THE HEALTH REPORT OF COULSDON AND PURLEY for 1945. Cou 11 I ERIK REPORT. Ladies and Gentlemen, In accordance with the instructions of the Ministry of Health I beg' to present to you^ari. interim Report on the state of the Public Health in this District during 1943 this being my 12th Annual Report as your Medical Officer of Health. It will be noted that for the fourth year in succession only an abbreviated report is being circulated in the interests of public safety and paper economy, but, the full report having been written and preserved each year, it is hoped that it will not be long before a comprehensive report covering the war time period will' be authorised. Reviewing conditions during 1943 it can be said that the general situation was very similar to that of 1942. Comparatively little enemy air activity disturbed the life of the community except, for a few isolated and heavier night raids towards the end of the year. As. in the remainder of London, further sections of the population, previously evacuated, returned, while the steady drain into the Services and industry appeared to slacken somewhat. In a district such as this there is always a constant movement of an appreciable proportion of the population, but life continued as normally as could be expected in war time, diminishing the adverse environmental influences upon health. In 1942 it was noted that the Birth Rate had suddenly increased by a third over the average for the previous five years and for the first time ???eeeded the national rate. In 1943 there was a further slight rise, this rate being still well above that for the whole country, though not quite to such a marked degree. Further modifications of the Maternity and Child Welfare Services were called for as a result, some materialising during the year but others being deferred until 1944. The Maternal Mortality Rate was even lower than in the preceding year and the Infant Mortality Rate, which had tended to increase, fell in a gratifying manner to the lowest level since the war began. It is hoped that it will .1 be possible to maintain it at this lower level if all who have the care of babies take every practicable step to keep them from the risks of infection, especially those of a common and usually inoffensive character With the removal of the younger and fitter sections the population it was expected that the Death Rate would rise as the remaining population gradually increased in age, but since the initial rises of 1940 and 1941 there has been a slight tendency for this rate to fall in the last two years. It was also anticipated that the influence of war would be to increase infectious disease and in some measure this has been realised, although to nothing like the extent originally thought probable. But for a very extensive wave of Scarlet Fever, which was to be expected after a number of years of comparative quiescence and which, fortunately, was of a mild type, the position in the District in relation to infectious disease -2- generally was as good, as in the Lest of the pre-war years. Even an outbreak of Influen at the end of the year did not reach the severity which might have been feared. Summarising, it nay be conclude that after four years or more of war the health of the District remained very good on the whole. Events have occurred since the end of the year but before this report could be published which have affected the District more definitely than any in preceding years, thus emphasising the uncertainties of the life of the community as of the individual, particularly in war-time, and making further comment on the comparatively normal year of 1943 redundant. I should, however, be failing in my duty if I did not once again express my gratitude to my colleagues for their loyal and generous support in the maintenance of the health services of the District. My thanks are due particularly to the Senior Health Visitor, who has concluded a long period of very valuable service since the year ended, to the Sanitary Inspector and my Chief Clerk in preparing this Report, but many more, including the staffs of the Wartime Nurseries, the Civil Defence Casualty Services, the Voluntary Services, and the Council's temporary and permanent staff have made a great contribution. The work of the medical practitioners of the District should be particularly emphasised for they have given ungrudging service to the community under very difficult circumstances. It is hoped this will be remembered in the post-war era and that after the dangers of war have passed the spirit of service provoked by the national emergency among all sections of the nation will continue to flourish, finding useful and constructive means of expression. I am - Mr. Chairman, ladies and Gentlemen, Your obedient Servant, F. R. EDBROOKE. Medical Officer of Health. THE HEALTH REPORT OF COULSDON & PURLEY for 1945. INTERIM REPORT. STATISTICS. Area (in acres) 11,142. Number of occupied houses, December 1943 15,745. Number of.occupied house , December 1951 9,533. Rateable value, December 1943 £749,878. Sum represented by a penny rate £3,020. Birth Rate per 1,000 of the estimated resident population 17.4 Still Birth Rate per 1,000 (live and still) births 36.4 Death Rate per 1,000 of the estimated resident population 10.5 Death Rate from Puerperal causes per 1,000 (live and still)births:- Puerperel and post abortive sepsis Nil. Other maternal, causes 1.07 Death Rates of Infants under 1 year of age All infants per 1,000 live births 36 Legitimate infants per 1,000 legitimate births 34 Illegitimate infants per 1,000 illegitimate birth 59 Deaths from Measles (all ages) 1 Deaths from-Whooping Cough (all age's) 1 Deaths from Diarrhoea (under 2 years) 3 VITAL STATISTICS. BIRTHS. The Birth Rate for 1945 was 17.4 per thousand of population, as compared with 17.1 last year, and 12.6,, 12.5, 13.5; 13.4; 12.8 and 12.5 in the preceding six years. The rate for 1945 was much the highest Birth Rate experienced in the District. The corresponding Birth Rates for England and Wales were 16.5 in 1943; and 15.8 14.2, 15.1; 14.9 14.8 and 14.7 in the preceding six years. The percentage of total births, which were illegitimate was 5.7 which. is the same as in 1941 an the average for 1915-19 locally, although about twice the percentage for the prewar years. The local Stillbirth Rate was 0.66 per thousand of population,as compared with O.56 0.42 and 0.55 in the last three years and a rate of 0.51 for England and Wales in 1943. DEATHS. The crude Death Rate for the year was equal to 10.5 per thousand of population, as compared with 10.7 last year, and 11.6, 11.5, 8.9, 7.9. 8.5, 7.9, 7.6 arid 7.1 in the preceding eight years. The crude Death Rates in England and Wales were 12.1 in 1945, and 11.6, 12.9, 14.5, 11.9 11.6, 12.4, 12.1 and 11.7 in the preceding eight years. Of the deaths which occurred in Coulsdon and Purley in 1945, 59 per cent. were over 65 years of age-, compared with 56 per cent. last year and an average of 55 per cent. for the five years ending 1959 and. 45 per cent. for the five years 1926-50. The present figure is not really comparable owing to the absence of an increasing poportion of younger persons in the Services. -2- HEART AND CIRCULATORY DISEASE. The percentage of deaths due to heart and other circulatory diseases was about the same as last year, altogether constituting slightly more than two-fifths of the total deaths. As has been previously stated, insofar as this group includes deaths in elderly people from what is really old age it is hoped that the proportion of deaths coming under this heading will increase. This year 8l per cent. were over 65 years of age at the time of death, while 54 per cent. were over 75 years of age, both of these percentages being appreciably higher than the corresponding figures last year. CANCER. The Cancer Deat. Rate was 1.51 per 1,000 population in 1943 compared With 1.7- in 1942 end 1.92, 1.45 and 1.58 in the three preceding years. The decrease this year is of particular note when it is remembered that with the absence of certain of the younger sections of the population the average age is increasing. More Deaths from this disease could, however, be prevented if only advice were sought earlier, e.g. more than half of the Deaths in women resulted from Cancer of the breast, which is one of the accessible forms of the disease. VIOLENCE. Deaths from Violence (including Suicide) were about the same during 1943 as in 1942, the Death Rate per thousand of . population being 0.42 comparerd with 0.40 last year and 0.75, 1.18 0.49 an 0.49 in the previous four years. Of the deaths from Violence other than Suicide only 2 were due to road accidents, compared with 4 last year, while only 2 Were due to enemy action and these occurred away from the District. The Death Rate from Suicide was 9 per 100,000 of population, as compared with 10 last year, and 17, 11 and. 14 in the preceding 3 years. MATERNAL MORTALITY. ' The Maternal Mortality Rate was 1.07 per thousand total births as compared with 1.10 and 1.68 in the two preceding years. The corresponding figures for England and Wales were 2.29, 2.01 and 2.23. INFANTILE MORTALITY. The Infantile Mortality Rate for 1943 was 36 per thousand registered births, compared with 45 last year and 52, 37, 43 and 51 in the preceding four year The corresponding Rates for' England and Wales were 49 in 1943 and prior to that 49, 59, 55 and 50. The fall in the local rate and the record rates for this Country as a whole are a pleasing reward for the amount of thought and effort given to the welfare of children,especially during the period of the War. The commonest cause of death locally was again "prematurity" but infections of various kinds accounted for nearly half of the infant deaths, thus emphasising the importance of segregating , babies and young children when any infectious disease exists' in a house, however mild this ,may appear to be Even the common cold may produce serious consequences in a young baby. The neo-natal mortality rate (i???e. deaths in the first month per thousand live births) was 23, which is the lowest since 1936, this rate in recent years being 31, 36, 32 and 29. -3- INFECTIOUS DISEaSE. It was pointed out in the Interim Report for 1942 that the total number of infectious disease cases in recent years has can apt to mislead, owing to the inclusion of relatively large number£ of cases of Measles and Whooping Cough, the notification of which diseases was only reintroduced in 1939. If these two diseases are excluded, together with Tuberculosis, which is dealt with separately later in this Report, it will be found that the number of cases of notifiable infectious disease in 1943 was only slightly greater than in 1942. The increase was almost entirely due to the number of cases of Scarlet Fever which rose from 45 to l84, reductions in the number of cases of Dysentery by 100, in Pneumonia by 11 and Erysipelas by 17 compensating in part for this rise. Related to the population at risk the prevalence of Scarlet Fever caused an increase in the Infectious Disease Rate very similar to the peak years for Scarlet Fever before the war. In other words, apart from this one disease, which was fortunately of a mild ???e as little infectious disease was experienced in 1945 as in the district's best years immediately preceding the war. After four years of war conditions this is a very gratifying position to be able to report. The following table summarises the position in 1943:- DISEASE, NUMBER NOTIFIED. NUMBER REMOVED TO HOSPITAL. TOTAL DEATHS. Diphtheria 7 7 - Typhoid 3 - — Paratyphoi 1 - - Scarlet Fever 184 176 - Erysipelas 5 l — Puerperal pyrexia 3 3 — Pneumonia 27 - 30 x Dysentery 21 — - Acute Poliomyelitis 3 2 - Cerebro-spinal Fever A 2 1 cephalitis Lethargica 1 - - Ophthalmia Neonatorum 1 - - Measles 275 4 1 Whooping Cough 55 - 1 TOTALS 590 145 33 x Includes deaths from all forms of Pneumonia. El' TERIC FEVER. Typhoid. There were only 3 isolated cases of Typhoid Fever notified during the year including one at each of the Mental Hospitals. These cases appeared to be in no way connected with each other nor with any known source of infection. Paratyphoid. One case of Paratyphoid Fiver notified and this was only diagnosed pstmortem in hospital. The source of infection was not traced. SCARLET FEVER. In common with neighbouring districts a wave of Scarlet Fever occurred, chiefly affecting this District during the last four months of the year. The total number of cases notified in this District was the highest yet recorded, viz. 184, compared with previous peaks of 136 in 1921, 125 in'1929 and 124 in 1935. During the last two years the number of Scarlet Fever cases had been very low, viz. 35 and 45, and it was anticipated that an 1 increase woud occur, through scarcely so suddenly. Probably the most important factor influencing the rate and extent of the-spread of this disease was the mildness of its character. The term "Scarlet Fever" is applied only to those casus exhibiting a rash in addition to the other symptoms associated with a streptococcal infection, i.e. malaise, headache, feverishness, aching limbs or back., sore throaty etc. In this epidemic the rash was often atypical or so transient that it was frequently overlooked. In addition a very appreciable proportion of the population had some of the symptoms indicating streptococal infection but without the rash, or else were found to be carrying the germ without apparent inconvenience. Neither of these groups being notifiable under the present Infectious Disease Regulations, there was no hope of limiting appreciably the spread by isolating known cases of infection. It was noted in this epidemic that the percentage of school children and even more of pre-school children affected was increased, the proportion of adults being greatly reduced. Owing to the large numbers of notified cases in this and surrounding Districts the infectious disease hospitals were unable to accept more than a proportion of the cases and as far as possible thc.se were selected on the grounds of special physical or social heed. It is generally accepted that when the home conditions permit the treatment of these cases in their own houses it is to their advantage, as, the risks, of cross infection and subsequent complications are thereby diminished. One difficulty arises, however, which is often overlooked, viz. that of providing medical attention for then in their homes. General Practitioners who are also doing midwifery are naturally very reluctant to visit cases of streptococcal infection. Ideally therefore a bountiful provision of cubicle wards at infectious diseases hospitals is most desirable but in times of epidemic even what is normally very adequate bed accommodation is apt to prove insufficient. At such times the provisions of S.l77 of the Public Health Act 1936 do not meet the circumstances completely as the cases treated at home are by no means limited to "the poorer inhabitants" of the District, in fact they are chiefly those in better financial circumstances. As previously stated the recent epidemic was fortunately of a r±ld type, hence this problem was not so acute as it might well become in a severer type of infection. A point re-emphasised by this outbreak is the importance of early isolation and treatment, not necessarily in hospital, of those cases who during their convalescence after Scarlet I over develop colds with nasal or ear discharges and, to a less extent, those contracting sores on exposed parts of the skin. Quite an appreciable number of secondary cases contracted the infection during the year through failure to recognise the risk caused by these convalescent carriers. ERYSIPELAS. By contrast with Scarlet Fever, although Erysipelas is also caused by streptococci, only 5 cases of this disease "ere notified during the year, this being the lowest number for 14 years. In 1941 and 1942, 27 nd 22 cases were recorded. Of the 5 eases, none of which were inter-connected, 2 occurred in one of the mental hospitals. All recovered. PUERPERAL FEVER. Similarly although the cause of this Fever is often a streptococcal infection, only 5 cases of puerperal fever were notified; this being about the same as in recent years. It is a tribute to the standard of midwifery locally that more cases did not occur, as well might ???e happened with less rigid aseptic techni??/ae. All three cases were admitted to the Isolation Hospital where they recovered. -5- DIPHTHERIA. The incidence of this disease was again very low, only 7 cases being notified, and of these 1 was not confirmed, the final diagnoses being quinsy. In only one of these cases was there a history of contact with another known case and that occurred outside the District. The most interesting fact was that all the cases were in adult women, the youngest being 20 years and the eldest over 60 years of age. It is hoped that we are thus seeing the benefit of the widely spread artificial immunisation of the younger sections of the population. All the cases recovered. DYSENTERY. After 3 years in which Dysentery was more prevalent than usual with 85, 224 and 121 cases mostly in the mental hospitals, it was gratifying that in 1943 only 21 cases were, notified, all but one emanating from the two mental hospitals (12 cases in one and 8 in the other) also that only 2 of the cases occurred in the second half of the year. The origin of the isolated case among the general population could not be traced. It was of a comparatively mild type and recovery was uninterrupted. CEREBRO-SPINAL FEVER. ' Four casus were notified during the year, one in each of the following months, .May July, November and December. The diagnosis proved incorrect in 1 case, (a fatal one due to Septicaemia), and in the other cases diagnosis was not confirmed bacterologically, the illnesses proving mild and the cases recovering without complications. On the other hand death occurred from this disease in an unnotified case of a child admitted to a County Hospital. ENCEPHALITIS LERHARGICA. One case was notified in an adult male who was employ, in a mental hospital outside this District. He was admitted ? hospital and recovered. ACUTE POLIOMYELITIES. Three isolated cases of Poliomyelitis were, notified during the year, one in each of the following months, June, July and October. Two were admitted to Hospital and subsequently transferred to other institutions for orthopaedic treatment. The other recovered completely. OPHATLMIA NE0NATORUM. One case only of mild Ophthalmia Neonatorum was notified in respect of a child born in one of the County Hospitals. Complete recovery occured with no impairment of vision. MEASLES. There were 275 notifications of Measles received under the Measles and Whooping Cough Notifications Order 1940, compared with 479 in 1942 and 214 in 1941. As emphasised in the Interim Report for 1942. the number of notifications received does not by any means include all the cases which have occurred as many families do not call in a D or, and if they do so often limit this procedure to the first case in the house. Further, the frequent delay between the onset of the disease and the receipt -6- of notification reduces the value of visitation, which, as a result, has been limited to cases occurring in very young children. It was for this reason that the Health Visitors only visited 111 children during 1943. WHOOPING COUGH. Similarly; although 55 notifications of Whooping Cough were received under the sane Order, compared with 36 and 156 in the two previous years, this number is undoubtedly much less than the number of cases; which actually occurred; 56 cases were visited by the Health Visitors, but more must have occurred of which the Department was unaware. PNEUMONIA. Only acute primary and acute influenzal pneumonia are notifiable and 27 such cases were notified during the year compared with 58 and 32 in the two preceding years and 52 in 1939. THE CONTROL OF INFECTIOUS DISEASE. The usual measures to restrict outbreaks and spread of infectious disease were again employed during 1943. In addition the following more recently introduced methods justify comment. 1. DIPHTHERIA IMMUNISATION. The national policy of encouraging the immunisation of all children against diphtheria was continued during the year and locally the degree of success achieved can be deduced from the fact that at the end of the year it was estimated that 45% of the children under 5 years of ag and 85% of the children of 5 years or over but under 15 years had been immunised. It is becoming more and more a recognised procedure to have children so treated after their first birthday but the custom is not so deeply rooted yet that steady propaganda can be discarded. Similarly parents need encouragement to have their children tested and/or given a "boosting" dose before admission to school. At the present time the concensus of medical opinion appears t< favour an initial course at the first birthday with a single boosting dose at 4½ years of age, possibly repeated at 10 years of age. Where practicable the use of the Schick test may assist in the discovery of the small minority requiring special attention. It is also possible that it may prove desirable for antenatal mothers to be actively immunised in order to convey increased immunity to their children for their protection curing the first year of life. The following are the local figures showing the number of children immunised at the local clinics during 1943. These do not include the appreciable number treated privately, of whom it has proved impracticable to obtain reliable data. CLINICS. Number of sessions held during 1943 141 Number of children who commenced treatment 666 Number of children who completed treatment619 Number of Schick tests made 573 Total number of attendances 3579 SCHOOLS. Number of visits made 52 Total number receiving complete course 165 Number of Schick tests made 440 -7- 2. MEASLES AND WHOOPING COUGH. At the end of July the Council authorised, the supply of placental serum for the prevention of Measles to general practitioners at cost price, except in respect of children under 5 years of age where the family income was below a specified and very low level. During the last five months of the year, however, there were only very few cases of Measles and no advantage was taken of this very United scheme. Unfortunately, although this preparation is more durable than its predecessors, its reliability and the necessity for giving it within a very short time of the onset of the disease limit its value very considerably as a method of prevention which can be generally adopted and urged. It is also unfortunate that the position with regard to immunisation against Whooping Cough appears to be somewhat similar, although apparently a considerable amount of research work is being done on the subject. Until more reliable materials can be produced, comparable with those used for the prevention of Diphtheria, both in their ability to reduce the disease and the length of time immunity lasts, the administrative difficulties are such that not much progress can be expected in reducing these diseases. Notification under the Measles ad Whooping Cough Order 1940, has but very limited value in a District such as this. By the time Notifications are received the disease is well established and preventive inoculations are useless. It is usually too late to give advice on prevention of the spread of the disease. Advice is therefore limited to that on nursing the case. The families which call in a Doctor and are subsequently notified are those least needing advice and the very cases who might most benefit by visitation are the ones least likely to be notified. Such families will, however, often accept Diphtheria immunisation, and could therefore be expected to cooperate in a scheme for general immunisation against other diseases, particularly Whooping Cough, which is of considerable inconvenience to a family. The day is therefore eagerly anticipated when stable and easily procurable preventive vaccines or sera can be used at immunisation clinics with freedom from reactions, and a. guarantee of an effective and lasting immunity, for at least the majority, against these diseases. 3. SCARLET FEVER. In view of the widely, spread epidemic of Scarlet Fever towards the end of the year and the relative shortage of hospital beds, Sulphonamides were again used, as in 1940, in an endeavour to delay and, if possible, curtail the spread of the. disease in a large residential institution. Without being able to produce conclusive statistics it was again thought that both objects were achieved. Certainly it appeared that a number of cases were postponed until a later date when hospital accommodation was available, which was the chief object on this occasion. 4. TYPHUS FEVER. Negotiations with the Ministry of Health, the County Council adjoining Local Authorities and the Joint Hospital Board, were commenced during the year with a view to providing for the treatment of cases of Typhus should these arise and the prevention of the spread of the disease. Arrangements for treatment, the responsibility for which was accepted by the County Council, wore concluded during the year, but endeavours to make corporate arrangements for delousing contacts and their possessions in the face of a threatened Typhus epidemic ran a more protracted course and were not terminated successfully until 1944. -8- TUBERCULOSIS. The cc.Su rate for new cases of Pulmonary Tuberculosis notified during 1943 was 75 per 100,000 population, compared with 90, 68, 6l, 56, 58 and 65 in the last six years. The average case rate for this District from 1915 to 1924 was 115 -and from 1925 to 1954, 88, While still above the low level achieved. before, the war, the reduction this year is very welcome. The increased proportion of notifications of males over 45 years of age, noted in 1942, was even. more marked, in 1943, when more than a half of the male notifications were, in this age group. A similar, thoughtless marked rise among women of the same age is noticeable. In part these rises are accounted for by the changing age distribution in the population, but in the case of males at least this is probably not the full reason, other war time conditions affecting men of this age adversely. On the other hand the Non-pulmonary Tuberculosis case rate of 17 per 100,000 was about the average for the last 6 years, and the mean of the averages for the decades 1915-24 and 1925-34. The death rate from Pulmonary Tuberculosis was 38 per 100,000 population which compares quite favourably with rates of 40, 55, 43, 21 and 27 in th_ last 6 years and those for the quinquennial period 1915-34 which were 72, 57, 36 and 38. Similarly the non-pulmonary Death Rate was only 7 per 100,000 Compared with 8, 11, 6 and 9 in the previous 4 years. All the methods reviously employed in an attempt to prevent the spread of this disease were continued throughout the year. NON-NOTIFIABLE 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 Head Teachers of the Public Elementary Schools. From the former it is noted the 20 deaths from Influenza occurred, this disease being rather more prevalent than in 1942, and assuming epidemic proportions towards the end of the year when arrangements were made to provide voluntary assistance. in the homes for persons or families unable to cope with their domestic needs while so suffering. From the latter the chief offender appeared to be Mumps, which was prevalent at Selsdon from January to March (130 cases notified); Purley, March to May(39); Old Coulscion. May to June and September (36 cases) with occasional cases in other schools. Chicken Pox was common in Selsdon, particularly in June (total 83) and .Kenley (78). Occasional cases of Infective Jaundice occurred in the first and last months, a total of 14 being notified, of which 8 occurred in one school. OTHER DISEASES. DIBETES. Following the receipt of a circular from the Ministry of Health requesting Local,Authorities to assist patients not otherwise helped by the existing legislation to obtain insulin when required, either free or at reduced cost, the Council introduced a scheme for this purpose. It was estimated that more cases of this type existed than were subsequently discovered, hence the limits of the scheme were rather exclusive, only 2 persons benefiting during the year, one to the extent of half cost and the other paying one-tenth cost. Only 5 other applications were received mostly well above the prescribed income limit. 9 SCABIES. In the Interim Report for 1942 an account was given of the establishment of a Scabies treatment centre at the Coulsdon First Aid Post in May 1942 and the result of the treatment provided for the 257 cases who attends during the remaining 8 months of that year. In 1943 a total of 326 persons attended for treatment (180 children, 40 men and 106 women) compared with 237 person. (13Q children and 107 adults) in the last 8 months of 1,942. Altogether 1217 baths were given by the staff of the First Aid Post who continues to co-operate enthusiastically in spite of the monotonous and not very attractive nature of their occupation. Of the 326 persons, 259 (138 children, 34 men and 87 women) appeared to recover after the routine treatment of 2 01 3 baths at 6 - 8 days interval (it is difficult to obtain the re-attendance of all cases six weeks after the last bath for re-inspection but it is assumed that the non-appearance of school children, especially after an interval of several months, indicates that the condition has been cured. It Is found also that most adults who suspect recurrence re-attend, having benefited by the relief of the distressing irritation even if not cured by the first course of treatment.) It was very exceptional to find persons requiring more than 3 baths to produce apparent cure and the number who had relapses within ~6 weeks was very 3. 11 unless there were exceptional circumstance . The chief problem was some 14 large families made up of 58 persons (5 men, 17 women and 36 children) in which through failure of all the members to attend together reinfection was kept up and individual members of the families were constantly returning for treatment. The same type of difficulty arese in other cases in which either the husband only reappeared on leave periodically and did not get treatment or one member of the family did not at end until those receiving the initial treatment had been reinfected. Even in these, circumstances cure- was eventually obtained in almost all cases. Undoubtedly the centre has justified its existence and served a very useful purpose. VERMIN. The number of cases of infestation with body vermin discovered during the year was very small and almost all were cases of head lice found by the Health Visitors or School Medical Service. Apart "from casual infestations there adjust a few families in which it is difficult permanently to eradicate head lice, the position being complicated in each case by physical or mental defects usually of the mother. Since the war the Council has supplied Sacker's Combs to persons found to have been infested, usually at full cost though repayable by instalments and in recent years Lethane Special has also been given free of cost together with advice on the measures to be- taken. Where necessary the Medical Officer of Health has visited persona11y and encouraged the treatment of the whole family as a unit. The visits have been very satisfactory with the very few chronic exceptions which improve temporarily but are, liable to relapse. AMBULANCES. For Infectious Disease Cases. The arrangements made for the conveyance of cases of infectious diseases remained unchanged during the year. Accident and General Cases. Similarly no alteration was made in the Civil Ambulance Service, which since August 1941 has been under the control of the Medical Officer of Health and is staffed very ably by the First Aid and Light Rescue Service. -10- The services of the local Report and Control Centre were again utilised in despatchhing the ambulances. The enthusiastic co-operation of each of the above branches of the Civil Defence Services has been very satisfactory and much appreciated. 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 1943 was that all the bacteriological examinations of samples of milk and water, together with swabs for the grouping of streptococci were, made by the staff of the Emergency Medical Service Laboratory at Epsom College, whose assistance and valuable co-operation was greatly appreciated. It is hoped that this or a similar arrangement will be practicable after the war. Examinations of swabs for diphtheria and sputa for tuberculosis were carried out 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. 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. In addition two splays of the excellent film on Scabies were given in the Council Chamber to selected audiences of Doctors, Nurses, Public Health Staffs and others, which were very instructive. MATERNITY AND CHILD WELFARE. MATERNITY CLINICS. The usual three maternity clinics were held throughout the year, additional sessions, being necessary as in the two previous years. The total number of hew ante-nat .1 cases which attended was 413 compared with 431 in 1942, 438 in 1941 and 243 in 1938, The number of sessions hole was 115, this being 7 more than in 1942 and 24 more than in 1941, thus enabling the mothers to be seen more frequently. As a result the total number of antenatal visits was 2,401 compared with 2,603 and 2,078 in the two previous years. There was a very slight increase in the, number of postnatal attendances from 169 in. 1941 and 203 in. 1942 to 225, but the proportion attending for post-natal examination ana advice is still much lower than in pre-war years. Encouragement to reattend will need to be given to mothers as the war conditions subside, for it is important it should be ascertained that no residual abnormalities lain after child birth. Frequently inconvenience and. suffering in after-life can thereby be avoided. Almost all cases which attend the Clinics are subsequently confined by Midwives in .eir own homes or at Purley Hospital, or are admitted to the Count;, 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 all their ante-natal treatment. -11- Where necessary dental treatment for ante-natal mothers was arranged and sterilsed dressings. provided, as in preceding years, while appliances were supplied to those post-natal mothers who needed them. A11 the above an provided, if necessary, at reduced cost. EMERGENCY UNIT. The Emergency Obstetrical Unit based on Mayday Hospital was called upononce during the year-, this being the first occasion on which its service have been required in this District since its ince???tion in 1938. On this occasion it proved of great value, OBST???IC SPECIALITS. 0ne of the obstetric Specialists appointed by the Ccuncil was called in for consuliation on two occasions during the year. The Council doesnot attempt to recover the fee from the patient in such circusmtances. MATERNITY CASES. During 1943 the umber of maternity cases admitted to Purley Hospital under the Council's scheme was 73,compared with 6.9 and 53 in '1942 and 1941,and a average of 62 for the preceding 4 years. In addition 150 cases were admitted to the Surrey County Council Hospital, Redhill. This is a reduction of 53 on 1942. and 20 on 1941 though 52 more than in. 1939 and 1940, and 86 more than in 1938. Owing to the increasing tendency for maternity Cases to seek admission to hospital for their confinenments", which tendency has been experienced throughout the whole Country the process of selection,based on medical and social need, which had to he introduced in view of the relative inadceuacy of hospita1 accommoidation and nursing- staff. has had to be. even more stringently applied. 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• MID???ERY SERVICE. The Council's Midwive attended 105 cases in 1943, compared with 90, 76, 96,7 and 87 in the preceding, 5 years. Of the 103 cases, . 57 wore Undertaken Purley Midwife (41 being midwifery, and ??? maternity cases) and 46 by the Selsdon Midwife (24 ???y and 22 maternity). HOME HELPS. The Council has employed 2 whole time Home Helps since 1942 and in admition a number of temporary Home Helps. During 1943, 56 cases received. this form of a; istance compared with 25 in 1942 and a previous maximum of 35 in 1937. The Council's scheme aims at rendering help during times of domestic embarrassment arising through childbirth. Towards the end of the year, when Influenza was prevalent an endeavour was made to provide assistance to families who were as a result experiencing domestic difficulties Help was rendered in a number of instances by introducing parttime home helps, members of the voluntary organisations (British Rod Cross Society, St.John .Ambulance Brigade and the Women's Voluntary Service; or even neighbours to such cases, the Department co-operating closely with the Citizens Advice Bureau in the process. From experience gained during this period. there would appear to be a need for a permanent organisation to deal with such cases, although the position is accentuated in war time -12- by the. shortage, of domestic assistance. Only a proportion of the eases assisted arose through Influenza the affects of which were Usually so sudden and se short lived that the majority of residents dealt with their personal problames themselves often at great inconvince, being unware of any body able to assist then or being unable communicate with that body when the emergency arosed. It would appear desirable for the Citizen's Advice Bureau to act as the first ay to be approached on. such hatters as freuently there arc primary social ???uestions which can be given immediate attention. n close liaison between this Bureau and the public Health Department has always existed if questions of medical service and pas???ed on as hitherto, but little time is lost, and often much seved, by this method of approach. The Public Health Department should act as the connecting link between the enquirer an the Home Help Service or the voluntary medical organisations with which latter it is hoped close co-operation will continued in the post-war era. Under war tine conditions the Ministry of labour can assist by seeing that sufficient part-tine Home Helps are vailable upon when the Public Health Department c n call and consideration will still need to bo given to this question of supply after the war. A local ruling that the Council cannot assist financially in such cases, unless they are connected with confinements, limits considerably the help which can be rendered in this way. Finally, the need for special accommodation for elderly folk was very obvious and this question should be kept in the fore front of post-war planning. Suitable accommodation for elderly couples or single persons, both in health and sickness, is urgently needed, including typos within the means of folic of varying social grades. BIRTH CONTROL. The Council continues to subscribe towards the Croydon Mothers and Infants' Welfare Association and curing the year 58 new cases were referred their clinic from the Council's centres or clinics, all but one needing advice on family planning owing to medical or social circumstances. While only one is elated case from this District in 1943 needed advice as she had previously been unsuccessful in having a baby, the number of cases faced with this same problem has increased latterly and the Association has arranged a special clinic for such cases, consultations being by appointment. HEALTH VIITATION. During 1943 the Council employ u four Health Visitors who continued to work under the supervision of the Medical Officer of Health, and a total of 8,341 visits were paid by them. This represented an increase of 417 over 1942 ana was chiefly made possible by the relief afforded thorn through the assistance of civil defence volunteers at the in unisation clinics. The previous year's record of 777 primary visits to babies, which was 290 more than in 1941, was exceeded as no less than 836 such visits were paid. Of the total births registered 93% Were visited and on an average 2 visits wore cade to each child under 1 year, this being a further reduction from the average of 3 visits per child paid in 1941. This reduction was unfortunately necessitated by the increased number of births not being compensated by an increase in the number of Health Visitors. Similarly although the number of visits to children over 1 year was slightly increased owing to fewer visits being paid to cases of infectious disease, the fact was recognised that more routine visitation was desirable and in 1044 the Council appointed a fifth Health Visitor. 13 INFANT WELFARE CENTRES. The six Infant' Welfare Centr s which have been established by the Council continued to he held during the year, the Sander stead Centre /eing opened weekly instead of twice monthly as hitherto. While the total number of attendances increased from 12,328 in 1942 to 13,904, the number of new cases diminished from 848 to 8ll, The- reduction in new cases was most narked at 1 Old Coulsdon but Senderstead and to a slight extent Kenley shewed increases. The most marked fa11s in the attendances of old cases were at Rickman Hill (where the average attendance fell from 45 to 38) and Selsdon (average reduces from 63 to 59).whereas increases were noted at Sanderstead (from 53 to 5o) and Old Coulsdon (53 to 57). On the whole total number of attendances was good, but still well below the 17,038 made in 1958. The total number a consultations with the Doctors increased slightly but only owing to a marked increase at Brighton Road, Coulsdon, the number being reduced at all other Centres, particularly at Kenley and Sanderstead. There was a pleasing drop in the number of cases needing to be referred to hospital for minor op rative or other treatment viz. from 59 and 68 in the previous 2 years and 41 in 1938 to 58 in 1943. TODLERS CLINICS. The year under review was the fourth complete year in which special toddlers sessions were held at which the Doctors confined their attention to children from 2 to 5 years of age. While the number of sessions increased by 3 to 44 compared with 1942, the number of primary examinations increased from 198 to 241 anil re-examinations from 261 to 323. Increases were most narked at Brighton Road, Coulsdon, and at Selsdon, but Rickman Hill ea;erienced a reduction- DISTRIBUTION OF MlLK. ETC. 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, 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 Office, 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 was continued with its usual efficiency. It is still thought to be the best arrange ent which can be made under existing conditions, but it has always had the disadvantages of being ponderous and relatively expensive. The number treated in 1943 was 97, compared with 100 in 1942, 85 and 67 in the two preceding years and 90 in 1938. DAY NURSERIES. The two voluntary Day Nurseries, to each of which the Council gives a substantial annual grant, continued to perform useful service during the year, being generally full to capacity and accommodating a total of about 60 children. The Purley Wartime Nursery was open throughout the whole year accommodating up to 45 children. Owing to difficulties experienced in working in a converted house of two storeys, the maximum accommodation Was reduced to 40 children towards the end -14- of the year. Apart from epidemic periods the demand always exceeded the accommodation. The Old Coulsdon and Selsdon Wartime Nurseries, both of which are constructed- on the pavilion system of pre-fabricated units, each with accommodation for 60 children, were opened in June ana July, 1943. The numbers attending the former steadily increased to the maximum but the demand at the Sclsdon Nursery has always been more limited, and from Very early days was supplemented by children transferred daily by civil defence ambulance from lower Sanderstead and South Croydon who Were attending or who would have attended the Purley Nursery. On the whole the health of the children has been good,but as was expected, the attendance at all the Nurseries was affected from time to time by outbr??? of infectious disease, none of these fortunately of a serious character. The necessity for keeping the maximum number of mothers at work was a complication which always had to be borne in mind when attempting to control outbreaks ???a factor which has less often to be considered when dealing with infection in schools. On the whole the measures taken were reasonably successful, bearing in mind the susceptibility of the age groups and the inadequacy of our knowledge of specific preventatives in most cases. CHILD LIFE PROTECTION. During the year 24 Foster Mothers were under supervision, 41 children being distributed among them, this being 1 less mother but the same number of children as in 1942. SANITARY CONDITIONS. HOUSING, The total number of houses inspected luring 1943 under the Public Health or Housing Acts was 453, the number of inspections for this purpose being 475. No houses were found to be in a state so dangerous or injurious to health as to be unfit for human habitation, but 413 were found not to be in all respects reasonably fit for human habitation. As a result of informal action 360 were rendered fit. Proceedings under Sections 9, 10 and 16 of the Housing Act 1936 led to the service of 7 notices which resulted in 3 houses being rendered fit by the owners, while 56 notices served under the Public Health Acts resulted in 43 houses having their defects remedied by the owners and 7 by the Local Authority in default of the owners. No proceedings under Sections 11, 12 or 13 of the Housing Act, 1936, were taken. No new cases of overcrowding were reported during the year and one case wars relieved, 6 persons being involved. At the end of the year 2 dwellings remained overcrowded, 2 families and 20 persons being concerned. There is in addition, of course, a considerable amount of undesirable crowding in some parts of the District owing to the migration of families due to war conditions. WATER SUPPLY. No alteration in, the water supply was made during the year. The East Surrey Water supply and that of the Sutton Water Company were each examined chemically and bacteriologically four times during the year and all 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. -15- There was no shortage of water during the year. The supply is constant to all parts of the area. The statutory ???imun limit for hardness in the water supplied by the East Surrey and Sutton District Water Companies is 9 degrees and 36 samples were examined by the Department during 194.3 to ascertain that this was not exceeded. In no case was this found to occur. RAINFALL. The rainfall registered at the Refuse Destructor was 25.01 inches, this being 3.92 inches less than that of the previous year. CLOSET ACCOMMODATION. Nearly the whole district is on the water carriage system and owing to the' war very little alteration of other forms of sanitation was made. The approximate numbers using the following methods of disposal at the end of the year were:- Premises with water closets drained to sewers 15,285 Premises with pail closets - excluding temporary buildings 216 The total number of cesspools throughout the district is approximately 164 The contents of all pail closets are collected by the Council's gully emptiers and disposed of in the public sewers. public cleansing There has been no alteration in the system of house and trade refuse collection airing the year. The fortnightly system of collection instituted in 1941 has continued with special drives for waste paper, books, rubber 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 matt r 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. No complaints of bonfires were received. RIVERS AND STREAMS. DRAINAGE AND SEWERAGE, FACTORIES AND WORKSHOPS, SCHOOLS AND SHOPS presentee no special problems during the year, SWIMMING POOLS. One swimming pool was in use by the Public and two bacteriological examinations of the water were made which proved satisfactory. SANITARY INSPECTIONS, ETC. The number of complaints received during the year increases considerably, owing to the number of reports of rats and mice being nearly trebled. Similarly the number of inspections made increased very considerably, chiefly owing to the Rat Campaign. There was also a marked increase in the number of infectious disease investigation and disinfections. r * -16- ERADICATION OF BED BUGS. The methods adopted during the last few years for the eradication of bed bugs were continued during 1943 and have proved satisfactory. In one case the disinfestation was carried out by a private firm of disinfestors. The number of houses found to be infested and subsequently disinfested were as follows:- Counci11 houses 3 Other houses 10 This shews an increase of two council houses and six private houses when compared with the, previous year's figures. RATS AND MICE DESTRUCTION . The year was marked by special efforts, inaugurated by the Ministry of Food, to exterminate rats, and. householders were encouraged to become rat reporters. ???cilities to report were provided through the Wardens' Service but the majority of complaints were forwarded direct to the Council Offices either by letter or by use of the printed form published in the newspapers. As a result the number of complaints increased from 74 in 1942 to202 and the number of inspections increased from 667 in "1942 to 3,815 in 1943. 215 premises were found to be infested on a small scale, chiefly owing to the large increase in the number of domestic poultry keepers. The methods adopted for rat destruction were the use of poison baits, barium carbonate, phosphorous preparations, arsenic and cyanogas. Traps and rat limes were also used but were not very successful. LEGAL PROCEEDINGS. Legal Proceedings were taken under the Public Health Act, 1936, Section 94, in one case. When an Order was made the work was eventually carried out. REGULATED- TRADES. COWSHEDS AND DAIRIES. Two new dairy farms commenced to function during the year, but one of those previously registered ceased to produce milk in October 1943, its registration being cancelled. As in the previous year two fa???s were licenced,by the Surrey County Council to produce "Accredited" milk, While in addition one of the new farms was licenced to produce "Tuberculin tested" milk. At the end of the year there were 11 registered dairies, an increase of 1 compared with 1942, and 14 registered retailers, of whom 6 live out of the District. This was a reduction of 11 registered retailers, (3 from outside the District), compared with last year, and 16 less than in 1941. SLAUGHTER HOUSES. There are two slaughter houses within the district but neither was licenced during the year. on licenced to slaughter animals was issued to slaughtermen. ,<ii '■ -17- BAKEHOUSES There were seven bakehouses engaged chiefly in the manufacture of bread and confectionery, and 27-piaces at which confectionery was produced for sale- or consumpton on the premises. There are also bakehouses at private institutions, hotels, etc. OTHER FOOD PREMISES. Fish frying is carried on at four premises, one-each in Selsdon, Purley, Coulsdon ana 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 wore also inspected periodically. INSPECTION AND SUPERVISION OF FOOD MILK During the year 37 samples of milk were submitted for bacteriological and microscopical examination, 39 being satisfactory, as judged by the total bacterial count and presence of coliform organisms. ,Eight biological examinations were made, 1 of which was positive, the -result being referred to the Surrey County Council; as a result one cow was removed from one herd: for slaughter. Twenty-four samples of pasteurised milk and two samples believed to have been pasteurised were submitted to the phosphatase test, all being satisfactory. MILK (SPECIAL DESIGNATIONS) ORDER 1936. No licences were issued for the pasteurisation of milk. During the year the Council granted the! following licences tp sell milk under the above Order:- Principal. Supplementary. Tuberculin tested 5 3 Accreted 3 - Pasteurised 9 3 MEAT. As slaughtering ceased at the two licenced slaughterhouses in January 1940 no carcases of meat 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. UNSOUND FOOD. The following unsound foods- were surrendered during the year:- lbs. 02s. Bacon 143 2. Fish 669 6. Cheese 37. 9¾. Meat 325. 12. Flour 061. 8. Tinned goods, etc. 1073. 3. 3110. 8¾. This is an increase on last year's figures. The whole -18- of these goods were disposed of as animal or poultry food largely through the Ministry of Food Salvage Organisation. FOOD AND DRUGS ACT, 1938. SAMPLES' TAKEN DURING 1943. ARTICLES. ANALYSED ADULTERATED OR DETERIORATED. Prosecutions . Convictions Formal Informal Total Formal Informal Total Arrowroot 1 — 1 — — — — — Baking powder 1 - 1 - - — - — Beer and rum 2 — 2 1 - 1 - — Biscuit & cake mixtures 4 - 4 1 — 1 — — Brawn & breakfast sausage 2 — 2 — — — — — Bun powder & scone mixtures 2 — 2 / — — — — — Bread 5 — 5 - — — — — Butter 4 — 4 — — _ — — Cake 1 - 1 - - - - Castor oil 1 — 1 — - - - - Cocoa, coffee & Nescafe 7 — 7 — — — — — Dried apple rings 1 - l — — — — — Egg: dried & substitute powder 2 - 2 — — — — — Fish cakes, roll and paste 5 - 3 — — — — — Flour: self raising & soya 2 - 2 - - - - - Friquix savoury 1 - 1 1 - 1 — — Gelatine leaf 1 - 1 1 — 1 — — Ginger beer extract 1 — 1 — — — — — Gravy salt & powder 2 — 2 — — — — — Ground nutmeg 1 - 1 — — — — — Golden syrup 1 - 1 - - — — — Haricot beans — 1 1 — 1 1 — — Jam and Marmalade 11 — 11 — — — — — Lard 5 - 5 — — — — — Lemon essence 2 - 2 — — — — — Lentils 1 - 1 - — — — — Macaroni and Semolina 3 — 3 - — — — — Margarine 6 - 6 6 - 6 - — Meat pie 1 - 1 — - — — — Milk 31 1 32 1 — 1 — — Milk, condensed 1 —. 1 1 — 1 - _ Minced beef & mince & beans 2 — 2 — - _ Mustard prepared 1 — 1 — — - — - Oatmeal 2 _ 2 — - — - - Ovaltine 1 1 - - - - - Pickles and sauce 3 — 3 — - - — - Pudding mixture 10 — 10 1 - 1 — — Soupes & soup powder 8 - 8 — — — — — Sausage meat 6 - 6 - — - — — Scotts M.O.F. 1 — 1 1 — 1 — — Spaghetti 1 - 1 - — — — — Vinegar malt and spirit 2 - 2 - — - — - Yeast spread 1 — 1 — — — — — TOTALS 144 2 146 13 1 14 - -