Annual Report of M. O. H. Please circulate as quickly as possible (1) Miss Newham (for Dr. Hutchinson) (2) Dr Norman-Smith (3) Dr. Lethen (4) Library-To retain From 26 C/Rcg. THE HEALTH REPORT OF COULSDON AND PURLEY FOR 1942. Cou 10 INTERIM REPORT. Ladies and Gentlemen, In accordance with the instructions the Ministry of Health I beg to present to you an interim report on the state of the Public Health in this District during 1942, this being my 11th Annual Report as your Medical Officer of Health. As in the previous three years the full report, has been prepared, including ail records and statistics, and steps have been [taken to ensure their preservation with a view to the publication of a complete report after the War covering the period of its duration. Again 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 deduced have been avoided, e.g. the Birth Rate, Death Rate, etc., are given, but not the Actual number of Births, Deaths, etc. Reviewing conditions during 1942, we, as residents, have very much for which to be thankful. No heavy raiding occurred, such as had been experienced in the two previous years, thus further diminishing, the environmental factors likely to prejudice the health of the public,and facilitating the return to as normal a way of life as could be expected under conditions of modern warfare. As in the rest of London, the return of further sections of the population, previously evacuated, took place, influencing both the size and constitution of the population. Thus no degree of stability comparable with even pre-war standards for this District was realised, while the calls of the services and industry accentuated these variations altering the mode of life and habits of residents. One of the most outstanding facts, with regard to the public health of the District during 1942 was the extraordinary increase in the birth rate as judged by the average local rate over a period of some years, although not by earlier national standards or those of other countries. A sudden increase of 32% on the average for the previous 5 years suggests social changes in the District, all of which are not due to differences in the type of population. The fact that this is the first time the local birth rate has been higher than the corresponding national rate is worthy of note. The increased birth rate has necessitated modifications in the Maternity and Child Welfare Service, which are reported upon in the section of this report dealing with that branch of public health work. To date, in view of the uncertainty of future developments in the economic, social and political spheres, such improvisations have been introduced as have appeared expedient, but if, as seems possible, the sudden increase in the local birth rate is indicative of more permanent changes, consideration will have to be given to more far reaching alterations in the service. While the maternal mortality rate remained low during 1942, the infant mortality rate has tended, on the average, to increase during the last two decades and approximate to the falling national infant mortality rate. That the national rate should reach a new low level record, especially during war time, is most commendable, but it is hoped that a District such as this, with social and economic advantages over many parts of the Country, will continue to set the pace, rather than be content with average results. The help of all who have the care of babies will be needed to achieve this aim. Owing to the absence of the fittest of the young adult sections of the' community, the crude death rate is of less importance than formerly since it is not truly comparable from year to year, and. might well be expected to increase with an ageing population. Locally this rate tended to fall during 1942, being rather less than in the two preceding years, although still higher than it was in the years before the War, A further result of the movements of population referred to above might well be an increase in infectious disease. It was anticipated, for example, before the War that mass evacuation would -2- result in wide-spread outbreaks. Fortunately this has not generally been the case to date, although prolonged war, especially if accompanied by deprivation, may still have such an effect. Apart from mass movements, the position locally has always been influenced by the fact that this District, whatever its advantages in other respects, is part of the greater London area, with no natural boundaries dividing it from the surrounding centres of population with which it is linked by frequent daily contacts. This intimate relationship is illustrated by the distribution of that annoying but fortunately not dangerous disease, scabies, upon which attention has been focussed during recent years. Its treatment locally is dealt with in the text of this Report, but its abolition from the District being dependant, not only on similar activity in the Services and in all parts of the Country, but on the co-operation of all affected, cannot be achieved by local or official effort alone. In spite of, or it may, in some cases, be because of these frequent contacts and movements of residents, the incidence of infectious disease has remained low in this District and in 1942, if the war-time notifications of measles and whooping cough are disregarded, together with the cases of dysentery occurring in the local mental hospitals, the prevalence of infectious disease was lower than in any previous year, except 1938 This welcome though unexpected reduction in incidence emphasises the fact that there are many contributory factors influencing the spread of infectious disease of which deliberate "control", especially if regarded in its former limited sense as being synonymous with isolation and disinfection, plays but a relatively small part. Change in the virulence of the offending germs themselves undoubtedly occurs, as witness the inoffensive character of Scarlet Fever at the present time, but these changes we cannot predict or generate at present. What can be done, by the intelligent co-operation of all, is:- (1) To improve bodily health and resistance by following the comparatively simple"laws of health" (e.g. by cleanliness, by living as far as possible in really fresh air and sunshine,-by getting sufficient sleep and relaxation combined with suitable exercise for the age period and by taking simple nourishing food): (2) To reduce the risks of heavy infection by avoiding congested surroundings, by scrupulous cleanliness, especially when dealing with foods and drinks, by treating seriously our greatest enemies, the common colds, coughs and influenza, (showing intelligence by ceasing to mix with others in the early stages, using such handker chieves as we are allowed when coughing or sneezing and, especially when dealing with young children, wearing masks temporarily): and (3) To utilise such knowledge as we possess of artificial immunisation, e.g. against smallpox and diphtheria. By such means' further progress can be achieved. When giving general consideration to these factors I would particularly draw attention to the references in this report to th influence of infection on the infant mortality rate and to the increase of Pulmonary Tuberculosis, especially among older men, and, to some extent, among young adults. It is thus, with gratitude for another reasonably satisfactory year and with a call for continued progress, that I would conclude this introduction by once-again thanking all who have co-operated in the her 1th services curing the year 1942, including the most recent recruits, the staffs of the Wartime Nurseries, the Civil Defence Casualty Service Staff, the temporary and permanent Council staffs and particularly the Senior Health Visitor, the Sanitary Inspector and my Chief Clerk for assistance ih the preparation of this Report. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient Servant, F. R. EDBROOKE. Medical Officer of Health. THE HEALTH REPORT OF COULSDON & PURLEY FOR 1942. INTERIM REPORT. STATISTICS. Area (in acres) 11,182 Number of occupied houses, Dec. 1942 15,652. Number of occupied houses, 193L 9,533. Rateable Value, December 1942 £748,669. Sun represented by a penny rate £3,053 Birth Rate per 1,000 of the estimated resident population 17.1 Still Birth Rate per 1,000 (live and still) births 31.8 Death Rate per 1,000 of the estimated resident population 10.7 Death Rate from Puerperal causes per 1,000 (live and still) births :- Puerperal and post abortive sepsis Nil. Other Puerperal causes 1.10 Death Rates of Infants under one year of age:- All infants per 1,000 live births 45 Legitimate infants per 1,000 legitimate births 47 Illegitimate infants per 1,000 illegitimate births Nil. Deaths from Measles (all ages) Nil. Deaths from Whooping Cough (all ages) Nil. Deaths from Diarrhoea (under 2 years) 1. VITAL STATISTICS. BIRTHS. The Birth Rate for 1942, was 17.1 per 1,000, as compared with 12.6 in 1941 and 12.3, 13.5, 13.4 and 12.8 for the preceding four years. The average Birth Rates locally for the four quinquennial periods from 1915-34 were 13.9, 13.5, 12.9 and 11.6. Nationally the Birth rate was 15.8 in 1942 compared with 14.2 in 1941. The sudden increase in the Birth Rate, especially locally, undoubtedly reflects the influence of war-time conditions and particularly those relating to the phase of the war through which we were passing during 1942, some of which influences are common knowledge. The percentage of total births which were illegitimate was 4.8, which is less than that in 1941 (5.7) and less than the average during the. last war though higher than the average rate which appertained 10 or 15 years ago. The local stillbirth rate was 0.56 per thousand population, compared with 0.42 in 1941 and 0.35 in 1940. The stillbirth rate for England and Wales in 1942 was 0.54. DEATHS. The crude Death Rate for the year was equal to 10.7 per thousand of population, as compared with 11.6 and 11.5 in the two previous years and 8.9, 7.9, 8.5 and 8.5 for the preceding four years. The crude Death Rates for England and Wales were 11.6 in 1942, 12.9 in 1941, 14.3 in 1940 and 11.9 in 1939. -2- Of the deaths which occurred in Coulsdon and Purley 56% were in persons over 65 years of age, compared with 57% last year and averages of 53$ in the five years ending 1939 and 45% for the quinquennial period 1926-30. The present figure is not really comparable owing to the absence of an increasing proportion of younger persons in the Services. CAUSES OF DEATH. HEART & CIRCULATORY DISEASE. The percentage of deaths due to heart and other circulatory diseases was slightly more than last year, being about 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 were 65 years of age and over at the time of death and 46% were 75 years and over, both figures being slightly less than in 1941. CANCER. The cancer death rate was 1.74 per thousand of population in 1942, compared with 1.92 in 1941, 1.45 in 1940 and. 1.58 in 1939. While there is an improvement this year, the general tendency to increase probably reflects in part the absence of certain of the younger sections of the population. VIOLENCE. Deaths from Violence, including Suicide, decreased considerably during 1942, the death rate per 1,000 of population being 0.40 compared with 0.75 in 1941, 1.18 in 1940 and 0.49 in each of the preceding two years. Of the deaths from violence other than suicide only 4 were due to road accidents (2 pedestrians, 1 cyclist and 1 motorist) while only 2 were due to enemy action (these occuring away from this District). The death .rate from Suicide was 10 per 100,000 population compared with 17, 11 and 14 in the preceding 5 years and averages of 11 and 12 in the two decades 1915-24 and 1925-34. MATERNAL MORTALITY. The maternal mortality rate was 1.10 per 1,000 total births, compared with 1.68 last year. The corresponding rates for England and Wales were 2.01 in 1942 and 2.23 in 1941. INFANT MORTALITY. The infant mortality rate was 45 per 1,000 registered births, compared with 52 37, 43 and 51 in the preceding four years. The corresponding rates for England and Wales were 49 in 1942 and 59, 55 and 50 in the preceding three years. The rate for 1942 was the lowest ever experienced nationally. While the local, infant mortality rate was slightly below the average for recent years there is still a possibility of considerable improvement, particularly by the avoidance of respiratory infections, a third of the infant deaths being due -3- to bronchitis or broncho-pneumonia. The "common cold" is a tine wasting and debilitating enough experience for adults. In the case of young infants serious illness often results from carcless exposure to the family cold, causing frequently a tendency to chronic chest trouble, even if the baby recovers. Parents and all attending young infants should treat "colds" seriously, and by isolation, wearing masks which can be easily improvised, arid similar measures do all they can to prevent babies getting colds. The death of two babies from 'drowning during the year also emphasises the need for the more general use of those, safety straps which are really effective. These too can be easily improvised and details can be obtained from the Health Visitors and similar sources. The neo-natal mortality rate (i.e. deaths in the first month per thousand live births) was 31 compared with 36 in 1941, 32 in 1940 and 29 in 1939. INFECTIOUS DISEASE. The table given below of the number of cases of infectious disease notified curing the year appears at the first glance to suggest that 1942 was the worst year experienced in this District, especially when compared with the years between 1919 and 1940. The inclusion of measles and to a lesser degree whooping cough among the notifiable infectious diseases during the war period has produced total numbers which are out of all proportion to the remaining infectious diseases and therefore rather misleading. Excluding these two diseases, the number of cases notified was 107 less than in 1941, which number represents almost exactly the reduction in the cases of dysentery. As the dysentery cases all occurred in the two mental hospitals they can be disregarded in assessing the health of the general public. The nett number of notifications excluding measles, whooping cough, hospital dysentery and tuberculosis was only slightly above that for 1938 and apart from that year, was the best recorded since 1932. When the population at risk is considered the position is seen to have been even more satisfactory, the number of notifications per 1,000 population having only once (in 1938) been better. It is very gratifying to be able to report so favourably on the position regarding infectious disease after 3 years of war conditions. DISEASE. NUMBER NOTIFIED. NUMBER REMOVED TO HOSPITAL. TOTAL DEATHS. Diphtheria 9 10 1 Typhoid 1 - - Paratyphoid 2 - - Scarlet Fever 45 42 - Erysipelas 22 1 - Puerperal pyrexia 2 2 - Pneumonia 38 1 37 x Dysentery 121 - - Acute Poliomyelitis 3 2 - Cerebro-spina1 meningitis 1 1 - Measles 479 5 - Whooping Cough 36 2 - TOTALS 759 66 38 Includes deaths from all forms of Pneumonia. -4- ENTERIC FEVER. Typhold. There was only 1 ease of Typhoid Fever notified during the year and the diagnosis was doubtful even in this case, being associated with a vague illness among other members of the family which was shewn not to be due to Typhoid. Paratyphoid. Two cases of Paratyphoid Fever were notified as occurring in one of the mental hospitals, but none in the remainder of the District. SCARLET FEVER. There were 45 notifications of Scarlet Fever received during the year, and in addition 1 case admitted to hospital as a case of Diphtheria was subsequently diagnosed to be suffering from Scarlet Fever. This was compensated for, however, by the diagnosis not being confirmed in 1 case, which was admitted as Scarlet Fever. While slightly more prevalent than in 1941, when only 39 cases occurred, the incidence was still very low compared with the moderate numbers (6l-7l) occurring each year since 1936. Towards the end of the year increased numbers of cases occurred in adjoining Districts, tending to overfill the Isolation Hospital, hence the treatment of cases at their homes had to be encouraged. Fortunately the disease continued to be of a very mild type, all cases recovering. ERYSIPELAS. The number of cases of Erysipelas notified, 22, was slightly less than in 1941 (27), the latter being the highest recorded in this District. Of the 22, one mental hospital reported 8 cases and the other 4 cases, thus leaving 10 cases among the general population compared with 4 last year. There was no association between these 10 cases, only one of which was admitted to Hospital. All recovered. DIPHTHERIA. The incidence of this disease remained at a low level during 1942, there being only 9 notifications, in one of which the diagnosis was not confirmed, compared with 7 last year and 25 in 1940. Three of the cases were in adults, one of whom had been immunised 13 years previously. All the adults recovered. The question of the efficacy of immunisation naturally arises in considering these cases but before analysing the 5 notified and confirmed cases which occurred among children it is advisable to emphasise two preliminary points, viz:- 1. In judging the efficacy of any treatment, whether curative or preventive, one must reduce the element of chance by considering the effect on the largest group of persons treated rather than generalising on the effects on a small group. Thus to suggest that the effectiveness of Diphtheria Immunisation should be judged by the comparatively small number of individuals concerned in a District such as this would be folly when statistics are available for the whole country, The latter are obviously much less likely to be influenced by coincidence and do in fact show a greatly reduced risk of contracting Diphtheria following immunisation accompanied usually by a less severe form of the disease if and when this is contracted. 2. It must be realised that diphtheria-like germs may be present in the throat of a person suffering from tonsillitis without being the cause of the latter. Two cases which occurred locally in 1942 will illustrate this point. The first occurred in a part of the District in which a large -5- number of persons were suffering from tonsillitis at the tine and the child in question, who had previously been immunised-, was one of three members of a family, all of whom had tonsillitis. On swabs being taken this child was shewn to. have diphtheria-like germs in her throat and although she was so much less ill than the other two that she was acting as their nurse, she was removed to hospital as a suspected case of Diphtheria, though not notified as a case. It is almost certain that the cause of her tonsillitis was the same germ as produced tonsillitis in the remainder of the residents of that locality. Similarly in another part of the District, one child in a family of three children, all of whom had been im unis^d against Diphtheria, developed Scarlet Fever. The following day a second child had a sore throat diagnosed as tonsillitis. As, however, this did not improve as expected the Doctor was called in again some days later and took a swab which showed diphtheria-like germs to be present. The child was notified as a case of diphtheria and removed to hospital only 1 day before the third child was removed with definite Scarlet Fever. Subsequently all three children had the typical peeling of the skin which follows Scarlet Fever> hence it was considered that the second child was incorrectly diagnosed as having Diphtheria, having only by coincidence carried the diphtheria-like germs at the time he was swabbed. It would have been additional evidence had it been possible to show that the diphtheria-like germ found in these two cases was not capable of causing diphtheria in a laboratory animal, but unfortunately in neither case could the germ be found after admission to hospital. These cases are quoted at length in order (1) to illustrate a condition which may occur more frequently as the number of immunised persons increases and (2) to refute the charge sometimes unjustly made that results are being unfairly stated when such cases are not included as suffering from Diphtheria. To turn to the five confirmed cases among children, three of these were children who had not previously been fully immunised. (One had received only 1 injection some time previously and failed to re-attend for the two further necessary doses.) Two children had been both immunised and Schick tested. In passing it may be noted that the three unimmunised cases occurred among an estimated population of 3,752 unimmunised children under 15 years of age in the district (i.e. 1 in 1250), whereas the two immunised cases were the only cases which are known to have occurred among an' estimated total of 5,046 immunised children in the district under 15 years of age (i.e. 1 in 2523). With such small numbers, however, nothing should be deduced from these figures. Useful lessons can and should be learned from the two cases occurring among the immunised children, the first of which is that, even when supported by the evidence of a negative Schick test, clinical diphtheria can occur amongst such children, although the risk of such an occurrence has been reduced by immunisation. Further, unless suspected diphtheria in a child who has been immunised is treated as promptly as it would be in an unimmunised child a fatal result may occasionally be experienced, as unfortunately happened in the first of these two local cases. Parents, nurses and doctors alike should have this possibility in mind. While Diphtheria Immunisation should therefore be encouraged in view of the reduced risks of contracting the disease and of a severe attack if the disease does occur, nobody should imagine that because a child has been immunised it cannot possibly develop diphtheria. If ill with a suspicious tonsillitis it should be as promptly and adequately treated as if it had never been immunised. (The position with regard to immunisation in the District is dealt with later in this Report.) -6DYSENTERY. A total of 121 notifications of Dysentery were received, all being from the mental hospitals, 40 from one and 8l from the other. In both hospitals the disease was of a mild type the causal organism being Flexner's dysentery bacillus. The 40 cases at one hospital were all of Type X and were limited to the first 6 months of the year. All the cases at- the other hospital were of Type Z, many being very mild and only suffering from slight diarrhoea. Here too the number of cases was diminishing in the second half of the year. PUERPERAL FEVER. Two cases of Puerperal Fever were notified, one being a mild case and the other, which was admitted tc hospital, a serious one. A further unnotified case was admitted to Hospital where both cases recovered. ACUTE POLIOMYELITIS. There were three cases of this disease notified during the year, one occurring in April and the others in September and December. The first was diagnosed and treated at home, being a very mild case. The others wore admitted to isolation hospital and subsequently to Orthopaedic Hospitals for special treatment. Only slight permanent paralysis resulted in these two cases. CEREBRO-SPINAL MENINGITIS. Only one case was notified during the year compared with six in 1941. The patient, who was an adult male, was admitted to hospital and recovered. PNEUMONIA. There were 38 notifications of cases of acute primary or influenzal pneumonia compared with 32 in 1941 and an average of 25 for the preceding 5 years. Five of the cases were patients in one of the mental hospitals and eight in the other mental hospital, leaving 25 cases among the general population, compared with 10 in 1941, One case was admitted to the Isolation Hospital. MEASLES. There were 479 notifications of Measles received under the Measles-and Whooping' Cough Notifications Order 1940, this being more than twice the number notified in 1941 (214) and Slightly more than the 468 notified in 1917, which was the peak year when Measles was notifiable during the last war period. The population at risk during 1942 was, of course, much greater than in 1917. In addition to the 479 cases notified by Doctors there were many other cases in which a Doctor was not called in, e.g. from the Public Elementary Schools came a total of 231 notifications. While many of the latter were notified by both Doctors and Schools, and the school returns included some children living outside the Urban District, the figure of 479 was undoubtedly much less than the total number of cases which occurred in the Urban District. It is considered that this was in the neighbourhood of 600 cases. Only 5 cases were admitted to the Infectious Diseases Hospital and no deaths occurred. The Health Visitors paid 178 first visits .and four revisits, 37 being connected with school children. The number of visits had to be limited awing to the large numbers of cases occurring at the same time, (three quarters of the cases occurred in the three months February - April), attention being given chiefly to those homes in which children under 3 years were known to reside, this being the age period at which complications are most likely to develop. -7- Unfortunately considerable delay usually occurs between the. onset of the disease and receipt of notification which diminishes the value of visitation. It is hoped that in future the use of placental serun nay be of help in preventing complications in soac of the younger children, but to be of value the delay in calling in a Doctor will have to be reduced. WHOOPING COUGH. There were only 36 notifications of Whooping Cough by Doctors under the Measles and Whooping Cough Notification Order 1940, these all being received in the first seven months of the year, compared with 136 in 1941, which chiefly occurred in the last quarter of that year. Of the 36 notifications 20 were in children under 5 years and 2 in adults. From the Public Elementary Schools came a total oi 13 notifications, 4 of which lived outside the District, In no case were these children notified by Doctors, so it is probable that the total number of cases in the District was about 50. The Health Visitors paid 58 first visits and 7 revisits but as the interval between the onset of the disease and the first visit was about 3 weeks on the average the value of this service was reduced usually to giving advice on convalescence. Two cases were admitted to the Infectious Diseases Hospital and nc deaths occurred from this disease locally during 1942. TEE CONTROL OF INFECTIOUS DTSEASE. The well recognised methods which attempt to restrict the outbreak and spread of infectious disease were continued during 1942, and in particular efforts were made to follow up the national campaign in favour of diphtheria immunisation launched in 1941. DIPHTHERIA IMMUNISATION. It will be remembered that the Council first established two clinics for diphtheria immunisation in 1937 97 children being treated that year and 50, 40 and 120 ir the following 3 years. Three quarters of the children then treated were children under 5 years of age. With the launching of the National campaign supported by the Ministry of Health in 1941 free treatment was extended to the schools and during that year 920 children completed treatment at the clinics and 2,367 at the schools visited by the Council's medical staff. At the end of 1941 it was estimated that 19% of the children in the District under 5 years of age and 60% of the children between the ages of 5 and 15 yea.es had received the full course of treatment. The following table states briefly the work undertaken during 1942:- CLINICS. Number of sessions held during 1942 126. " " children who commenced treatment 806. " " " " completed treatment 903. Total number of attendances 3,685. SCHOOLS. (Public Elementary and Secondary) Total number receiving complete course 546. Number still receiving treatment at the end of the year 26. Number of Schick tests made at the Schools 652. The number who completed treatment at the clinics during 1942 was only slightly less than in 1941 (via. 903 compared with 920). On the other hand, as might be expected, the number who completed treatment at the Public Elementary ana Secondary Schools was greatly reduced (546 compared with -8- 2,367) there, .being fewer children who had. not already received treatment. An enquiry at the end of the year elicited that of the children under .15 years 75% of the children attending local private schools, 77% attending the Public Elementary and 78% of the Secondary School children had been treated. In the case of the children under 5 years of age it was estimated, that at the end of the year 30% had been treated. This percentage is somewhat misleading in that treatment is only rarely commenced before children are 1 year old Disregarding the children under 1 year it is thought that 41% of the remainder had been immunised. With a floating population, however, it is difficult to obtain a very accurate figure and it may be that this is too conservative an estimate, but attention continues to be centred on this age group. The use of Toxin Antitoxin Floccules was continued throughout the year and it is very exceptional for any disturbance to follow which can be attributed to this preparation. The necessity for a third visit is a disadvantage but the percentage not completing treatment is very small indeed. The general practice of Schick testing all children over 3 years of age about 6 months after completing treatment has been continued, but in view of the recommendation of the Ministry of Health to give an additional or "boosting" dose to all immunised children when entering school, this procedure may be modified in the near future, both test and dose being given at about 4½ years of age. NON-NOTIFIABLE 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 Head Teachers of the Public Elementary Schools. From the former it is noted that only 8 deaths from Influenza occurred, which confirms the impression that this disease was not very prevalent in a severe form. One infant death from Enteritis occurred in May. From the school returns it appears that Chicken Pox was fairly prevalent in the early months of the year, reaching its peak in May, Old Coulsdon and Purley being chiefly affected. Cases of Mumps occurred throughout the year but only became very noticeable at Reedham in March and Kenley from October to December. Isolated cases of Conjunctivitis and German Measles only were noted. INFECTIVE JAUNDICE. The department became aware of a number of cases of Infective Jaundice in the latter half of 1942, chiefly through the day nurseries where a considerable proportion of the children and staff were affected. Among the children the disease was usually mild, some only showing slight diarrhoea or alteration in the colour of urine or faeces without recognisable jaundice. Among adults the attacks were much more acute and cases appeared latterly to occur at intervals of about 5 weeks. SCABIES. Attention became focussed on the increasing prevalence of Scabies among the population of the Country towards the end of 1941. During that year 7 cases had been notified by the Public Elementary Schools and had received treatment through the School Clinics. The well known method of treatment by inunction with sulphur ointment after hot baths, together with steam disinfection of clothing and bedding was found often to result in prolonged absence from school, while dermatitis was frequently caused by the prolonged uncontrolled use of sulphur. Realising that the disease was becoming more prevalent, though often unrecognised, more attention was given to other members of affected households, the Medical Officer of Health visiting personally and encouraging the treatment of all suspects and contacts, providing extra soap vouchers, etc. Some 70 cases were thus treated between January and April 1942. Contemporaneously newer methods of treatment were introduced, including derris powder, which had the advantages of being cleaner to use and cheap. The results, however, were not very encouraging until, with the introduction of benzyl benzoate and the publication of valuable research work, it was decided to establish a treatment centre at the Coulsdon First Aid Post where -9- baths could be easily and economically provided. The First Aid personnel co-operated whole-heartedly from the first and from early in May 1942 a very useful service was provided for the District at negligible cost except for that of the materials used. The efficacy of the treatment and the fact that children could return to school after their first treatment rapidly popularised the Centre and more and more cases were detected among residents, often with a history of months duration. The issuing of the Scabies Order 1942 increased the powers of the Medical Officer of Health to require the submission to examination of contacts and their subsequent attendance for treatment, if necessary, in the minority of cases who were non co-operative. The number of cases from Schools diminished rapidly and a special clinic which was established for the treatment of such cases was discontinued. More cases were sent by general practitioners who realised the value of the treatment provided. A routine gradually became established whereby cases not sent by a doctor are seen by the Medical Officer of Health who also visits and follows up all contacts who fail to attend for preventive treatment. As it has been shown that the disease can take 5 weeks to reveal itself it is important that all contacts should have one preventive treatment, usually at the time when the original case is having its second or third bath, which baths are given at intervals of 6 or 8 days. Instructions are given at the time of treatment on changing clothes, bedding, etc., and its subsequent disinfection by the patient's family at home. The discontinuance of steam disinfection since the use of benzyl benzoate has saved much inconvenience, the bedding, etc., formerly being away from the family for 24 hours at least, and much expense, as formerly it cost the Council 10/- for every load conveyed for disinfection to the Wandle Valley Isolation Hospital. Cases and contacts are encouraged to attend for inspection about 5 weeks after the completion of treatment, if necessary further treatment being provided. During the last 8 months of the year 237 persons were treated at these baths (107 adults and 130 children) almost all of whom showed some evidence of infection, A total of 695 baths were given; 40 persons were still undergoing; treatment at the end of the year or reappeared for further treatment in 1943. Of the total of 237, the single course of 2 to 3 baths proved sufficient in 175 cases. 3d of the remaining 62 (26%), return for further treatment occurred within 6 weeks in 24 cases (8 families) (10%) suggesting a relapse in some cases due to an incomplete initial course, while 38 cases (14 families - 16%) returned after 6 weeks, suggesting reinfection. In almost all the latter it was obvious that reinfection occurred owing to incomplete initial treatment of the whole household which must be considered and treated as a unit. For the early months of such a scheme in which compulsion has not been used, these results are not unsatisfactory. It is hoped that with more experience and fuller co-operation of the patients better results will be reported in future. VERMIN. Attention was given during the year to the small number of families in which it has-been found by the school nurses that head lice are more than casual residents. Again the family has to be approached as a unit and encouraged by the use of special combs which are supplied at cost price, if necessary repayable by instalments, and "Lethane" etc. to institute regular habits of cleansing. The results have not been quite so satisfactory as in the case of Scabies treatment, chiefly owing, to the lack of discomfort experienced by the infected persons, but constant vigilance is being maintained. -10- TUBERCULOSIS. The case rate for new cases of pulmonary tuberculosis notified during 1942 was 90 Per 100,000 population compared with 68, 61, 56, 58 and 65 in the last 5 years. The average case rate for this District from 1915 to 1924 was 115 and from 1925 to 1934, 88. In common with the rest of the country an increase in the incidence of this disease has undoubtedly occurred, a fact which could not be stated locally until the end of 1942. In this District during 1942 the increase was most marked among males, particularly those over 45 years of age, 2/3 of whom were over 55 years at the time of notification. Presumably this increase is due to the influence of war conditions and it might be considered if and how these can be modified. On the other hand the non-pulmonary case rate was only 14 per 100,000 population compared with 23, 16, 21, 18 and 13 in the last 5 years and averages for the decades 1915-24 and 1925-34 of 15 and 18. The death rate from pulmonary tuberculosis was 40 per 100,000 which compares favourably with 55, 43, 21 and 27 in the last four years as also with the rates of 72, 57, 36 and 38 for the four quinquennial periods 1915-34. Similarly the non-pulmonary death rate was only 8 per 100,000 compared with 11, 6 and 9 in the last three years. All the methods previously used in an attempt to prevent the spread of this disease were continued throughout the year. AMBULANCES. For Infectious Disease Cases. The arrangements made for the conveyance of cases of infectious disease remained unchanged during the year. Accident and General Cases, Similarly no alteration was made in the General Ambulance Service, which since August 1941 has been under the control of the Medical Officer of Health and is staffed by the First Aid and Light Rescue Service'. The services of the local Report and Control Centre were again utilised in despatching the ambulances. HOSPITALS. No major alteration was made during the year in the hospitals providing for the needs of the district. LABORATORY FACILITIES AND DISINFECTION. The only alteration in the above services made during 1942 was that a proportion of the samples of milk and water for bacteriological examination were sent to the E.M.S. Laboratory at Epsom College. Examinations of swabs for diphtheria and sputa for tuberculosis were carried cut as usual by the Medical Staff of the Wandle Valley Isolation Hospital. In addition an arrangement exists whereby other specimens, the examination of which is important to public health, are examined by the Bacteriologist at Croydon General Hospital. No alteration was made in the arrangements for disinfection, except those referred to under "Scabies" above. HEALTH PROPAGANDA. This was continued chiefly through the Health Visitors and by the use of selected posters, pamphlets, etc. published by the Central Council for Health Education. -11- MATERNITY AND CHILD WELFARE. MATERNITY CLINICS, Three Maternity Clinics have been established and additional sessions had to be held at these, as in 1941, owing to the increased number, of cases attending. In addition extra staff had to be employed to cope with the work, and this in spite of the fact that the County Council continued to deal with those cases which reside outside the District but were previously seen at the local Clinics. In 1942, the total number of new Ante-natal cases which attended was 431, this being only 7 less than in 1941, compared with 207 in 1940 and 248 in 1938. The actual number Of sessions held was 108 compared with'91 in 1941. As a result it was possible to see the ante-natal mothers more frequently, the total number of ante-natal visits being 2,603, which was 525 more than in the previous year. With the first consideration being given to the ante-natal mothers, it was not Surprising that the increase in the proportion of cases attending post-natally was not great. There was, however, a slight increase in the post-natal attendances from 169 in 1941 to 203 in 1942. It will be necessary to consider, when conditions become more stabilised, whether the facilities provided for post-natal examination are adequate. Almost all 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 would occur if each patient had to travel to Redhill for ante-natal treatment. Where necessary dental treatment for ante-natal mothers was arranged and sterilised dressings provided, as in preceding years, while appliances were supplied to those post-natal mothers who needed them, all the above being provided, if necessary, at reduced cost. The issue of clothing coupons to ante-natal mothers, which commenced in 1941, continued throughout the year, the scheme being administered by the Public Health; Department on behalf of the Ministry of Health. On the instructions of the latter, however, the future responsibility for this issue is to be transferred to the Food Office. EMERGENCY UNIT. The Emergency Unit based on Mayday Hospital is still available but its services have not been called upon since its inception. OBSTETRIC SPECIALISTS. During the year none of the Obstetric Specialists was called in for consultation under the Council's Scheme, although attending privately where necessary. MATERNITY CASES. During 1942 the number of maternity cases admitted to Purley Hospital under the Council's Scheme was 69, compared with 55 last year and an average of 62 for the preceding four years. In addition 203 cases were admitted to Redhill County Hospital, compared with 170 cases in 1941, 98 in each of the two preceding years and 64 in 1938. Owing to the increasing tendency for maternity cases to seek admission to hospital for their confinements, which tendency has been experienced throughout the whole Country, the process of selection based on medical and social need, which had to be introduced in view of the relative Inadequacy of hospital accommodation and nursing staff, has had to be even more stringently applied. -12- A uniform charge of 5/- per case is made for the conveyance of maternity cases by ambulance to any hospital approved by the Medical Officer of Health. MIDWIFERY SERVICE. The Council's Midwives attended 96 cases in 1942 compared with 76 cases in 1941 and 96 and 87 in the two preceding years. HOME HELPS. The Council has made arrangements for the supply of Home Helps in necessitous cases and during the year 25 cases were assisted in this way, compared with 28, 26, 18 and 31 in the preceding 4 years. In view of the fact that increasing difficulty has been experienced in finding suitable persons to undertake this work and particularly the temporary assistance made necessary by the overlapping of cases, the Council appointed a second wholetime Home Help during the year, in spite of which, however, on several occasions further temporary assistance had to be arranged. BIRTH CONTROL. Cases in which advice on birth control or family planning is considered desirable on medical grounds by the doctors at the Clinics, are referred to the Croydon Mothers' and Infants' Welfare Association Clinic in Croydon. An annual grant is made by the Council in return for which any necessitous residents so referred are provided with advice, etc., at reduced charges. HEALTH VISITATION. Since July 1959, the Council has employed four Health Visitors, who work under the supervision of the Medical Officer of Health. During the year 7,924 visits were paid by the Health Visitors. This was an increase of 56 over 1941 but still more than 1,000 less than 1940, owing to the large number of Diphtheria Immunisation sessions and other fixed appointments at which the Health Visitors had to be present. The great increase in the number of births was evidenced by the number of primary visits to babies which monopolised the attention of the Health Visitors. The number of these primary visits in 1942 was no less than 777, this being 290 more than in the previous year. Of the total births registered 91% were visited and on an average 2¼ visits were paid to each child under the age of one year, this being slightly less than the average of 3 visits per child paid In 1941. Visits paid to all other classes of cases, except cases of Measles, were reduced. Obviously it is undesirable that the visits being paid to older children and infectious disease cases should have to be sacrificed in this way for a long period and attention is being given to the matter during the current year with a view to relieving the Health Visitors from a number of their fixed appointments by the employment of civil defence personnel. This policy may have to be extended further if the present high birth rate continues. INFANT WELFARE CENTRES. The six Infant Welfare Centres which have been established by the Council were held as in the previous year. The year 1942 saw a further recovery in attendance, there being an increase of 131 new cases with a total of 848 new cases. -13- Similarly the total attendances increased by 2,144 to 12,328. These increases were equally distributed over all the Centres with the exception of Kenley where a slight reduction occurred. The total number of attendances is still well below that of 17,038 in 1938. The number of consultations with the Doctors was almost the same as in the previous year. Of the children attending, 59 cases were referred to Hospital for minor operations and other treatment, compared with 68 last year and 41 in 1938. TODDLERS' CLINICS. The year under review was the third complete year in which special toddlers' sessions were held, at which the Doctors confined their attention to children from 2-5 years of age. While the number of sessions held was 41, this being 5 less than in 1941, the total number of primary examinations of toddlers increased by 34 to 198 and re-examinations increased by 21 to 26l. These figures are, however, slightly less than in 1940. DISTRIBUTION OF MILK. ETC. The introduction of the Government Scheme for providing milk at reduced cost for children under 5 years of age and antenatal and nursing mothers has involved the distribution of less milk by the Council, but the Health Visitors and Doctors have had a considerable amount of work to do in completing the forms required for this and other purposes by the Government. The Government issue of milk, fruit juices and oil continued to be undertaken by representatives of the Food Officer, special assistants being employed on this work at all Child Welfare Centres and at the Central Food Office. DENTAL TREATMENT. The Scheme for the dental treatment of ante-natal and nursing mothers and children under 5 years of age, which was launched in 1934, was continued with its usual efficiency and popularity. During the year 100 cases were treated compared with 85 and 67 in the preceding two years and 90 in 1938. DAY NURSERIES. The Council continued to contribute generously during the year to the two Voluntary Day Nurseries which have been established in the District for a number of years. In addition the year 1942 was a landmark in that the first Wartime Nursery at Pampisford Road, Purley, was opened on the 7th April, providing accommodation for approximately 45 children. This accommodation was quickly taken up by the residents in the district, some children being brought daily by ambulance from Selsdon. The Council therefore gave consideration to the establishment of further Wartime Nurseries and plans were approved for the establishment of two new Nurseries. one at Grange Park, Old Coulsdon, and one at Queenhill Road/Byron Road, Selsdon, both since opened, with accommodation in each for 57 children. CHILD LIFE PROTECTION. During the year 25 Foster Mothers were under supervision, 41 children being distributed among them. This represented 9 more Foster Mothers and 13 more children than in 1941. s -14- SANITARY CONDITIONS. HOUSING. The total number of houses inspected during 1942, under the Public Health or Housing Acts was 488, the number of inspections for this purpose being 496. No houses were found to be in a state so dangerous or injurious to 'health as to be unfit for human habitation, but 418 were found not to be in all respects reasonably fit for human habitation. As a result of informal action 425 were rendered fit. Proceedings under Sections 9, 10 and 16 of the Housing Act 1936 led to the service of 3 notices which resulted in all 3 houses being rendered fit by the owners, while 33 notices served under the Public Health Acts resulted in 27 houses having their defects remedied by the owners and 3 by the local Authority in default of the owners. No proceedings under Sections 11, 12 or 13 of the Housing Act, 1936, were taken. Four new cases of overcrowding were reported during the year but a similar number were relieved, 34 persons being involved. At the end of the year 3 dwellings remained overcrowded, 6 families and 23 persons being concerned. In one case a dwelling became again overcrowded after the Local Authority had taken steps for the abatement of overcrowding. The latter was remedied by the provision of a council house for the sub-tenant early in 1943. 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 42 samples were examined by the Department during 1942 for total hardness. In no case was the maximum found to have been exceeded. RAINFALL. During the year the rainfall was 28.93 ins. this being 1.48 ins. less than in the previous year. CLOSET ACCOMMODATION. Nearly the whole district is on the water carriage system, all premises 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 164, the drainage of one house having been connected to the sewer. 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. -15- PUBL1C CLEANSING. There -was no alteration in the system of house and trade refuse collection during the year. The fortnightly system of collection. ihstitut.ee in 1941 was continued with special drives for Waste paper, books, rubier and non-ferrous metals. There was also no alteration in the charges for the removal of trade refuse, or for cesspool emptying. SMOKE ABATEMENT. As in previous years this matter gave rise to little trouble. Occasionally a few small chimneys 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 AND SEWERAGE, SCHOOLS AND SHOPS presented no special problems during the year. SWIMMING POOLS. Only one of the swimming pools of the district was used. Two bacteriological examinations of the water proved satisfactory. SANITARY INSPECTIONS, ETC. During the year there was a definite increase in the number of complaints received referring to nuisances of all types. The visits paid were however somewhat less than in the previous year, this being most marked in the number of reinspections of houses, etc. Piggeries, yards and drains caused a greater number of inspections, as also disinfections and inspections of static water tanks. There was a slight increase in the defects reported and remedied. ERADICATION OF BED BUGS. The methods adopted during recent years were continued throughout 1942. The number of houses infested with bugs and disinfested was one more than last year, viz: 5, including 1 Council House. RATS AND MICE DESTRUCTION. Greater activity in the destruction of rats and mice was a feature of the year. The number of complaints increased from 40 to 74, and the number of inspections made was 667 which was an increase of nine on the year 1941. 82 premises were found to be infested and by the end of the year 97 disinfestations had taken place. The methods adopted were the use of poisoned baits, chiefly phosphorous preparations and barium carbonate biscuits, and the use of cyanogas. Rat limes and traps were also used but were not a great success. LEG L PROCEEDINGS. No legal proceedings under the Public Health Act 1936 were taken during the year. -16- REGULATED TRADES. COWSHEDS AND DAIRIES. One extra dairy farm commenced to function during the year, the others being 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 10 registered dairies, this being one more than in 1941, and 25 registered retailers, 9 of whom were outside the District, these latter figures being 5 and 6 less than the corresponding figures last year. SLAUGHTER HOUSES. There are two slaughterhouses within the district but neither was licenced during the year. A licence to slaughter animals was issued to one slaughterman. BAKEHOUSES. There were 7 bakehouses chiefly engaged in the production of bread and confectionery and 29 where confectionery was produced for consumption on the premises. In addition there are other bakehouses at private institutions, schools, etc. OTHER FOOD PREMISES. Fish frying is carried on at four premises, one each in Selsdon, Purley, Coulsdon and Old Coulsdon. Fish frying is not scheduled as an offensive trade in this district but registration of such premises under Section 14 of the Food and Drugs Act 1938 is required. The canteens set up for supplying food to the various civil defence services were also inspected periodically. FACTORIES. There were 137 factories within the district and 19 workplaces, this being an increase of 4 factories during the year. INSPECTION AND SUPERVISION OF FOOD. MILK. During the year 8l samples of milk were submitted for bacteriological and microscopical examination, 54 being satisfactory as judged by the total count. Six biological examinations were made, 5 of which were negative, the source of the remaining sample being carefully investigated. Thirty-three samples of pasteurised milk were subjected to the phosphatase test, 30 being satisfactory. MILK (SPECIAL DESIGNATIONS) 0RDER. One licence was granted for the pasteurisation of milk and 7 samples were taken, all of which were satisfactory bacteriologically but one sample failed to pass the phosphatase test. During the year the Council granted the following licences to sell milk under the Milk (Special Designations Order, 1936. Principal. Supplementary. Tuberculin tested 7 4 Accredited 2 - Pasteurised 9 3 -17- MEAT. As slaughtering ceased at the two licenced slaughterhouses in January 1940 no carcases of neat were inspected except those of animals, which were privately owned and slaughtered partly for their owners' consumption on the authority of the Local Food Office. Only 8 pigs were thus killed and inspected, the carcases of all being satisfactory. UNSOUND FOOD. The following unsound foods were surrendered during the year:- Vegetables 336 lbs. Cheese 101½ " Coffee 162 " Butter 92½ " Meat 19 " Bacon 104 " Fish 509 " Tinned goods etc: 1,236¼ " 2,560¼ lbs. This amount is more than seven times the quantity, found to be unfit for human food in the previous year. Certain of these goods were collected by the Ministry of Food Salvage Department, the majority being disposed of locally for animal food and the remainder destroyed. FOOD AND DRUGS ACT, 1938. SAMPLES TAKEN DURING 1942. Articles. Analysed. Adulterated or deteriorated. Prosecutions. Con victions ] Formal Informal Total Formal Informal Total Anti-gas ointment No. 1 2 2 1 1 -do- -do- No. 2 1 1 Appella apple juice 1 1 Apple rings 1 1 Ashex flavoured spread 1 1 Aspirin tablets 1 1 Bacon 1 1 Baking powder 1 1 Batter flour 1 1 Batter mix 1 1 Beer 1 1 Betox sandwich spread 1 1 Blancmange powder 2 2 Bread 6 6 Butter 6 6 1 1 Cake flour 4 4 Castor oil 1 1 Cheese powder 1 1 Citrate of magnesia 1 1 Cocoa 2 2 Coffee 1 1 Cooking fat 1 1 Compound syrup of figs 1 1 Confectionery 1 1 Curry powder 1 1 Custard powder 2 2 Custard pudding powder 1 1 Dessert powder 2 2 Drinking chocolate sweetened 1 1 Egg substitute powder 3 3 1 1 Epsom salts 1 1 -18- Articles. Analysed. Adulterated or deteriorated. Prosecutions. Convictions. Formal Informal Total Formal Informal Total Figs 1 1 Fish cake roll 1 1 Fish paste 4 4 Flour 2 1 3 Forcemeat 1 1 Fruit puree 1 1 Fynnon salt 1 1 Head & stomach pills 1 1 Homogenised cereal 1 1 Jam 4 4 Junket powder 1 1 Lard 3 3 Lemonade powder 1 1 Lemon flavour 1 1 Maggi Bouillon cubes 1 1 Margarine 20 20 10 10 Marmalade 1 1 Meat extract 1 1 Milk 29 29 6 6 3 3 Milk dried machine skimmed 1 1 Milk evaporated 1 1 Milk condensed 1 1 Milk pudding mixture 1 1 Minced beans 1 1 Mint sauce 1 1 Oatmeal 2 2 Orange cordial 1 1 1 1 Peppermint cordial 1 1 Pepper, white 1 1 Prunes 1 1 Rice custard pudding 1 1 Rice pudding powder 1 1 1 1 Saccharine 1 1 Sage & onion stuffing 1 1 Sago 1 1 Sandwich spread 1 1 Sausage meat 3 3 Sausage rolls 1 1 Sausages preserved 1 1 Sardines 2 2 Semolina 1 1 Semolina pudding 1 1 Steak & vegetables 1 1 Soup powder 1 1 Sponge mixture 1 1 Soup 3 3 Stewed steak canned 1 1 '546' soft drink 1 1 Tinned beetroot 1 1 Tomato sauce 1 1 Vironita 1 1 Whisky 1 1 162 4 166 20 1 21 3 3