Cou 8 URBAN DISTRICT COUNCIL OF COULSDON AND PURLEY. interim health report for 1940. Ladies and Gentlemen, In accordance with the instructions of the Ministry of Health and with a view to economy, especially in the use of paper, I beg to present to you an Interim Report on the state of the Public Health of this District curing 1940, this being my 9th Annual Report as your Medical Officer of Health. As in the case of the 1939 Report all records and statistics for the year have been prepared in the usual way and steps will be taken for their preservation, it being suggested that at the termination of the war a report could be made dealing more fully with the period during which hostilities have occurred and giving separate statistics for each year in order that the annual records should, as far as practicable, be continuous and complete. The year 1940 was the first complete year under war time conditions and it is therefore more than usually interesting to observe their effect on the health of residents. The slight fall in the Birth Rate probably reflects the very marked decrease in the population which has resulted from the air attacks made on the London region. The increased Death Rate is partly due to the number of deaths caused by direct enemy action, but even if these are excluded a slight rise has occurred. This is chiefly attributable to an increase in the death rates from heart disease and cerebral haemorrhage which have probably resulted from the increased strain and stress of the war. The Tuberculosis Death rate, which is one of the indices of the general nutrition of the population, only slightly increased, and considering the fluctuation to which it is liable in a District of this size the rise is not sufficient to suggest any deterioration in the nutrition of residents generally. Contrary to expectations the number of cases of infectious disease in the District as a whole was remarkably low, but outbreaks in three institutions, two of them associated with changes due to the War produced a higher incidence than for several years. Summarising it can be said that 1940 saw but little change in the general nutrition and surprisingly little infectious disease, but on the other hand the expectation of life was slightly reduced not only from the risks attendant on direct enemy action but also from the wearing effect of war strain. While there is little statistical evidence of ill health resulting from the effect of the air raids which were experienced very frequently during the autumn and throughout almost every night for the last four months of the year, apart from the very small minority directly injured, they undoubtedly had an effect if this was only largely psychological. The result of the early raids was chiefly the production of a state of mental depression, particularly a few days after the raids were actually experienced, when it was realised what lay ahead. This, combined with a state of tension, was increased when night raiding commenced seriously, partly due to lack of sleep. In many cases sleep was further depleted when the barrage commenced, though some found this reassuring. Hypersensitiveness to sounds, and particularly 2 those which might be associated with air raids, was noticeable in the majority while not only was the opportunity for work restricted but the ability to do so was diminished through mental fatigue. Inability to concentrate and to some extent a diminished sense of proportion wore evident especially in those who were permitted or permitted themselves only very limited holidays or periods for relaxation. Gradually, however, the majority adapted themselves in varying degrees to the new conditions. A fatalistic attitude became common, day raiding was less intense and gave comparative respite, while a steady succession of moderate nightly attacks proved less disturbing than intermittent ones. The reaction of the children was to all appearances remarkably good. Those most affected appeared to be the middle aged and those advancing to old age. The really aged appeared to accept the situation as well as the young but at all ages there was considerable variation between individuals. Apart from the spread of Scarlet Fever among the children in the shelters at Reedham Orphanage, there was no evidence in this District of ill health resulting from the actual congregation of people in all sorts of air raid shelter nightly. At the end of the year the shelter habit commenced to diminish. I am again indebted to the Sanitary Inspector and Senior Health Visitor for their assistance in preparing the sections of this Report dealing with their work, as also to the Medical Officer for Reedham Orphanage, Dr. Lindsay, and the Medical Superintendents of the two Mental Hospitals for information on the outbreaks they experienced. May I finally express my gratitude not only to my staff in the Public Health Department, who have always responded loyally and accepted extra duties wholeheartedly, but to the very many members of the First Aid Service, to which Service the majority of my time was devoted during 1940. As is to be expected a constant change of a percentage of the First Aid personnel has occurred, but the majority, who form the backbone of the Service, undertook their training zealously and in the latter half of 19-10 when called upon to do actual air raid duties gave of their best. This service has been publicly acknowledged. May I extend my thanks for the very many unadvertised forms of service they have willingly rendered the public, including the daily delivery of babies' and invalids' gas masks, manning the Hospital Out-Patient Department and Civil Ambulances, assisting in immunisation work, in conveying the midwives to their cases, in the reception of refugees, in furniture removal, etc. It is healthy, though not always officially acceptable, for the First Aid and Public Health Services to be so linked in service to the community, and it is particularly gratifying to be able to undertake jointly positive and creative work amidst so much destructive effort, the anomaly of which latter is thereby emphasised. I am, Ladies and Gentlemen, Your obedient Servant, F. R. EDBROOKE. Medical Officer of Health. September, 1941. 3 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 11,182 Registrar-General's estimate of population, 1940 50,920 Population, Census 1931 37,666 Number of occupied houses, December 1940 16,535 Number of occupied houses, 1931 9,533 Rateable Value, December 1940 £745,150 Sum represented by a penny rate £2,80L VITAL STATISTICS. Total. M. F. Birth Rate per 1,000 of the estimated resident population. Live Births - Legitimate 607 312 295 12.3 do - Illegitimate 19 9 10 626 321 305 Rate per 1,000 (live and still) births. Still Births - Legitimate 18 8 10 27.9 Death Rate per 1,000 of the estimated resident population. Deaths 588 266 322 11.5 Deaths from Puerperal causes:- Rate per 1,000 (live and still) births. Puerperal Sepsis l 1.56 Other Puerperal causes 2 3.11 Death Rates of Infants under one year of age:- All infants per 1,000 live births 37 Legitimate infants per 1,000 legitimate births 33 Illegitimate infants per 1,000 illegitimate births 158 Deaths from Cancer (all ages) 74 Deaths from Measles (all ages) Nil. Deaths from Whooping Cough (all ages) Nil. Deaths from Diarrhoea (under 2 years) Nil. 4 THE HEALTH REPORT OF COULSDON AND PURLEY IN 1940. INTERIM REPORT. 1. AREA AND POPULATION. There was no alteration in the area of the Urban District during 1940. The population of the District, however, continued to decline during the year from approximately 54,000 in January to 45,000 in December 1940, both figures including about 5,000 residents in the institutions in the District. The Registrar General's estimate of the population in mid-1940 was 50,920. By comparison the population was just under 59,000 in September, 1938. VITAL STATISTICS. BIRTHS. During the year 626 Births were registered as belonging to the District, of which 321 were males and 305 were females, as compared with 762 in 1939. This is equal to an Annual Birth Rate of 12.3 per thousand of population, as compared with 13.5 last year, and 13.4, 12.8 and 12.5 in the preceding three years. Nationally the Birth Rate was 14.6. The fall in the local rate undoubtedly reflects the voluntary evacuation from the District of a large proportion of that section of the population having or expecting the care of young children, especially during the second half of the year. There were 19 illegitimate births (9 males and 10 females) registered, this being 7 less than in the preceding year. Expressed as a percentage of total births, 3.0 were illegitimate. The number of stillbirths registered in 1940 was 18 (8 males and 10 females) this being 6 less than last year. All the stillbirths occurred in legitimate children. The local stillbirth Rate was thus 0.35 Per thousand of population, as compared with 0.55 for England and Wales. DEATHS. The number of Deaths registered during the year as belonging to this District was 588,(266 males and 322 females) as compared with 492 in 1939. The crude Death Rate for the year was equal to 11.5 per thousand of population, as compared with 8.9 last year. A slight modification, however, is necessary if the rate is to be compared with that of England and Wales, the age and sex distribution not being typical of the Country as a whole. The corrected Death Rate for 1940 thus becomes 10.9 per thousand of population. The Death Rates in England and Wales were 14.3 in 1940 and 11.9 in 1939. (All the above rates refer to civilians.) 5 CAUSES OF DEATH. HEART AND CIRCULATORY DISEASE. This was, as usual the largest group representing just under two-fifths of the total Deaths. However, 73% of these deaths were in persons over 65 years of age. CANCER. There was a considerable reduction in the number of deaths from cancer during 1940, only 12.58 per cent. of the total deaths being due to this disease as compared with an average of 17.4 for the preceding seven years. Considered in relation to population, the Cancer Death Rate was 1.45 per thousand of population in 1940, compared with 1.58 last year. VIOLENCE. Deaths from Violence (including Suicide) increased during 1940, the Death Rate per thousand of population being 1.18 compared with 0.49 for the last two years. In 1940 there were 54 deaths from Violence other than Suicide as compared with 27 last year. Of the 54 Deaths only 8 were due to road traffic accidents, while 36 were due to War operations. Deaths from Suicide decreased in number, there being only 6 (1 male and 5 female) as compared with 8, 13, 8, 3 9 and 6 in the preceding six years. The Death Rate from this cause was thus 11 per 100,000 of population, as compared with 14 last year and averages of 11 and 12 in the preceding two decades. MATERNAL MORTALITY. There were 3 deaths associated with childbirth during 1940, the Maternal Mortality Rate being 4.66 per thousand total births as compared with 2.16 for England and Wales. While the local rate is higher than in 1939, when it was 2.62, the national rata has fallen from 2.82. The deaths which occurred locally were due to embolism following childbirth in one case and eclampsia in two cases, the latter occurring in Institutions outside the Urban District. INFANTILE MORTALITY. The number of deaths occurring in children under one year of age was 23 (16 male and 7 female) as compared with 33 last year. Three of the deaths were in illegitimate children. The Infantile Mortality Rate was thus 37 per thousand registered births, as compared with 43 and 58 in the last two years. The Infantile Mortality Rate for England and Wales in 1940 was 55 compared with 50 in 1939 which was the lowest ever experienced. The neo-natal mortality rate (i.e. deaths in the first month per thousand live births) was 32 which is 3 more than last year. 6 INFECTIOUS DISEASE. But for three Outbreaks of infectious disease in Institutions in the District, the year 1940 would have compared very favourably indeed with its predecessors. A tot 1 of 284 cases of notifiable infectious disease other than tuberculosis were notified, but of these 131 related to the 3 institutional outbreaks,(20 scarlet fever, 43 paratyphoid and 68 dysentery). Had it not been for these outbreaks the number of notifications per 1,000 population would have been only 3.0 which was that experienced in 1939, than which only two lower figures have been recorded, viz. 2.8 in 1937 and 2.1 in 1938. as the institutional outbreaks have to be included, the rate per 1,000 population was nearly 5.6 but even this is less than the average rate for the decade 1915-1924, which was 6.7. It will thus be seen that the amount of infectious disease in the general population was very low, contrary to pre-war expectations, although it should be noted that until the second half of the year the effects of the war on the life of the community were slight, evacuation and the lack of ventilation accompanying the black-out being the two most marked social changes considered likely to affect the health of the community. To these were added, in the second half of the year, the strain of very frequent air raiding and the acute and prolonged herding together of people in various forms of shelter which were generally speaking well below the standard of hygiene normally enjoyed by the population. When it is considered that for many this was in addition a period of overwork, while the majority had their hours of sleep considerably reduced it is surprising that more ill health did not result. Judged by local results evacuation, as evidenced by the outbreak of dysentery at Cane Hill, and overcrowding in shelters, as occurred at Reedham, were the two social changes having the most effect on the health of the community, but both of them it will be noted were confined to "closed" sections of the population. 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 Isolation Hospital. Total Deaths. Scarlet Fever 61 52 — Diphtheria 25 24 — Typhoid 8 1 — Paratyphoid 45 1 — Erysipelas 17 4 — Puerperal Pyrexia 2 2 1 Ophthalmia Neonatorum 1 — — Pneumonia 19 — 37 Dysentery 85 — — Cerebro-Spinal Fever 8 6 — Poliomyelitis 1 — — Measles 11 — — Whooping Cough 1 — — TOTALS 284 90 38 Includes deaths from all forms of pneumonia. 7 DIPHTHERIA. After three years, during which very few cases of diphtheria occurred in the District, a slight increase was experienced in 1940 when 25 cases were notified. Nearly half the cases, however, occurred in, January, following an outbreak in Coulsdon around Christmas, 1939. In this outbreak the majority of cases occurred among adults. By March it had died out. In July a further case was notified but proved to be tonsilitis only, while in August two isolated cases occurred in children in Sanderstead and Selsdon. No further cases occurred in the District as a whole during the remainder of the year, but six cases of diphtheria were diagnosed among a series of cases of scarlet fever among the children of Reedham Orphanage between September and November. Further reference to these cases will be found in the section on scarlet fever. Fortunately, no deaths from diphtheria occurred during the year. It is hoped that with the greatly increased proportion of children who have been immunised against this disease since the end of the year that the number of cases occurring in future years will be greatly reduced. Only 140 children received or completed the full course of treatment for their immunisation against diphtheria at the two clinics established by the Council during 1940. TYPHOID FEVER. Eight cases of typhoid fever were notified during the year but all except one occurred in one of the mental hospitals in the District. The source of infection in the isolated-case could not be traced. The Institutional cases were caused by chronic carriers, inspite of the general use of T.A.B. vaccine; thus one case had only received injections 9 months previously. PARATYPHOID FEVER. Of the 45 cases of paratyphoid fever notified during 1940 only one was in the District as a whole, and again the source of infection could not be traced. Forty-three of the cases occurred in one of the mental hospitals in the month of June and were due to B. Paratyphosus B. All except one of the cases occurred in one of the blocks of buildings and was thought to have been associated with certain food but unfortunately, as so often happens, the first notification was not received until some time after the suspected food had been eaten or destroyed. Of the 43 cases notified 22 were as a result of bacteriological examination of the faeces only, the cases presenting no symptoms. One member of the staff only was affected. Four of the inmates affected died as a result of the disease. By the usual measures for Immunisation, isolation, disinfection, etc., the outbreak was limited, once it was recognised, to one block of buildings. SCARLET FEVER. The number of cases of Scarlet Fever notified during 1940 was about the average for the preceding 4 years, viz. 6l. This number would have been still smaller but for an outbreak at Reedham Orphanage between September and November in which 20 children contracted the disease. The outbreak at this institution is of interest in several respects. The first case, which was taken ill on the 12th September, was one of 32 infants who were sleeping every night in the Air Raid shelter in close proximity with each other and with approximately 79 girls. It was found that a number of the other infants had colds and sore throats at this time and owing to the very frequent raids it was impossible to segregate the children with these possibly premonitary symptoms or to determine by swabbing « 8 which were harbouring strepto cocci in their throats or noses. One of the girls was removed to Hospital on the l8th and a further five girls and one infant on the 19th all having had sore throats for one or more days before removal. Consideration was given to the possibility of Dick testing and injecting Scarlet Fever anti-toxin but the number of children was large compared with the staff available and the circumstances then prevailing locally in the matter of air raids prohibited this course of action. The 138 boys at the Orphanage who had previously mixed with the girls during the day time were kept separate and at the suggestion of the Medical Officer to the Wandle Valley Isolation Hospital it was decided to give the girls and infants 2 tablets (i.e. gr. 15) each of Sulphonamide-P daily for 3 days. These tablets were given on the 20th - 22nd September during which 3 days three more infants and three girls were admitted, one of the latter being diagnosed clinically and bacteriologically as a case of diphtheria. No further cases occurred until the 28th when a member of the Junior Nursing Staff and one boy commenced with scarlet fever. A second course of sulphonamide was therefore given to the girls and infants and a first course to the boys after which no further cases occurred among the former, but the boys having one further case on each of the 7th, 9th and 11th October a second course was given to them and the epidemic ceased. It is regretted that circumstances marred the observation of this outbreak and especially that detailed bacteriological examinations could not be made. While it is appreciated that without a comparable group who were not treated with Sulphonamide P. no reliable conclusions can be drawn, the comparatively sudden cessation of the epidemic after the use of this drug suggests the desirability of its further trial under similar circumstances. After a break of 19 days, during which 14 of the scarlet fever cases but not the case of diphtheria had returned from the Isolation Hospital, 2 cases of diphtheria occurred among the girls, followed by a further 2 eases on the 6th November and one on the 9th November. During this period regular clinical examinations of the throats were made but very few swabs were taken and no innoculations given. It is interesting to consider why this outbreak of diphtheria died out so quickly and without further cases occurring as only about 10% of this school population had then been immunised or had suffered from diphtheria previously, whereas, in 1924 no less than 90 cases of diphtheria occurred in this Institution during a similar outbreak. Possibly a number of the children carried the germs for a while without suffering from the disease, but during the spring of 1941 when general immunisation was being carried out 34 children were Schick tested Who had previously had diphtheria or been immunised and of these 3 were still Schick positive suggesting that at least some of the susceptible were not attacked although presumably exposed to infection. ' ERYSIPELAS. There were 17 notifications of erysipelas during the year as compared with 10, 13 and 14 in the last three years. Of these 7 were patients in the Mental Hospitals, the remaining 10 being unconnected cases scattered over the District. Four cases were admitted to the Isolation Hospital. No deaths occurred. PUERPERAL PYREXIA. Two cases were notified as compared with 3 last year. Both cases were admitted to the Wandle Valley Joint Hospital where they recovered. 9 OPHTHALMIA neonatorum. Only 1 case was notified and the child recovered without impairment of vision after treatment at Redhill County Hospital. ACUTE POLIOMYELITIS. Only 1 case of poliomyelitis was notified in the District. The disease was not suspected until the child had been under treatment for an orthopoedic defect for a year, hence, it can be taken that no acute case of this disease occurred in the District during 1940. CEREBRO SPINAL FEVER. Eight cases were notified during the year compared with four in 1939 and only one in each of 1935 and 1936. The local increase in the incidence of this disease represented part of a wave affecting the whole Country. Fortunately the local incidence was less than that in England and Wales, notifications being 0.15 per 1,000 civilian population compared with 0.32 in the Country as a whole. The local cases were scattered throughout the first three quarters of the year and over the District, each being apparently unconnected with either of the others. All were admitted to hospital, two going to the Redhill County Hospital, and no deaths were reported among the residents of this District. pneumonia. There were 19 notifications of acute primary or influenzal pneumonia during the. year as compared with 52, 12 and 30 in the previous three years. Twelve of the cases were inmates of the Mental Hospitals. No cases were removed to the Isolation Hospital, but 2 were treated at Purley Hospital and 1 at Redhill County Hospital. DYSENTERY. Eighty five cases of dysentery were notified, this being the largest number of cases recorded as having occurred in the Urban District, the previous highest being 17 in 1923. The cases occurred in two main groups one of 17 cases being notified in Selsdon by one Doctor. The diagnosis of these cases was not confirmed by bacteriological examination but bacilliary infection was suspected. The occurrence of a number of cases presenting gastro-intestinal symptoms at one time suggested a common cause but no common factor could be traced except the water supply which was shown to be satisfactory. The other group all occurred at one of the mental hospitals, viz. 1 in May, 1 in September, 20 in October, 40 in November and 6 in December. The organisms causing these cases were 3 or 4 types of Flexner bacilli with a few cases due to Sonne bacilli. The variety of types and the dimensions of the outbreak were due to the transfer of cases from other hospitals in London owing to air attack. MEASLES. Only 11 cases of measles were notified during the year under the Measles and Whooping Cough Notification Order, 1940, but the Health Visitors paid visits to 32 households in which cases had occurred, 20 being cases in school children and 2 in adults. No cases were admitted to the Isolation Hospital during the year. WHOOPING COUGH. Similarly, only 1 case of whooping cough was notified although 2 cases were reported upon by Head Teachers and the Health Visitors visited 11 households on this and other sources of information. One case was admitted to the Infectious Disease Hospital. It is not anticipated that the compulsory notification of measles and whooping cough will prove of great 10 assistance in. this District as in the majority of cases no Doctor is called in, while visitation following school notification of absence is too late to prevent the spread of infection. Advice on the importance of treating cases seriously in order to avoid complications is only necessary for a very small proportion of the local residents. Large scale immunisation of contacts has not so far proved practicable, but when this can be encouraged notification and Health Visitation will doubtless prove more valuable than at present. TUBERCULOSIS. The following table presents concisely the position with regard to Tuberculosis in this District during 1940:- PULMONARY. NON-PULMONARY. TOTALS. M. F. M. F. M. F. Number of cases on register 1st January, 1940. 91. 90. 18. 26. 109. 116. ADDITIONS 1940. New cases notified 18. 13. 3. 5. 217. 18. Cases removed into District. 7. 11. 1. 2. 8. 13. Restored to Register l. —. —. —. 1. —. TOTAL ADDITIONS 26. 24. 4. 7. 30. 31. REMOVALS 1940. Deaths 10. 11. 3. 2. 13. 15. Removed from District. 19. 21. 2. 6. 21. 27. Recovered. 2. 5. —. —. 2. 6. Non-Tuberculous 1. — —. —. 1. —. Total removed from Register. 32. 37. 5. 9. 37. 46. Number on register 31st December 1940. 85. 77. 17. 24. 102. 101. While the number of new cases of both pulmonary and non-pulmonary Tuberculosis notified were slightly less than in recent years, the incidence per 1,000 population was about the average. Similarly the death rates from both forms of the disease showed but little change. The only variation in the routine measures taken for the prevention of Tuberculosis was the institution of an enquiry into the methods being used by notified cases for obtaining shelter against air attack at nights. No cases likely to cause infection were found to be using the public shelters and in the few cases in which risk was being incurred through the communal use of private air raid shelters an appeal was made to adopt suggested alternative forms of protection 11 AMBU1ANCES. The arrangements for ambulances to convey infectious disease cases remained unchanged during the year, while the only alteration with regard to the civil ambulance service was that the ambulance undertaking the conveyance of the majority of accident cases was again staffed by the Fire Service, the two remaining civil ambulances continuing to be controlled by the Medical Officer of Health and staffed by First Aid personnel. The service rendered to the Public by these ambulances was maintained almost uninterruptedly throughout the year in spite of difficulties, and was in fact in certain respects improved upon through the co-operation of the First Aid Service. HOSPITALS. The infectious disease hospitals remained as in previous years and provided adequate accommodation. The general and county hospitals enlarged under the Emergency Hospital Scheme also proved adequate to the local demand. Sufficient maternity accommodation was provided at Purley and Redhill County Hospitals for cases desiring admission under the Council's Scheme. BACTERIOLOGICAL WORK AND DISINFECTION. No alterations were made in these branches of the service. HEALTH PROPAGANDA was continued through the Health Visitors, and some use was made of contact with the A.R.P. Services and public shelters for disseminating information. MATERNITY AND CHILD WELFARE. ANTE-NATAL CLINICS. These were continued as before the War and 207 new cases attended at the 70 sessions held. While the number of cases was 41 less than in 1938, the proportion of the total births was the same, namely one third. Arrangements for the provision of dental treatment, home helps, sterilised dressings, etc., were continued as previously, as was also the free milk scheme for necessitous cases until largely superseded by the Government Scheme. POST NATAL CLINIC. This was held as in 1939 but in practice, as ante and post-natal cases attend all sessions indiscriminately irrespective of the name of the clinic, there would appear to be no useful purpose served by preserving this name for one session a month. All clinics might be better described as Ante-Natal and Post-Natal Clinics or simply Maternity Clinics. The diminution in post-natal attendances at all centres during 1940 was more marked than in the case of the ante-natal visits possibly due to more mothers leaving the District after their babies were born than before that time, while the frequency of day raiding during the second half of the year probably had some influence. EMERGENCY UNIT. The services of this unit were not required during the year. OBSTETRICAL SPECIALISTS. The specialists available were the same as in recent years and one of them was called in on five occasions, operating subsequently on one case. The decision not to attempt to recover fees for these services from the patients, originally made in September, 1938, was continued throughout 1940. 12 MATERNITY CaSES. Curing the year 62 cases were confined in Purley Hospital and 98 at Redhill County Hospital under the Council's Scheme, the former number being two less than and the latter the same as in 1939. The system of charging was not varied during the year. Reduced ambulance charges continued to be made for those cases whose confinements were arranged through the Council' Scheme. MIDWIFERY SERVICE. The two Midwives employed by this Council attended 96 cases during the year compared with 87 in 1939. In common with other midwives they are to be commended upon the way in which they continued their work disregarding the dangers of air attack. The Council Midwives had the additional disadvantage of having no means of transport at night as vehicles could not be hired and no cars have been provided for their use. In spite of strong representations on the matter it was not until 1941 that a means of transport was found for them. HOME HELPS were provided in 26 cases, this being 8 more than in 1959. BIRTH CONTROL. Arrangements with the Croydon Clinic continued as in recent years. HEALTH VISITATION For the first time the Council had the services of four Health Visitors for a full year and the number of visits paid increased from 6,677 in 1938 to 9,192, this figure including 540 first visits to babies, 1,910 visits to babies under 1 year, 5,724 visits to children from 1-5 years, 350 visits to cases of Tuberculosis and 118 visits to Refugees. INFANT WELFARE CENTRES. The six infant welfare centres established by the Council were opened for 237 sessions, during 1940, this being 2 less than in 1958, but the total number of new cases which attended was exactly the same. With a diminishing child population and the difficult circumstances under which the centres were held during the second half of the year, it was to be expected that the attendances would show a corresponding decrease. Actually this was most marked in the reduction in the number of attendances made by old cases, these being 6,126 fewer than in 1958. Those who did attend saw the Doctors more frequently, as there were 3,243 consultations which is only 279 less than in 1958. The average attendances at the Centres were Brighton Road, Coulsdon, 48; Rickman Hill, 40; Old Coulsdon 38; Kenley, 43; Selsdoa, 50; and Sanderstead, 54. Ten children were referred to hospital for treatment including minor operations and two were referred for orthopaedic treatment. TODDLERS CLINICS. Special sessions were devoted to the inspection and welfare of toddlers at four of the centres during 1940, this being the first almost complete year of this work. Forty-four sessions were held compared with twentythree in 1939, 237 toddlers being examined (10 less than in 1939) and 215 re-examinations made (29 in 1939). The staffing of the Centres was unaltered during 1940. SUPPLY OF MILK. The usual scheme for the provision of dried or liquid milk continued until the Autumn when the Government introduced its scheme for the provision of liquid milk at reduced cost for all children under 5 years of age whose parents applied for the same and also for Ante-natal or Nursing Mothers. It was apparent from the first that this would involve considerably more administrative and clerical work than hitherto, the 13 distribution being irrespective of the means of the family if the full but reduced cost of the milk is paid. Also a nodical certificate is no longer required, it being acknowledged that all children, and Ante-natal or Nursing Mothers must have cow's milk. The Food Officer therefore appointed Mr. Harrison as Milk Officer, who, although he has worked in the closest co-operation with the Public Health Department has administered a separate Department. During 1940, approximately 2,700 persons were supplied with milk under the Government Scheme. After the introduction of the latter the local Council confined its spending to the provision of extra milk for cases in which more than 1 pint per day was considered desirable and the parents were unable to pay the full cost of the extra milk required. During the year the Council supplied 4,118 gallons of liquid milk free of cost and also distributed 473½ lbs. of dried milk. DENTAL TREATMENT. The scheme for providing dental treatment for AnteNatal and Nursing Mothers and children under 5 years of age was continued throughout 1940 but only 67 cases received treatment compared with 76 and 90 in the last two years. DAY NURSERIES. The Purley and Coulsdon Day Nurseries were enabled to re-open in 1940 after shelters had been provided by the Council, but their total attendances were reduced owing to war influences from 13,044 in 1938 to 5,768. CHILD LIFE PROTECTION. Inspections under Section 209 of the Public Health Act 1936 continued uninterruptedly, 24 foster mothers being under supervision and 41 children distributed among their homes. The conditions found were generally satisfactory. HOUSING. The total number of houses inspected during 1940 including inspections under the Housing Act 1936 was 310, the number of inspections for the purpose being 315. A total of 128 dwelling houses were found not to be in all respects reasonably fit for human habitation but 85 of these were rendered fit in consequence of informal action. Notices were served as follows:-under the Housing Act 1936, 1,(rendered fit by Local Authority in default of owners); under Public Health Act, 23,(9 rendered fit by Local Authority in default of owners. Two new cases of overcrowding were discovered during the year but both were abated, together with 3 of the 6 cases known to exist at the begining of 1940. Thirty two persons were concerned in the five cases relieved, while 25 persons in 3 families occupied the 3 houses still overcrowded at the end of the year. WATER SUPPLY. No alterations in the sources of supply were made during 1940. As a result of enemy action more samples were examined than usual, 9 bacteriological and 4 chemical examinations being made, but all reports were satisfactory. Both companies continued their practice of maintaining a fairly high percentage of free chlorine and very careful measures were taken to prevent infection resulting from injury to mains, the Public Health Department co-operating in the observation of results. There was no shortage of water during the year to the District as a whole and although 36 samples were examined by 14 the Department in no case was it found that the statutory maximum degree of hardness had been exceeded. DRAINAGE AND SEWERAGE. No extensions to the public sewers were made during the year. Repairs to damaged sewers and drains were effected as rapidly as possible. CLOSET ACCOMODATION. The situation with regard to closet accommodation was altered but little during 1940, very little drainage work being practicable. Four pail closets were converted to water closets and connected to the sewers. PUBLIC CLEANSING. The collection of house and trade refuse proceeded on similar lines to those of previous years. The disposal of the refuse was complicated by the hours of black out diminishing the time during which burning could be undertaken, while the great diminution in the proportion of combustible matter, especially waste paper, increased the difficulties. Residents can assist in solving this problem by disposing of as much fine ash, damp vegetable matter, etc., in their own gardens. SMOKE ABATEMENT, RIVERS AND STREAMS, SHOPS, SCHOOLS AND SWIMMING POOLS presented no special problems, the use of the last named by the firefighting services preventing their normal use, hence no samples of the water were taken. SANITARY INSPECTIONS ETC. Compared with 1939 there were 107 fewer complaints received and 1,586 fewer inspections made; 79 fewer defects had to be reported, while 539 fewer defects were remedied. These figures very largely reflect the fact that the population was considerably reduced during the year while the staff of the Sanitary Inspectors was also reduced by the calling up of one of its members. Working often under difficulties, however, no complaint failed to receive prompt attention, while all the most essential routine inspections were made. ERADICATION OF BEDBUGS. Fewer cases of infestation were found, only two Council houses and two other houses needing to be disinfested. This was carried out privately. RATS AND MICE DESTRUCTION. Continued activity was sustained in this respect; 48 complaints were received, 215 visits made, 43 premises were found to be infested and by the end of the year 39 premises had been satisfactorily cleared. LEGAL PROCEEDINGS. No legal proceedings were taken curing the year REGULATED TRADES. DAIRIES AND COWSHEDS. The dairy farms in existence at the end of 1940 were the same as in recent years One additional farm was licensed by the Surrey County Council as "Accredited" under the Milk and Dairies (Special Designations) Order 1936, making two farms so licensed in the District. 15 At the end of the year there were 10 registered dairies, one new dairy having been registered during 1940, while the number of registered retailers was 29, compared with 44 in 1938, 16 of whom are outside the District. SLAUGHTERHOUSES. There are two slaughter-houses within the district both of which were licensed. Owing to the centralisation of slaughtering under the Government Scheme no slaughtering occurred at these two slaughter-houses after 15th January, 1941, and as a result the total animals slaughtered was only 66. Licenses to slaughter animals were issued to six slaughtermen. BAKEHOUSES. During the year one Bakehouse closed down leaving seven which are mostly used for making bread and confectionery. At twenty-two other premises confectionery is made for sale on the premises. Generally speaking the premises are kept in a c1eanly condition. OTHER FOOD PREMISES. As one fish frier ceased to carry on business during the year, the number now remaining is three. Fish frying is not scheduled as an offensive trade in this district. The canteens set up for supplying food to the Civil Defence Services throughout the District are periodically inspected, as are all shops, kitchens of restaurants, tea rooms and other places where food is prepared or sold. FACTORIES. There are 146 factories and 17 workplaces within the Urban District. A total of 236 inspections were made, viz:117 inspections were made of factories with mechanical power, 10; of factories without mechanical power and 12 of other premises under the Act. Defects found totalled 21 and 24 were remedied viz;- want of cleanliness 7, (8 remedied), insufficient conveniences 2,(3 remedied) and other offences 12,(13 remedied). (The excess in the number remedied refers to cases arising in 1939.) INSPECTION AND SUPERVISION OF FOOD. MILK. During the year 67 samples of milk were submitted for bacteriological and microscopical examination. Five biological examinations were made and twenty-two samples of pasteurised milk were submitted to the phosphatase test. Eight samples proved unsatisfactory bacteriologically but repeat samples taken after warnings had been given generally proved satisfactory. Post mortem examinations of the guinea pigs failed to reveal any evidence of tuberculosis in the five samples tested biologically. Of the 22 samples of pasteurised milk submitted to the phosphatase test 16 were satisfactory. 16 One licence was granted under the Milk (Special Designations) Orders 1936-8 for the pasteurising of milk and twelve samples of this milk were submitted for examination. Of these ten were satisfactory and two had a total count above the prescribed limit. Seven phosphatase tests of this milk were below 2.3 Lovibond Blue units and two slightly above. Investigation of the cause of the latter showed a defect in the mechanism which when remedied resulted in satisfactory pasteurisation. During the year the Council granted the following licences to sell Milk under the Milk (Special Designations) Orders l936-8. Ordinary. Supplementary. Tuberculin Tested 8 7 Accredited 2 — Pasteurised 11 3 ICE CREAM. During the year seven samples of ice cream were taken. This was twenty-two samples less than in the previous year owing largely to the effect of the war both on manufacture and consumption. All seven results were very satisfactory. MEAT. As slaughtering ceased at the two licensed slaughterhouses in the district after 15th January, 1940, the number of carcases killed and inspected was small, viz. 1 calf 47 sheep and lambs and 18 pigs. Wo part or organ of any of these was condemned. The following unsound food was, however, destroyed during the year:- Meat and fish 450 lbs. Other foods 143 lbs. FOOD AND DRUGS ACT, 1938. The powers under this Act were taken over by the Council from the Surrey County Council in October, 1939 and the following table shows the samples taken during the year. In all cases of adulteration etc. warning letters were sent. Articles. Analysed. Adulterated or Deteriorated. Prosecutions. Convictions Formal informal Total Formal Informal Total Milk 43 — 43 4 — 4 Butter 7 — 7 — — — Margarine 4 — 4 — — — Lard 4 — 4 1 — 1 Sugar 1 — 1 — — — Sausages 10 — 10 — — — Jam 1 — 1 — — — Bread 7 — 7 — — — Mincemeat 1 — 1 — — — Vinegar, Malt 7 — 7 3 — 3 Bread & Butter 6 — 6 1 — 1 Cheese 1 — 1 — — — Coffee 3 — 3 — — — Confectionery 4 1 5 — — — Cream 2 — 2 — — — Custard Powder 2 — 2 — — — Dripping 4 — 4 — — — Flour 2 — 2 — — — Lemonade Crystals 1 — 1 — — — 17 FOOD & DRUGS ACT. 1938. Articles. Analysed. Adulterated or Deteriorated - Prosecutions Convictions. Formal Informal Total Formal Informal Total Lemon Barley Water 1 — 1 — — — Meat Paste 1 — 1 — — — Milk, Condensed 1 — 1 — — — Pears, tinned 1 — 1 — — — Pineapple Cubes 2 — 2 — — — Rice, Flaked 1 — 1 — — — Sardines 6 — 6 1 — 1 Spice, mixed 1 — 1 — — — Sponge mixture 1 — 1 — — — Tomatoes, tinned 1 — 1 — — — Arrowroot 1 — 1 — — — Beer 2 — 2 — — — Cocoa 2 — 2 — — — Cooking Fat 3 — 3 — — — Egg Powder 1 — 1 — — — Fish Paste 1 — 1 — — — Ginger Wine 1 — 1 — — — Herrings, tinned 2 — 2 — — — Honey 2 — 2 — — — Macaroni - 1 1 — — — Oatmeal 1 — 1 — — — Oxtail Soup Powder 1 — 1 — — — Sago 2 — 2 — — — Shredded Suet 2 — 2 1 — 1 Sultanas 1 — 1 — — — Beef, minced 2 — 2 — — — Cake Mixture 1 — 1 — — — Dried Fruit 1 — 1 — — — Fish Cakes 2 — 2 — — — Golden Glucose — 1 1 — — — Peanut Butter 1 — 1 — — 1 Whiskey 3 — 3 — — — Meat 2 — 2 — — — Beef Suet 1 — 1 — — — Black Pudding 1 — 1 — — — Breakfast Sausage 1 — 1 — — — Coffee Cream 1 — 1 — — — Cornflower 1 — 1 — — — Ground Almonds 1 — 1 — — — Lemon Jelly 1 — 1 — — — Mixed Candied Peel 1 — 1 — — — Pepper 1 — 1 — — — Sauce 1 — 1 — — — Soup Powder 1 — 1 — — — Table Salt 1 — 1 — — — Tea 1 — 1 — — — Tinned Peas 1 — 1 — — — Treacle 1 — 1 — — — Totals 175 3 178 12 — 12