THE HEALTH REPORT QF COUILSDON & PURLEY FOR 1941. INTERIM REPORT. Ladies and Gentlemen, In accordance with the instructions of the Ministry of Health I beg to present to you an interim report on the state of the Public Health in this District during 1941, this being my tenth Annual Report as your Medical Officer of Health. As in,the previous two years the full report has been prepared, including all records and statistics, steps being taken to ensure their preservation, with a view to the publication of a complete report after the War covering the period of its duration. This year not only has the necessity for economy in paper been emphasised but also the need for avoiding the publication of statistics which might not be desirable in the public interest. As a, result not only has the section on population been omitted, but statistics from which this could be acuced have been avoide, e.g. the Birth Rate, Death Rate, etc., arc given but not the actual number of Births, Deaths, etc. Reviewing conditions during 1941, as residents we have much for which to be thankful. The continuous raiding experienced during 1940 gave place to heavier but less frequent attacks until May, 1941 after which raiding ceased, resulting in a diminution in the conditions likely to prejudice the health of the public and the return to a more normal ay of life. In common with the rest of the London region the reduced risk of air attack contributed to the return of a proportion of those previous evacuated thus influencing not only the size of the population but its age ana sex distribution. It might have been expected that this movement of population and especially. the congregation of persons in the Services with their periodical contacts with civil life would have fostered the development and sure of infectious disease. Such did not however, materialise to any great extent and, as will be seen in the report, with the exception of a few diseases, the year's record was one of the best experienced. The only widely spread infectious diseases were Measles and, to a lesser extent, Whooping Cough, but for an epidemic year the numbers of cases of these diseases were not surprising. A large number of cases of Dysentery was notified but these were, all associated with the two large mental hospitals in the District. From the local figures alone one would be reluctant to deduce an increase in Tuberculosis but against the background of the national tendency some deterioration must probably be accented as having occurred. There was a slight recovery in the local Birth Rate during 1941. On the other hand the Death Rate slightly increased, probably reflecting the tendency to a rather older population than before the War. This is also probably at least part of the reason for an increase in the Cancer Death rate. It is pleasing to note an improvement in the Maternal Mortality-Rate, but unfortunately the Infant Mortality Rate was higher than would be wished. To some extent at least this increase can be attributed to the influence of the war. The year 1941 will stand out for those interested in Public Health matters as the year in which the national campaign against Diphtheria w. s. launched. Intense activity was evident locally the results of which can be summarised as follows:- At the beginning of the year only 1 in 14 of the children from 1 to 5 years of age and 1 in 10 of these from 5 to 15 years had been immunised, but by the end of the year 1 in 5 of the younger children and more than 1 out of every 2 older children had been treated. These figures have since been improved upon, but while there are grounds for congratulation it is to be regretted that the number of parents of young children who avail themselves of this offer of free preventive treatment is so small. Attention is at the present time again being focussed on the great need for early immunisation against this disease. -2- While reporting on this aspect of the work during 1941, it is fitting that record should be made of the closer co-operaticn with the School Medical Service which resulted from this work, and which has continued since. One would wish to take this opportunity not only of expressing one's appreciation of the assistance rendered by the staff of the Public Health Department throughout the year, and particularly that of the Senior Health Visitor and Sanitary Inspector in preparing this report, but also of expressing thanks for the co-opration of the staffs of theCounty Health and Education Departments, the General Practitioners ana the personnel of the Civil Defence Casualty Services. One of the good results of war-time conditions has been a closer linking up of the agencies sharing the responsibility for the health of the District which tendency it is hoped will continue in the future. During 1941 the responsibility for the local Ambulance Service passed oficially to the Medical Officer of Health, while more recently permission has been received to utilise other Civil Defence Services in the Public Health activities of the Council. locally willing assistance has always been forthcoming for such service and this report would be incomplete without appreciative reference not only to the ambulance personnel but to those members of the Civil Defence Casualty Services who have assisted in many ways, including the Diphtheria Immunisation campaign and the conveyance of midwives, in hospital work and the blood transfusion service, and more recently in connection with the- Day Nurseries and the treatment of Scabies. May all the self-sacrificing efforts of the present augur well for the post-war era. I am, Ladies and Gentlemen, Your obedient servant, F. R. EDBR00KE. Medical Officer of Health. November. 1942. STATISTICS. Area (in acres) 11,182. Number of occupied houses, December, 1941 15,500. Number of occupied houses, 1931 9,533. Rateable Value, December, 1941 £741,754. Sum represented by a penny rate £2,849. Birth Rate per 1,000 of the estimated resident population 12.6 Still Birth Rate per 1,000 (live and still) births 32.6 Death Rate per 1,000 of the estimated resident population 11.6 Death Rate from Puerperd causes per 1,000 (live and still) births:- Puerperal and post abortive sepsis 1.68 Other Puerperal causes Nil. Death Rates of Infants under one year of age:- All infants per 1,000 live births 52 Legitimate infants per 1,000 legitimate births 46. Illegitimate infants per 1,000 illegitimate births 151 Deaths from Measles (all ages) Nil. Deaths from Whooping Cough (All ages) 2. Deaths from Diarrhoea (under 2 years) 2. -3- THE HEALTH REPORT OP COULSDON AND PURLEY FOR 1941. INTERIM REPORT. V I T A L S T A T I S T I C S, BIRTHS. The annual Birth Rate for 1941 was 12.6 per thousand of population, as compered with 12.3 last year, and 13.5, 13,4 and 12.3 in the preceding three years. Nationally the Birth Rate as 14.2. The fall in the Birth Rate locally during the last two years undoubtedly reflected the voluntary evacuation from the District of a large proportion of the population having or expecting the care of young children during the period of air attack. This showed a tendency to return to normal during the second half of the year, 1941. The percentage of the total births which ere illegitimate was 5.7, which was the average percentage locally during the last war and twice that in 1929-34. The loca1 stillbirth rat was 0.42 per thousand of population, as compered with 0.35 last year and 0.51 for England and Wales. DEATHS. The crude Path Rate for the year was equal to 11.6 per thousand of population, as compared a with 11.5 last year, and 8.9, 7.9 8.5 and 8.5 in the preceding four years. The crude Death Rates in England and Wales were 12.9 in 1941, 14.3 in 1940 and 11.9 in 1939. Of the Deaths vhich occurred in Coulsdon and Purley, 57 per cent. were in persons over 65 years of age compared with the average of 53 per cent, for the five years ending 1939 and 45 per cent for the five years 1926-30. The present figure is not really comparable owing to the absence of younger persons in the Services, and increasing longevity should not be deduced there from. C A U S E S O F D E A T H. HEART & CI CIRCULATORY DISEASE. The percentage of deaths due to heart and othercirculatory diseases was rather less than last year, constituting under two-fifths of the total deaths. It is always hoped that the number of deaths in this group of causes will increase relatively as it includes so many dying from what is virtually old age. This year 80 per cent. were over 65 years of age at the tine of death and 47 per cent. over 75 years. CANCER. The Cancer death rate was 1.92 per thousand of population in 1941, compare. with 1.45 last year and 1.58 in 1939. This increase probably reflects in part the absence of certain of the younger sections of the population. VIOLENCEc Deaths from Violence (including Suicide) decreased during 1941, the death rate per thousand of population being 0.75 compared with 1.18 last year and 0.49 for each of the preceding the years. Of the deaths from Violence other than Suicide only 4 were due to road accidents, while 14 were due to direct and two to indirect enemy action. -4- The death rate from Suicide was 17 per 100,000 of population, as compared with 11 last year, 14 in 1939 and averages of 11 and 12 in the two decides 1915-24 and 1925-34. MATERNAL MORTALITY. The Maternal Mortality Rate was 1.68 per thousand total births as compared with 2.23 for England and Wales. The local rate has fallen this year though the national rate has slightly increased the corresponding figures for 1940 being 4.66 locally and 2.16 nationally. INFANTILE MORTALITY. The Infantile Mortality Rate was 52 per thousand registered births, compared with 37, 43 and 58 in the three preceding years. The Infantile Mortality Rate for England and Wales in 1941 was 59, in 1940, 55, while that of 50 in 1939 was the lowest ever experienced nationally. The neo-natal mortality rate (i.e., deaths in the first month per thousand live births' was 36, which is 4 more than last year and 7 more than in 1939. Eight of the deaths in infants under 1 year were associated with infections, (1 whooping cough, 5 from bronchopneumonic conditions and 2 from gastro-enteritis) all of which are regrettable as with more care they might have been prevented, As the deaths from gastro-enteritis occurred in November and De ember it is more likely that they were associated with one of the waves of this complaint which appear to occur in the early and late winter among persons of all ages rather than from fly-borne infection. INFECTIOUS D I S E A SE. The table given below of the cumber of cases of infectious disease notified during the year 1941 gives at first glance a picture of what would appear to have been by far the worst year experienced by the District in this respect, especially when it is noted that on only one occasion has the number of cases of infectious disease previously exceeded 283, namely in 1917, when 540 cases were notified, 468 of these, however, being cases of measles. DISEASE. NUMBER NOTIFIED. REMOVED TO HOSPITAL TOTALDEATHS. Diphtheria 7 6 - Enteric 12 4 - Dysentery 224 - - Scarlet Fever 39 27 - Erysipelas 27 1 - Puerperal Pyrexia 1 1 1 Ophthalmia Neonatorum 1 1 Pneumonia 32 - 26 X Acute Poliomyelitis 2 2 1 Cerebro-spinal Meningitis 6 5 - Measles 214 3 - Whooping Cough 136 7 - TOTAL. 701 57 28 . . x Includes deaths from all forms of Pneumonia. On analysis, however, it is found that in 1941 several factor-; contributed to the large total, namely the very high number of cases of dysentery, and the coinciding of waves of measles and whooping cough, which diseases have only been notifiable during the two war periods. -5- All of the Cases of dysentery, except 1, occurred in 1 or other of the 2 menta1 institutions in the, District., which institutions accounted also for 7 cases of enteric, 23 cases of erysipelas and 22 cases of pneumonia. When the influence of these factors is removed, i.e. the effect of the mental hospitals and the inclusion of two diseases not notifiable curing the inter-war period, it is found that the position in the District during 1941 compared very favourably with its predecessors In point of fact, excluding only dysentery, measles and whooping cough, the number of notifications per 1,000 population has only once been lower, namely in 1958 As evidence of the state of the health of the District during the second complete war year, during the first half of which the region was subjected to periodical air attack, the position can be recognised as having been very satisfactory DIPHTHERIA. The slight increase in diphtheria experienced locally in 1940 when 25 cases of this disease were notified did not persist, during 1941, only 7 cases being notified. As in the previous year the majority of cases were in adults, only 2 young babies of 9 and 17 months being affected. Of the 5 adults, all of whom were women, 3 were aged 21 years, 2 being nurses. None of the patients had been immunised and in no case was the source of infection traced. All were admitted to Hospital where the diagnosis was not confirmed in two instances. No deaths occurred from the disease. It would be too early to assume from these local figures that the small number of cases was directly attributable to the greatly increased proportion of the population immunised, as both in 1931 and 1957 only 8 cases were notified. Should the proportion of the population who are immunised increase, as is hoped, and the number of cases remain at a very low level, this would tend to endorse the very conclusive statistics used in support of the practice of immunisation, the evidence for which is increasing annually. The occurrence of two cases among babies and none among school children during 1941 emphasises the importance of immunisation being carried out as soon after the first birthday as is practicable. TYPHOID FEVER. There were 6 notifications of Typhoid Fever during the year of which 5 occurred in one of the mental hospitals. The remaining case occurred in an adult male in August, the origin of the disease being untraced. The diagnosis was made in a County Hospital. PARA-TYPHOID FEVER. There were 6 notifications of cases of Paratyphoid Fever of which two were resident at a local Mental Hospital, The remaining 4 cases were unconnected with one another. In no case could the origin definitely be established. Only one of the notified cases was not treated in hospital and all recovered from the disease. SCARLET FEVER. The position with regard to Scarlet Fever was very satisfactory during 1041 as only 39 cases were notified. Waves of this disease occurred locally in 1920-21, 1928-29 and 1934-36 Since 1936 the number of cases has been very consistent, viz. 62, 71, 65 and 6l, at may therefore be that the very low figure for 1941 represents the lowest level of the trough between two waves, in which case a slight increase in incidence -6- may be expected in 1942 or 1943. There was no special feature about the cases which occurred in 1941 27 of which were admitted to hospital and all recovered. ERYSIPELAS The number of cases of Erysipelas notified was 27, this being the greatest number notified locally, the previous highest being 23 in 1933, Only 4 of these cases were among the normal residents of the District, 23 being inmates of two of the local mental hospitals. There was no association between either of the 4 adults infected, one of Whom was treated in hospital. All recovered. PUERPERAL FEVER. Only 1 case of Puerperal Fever was notified during the year, fortunately a mild one. The patient was admitted to the Isolation Hospital and recovered. OPHTHALMIA NEONATORUM. One Case was notified and this being acutely affected was admitted to Whiteoaks Hospital, Swanley, where complete recovery without impairment of vision was made. ACUTE POLIOMYELITIS. Two unconnected cases of this disease were notified during the year, and removed to hospital. CEREBRO-SPINAL FEVER. Six cases, of this disease were notified, 4 being in adult males who all worked in London and two in young children. There was 110 direct connection between any of the cases, which were scattered over the District. All except one were treated in hospital and all recovered. PNEUMONIA. There were 32 notifications of cases of acute primary or influenzal pneumonia, which is slightly more than the average for the last five years. Of this number 22 occurred in the mental hospitals None of the 10 cases among the normal residents was admitted to the Isolation Hospital. MEASLES. There were 214 notifications of measles received under the Measles and Whooping Cough Notification Order 1940, this being less than half the number recorded in 1917, which was the peak year when Measles was notifiable during the last war period. By comparison with these 214 notifications received from medical practitioners, 288 were notified by Head Teachers of the public Elementary Schools, but a small proportion of these related the children living outside the District, although attending Schools in the District. Some were notified from both sources. as is to be expected in a measles epidemic, only a proportion are seen by Doctors, the including a high percentage of children under school age or attending private schools. While school notifications are confined to the Public Elementary Schools., almost all the children attending these who suffer from the disease art notified by the Teachers, hence these forms of notification are supplementary to each other. ' There were probably well oyer 300 cases in the District and of these only 3 needed to be admitted to the Isolation Hospital and no deaths occurred. -7- The Health Visitor paid 164 first visits, and 13 revisits, 64 being connected with school children. It was necessary to limit the visits owing to the large number of cases occurring at the sane time, more than half being notified in June and July. Attention was chiefly given to those families in which children under" school age were suffering from or in contact with the disease. It is very doubtful whether compulsory notification and subsequent visitation is justifiable in a District such as this particularly when notifications are frequently received too late for the visits to be of service. (On the average it was found that the Health Visitor visited on the 14th day of the illness owing to the lapse of time before diagnosis was made and notification received.) Protective immunisation is impracticable at the present time. From February until April the disease was most prevalent in Coulsdon, in June and July in Purley and Selsaon, while Sanderstead, which had missed the main, epidemic, had its cases in December, extending into 1942. WHOOPING COUGH. There were 136 cases of whooping cough notified by Doctors under the Measles and Whooping Cough Notifications Order, 1940, these being chiefly received during the last quarter of the year. From the Schools came 176 notifications, which number bears about the sane relation to the number notified by the Doctors as in the case of Measles, the same conditions applying. On analysis it is found that the degree of duplication in notification was much less than would have, been expected, only 24 names coning from both Doctors and School There was thus a tota1 of at least 286 cases. Of the 13o cases notified by Doctors more than half were children over 5 years of age. Of the cases notified by both Doctor and School, in 17 cases the schools notified before the Doctor (the average of 11 days in advance being due to 7 cases in which the Doctor delayed notification for 21 days). In the 7 cases in which the Doctors notified first the average difference in dates of notification was 7 days, only 1 case, of 3 weeks' delay having occurred. Of the total of some 3OO cases 7 were admitted to the Isolation Hospital and recovered, but two deaths occurred from this disease in Patients treated in their own homes, neither of whom was notified. The value of notification of whooping cough at the present time is even more doubtful than that of measles. Very occasionally the Health Visitors can follow up a case fairly soon after the onset but the average time which elapses is 3 weeks between the onset and visit. In nearly all the cases of whooping cough visited by the Health Visitors the Doctor had been already in attendance for some time. In the first 3 months of the year the infection was most prevalent at Selsdon, in July at Old Coulsdon, by September it was generalised with Selsdon and Coulsdon chiefly affected in October. DYSENTERY. A total of 224 cases of dysentery-were notified during the year, all of which except one occurred in one or other of the two mental institutions in the District. During the first 8 months of the year the cases, chiefly of the Flexner types of bacillary dysentery occurred solely in one of the Institutions which had had 68 cases in the latter half of 1940, the infection originating with the movement of patients from London Hospitals during the period of air attack. After the wave had died down in this Hospital and two free months had been experienced a further 10 and 2 cases occurred in November and December. A considerable amount of research was undertaken by Specialists during this period and the results published In the medical literature. At the other institution 104 cases occurre also of Flexner types, during the last four months of the year, -8- chiefly in October and November. Both waves of infection had subsided at the end of the year. There were three cases in which 10 dysentery was the terminal infection causing death. THE CONTROL OF INFECTIOUS DISEASE. The well recognised methods which Attempt to restrict the outbreak and spread of infectious disease were continued during 1941, but in the case of diphtheria a special national effort was made to reduce the loss of life caused by this very serious disease, the Ministry of Health supporting a campaign to popularise immunisation. DIPHTHERIA. IMUNISATION. Locally the Council had established two immunisation clinics in Selsdon and Purley in April 1937, and during the remainder of that year 97 children attend for treatment. In 1958 only about 50 further children were created, in 1939 about 40 and in 3940 about 120. The policy of the Council during this period was to provide free treatment for children under 5 years of age and charge only for the cost of materials (5/-) for children over that age, the chief reason being to encourage the immunisation of pre-school children, in whom the disease is most deadly. Experience elsewhere shewed that, if generally encouraged the school children would receive primary and almost exclusive attention to the detriment of the younger children for whom the risk might be increased. Moreover during this period when the proportion of children under years who were immunised was about 3 times the number of chose of school age, the scheme was made known but not over-advertised. The reason underlying this policy was that unless a good proportion of children could be expected to respond, no appreciable influence on the incidence of the disease could be expected locally and infact an increased number of cases might happen to occur, thus possibly depreciating the value of the treatment. As from 1937, to 1940 inclusive only 53 cases occurred locally, nearly half of these being at the end of the period, a poor response was anticipated, especially among the susceptible children below school age. In 1941, however, the powerful support of the Ministry of Health completely altered the position. With the arrival for the first tine of strong national propaganda it was possible to foresee a previously unobtainable degree of success. Free treatment was therefore offered by the Council to all children under 16 years of age, and, in co-operation with the Surrey County Council, arrangements were made to encourage and provide for the immunisation of all public elementary and secondary school children while at School. The result was a period of intense activity during which the local staff was augmented by parttime Doctors and the School Medical staff From the first it was decided to continue the use of Toxin Antitoxin Floccules (T.A.F.), although this meant three injections being given to each child, rather than change to the two injections of Alum Precipitated Toxoid (A.P.T.) supplied free of charge by the Government. It was felt that T.A.F. was of well-proved efficacy and was the preparation least likely ??? cause complications. From March until May the School work was chiefly undertaken by outside staff, but after that month the numerous school sessions and extra clinics were entirely staffed by Officers of the Council. After September it was decided not only to continue the extension of the campaign but to test all the children over 3 years who had received their injections some 6 months before. This work, which occupied the remainder of the year, was entirely undertaken by the Medical Officer of Health assisted by the Health Visitors and Civil Defence staff. The following tabular statements give the results to the end of 1941. -9- Clinics Number of sessions held during 1941 129 Number of children who commenced treatment during 1941. 872 Number of children who completed treatment during 1941. 920 Total number of attendances 3,404 Schools. (Public. Elementary and Secondary Schools and St.Anne's College. Total number of children attending these schools 3,867 Total number of children who received complete course at school during 1941 2,367 Number still receiving treatment at end of year 50 Number Schick tested at end of year 1,218 Number Schick negative 1,072 (89% Number Schick result slightly positive 92 (7% Number Schick result definitely positive 31 (2.8% The points worth noting are:- 1. That a total of 3,307 children were treated directly under the Council's scheme in addition to a few hundred by private practitioners. It was estimated at the end of the year,that 19% of the children under 5 years of age and 60% of the children between the ages of 5 and 15 years had received the full course of treatment. 2. While the number of clinics held was twice that in previous years the number of children treated at these sessions was 10 times as great. 3 . At the end of the year about half the school children had been Schick tested, these being those first treated. This procedure justified itself in that, in addition to nearly 3% who were definitely positive, which is about the average who normally fail to respond with T.A.F., nearly 8% of children were slightly positive. This percentage is probably attributable to the circumstances under which the treatment was provided, including the inexperience of some of the staff. Had these tests not been performed those positive would have had a lower degree of immunity than could have been expected. All these children have since had further treatment to increase their immunity. The most noteworthy feature of the year's work was that, as previously feared, the percentage of children under 5 years who obtained treatment was low. Having made an effort to immunise all the children in the District it is important to continue until as large a proportion as possible has been treated. In view of the severity of the disease in toddlers it is imperative that more should be treated, and this as soon after their first birthday as practicable. Not more than 1 in 5 of these younger children had been treated at the end of 1941, which is not satisfactory. NON-N0TIFIABLE INFECTIOUS DISEASE. The chief sources of information as to the prevalence of the group of non-notifiable infectious diseases are the death returns and notifications from the Head Teachers of the Public Elementary Schools. From the former it is noted that only four deaths from influenza occurred, which confirms the impressior that this disease was not prevalent in a severe form. Two infant deaths from diarrhoea are probably indicative of the waves of gastro-intestinal infections which pass through the District from time to time, especially during early and late winter,without statistical evidence being obtained of their presence. From the school returns it appears that neither Chicken Pox, German Measles nor Mumps were very prevalent. -10- Scabies. Only 7 cases were notified by the Head Teachers and these were isolated cases. Public attention became focussed on this disease towards the end of the year, since when much hasbeen done to eradicate it locally, as will be reported in the Annual Report for 1942. TUBERCULOSIS. In 1941 the case rate for new cases of Pulmonary Tuberculosis notified was 68 per 100,000 population, compared with 61, 56, 58 and 65 in the preceding 4 years. (The average case rates for 1915-24 and 1925-54 were 115 and 88 respectively.; Similarly the Non-pulmonary Tuberculosis case rate was 25 per 100,000 population compared with 16, .21, 18 and 13 in the preceding 4 years, the average for the above-mentioned decades being 15 and 18. The non-pulnonary death rate was 11 per 100,000 population compared with 6 in 1940 and 9 in 1939. (In the quinquennial periods 1915-34 the rates were 20, 9, 7 and 8.) Similarly the death rate from Pulmonary Tuberculosis was 55 compared with 45 in 1940 but, though higher than the 21 and 27 in the two preceding years compares not so unfavourably with the averages for the quinquennial periods 1915-34, which were 72, 57, 36 and 38. From the above it may be assumed that there is a slightly increased prevalence of this disease locally, but if one were ignorant of the trend of events nationally one would be loath to deduce a true increase in prevalence from the above figures alone, owing to the fluctuations which occur when dealing with small numbers. All the methods previously used in an attempt to prevent the spread of this disease were continued throughout the year. AMBULANCES. 1. Infectious disease. The arrangements made for the conveyance of cases of infectious disease remained unchanged during the year. 2. Accident and general cases.' During the first half of the year one of the three civil ambulances owned by the Council remained under the control of the Fire Service but after August all three ambulances came under the control of the Medical Officer of Health. Staffed by the Civil Defence Casualty Service and augmented when necessary by the Civil Defence ambulances, the service to the public has been maintained and where possible improved. The local Report and Control Centre staff have assisted in dispatching the ambulances. HOSPITALS. No major alteration was made during the year, in the hospitals providing for the needs of the District. BACTERIOLOGICAL WORK & DISINFECTION. No alteration was made in the facilities provided. LABORATORY FACILITIES. No alteration was made during the year in the laboratory arrangements for the examination of samples of water, milk and other food stuffs. HEALTH PROPAGANDA. This was continued chiefly through the Health Visitors but use was also made of suitable posters, etc., in an attempt to counter the effects of respiratory disease and popularise diphtheria immunisation. -11- MATERNITY & CHILD WELFARE. MATERNITY CLINICS. Maternity Clinics were held as in recent years, except that additional sessions had to he arranged at existing clinics, and during 1941 a total of 438 new ante-natal cases attended the 91 sessions held. This is more than double the ante-natal cases which attended during 1940 (207) and far more than during the last completed year before the War (1938, i.e. 248). In part this increase was due to the numbers coming in from outside the District for whom other arrangements had to be made during the year. Although slightly more than in 1940 the number of post-natal visits was not at all in proportion to the ante-natal visits. The post-natal mothers were probably discouraged from attending by the large numbers of ante-natal cases seeking advice but doubtless other war conditions also influenced them. Almost all ante-natal cases which attend the clinics are subsequently confined by midwives in their own homes or at Purley Hospital, or are admitted to the County Hospital, Redhill. In the latter case much closer supervision is possible, and at less inconvenience than if the patient had to travel to Redhill for ante-natal treatment. The provision of dental treatment and the supply of sterilised dressings was continued as in preceding years. Appliances are supplied to post-natal mothers when required. The issue of clothing coupons to ante-natal mothers commenced during the year and while originally undertaken by the Milk Officer for the Medical Officer of Health is now administered by the Public Health Department. EMERGENCY UNIT. Th Emergency Unit based on Mayday Hospital is still available ???ut its services have not been called upon for residents ???n this District since its Inception. OBSTETRIC SPECIALISTS. During the year one of the Obstetric Specialists was called in on 5 occasions for consultation, in 4 of which he subsequent by operated. MATERNITY C^SES. During 1941 the number of maternity cases admitted to Purley Hospital for their confinements under the Council's Scheme was 55 compared with 62, 64, 6l and 6l in preceding years. In addition 170 cases were admitted to. the County Hospital, Redhill, compared with 98 in each of the two preceding years and 64 in 1938, Owing to this increasing tendency to hospitalisation of maternity cases, which is not confined to this District, a process of selection has had to be introduced based on medical and social need. A uniform charge of 5/- per case is made for the conveyance of maternity cases by ambulance to such hospitals as are approved by the Medical Officer of Health. MIDWIFERY SERVICE. The Council's midwives attended 76 cases in their homes during the year, which is less than in the preceding year owing to the pro????onged illness of one of the Midwives. ROME HELPS. The Council has made arrangements for the supply of Home Helps in necessitous cases, and during the year 28 cases were assisted in this,way, this being two more than in 1940 and 10 more then in 1939, though still 3 less than in-1938. -12- 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 being made by the Council. HEALTH VISITATION. Since July 1939, the Council has employed four Health Visitors, who work under the supervision of the Medical Officer of Health. During the year 7,888 visits were paid by them, this being 1,204 less than in the previous year, the reduction being chiefly due to the large number of diphtheric immunisation sessions at which they had to be present (86 at schools and 129 at clinics). The number of first visits to babies was slightly less than last year, but the proportion visited, was about the same, being 82% Visitation to cases of Tuberculosis also suffered. On the other hand increased visits were paid to ante-natal cases and cases of measles and whooping cough. INFANT WELFARE CENTRES. The six infant Welfare. Centres, which have been established by the Council, were held as in the previous year, and a recovery in attendances occurred, associated with the improved position with regard to air raiding in the Urban District. There, were no alterations in the premises used or staffing arrangements, but 7 more sessions were held than in the previous year. The number of new cases attending was 717 compared with 667 in both 1940 and 1938, while the total number of attendances was 11,032, compared with 10,912 in 1940 and 17,038 in 1938. The Chief reduction on 1938, was in the number of older children attending. The number consulting the Doctors was almost the same, however, and taken, in conjunction with the Toddlers clinics indicate that more children are being seen by the Medical Officers than previously. Of the children attending, 68 were referred to Hospital for minor operations or other treatment, compared with 12 in 1940 and 41 in 1938. TODDLERS' CLINICS. The year under review was the second complete year in which special toddlers' sessions were held, at which the Doctors confined their attention to children from 2-5 years of age. The number of sessions, 46, was 2 more than in 1940, but the total number of examinations was 46 less. The reduction was very marked in the number of primary examinations, only 164 being seen compared with 237. DISTRIBUTION OF MILK. ETC. While the introduction of the Government Scheme for providing milk at reduced cost for children under 5 years of age and ante-natal and nursing mothers has involved the distribution of less milk by the Council, the Health Visitors and Doctors have had to do a considerable amount of extra work completing the forms required for this and other purposes by the Government. The Government issue of Milk, together with the special issue of fruit juices and oil to young children in the latter part of 1941 were undertaken by the Milk Officer on behalf of the Food Officer, special assistant being employed for this purpose at the Centres and Food Office. The Council has continued to supply additional milk where more than 1 pint a day is considered desirable by the Medical Officer and necessitous persons are unable to procure the same through other channels. In this way 152 lbs. of dried -13- milk and 8l pints of liquid milk were supplied tree of cost during 1941. DENTAL TREATMENT. The scheme for the dental treatment of ante-natal and nursing mothers and children under 5 years of age was continued and during the year 85 cases were treated, as compared with 67 in 1940 and 90 in 1958. DAY NURSERIES. During the second half of the year a considerable amount of attention was focussed on the question of Day Nurseries owing to the Government's need for more accommodation for the children of working mothers throughout the Country and their encouraging the establishment of additional Nurseries where required by meeting the full cost of their provision and maintenance. From the point of view of providing rapidly for the needs of such mothers it was fortunate that two voluntary Nurseries already existed in the Urban District, each being assisted financially by the Council to the extent of £250 per annum. On the other hand the Council was not so fully recompensed as it would have been had it had to establish completely new Nurseries. The attendance at both the Voluntary Nurseries had shrunk to very small dimensions during the period of sustained air attack, but as the latter diminished so the attendance increased, a waiting list resulting in both Coulsdon and Purley. Consideration was given to the possibility of enlarging the existing Nurseries the Council possibly assuming complete responsibility for each. It was eventually decided, however, at the end of the year not to disturb these Nurseries but to proceed with the provision of a War-tine Nursery situated centrally, a house in Purley being acquired for this purpose. During 1941 the total attendance at the two voluntary nurseries was 10,374 compared with 13,044 in 1938. CHILD LIFE PROTECTION. During the year 16 Foster Mothers were under supervision and 28 children distributed amongst them. This represented 8 fewer foster mothers and 13 fewer children than in 1940. SANITARY CONDITIONS. HOUSING. The total number of houses inspected during 1941, under the Public Health or Housing Acts, was 467, the number of inspections for this purpose being 517. Four houses were found in a state so dangerous or injurious to health as to be unfit for human habitation, in addition to 360 houses not in all respects reasonably fit for human habitation. As a result of informal action 249 houses were rendered fit. Proceedings under Sections 9, 10 and 16 cf the Housing Act, 1936, led to the serving of 7 notices, following which action 6 were rendered fit by the owners, while 44 notices were Served under the Public Health Act, 58 houses being rendered fit by the owners after the service of such notices during the year. Six new cases of overcrowding were reported during the year but a similar number were relieved, 52 persons being concerned. At the end of the year 3 dwellings remained overcrowded, 4 families and 24 persons being involved. One case occurred in which a dwelling house again became overcrowded after the Local Authority had taken steps for the abatement of overcrowding owing to the occupants taking lodgers. -14- WATER SUPPLY. No alteration was made in the source of the water supply. The East Surrey Water Company's supply and that of the Sutton Water Company were each examined bacteriologically four times and twice chemically. In all cases the 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. The statutory maximum limit for hardness in the water supplied by both Water Companies is 9 degrees, and 48 samples were examined by the Department during 1941 for total hardness. In no case was the maximum found to have been exceeded. RAINFALL . During the year the rainfall was 30.41 inches being slightly greater than that of the previous year. CLOSET ACCOMMODATION. Nearly the whole district is on the water carriage system, all premise's being provided with water closets except for isolated buildings, dwelling houses in outlying districts and temporary buildings, the number of which latter has increased with Civil Defence and other activities. The total number of cesspools throughout the District was approximately 165. The contents of all pail closets are collected by the Council's Tank and disposed of in the Public Sewers, as are the contents of Cesspools when emptied by this means. PUBLIC CLEANSING. The collection of house and trade refuse was continued but instead of a weekly collection it was found necessary during the year to reduce to a fortnightly collection. Salvage work also increased and two special drives for waste paper and books resulted in an additional 200 tons of this material being collected, the total income from salvage for the year being just over £4,000. Scavenging has been carried out on a modified basis in order to effect a saving in man power, and litter baskets have been placed at points adjoining the bins provided for waste food. There was no alteration in the charge for the removal of trade refuse or for cesspool emptying by the Council tank. SMOKE ABATEMENT. As in previous years this matter gave rise to little trouble. A few small chimneys occasionally cause inconvenience through carelessness or inattention to methods of firing but no serious difficulty has been experienced in preventing the recurrence of such nuisances as have given rise to complaints. RIVERS AND STREAMS. DRAINAGE SEWERAGE, SCHOOLS AND SHOPS presented no special problems during the year. SWIMMING POOLS. Only one of the swimming pools of the district was used. A sample of water was taken from this bath and reported upon adversely but a later sample was found to be satisfactory. -15- SANITARY INSPECTIONS, ETC . The number of complaints received was slightly less than in 1940 and much less than before the War. On the other hand the number of inspections made was considerably more than last year, the increase concerning almost all sides of public health work, excepting those relating to infectious disease. Sixteen disinfestations were carried out, compared with 3 in 1940. As might be expected the number of defects reported and remedied both increased, although not to the same level as before the war owing to the reduction in staff. ERADICATION OF BED BUGS. The methods adopted during recent years for the eradication of bed bugs were continued and proved satisfactory. The number of houses dealt with was,the same as last year, viz. 4, including 1 Council house. The work was carried out privately or by the Council, and no firm of public contractors was engaged. RATS AND MICE DESTRUCTION. Increased activity in this branch of the work was a feature of the year. Forty complaints were received which was 8 less than the previous year but 658 inspections were made this being three times the number of visits paid in 1940. Only 46 premises were found to be infested, and 4o premises were satisfactorily cleared during the year. The type of poison used included rat biscuit (red squill), although the supply of these soon ceased owing to the War, phosphorous preparations, barium carbonate biscuits and cyanide gas. Rat lines and traps were sometimes used but were not found to be of material value. LEGAL PROCEEDINGS. Legal proceedings were taken in two cases in respect of seven houses under the Public Health Act 1936 in connection with nuisances, Orders of the Court being made in each instance. REGULATED TRaDES. COWSHEDS AND DAIRIES. The dairy farms in existence at the end of 1941 were the same as in recent years, 2 continuing to be licenced by the Surrey County Council as "Accredited" under the Milk and Dairies (Special Designations) Order 1936. At the end of the year there were nine registered dairies, the use of one having ceased, and 3O registered retailers of whom 15 were outside the District. slaughter houses. There were two slaughterhouses within the district but neither was licenced during the year. Licences to slaughter animals were issued to two slaughtermen. bakehouses. There' were seven bakehouses in use which were used mostly for making bread and confectionery. At 26 other premises confectionery was made for sale thereon. -16- OTHER FOOD PREMISES. Three fish frying Premises were in use, one each in Selsdon, Purley and Coulsdon. Fish frying is not scheduled as an offensive trade in this district out registration of such premises under the Food and Drugs Act 1938 (Section 14) is required. The canteens set up for supplying food to the Civil Defence Services are also inspected periodically, as are all shops, kitchens of restaurants, tea rooms and other places where food is prepared or sold. FACTORIES. There were 135 factories within the District and 19 workplaces. A total of 262 inspections? were made, viz: 125 of factories with mechanical power, 117 of factories without mechanical power and 20 of other premise. Four notices were served, one on each type of Factory and two on other premises. The defects found were 12 showing want of cleanliness, 1 with inadequate ventilation and 2 with insufficient and 2 with defective sanitary conveniences. All 17 defects were remedied in addition to 12 other offences found (13 remedied) in the year. INSPECTION. AND SUPER71SION OF FOOD. MILK. During the year 62 samples of milk were submitted for bacteriological and microscopical examination, of which 50 were satisfactory as judged by the total count. Four biological examinations were made, three of which were negative, the source of the fourth being carefully investigated. ,22 samples of pasteurised milk were submitted to the phosphatase test, 22 being satisfactory MILK(SPECIAL DESIGNATIONS) ORDER. One licence was grantee for the pasteurisation of milk and seven samples were taken from this source, of which six were satisfactory and one had a total, count above the prescribed limit. Seven phosphatase tests were made, all being satisfactory. During the year the Council also granted licences to sell milk under the following designations:- Principal. Supplementary. Tuberculin tested. 5 3 Accredited. 2 0 Pasteurised. 10 3 ICE CREAM. During the year only four samples of ice cream were taken for bacteriological examination, as,owing to war conditions, very little ice cream was made by local dealers and these made it very irregularly. Two samples from one source were satisfactory. The producer of the other two samples ceased to manufacture after hearing of their inferior quality. MEAT. As slaughtering ceased at the two slaughterhouses which were formerly licenced in January 1940, no carcases were inspected except those of animals owned privately and slaughtered partly for private consumption on the authority of the local Food Office. Only 8 pigs were thus killed and inspected, the part of one carcase being condemned owing to the presence of Tuberculosis.