological samples were taken about every fortnight. In addition, daily samples of the water have been collected and tested for free chlorine by the Medical Officer of Health. The results of the latter were very variable, but were of value in ascertaining that this protective measure was maintained, the question being taken up with the Company immediately free chlorine was noted to be absent from a sample. During the year 23 samples of water were submitted to bacteriological examination from the Old Coulsdon supply, all of which were reported upon as being satisfactory. The statutory maximum limit for hardness in the water supplied by the East Surrey and Sutton and District Water Companies is 9 degrees, and 48 samples have been examined by the Department during 1938 to ascertain that this figure was not exceeded. The results of the most recent chemical examinations are set out below:— 43 East Surrey Sutton & District Old Coulsdon Water Co.'s Water Co.'s Estate supply. supply. supply. Suspended solids nil nil nil Dissolved solids 22.76 21.20 37.8 Chlorine (as Cl2) 1.6 1.3 1.5 Free Ammonia 0.0015 0.0015 0.0075 Albumoid Ammonia 0.0015 0.0015 0.004 Nitrate (as N2) 0.74 0.66 0.85 Nitrite nil trace nil Oxygen consumed from Permangate (4 hours at 80° F.) 0.0032 0.025 0.0032 pH value 7.6 7.5 7.8 Temporary hardness 2.7 5.7 20.56 Permanent hardness 3.1 2.2 4.86 Physical Examination clear, clear, clear, colourless, colourless, colourless, odourless. odourless. odourless. RAINFA1X. During the year the rainfall was 26.98 inches, this being 10.85 inches lower than the previous year, and occurred as follows:— Inches. January 3.42 February .78 March .41 April .20 May 2.63 June .59 July 2.12 August 2.88 September 2.81 October 3.48 November 4.02 December 3.64 26.98 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. DRAINAGE AND SEWERAGE. The following extensions to the public sewers were made during the year:— Caterham Drive 480 yards Waddington Avenue 650 yards Shirley Avenue 430 yards Keston Avenue 350 yards 44 Instructions were also given to prepare plans, etc., for the provision of sewers in Old Farleigh Road and Beech Way, Selsdon, but no action had been taken in regard thereto at the end of the year. Estate developers also continued to provide sewers on private estates. The sewage of this District is disposed of by the County Borough of Croydon and the West Kent Main Drainage Board. In February a test was carried out to see whether sewage matter deposited on the ground at Farleigh Court Farm was liable to contaminate the Addington wells of the Croydon Corporation. Eight tons of salt were washed into the ground immediately below the irrigation bed, but although the saline solution was absorbed rapidly and in a manner to suggest the presence of fissured chalk, no evidence of the salt appeared in the well water during the following ten days. The point is of interest as the bed approximates to a line between the wells and the "swallow hole" at the adjoining but more distant Mental Hospital which had been shown to inter-connect about 30 years ago. CLOSET ACCOMMODATION. Nearly the whole of the District is on the water carriage system and the number of cesspools is gradually diminishing as new sewers are laid. Practically all premises are provided with water closets except for certain isolated buildings in public and private recreation grounds together with a small number of dwelling houses. The buildings in the public recreation grounds are of a temporary nature. Where more permanent buildings are erected the drains are connected to a sewer, if available, and if not, are connected to cesspools. During the year 1 pail closet was converted to a water closet. The approximate numbers of each type remaining at the end of the year were:— Premises with water closets drained to sewers 15,064 „ ,, ,, „ „ ,, cesspools. 243 ,, „ earth closets 1 ,, pail closets 66 During the year 32 cesspools were abolished, the total number of cesspools throughout the District being approximately 217 at the end of the year. PUBLIC CLEANSING. The collection of house and trade refuse has proceeded on similar lines to those in 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. The first bin of trade refuse is removed without charge, and any remaining bins of similar refuse at 6d. per bin. 45 During the year the Cpuncil reduced the charge for the emptying of cesspools throughout the area from 7s. 6d. to 5s. 0d. per load. The contents of the cesspools are disposed of in the public sewers. I am indebted to the Surveyor for the information that two additional cells at the Refuse Destructor which were provided during 1936 have permitted his Department to cope adequately with the quantity of refuse collected. SMOKE ABATEMENT. The chimneys of the small factories in the District gave little trouble during the year, and observations of the few large chimney stacks showed that stoking was carefully carried out. The burning of garden and trade refuse was responsible for 11 complaints, and once again it is necessary to direct the attention of the public to the facilities offered by the Council for the removal of this class of refuse. Garden refuse is removed at the rate of 6d. per bin. Books of twenty 6d. tickets can be obtained from the Treasurer at the Council Offices, Purley, or single 6d. tickets can be had from the foreman scavenger. Ratepayers are urged, if they do not choose to avail themselves of the above facilities or cannot bury garden refuse, to dry it thoroughly before attempting to burn it, and thus avoid unnecessary atmospheric pollution in the proximity of dwelling houses. 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. From time to time inspections have been made of the water courses in the District, and it has not been necessary to take any action regarding them. CAMPING SITES. Only one camping site was used during 1938, this being occupied by the Boy Scouts Movement. The site was used by several boys during week-ends, the maximum number at any one time being 15. No camping sites were licensed during the year. SWIMMING POODS. There is no public swimming bath within the District, but there are a number of private swimming baths, one of which, at the Reedham Orphanage, Old Dodge Dane, Purley, is also used by children from the elementary schools. During the year two samples of water were submitted for bacteriological examination, and in each case the result proved satisfactory. 46 SHOPS AND OFFICES. The sanitary provisions of the Shops Act, 1934, have been applied where necessary, and the requirements of Section 72 of the Public Health Act, 1925, as supplemented by Section 66 of the Coulsdon and Purley Act, 1937, have also been enforced. Some difficulty is experienced with tenant shopkeepers as they are adverse to carrying out permanent structural alterations to premises which may pass from their possession sooner or later, nor do they always regard with favour the legal machinery set up by the Act whereby they may rectify this state of affairs. Under the Coulsdon and Purley Act, 1937, the occupier of any room to which Section 72 of the Public Health Act, 1925, applies is required to provide in connection with the room "suitable washing sinks with a sufficient supply of hot water together with an adequate supply of soap and towels for the use for toilet purposes of persons employed therein." The application of this section to butcher's and grocer's shops has been instrumental in providing efficient washing arrangements so essential to the cleanliness of all persons engaged in these trades. Additional sanitary accommodation has been installed in 3 premises and washing facilities in 3 premises. The offices in the district are associated mostly with small businesses and are generally well kept, lighted and ventilated. SANITARY INSPECTIONS, Etc. The following is a statement of the complaints received, inspections made and defects remedied, etc. Compared with 1937 there were 22 fewer complaints received and 1,093 more inspections made, from which it may be concluded that the steady increase in the work of the Sanitary Department has been maintained. No particularly spectacular achievements have to be reported this year, but a satisfactory standard of efficiency was maintained throughout. COMPLAINTS. Dampness 36 Choked and defective drains 50 Insanitary conditions, general repairs, etc. 39 Insects, moles, foxes, etc. 11 Rats and mice 80 Accumulations of refuse 29 Inadequate soakaways 1 Defective water service pipes 5 Nuisance caused by keeping of animals 13 Smoke nuisances, burning of refuse, etc. 17 Overcrowding 8 Non-collection of house refuse 12 47 Improper or no water supply 22 Dustbins 6 Offensive smells 44 Defective water closets 7 Domestic uncleanliness 2 Verminous conditions 12 Defective gullies 2 Choked rainwater pipes 1 Unsound food 1 Caravans 4 Insufficient light 5 Noise 6 Want of paving 1 Defective sinks 2 Insufficient or no sanitary accommodation 1 Shops Acts contraventions 1 Miscellaneous 5 Total 423 Inspections. House inspections 1,135 Re-inspections and calls made 2,944 Inspections of workshops and factories 176 Inspections of offices 6 Bakehouses 44 Cowsheds and dairies 118 Slaughterhouses 129 Meat and other foods 580 Food preparing premises 48 Stables, piggeries, etc. 76 Drains, outbuildings, etc. 2,291 Rats and Mice Destruction Act 598 Shops Acts 536 Drains tested 128 Infectious disease enquiries 110 Disinfections carried out 241 Miscellaneous 4 Total 9,164 48 Notices Served. Preliminary notices 770 Statutory notices 87 Letters and final circulars 591 Defects Reported. Insufficient or defective drainage 40 Improperly drained yards 23 Cesspools requiring emptying 130 Defective cesspools 12 Drains choked 66 Defective fresh air inlets 69 Defective ventilation shafts 8 No wire cages to vent shafts 2 Unclean walls and ceilings 204 Defective plaster 64 Defective firegrates and wash boilers 27 Defective floors 25 Defective sashcords 44 Defective or choked rainwater pipes 30 Defective woodwork 51 Defective paving 50 Defective dustbins 148 Defective sinks and sink waste pipes 38 Defective kerbs around gullies 17 Dampness through defective roofs 48 Dampness through other causes 48 Defective W.C. fittings 21 Accumulations 20 Verminous conditions 12 Lack of domestic cleanliness 4 Overcrowding 3 Insufficient lighting and ventilation 6 Defective air bricks 5 Defective outbuildings 2 Brickwork and pointing defective 37 Paintwork defective 15 Glazing defective 13 Unclean outdoor premises 13 No proper sanitary accommodation 1 Absence of water supply 3 Rats 87 Insufficient water closets 8 Burning of refuse 2 49 Insufficient soakaways 1 Defective roofs 5 Miscellaneous 40 Total 1,422 Defects Remedied. Pail closets abolished 1 Cesspools provided 9 Drainage repaired or provided 82 Cesspools emptied 125 Cesspools repaired 7 Cesspools abolished 32 Soakaways provided 9 Drains cleansed 68 Fresh air inlets provided 58 Vent shafts provided or repaired 18 Wire cages to vent shafts provided 3 Drains connected to the sewer 22 New water closets 6 Gully traps, etc., provided 16 Inspection chambers provided 40 Walls and ceilings cleansed 163 Plaster repaired 51 Floors repaired 20 Firegrates and wash boilers repaired 17 Sashcords repaired 36 Rainwater pipes and eaves guttering repaired 26 Woodwork repaired 41 Paving repaired 43 Dustbins provided 129 Sinks and sink waste pipes replaced or repaired 25 Kerbs around gullies repaired 14 Dampness remedied due to defective roofs 49 Dampness remedied due to other causes 48 W.C. fittings repaired or provided 28 Accumulations removed 18 Verminous conditions abated 11 Domestic cleanliness improved 2 Overcrowding abated 4 Lighting and ventilation provided or improved 7 Outbuildings repaired 2 Defective brickwork repaired or repointed 32 50 Paintwork renewed 7 Windows glazed 9 Outdoor premises cleansed 10 Sanitary accommodation provided 6 Rat infestations abated 91 Water supply laid on 8 Burning of refuse abated 2 Roofs repaired 5 Washing facilities provided 3 Miscellaneous 33 % Total 1,436 ERADICATION OF BED BUGS. It has not been found necessary to alter the methods adopted for the eradication of bed bugs which have been successful in previous years. The work is still carried out by the Local Authority. During the year the following numbers of houses were dealt with:— Council houses 5 Other houses 6 Compared with last year this shows a reduction of eight. At three of the Council houses it was found necessary to apply a second fumigation owing in one case to failure to fumigate one of the bedrooms; in the second case it was due to failure to remove certain woodwork which was later found to be infested, and in the third case a cupboard in the roof was found to be infested. In no case was the infestation serious, and since the second disinfestation was carried out there has been no recurrence. Fumigation is carried out by sulphur candles and spraying by "Vermicine " Insecticide. 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 indicated above, before the removal is effected. It was not found necessary to submit any bedding to steam disinfection during the year. RATS AND MICE DESTRUCTION. The year was one of continued activity in the destruction of vermin, and every assistance was given to householders and owners on whose premises or lands vermin were found to exist. The complaints received numbered 80, and the total number of inspections and re-inspections numbered 598. 51 The work of eradicating vermin is undertaken on request by the Public Health Department at a charge of 2s. 6d. per hour with a minimum charge of 5s. 0d., the cost of the poisons being extra. Three statutory notices were served during the year, this being a reduction of three on the previous year. Many residents do not yet realise that the occupiers of premises are themselves responsible for the destruction of rats, although the Department is always willing to give advice as to the best means to adopt in any particular case. The infestation of houses is found to be chiefly due to broken air bricks and damaged walls around various kinds of service mains, e.g., gas, water, electricity. Cavity walls are sometimes responsible for the appearance of rats in rooms which they would not otherwise reach. SCHOOLS. School Closure.—No public elementary schools were closed during the year on the account of the prevalence of infectious disease amongst the scholars. 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 any further action is available should this be requested, and disinfection is provided when required. Under the Coulsdon and Purley Act, 1937, it is 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 Education Department of the Surrey County Council carries out the medical inspection of children attending the public elementary and secondary schools. School Clinics.—The County Council provide Clinics for the treatment of school children, as follows:- 52 General Medical Clinic: Surrey County Dispensary, Whyteclifie 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. do. 2.0 p.m. Fridays 9.30 to 11 a.m. do. 2.0 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 found necessary on one occasion to institute legal proceedings under the Public Health Act, 1936, when a fine of £5, together with a daily penalty of £2 were imposed upon the defendant, for failing to properly empty the cesspool on his premises. REGULATED TRADES. Dairies and Cowsheds. The following is a list of the dairy farms which were in existence at the end of the year:— Hooley Farm, Woodplace Lane, Coulsdon. Dean Farm, Brighton Road, Hooley. Elm Farm, Farleigh. Moorcroft Farm, Farleigh. Welcomes Farm, Farthing Downs, Coulsdon. Farleigh Court Farm, Farleigh, was removed from the register, and is now devoted to stock rearing. In addition there are two other farms which supply private institutions with milk, viz., Woodplace Farm, Woodplace Lane, Coulsdon, which supplies Netheme Mental 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 few persons who own a few cows and use the milk solely for their own consumption. The occupier of Dean Farm, Hooley, is licensed by the Surrey County Council under the Milk (Special Designations) Order, 1936, for the production of "Accredited" milk. 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. 53 Owing to the veterinary inspection of cows being taken over by the Ministry, the services of the Veterinary Officer previously employed by the Council to make quarterly inspections of all cows were terminated. At the end of the year there were nine registered dairies, one dairy having been removed from the register through disuse. The number of registered retailers was 44, of whom 16 reside outside the District. SLAUGHTERHOUSES. There are two Slaughterhouses within the District, both of which are licensed annually. The number of animals slaughtered during the year was 1,053. 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. Licences to slaughter animals were granted to four slaughtermen. Notifications of intention to slaughter are forwarded regularly by the occupier of one of the licensed slaughterhouses, a regular slaughter notice being supplied by the other licensee. The Sanitary Inspectors examined over 90 per cent. of the carcases before these were placed on the market. BAKEHOUSES. There are 15 bakehouses within the District, 8 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. No alteration in the number of fish friers took place 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 this District. All shops, kitchens of restaurants, tea rooms and other places where food is prepared or sold were inspected and appropriate action taken where necessary. FACTORIES. There are 161 Factories within the District. In addition there are 20 Workplaces. 54 INSPECTIONS OF FACTORIES AND WORKPLACES. Including Inspections made by Sanitary Inspectors. Premises. Number of Inspections. Written Notices. Occupiers prosecuted. (1) (2) (3) (4) Factories with mechanical power 57 - - Workshops without mechanical power 101 - — †Other Premises under the Act (including works of building and engineering construction but not including outworkers' premises) 18 - - Total 176 - - DEFECTS FOUND IN FACTORIES, AND WORKPLACES. Particulars. Number of Defects. Number of defects in respect of which Prosecutions were instituted. Found. Remedied. Referred to H.M. Inspector. (1) (2) (3) (4) (5) Want of cleanliness (S. 1) 8 6 - - Overcrowding (S. 2) - - - - Unreasonable temperature (S. 3) - - - — Inadequate ventilation (S, 4) - - - — Ineffective drainage of floors (S. 6) - - - - Sanitary Conveniencies (Sec. 7) insufficient 1 1 — - unsuitable or defective 3 2 — - not separate for sexes - - - - Other offences (Not including offences relating to Home Work or offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921, and re-enacted in the Third Schedule to the Factories Act, 1937). 6 6 - - Total 18 15 - - INSPECTION AND SUPERVISION OF FOOD. Milk. During the year 66 samples of milk were submitted for bacteriological and microscopical examinations, and of these 8 were also submitted to biological examination. Eight of the samples proved unsatisfactory bacteriologically or microscopically, and the producers or retailers were immediately informed. Repeat samples were taken and usually showed improvement, but in some cases more than one repeat sample was necessary. 55 The following is a summary of the results of the 66 samples examined bacteriologically:— TOTAL COUNT. Under 30,000 bacteria per c.c. 38 30,000—200,000 21 200,000—400,000 3 Over 400,000 4 COLIFORM BACILLUS. Absent in 1 c.c. — do. 0.1 c.c. 35 do. 0.01 c.c. 18 do. 0.001 c.c. 5 do. 0.0001 c.c. 8 No samples of graded milk were taken under the special instructions of the Ministry of Health. Three samples of Pasteurised milk were taken, all of which were 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 6 Accredited 2 - Pasteurised 10 4 ICE CREAM. The following Table shows the results of the ice cream samples examined during the year, and the effect of instruction and persuasion in dealing with the producers:— Sample. No. of Bacteria in 1 c.c. on agar at 37° C. in 48 hours. Coliform Bacilli. Present in Absent from 1. 38,400 - 0.1 c.c. 2. 112,000 0.001 c.c. — 3. 89,600 — 0.1 c.c. 4. 1,560,000 0.001 c.c. — 5. 6,000 0.01 c.c. 0.001 c.c. 6. 390 — 0.1 c.c. 7. 284,000 (repeat of No. 2) — 0.1 c.c. 8. 340 — 0.1 c.c. 9. 540 (repeat of No. 5) — 0.1 c.c. 10. 2,100 — 0.1 c.c. 11. 3,900 0.001 c.c. — 12. 14,600 0.1 c.c. 0.01 c.c. 13. 252,000 — 0.1 c.c. 14. 5,968,000 — 0.1 c.c. 15. 1,056,000 (repeat of No. 13) 0.01 c.c. 0.001 c.c. 16. 1,320 (repeat of No. 14) — 0.1 c.c. 17. 400 (repeat of No. 7) — 0.1 c.c. 18. 81,000 0.1 c.c. 0.01 c.c. 19. 568,000 0.001 c.c. — 20. 516,000 (repeat of No. 19) 0.001 c.c. — 21. 700 (repeat of No. 12) 0.1 c.c. 0.01 c.c. 22. 190,000 0.1 c.c. 0.01 c.c. 23. 224,000 (repeat of No. 20) 0.001 c.c. — 24. 308,000 (repeat of No. 22) 0.01 c.c. 0.001 c.c. 25. 120 (repeat of No. 24) 0.1 c.c. 0.01 c.c. 26. 256,000 (repeat of No. 23) 0.01 c.c. 0.001 c.c. 27. 190 0.1 c.c. 0.01 c.c. 56 Sample No. 7 was a repeat of No. 2. The Bacillus Coli content was considerably improved although the total count was more than doubled. Further encouragement and advice being given to the shopkeeper resulted in the number of bacteria dropping from 284,000 to 400 in the following sample (No. 17). Sample No. 4.—Was the first and only sample taken of ice cream made by this Firm. After receipt of the report on this sample the manufacture of ice cream ceased. Samples Nos. 5 and 9 are another case of improvement being effected, as also Nos. 12 and 21. Samples Nos. 13 and 15. The Firm producing these samples manufactures the product in a neighbouring district, and the results were passed on to the Authority for that area, who followed up the case during the remainder of the year. Sample No. 14.—This sample came from a shop at which the ice cream had been made on the premises, where formerly a wellknown brand had been sold. The report was immediately communicated to the maker, the method of manufacture examined, and advice given. As a result the count was reduced from nearly 6,000,000 to 1,320 (No. 16). Samples Nos. 19, 20, 23 and 26 illustrate a case in which but little improvement was shown. The season ended at the time the question of cancelling the registration was being considered. On the other hand, Samples Nos. 22, 24 and 25 show the improvement effected in still another case. It should be noted that the above samples do not cover all the dealers selling in the District, the Department concentrating on new manufacturers or those who have produced unsatisfactory samples in the past to the exclusion of those whose previous samples have justified reliance being placed upon their products. Numerically, however, it is satisfactory to report that of the 16 sources examined, 5 were good, and 3 fairly good upon the initial examination, 4 improved as a result of action by the Department, 1 was passed on to a neighbouring Authority for the necessary action, 1 ceased manufacture, and only 1 showed but slight improvement. 57 MEAT. The carcases of animals slaughtered in the licensed slaughterhouses in the District are inspected before being placed on the market. 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 is commenced immediately. The following unsound food was destroyed during the year:— Meat 184¾ lbs. Other foods 55 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 — — 57 777 219 Number inspected — — 57 699 199 All drseases except Tuberculosis:— Whole carcases condemned — — — — — Carcases of which some part or organ was condemned - - - - 3 Percentage of the number inspected affected with disease other than tuberculosis - - - - 1.5 Tuberculosis only— Whole carcases condemned - - - - - Carcases of which some part or organ was condemned - - 1 - 9 Percentage of the number inspected affected with tuberculosis - - 1.8 - 4.5 FOOD AND DRUGS (ADULTERATION) ACT, 1928. The Surrey County Council carries out the duties under the above Act. During the year the following samples were collected from this area. The total number shows a decrease of 23 on the total taken during the previous year, chiefly due to a smaller number of milk samples being taken. 58 Articles. Analysed. Adulterated or Deteriorated. Prosecutions. Convictions . Formal. Informal. Total. Formal. Informal. Total. Milk 31 2 33 2 - 2 — - Cream - - - - - - - - Butter 1 - 1 - - - - — Cheese 1 - 1 - - - - - Margarine - - - - - - - - Lard 1 — 1 — — — — — Meat 3 - 3 - - - — — Flour - - - - - - — — Tea - - - - - - — — Coffee - - - — - - — — Cocoa - - - - - - - - Sugar 4 - 4 - - - - - Sausages 4 — 4 - — - — - Confectionery and Jam 1 - 1 - - - - - Sausage Meat - - - - - - - - Wine — — — — — — — — Beer - - - - - - — - Spirits - - - - - - - - Drugs 2 - 2 - - - - — *Other articles 5 - 5 1 - 1 1 1 Totals 53 2 55 3 - 3 1 1 *Details of other articles Fish Paste 1 - 1 - - - - - Chocolate roll 3 - 3 1 - 1 1 1 Orange Squash 1 - 1 - — — — - CHEMICAL AND BACTERIOLOGICAL EXAMINATION OF FOOD. Samples of food and water are sent to the following Laboratories:— WATER SAMPLES:— Messrs. Rideal, Rideal & Sciver, 28, Victoria Street, S.W.1. MILK SAMPLES:— Messrs. Rideal, Rideal & Sciver, 28, Victoria Street, S.W.1. Royal County Hospital, Guildford. ICE CREAM:— Messrs. Rideal, Rideal & Sciver, 28, Victoria Street, S.W.1. 59 ADOPTIVE ACTS AND BYELAWS IN FORCE WITHIN THE URBAN DISTRICT. ACTS. Public Health Acts Amend- Parts I, II and II, so far as the ment Act, 1890. provisions thereof have not been repealed. Private Street Works Act, 1892. Public Libraries Acts, 1892/1919. Public Health Acts Amend- Sections 15, 16, 17, 18, 19, 20, 21, ment Act, 1907. 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. Part VI. Section 85 in Part VII. Public Health Act, 1925. Part II so far as the provisions thereof have not been repealed. The Coulsdon and Purley Urban District Council Act, 1937. BYE-DAWS. 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. 60 61 TABLE I.—CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1938. Disease. Number of Cases Notified. Total Cases notified in each Ward. Total Cases removed to Hospital. Deaths. At Ages—-Years. Coulsdon East. Coulsdon West. Purley. Kenley. Sanderstead. Selsdon and Farleigh. Woodcote. At all Ages. Under 1 Year. 1 and under 2. 2 and under 3. 3 and under 4. 4 and under 5. 5 and under 10. 10 and under 15. 15 and under 20. 20 and under 35. 35 and under 45. 45 and under 65. 65 and over. Scarlet Fever 71 - 2 - 4 2 39 6 6 8 3 1 - 11 30 7 3 9 8 3 59 - Diphtheria 10 - - 1 - - 5 1 - 2 1 - - - 3 - - 2 5 - 10 - Enteric Fever 5 - - - - — 1 - - - 1 1 2 - 3 - 2 - - - 1 — Eryspelas 13 - - - - - - - - 2 3 3 5 4 3 3 2 — - 1 1 - Puerperal Pyrexia 5 - - - - - - - - 3 2 - - — 2 — 1 1 1 - 5 - Ophthalmia Neonatorum 1 1 - - - - - - - - - - - - - - - 1 - - 1 - Pneumonia 12 - - - - - - - - 1 5 4 2 7 3 1 - - 1 - - *15 Dysentery 2 - - - - - - - - - - - 2 - 2 - - - - - - - Acute Polio-myelitis 1 - - - - - 1 - - - - - - - - - - 1 - - 1 — Totals 120 1 2 1 4 2 46 7 6 16 15 9 11 22 46 11 8 14 15 4 78 15 * All forms. 62 TABLE II.—THE MONTHLY INCIDENCE OF INFECTIOUS DISEASE. Disease. Jan. Feb. March. April. May. June. July. August. Sept. Oct. Nov. Dec. Total. Scarlet Fever 2 8 14 5 12 2 5 3 4 4 8 4 71 Diphtheria - 2 1 2 - 1 - - 4 - - - 10 Enteric Fever 1 1 — - - - - - - 1 2 - 5 Erysipelas 2 1 3 2 4 - - - 1 - - - 13 Puerperal Pyrexia — 1 - - 1 - - 1 — 1 1 - 5 Ophthalmia Neonatorum - - - - - - - - 1 - - 1 Pneumonia — 1 3 2 3 - — 1 1 — 1 - 12 Dysentery - - 1 1 - - - — — — - - 2 Acute - - - - - - - - - - - - - Polio-myelitis - - - - - - - — — — 1 — 1 Totals 5 14 22 12 20 3 5 5 10 7 13 4 120 63 TABLE III.—INFECTIOUS DISEASE NOTIFIED EACH YEAR SINCE 1917. Disease. 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938[ / Small Pox - - - - - - - - - - - - 2 2 3 4 - - - - - — Scarlet Fever 20 10 55 129 136 59 40 58 35 48 74 94 125 69 45 29 69 119 124 117 62 71 Diphtheria 17 4 26 44 62 70 27 101 14 17 11 23 26 17 8 21 16 24 52 35 8 10 Erysipelas 12 8 12 5 8 9 2 12 10 4 13 8 3 11 8 11 23 17 11 12 14 13 Typhoid & Paratyphoid Fever 18 73 31 15 5 16 11 5 24 9 9 9 6 4 4 7 5 5 1 3 26 5 Cerebro-spinal Fever 3 1 - - 1 - - - - - - - 1 - - - - - 1 1 - - Puerperal Fever 1 1 - - 2 - - - - 1 - - 1 - 1 1 - 1 1 1 5 - Puerperal Pyrexia - - - - - - - - - - 1 1 1 1 3 5 1 2 1 - 2 5 Poliomyelitis — - 1 1 - 1 - 1 - — 1 1 - 1 - 2 - 1 1 - 3 1 Polio-encephalitis - - - - - - - - - - - - - - - - - - - - 2 — Encephalitis Lethargica - - - 1 1 1 1 1 1 - 1 1 - - - 1 - - - - - - Ophthalmia Neonatorum 1 1 - 1 - - 1 - - 12 - 3 - 1 1 2 - 1 - 1 1 1 Pneumonia - - 18 8 9 21 6 16 11 - 9 7 38 11 14 29 28 20 32 13 30 12 Malaria - - 5 - - - - — - - - - - - — - - - - - — — Measles 468 33 12 - - - - - - - - - - - - - - - - - — — Dysentery - - 4 7 7 7 17 - - 1 - - 5 - - - - - 6 - 1 2 Chicken Pox — — — — — — 5 11 - - - - - - - - - - - - - - Tuberculosis— Pulmonary 17 25 28 24 12 29 16 24 14 19 25 23 22 38 44 36 44 28 30 27 36 32 Other Forms 4 2 2 2 3 5 3 6 5 2 9 4 2 7 4 6 10 17 5 3 7 10 Totals 561 158 194 237 246 218 129 235 114 113 153 174 232 162 135 154 196 235 265 213 197 162 TABLE IV.—DEATHS OCCURRING DURING THE YEAR 1938. Cause of Death. Males. Females. Total. Under 1 year. 1 and under 2. 2 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and over. Typhoid Fever,etc. - - - - - - - - - - - Measles 1 — 1 — — 1 — — — — - Scarlet Fever — - - - - - — — - - - Whooping Cough - - - - - - - - - - - Diphtheria - - - - - - - - - - - Influenza 4 5 9 1 — 1 — — 1 2 4 Encephalitis Lethargica - - - - - - - - - - - Cerebro-spinal Fever - - — - — - — - - — - Respiratory Tuberculosis 7 8 15 - - - - 3 9 3 - Other Tuberculous Diseases 1 3 4 - - - — - 2 2 - Syphilis 1 - 1 - - - - - - - 1 General Paralysis of Insane,etc. - - — — — — — — — - - Cancer 24 39 63 - — - 1 1 - 33 28 Diabetes 2 4 6 - - — — 1 - 1 4 Cerebral Hæmorrhage 6 9 15 - - - - - 2 3 10 Heart Disease 65 57 122 - — — 1 — 3 29 89 Aneurysm - - - - - - - - - - - Other Circulatory Diseases 10 20 30 - - — — — 3 7 20 Bronchitis 1 2 3 - - - — — - - 3 Pneumonia 8 7 15 3 — 1 — — 3 4 4 Other respiratory Diseases 1 2 3 - - - - - - 1 2 Peptic Ulcer 7 1 8 - - - - - 1 6 1 Diarrhœa, etc. (under 2 years) 1 3 4 4 - - - - - - - Appendicitis 3 2 5 - - - - 1 1 - 3 Cirrhosis of Liver - — — — — — — — — — — Other Diseases of the Liver - 3 3 - - - - - - - 3 Other Digestive Diseases 11 4 15 2 - - - - 7 3 3 Nephritis 8 5 13 - - - - 1 2 5 5 Puerperal sepsis — - - - - - - - - - - Other Puerperal Causes - 1 1 — - - — - 1 - - Congenital Debility, etc. 11 13 24 24 - - - - - - - Senility 3 2 5 - - — — - - - 5 Suicide 9 4 13 — — — — 2 4 6 1 Other Violence 9 5 14 1 - 1 1 1 2 4 4 Other Defined Causes 29 13 42 3 1 - 1 4 6 9 18 Causes Ill-defined or unknown - - - - - - - - - - - Totals 222 212 434 38 1 4 4 14 47 118 208 64 TABLE V.—WANDLE VALLEY JOINT HOSPITAL BOARD. Cases admitted to the Hospital during Year ended 31st December, 1938. Disease. Beddington and Wallington. Coulsdon and Purley. Merton and Morden. Mitcham. cases deaths cases deaths cases deaths cases deaths Diphtheria 15 - 10 - 33 2 76 1 Scarlet Fever 38 - 59 - 143 - 128 - Typhoid „ - - 1 - - - 1 - Erysipelas 4 - 1 - 6 1 2 1 Tonsillitis 1 — 1 - 2 - 4 — Measles - — 4 - 5 - 8 - Whooping Cough - - - - 2 - 1 - Rubella 1 — 1 - 2 — 3 — Enteritis 1 - - — - - 1 - Pneumonia 1 — - - 1 - — - Cancer of Bowel 2 1 - - - - - - Chill - - - - 1 - - - Chicken-Pox 1 - - - - - 2 - Tubercular Meningitis 1 1 - - - - 1 1 Septicæmia — - - - 1 - - - Rheumatism - - 1 — — - — - Puerperal Sepsis - - 1 - - - - - Malta Fever - — 1 — — — — - Anterior Poliomyelitis 4 - 1 - - - 2 - Mumps 1 - - - - - - - Impetigo - - — - - - 1 - Admitted with Mother - - 1 - - - 1 - Streptococcal Meningitis 1 1 - - - - - - Influenza - - - - - - 2 - Totals 71 3 82 - 196 3 233 3 65 INDEX. Page Advisory Committee 28 Ambulances 26 Analysis of Mortality 10 Ante-natal Clinics 29, 30 Area 8, 9 Bacteriological Work 27 Bakehouses 54 Bed Bugs, Eradication of 51 Birth Control 33 Birth Rates 4, 9 Births, Live, Illegitimate and Still 4, 9 Camping Sites 46 Cancer 11, 12 Causes of Deaths 10, 64 Chicken Pox 23 Child Life Protection 39 Clinics: Ante-natal 29, 30 Birth Control 33 Diphtheria Immunisation 21, 22 Infant Welfare 36 Post-natal 30, 31 School 11, 12 Toddlers 36 Tuberculosis 25 Closet Accommodation 45 Control of Infectious Disease 20 Convalescent Treatment 38 Dairies and Cowsheds 53 Day Nurseries 39 Deaths and Death Rates 4, 10, 64 Dental Treatment 38 Diphtheria 18 Diphtheria Immunisation 21 Disinfection 27 Drainage and Sewerage 44 Dysentery 20 Emergency Unit 31 Enteric Fever 18, 19 Erysipelas 19 Eye Defects 38 Factories 54, 55 Food and Drugs Act 58, 59 Food Supply: Milk 55 Meat 58 Food Preparing Places 54 Health Visitation 33, 34 Health Visitors, Visits by 34 Health Propaganda 28 Heart Disease, etc. 11 Home Helps 33 Hospitals 26, 27 Houses, Inspection of 40, 41 Houses, Inhabited 9 Housing 39, 40 Housing Statistics 40, 41 Ice Cream 56, 57 Immunisation 21, 22 Infantile Mortality 13, 14 Infant Life Protection 39 Infectious Disease: Cases notified 17, 18, 19, 61 Monthly Incidence of 62 Control of 20, 21 School Notifications 23 Page Inspection and Supervision of Food 5,7 Laboratory 27 Labatory Facilities 27 Legal Proceedings 53 Maternal Mortality 13 Maternity Cases 32 Maternity and Child Welfare: Services 28 Committee 3 Hospital Accommodation 27 Measles 23 Meat 58 Midwifery Service 33 Milk, Provision of 37 Milk (Special Designations) Order 56 Milk, Sampling of 56 Mortality: Analysis of 10 Infant 13,14 Maternal 13 Mumps 23 Non-notifiable Infectious Disease 23 Obstetric Specialists 31 Ophthalmia Neonatorum 19 Orthopaedic Treatment 37 Paratyphoid Fever 19 Pneumonia 20 Polio-myelitis and Polio-encephalitis 20 Population 8 Post-natal Clinic 30, 31 Prevention of Deafness 37 Public Cleansing 45 Public Health Committee 3 Puerperal Pyrexia 19 Rainfall 44 Rateable Value 51, 52 Rats and Mice Destruction 51, 52 Rivers and Streams 46 Sanitary Inspections, etc. 47, 48 Scarlet Fever 19 Schools 52 School Clinics 52, 53 Sewerage 44, 45 Shops Acts 47 Slaughterhouses 54 Small Pox 26 Smoke Abatement 46 Social Conditions 4,8 Staff 3 Statistics: Housing 40, 41 Vital 4,9 Still Births 4 Swimming Baths 46 Toddler's Clinic 36 Tuberculosis 24, 25 Tuberculosis Care Committee 25 Typhoid Fever 18, 19 Violence, Deaths from 12, 13 Vital Statistics 4,9 Wandle Valley Isolation Hospital 65 Water Supply 42,43, 44 Whooping Cough 23