COU 14 AC 4413(3) HEALTH REPORT FOR 1946 FOR THE COULSDON AND PURLEY URBAN DISTRICT BY THE MEDICAL OFFICER OF HEALTH REDHILL: The Surrey Fine Art Press, Cavendish Road. HEALTH REPORT FOR 1946 FOR THE COULSDON AND PURLEY URBAN DISTRICT BY THE MEDICAL OFFICER OF HEALTH REDHILL: The Surrey Fine Art Press, Cavendish Road. URBAN DISTRICT COUNCIL OF COULSDON AND PURLEY. 1946 Public Health Committee. Chairman : Councillor S. E. Littlechild. Councillor Mrs. Bartleet „ Mrs. Bluett ,, A. J. Crisp „ F. H. Glogg „ F. J obbins Councillor F. T. Q. Mason „ Mrs. D. May „ Mrs. M. Mayes „ Mrs. Nesbitt „ R. H. Pullen Representatives on the Wandle Valley Joint Hospital Board. Councillor W. H. Glanville. „ F. G. L. Moir, M.M.I.Struct.E., I.Mar.E. ,, F. Jobbins. „ J. Newton (ex-officio member). Representatives on the Purley War Memorial Hospital Committee. Councillor Mrs. M. Mayes. F. G. L. Moir, M.M.I.Struct.E., I.Mar.E. Representative on the Coulsdon and District Day Nursery. Councillor Mrs. Bartleet. Public Health Department. STAFF: Medical Officer of Health: F. R. Edbrooke, M.B., Ch.B., D.P.H. *Medical Officers of Ante-Natal Clinics : Isabel May, M.B., B.S., M.R.C.S., L.R.C.P., D.C.H. Sylvia E. Collingowod, M.B., Ch.B. Gladys Lenanton, M.R.C.S., L.R.C.P. *Medical Officers of Child Welfare Centres : Constance Hildred, M.B., Ch.B. (left District March, 1946). Gladys Lenanton, M.R.C.S., L.R.C.P. Janet E. D. Michael, M.D., M.R.C.P., M.R.C.S. Gordon Lindsay, M.B., B.S., M.R.C.S., L.R.C.P. Isabel May, M.B., B.S., M.R.C.S., L.R.C.P., D.C.H. (appointed March, 1946). *Medical Officer of Family Planning Clinic: Constance Hildred, M.B., Ch.B. (left District March, 1946). Gwyneth M. Cotterell, M.B., Ch.B. (appointed March, 1946). 3 *Medical Officer of Wartime Nurseries : Constance Hildred, M.B., Ch.B. (left District March, 1946). Isabel May, M.B., B.S., M.R.C.S., L.R.C.P., D.C.H. (appointed March, 1946) *Consulting Obstetric Specialist \ Douglas Lindsay, M.D., Ch.B., F.R.F.P.S. *Consulting Paediatrician : J. N. O'Reilly, D.M., M.R.C.P. Sanitary Inspector : H. Buxton, M.R.S.l. Additional Sanitary Inspectors : T. N. Ienkinson, A.R.S.I, (resigned October, 1946). S. E. Crisp, C.R.S.I. Assistant to Sanitary Inspector : W. H. Sands. Senior Health Visitor : Miss L. E. Letts, S.R.N., S.C.M., H.V.C. Health Visitors : Miss S. G. Paddle, S.R.N., S.C.M., H.V.C. Miss M. Steward, S.R.N., S.C.M., H.V.C. (resigned May, 1946). Mrs. M. I. Pointer, S.R.N., S.C.M., H.V.C. Miss M. Newton, S.R.N., S.C.M., H.V.C. Miss E. V. Bell, S.R.N., S.C.M., H.V.C. Miss K. A. Taylor, S.R.N., S.C.M., H.V.C. (appointed May, 1946). Midwives : Miss A. E. G. Neighbour, S.R.N., S.C.M. Mrs. C. Noakes, S.R.N., S.C.M Home Help Organiser: *Mrs. C. Savidge. Clerks: G. A. Lee (released from Forces January, 1946). J. R. Richardson (released from Forces March, 1946). Temporary Clerks: Mrs. J. E. Hodge (*after March, 1946). Miss P. Jenner (appointed October, 1946). Mrs. J. Templeton (appointed July, 1946). (*Part-time officials.) 4 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 11,142 Registrar-General's estimate of population, 1946 60,390 Population, Census 1931 37,666 Number of occupied houses, December, 1946 16,692 Number of occupied houses, 1931 9,533 Rateable Value, December, 1946 £745,720 Sum represented by a penny rate £3,008 VITAL STATISTICS FOR THE YEAR 1946. Total. M. F. Birth Rate per 1,000 of the estimated resident population. Live Births—Legitimate 1,028 532 496 do. Illegitimate 37 12 25 17.6 1,065 544 521 Rate per 1,000 (live and still) births. Still Births—Legitimate 39 22 17 do. Illegitimate 1 — 1 — — — 36.2 40 22 18 Death Rate per 1,000 of the estimated resident population. Deaths 591 280 311 9.8 Deaths from Puerperal causes Rate per 1,000 (live and still) births. Puerperal Sepsis 2 1.81 Other Puerperal causes 1 0.90 Total 3 2.71 Death Rates of Infants under one year of age All infants per 1,000 live births 25 Legitimate infants per 1,000 legitimate births 25 Illegitimate infants per 1,000 illegitimate births 27 Deaths from Cancer (all ages) 117 Deaths from Measles (all ages) Nil Deaths from Whooping Cough (all ages) Nil Deaths from Diarrhoea (under 2 years) 1 5 COULSDON AND PURLEY URBAN DISTRICT COUNCIL. Ladies and Gentlemen, I beg to present to you my Annual Report for 1946, this being my fifteenth Report as your Medical Officer of Health. I very much regret that owing to the sudden death of your Chief Sanitary Inspector early in 1947 and the very considerable changes in staff which have since occurred it has been impossible to complete the Report by an earlier date. As foreshadowed in my Report for 1945 I have endeavoured to indicate briefly, and where appropriate, the trends in the public health and the development of the local Health Services during the 31 years the Urban District has existed as such. This is, of course, in addition to reporting in greater detail on the health of the District during 1946. This, as judged by the available data, remained very satisfactory throughout the year. The Birth Rate was the highest yet experienced, the Death Rate continued to decline after its wartime rise, there was a reduction in the total number of cases of infectious disease, and only a slight rise in incidence among the general population due to mild scarlet fever, while the Infant Mortality Rate was one of the lowest which has yet occurred. On the other hand it has to be remembered that these indices are, even when subjected to further analysis, only crude guides to the state of a community. A much more reliable assessment can be made of the health of the younger sections of the population owing to the relative completeness of the records relating to their sickness and the results of regular medical examinations at infant welfare centres, nurseries and schools. There is reason for gratification that, in spite of the influence of war, the health of the children generally appears to be very good. With no corresponding data regarding adults one can only judge by general impressions. One would hesitate to say that there has been any marked change in the sickness rate, but there are considerable doubts as to whether the energy and stamina of the middle aged and more elderly sections of the community are as high as formerly. It is, however, very difficult to assess the degree to which post-war mental reaction and disillusionment resulting from retarded world recovery, particularly in food supplies, are underlying causes. It is easy to assume that given more adequate and varied supplies of food vitality would correspondingly increase, and to some extent this is almost certainly correct, but one has to remember in every case the normal effect of advancing years, and the profound influence of mental outlook upon the physical condition of people. It is very unfortunate that at this time a substantial proportion of the organs influencing public opinion, emphasise unduly the discouraging facts and circumstances in life, thereby tending to undermine morale. Inevitably after a world war, upheaval and prolonged unsettlement must result but, without cowardly escapism, hope and the enjoyment of life can and should be encouraged by more emphasis on the good, beautiful and successful aspects of our corporate existence. There are very many grounds for justifiable optimism and pleasure, and 6 a campaign to quell defeatism and foster 'joie de vivre' would be welcomed for its beneficial repercussions on the public health. In recording the success which has been achieved by the Council during the period of over 30 years as a Public Health Authority it is naturally regretted that the attempt at tidying Local Government anticipated under the National Health Service Act, 1946, will deprive the Council as a body of many of its responsibilities. If, however, equal interest and enthusiasm, combined with a wide outlook, are directed towards the use and development of the new administrative machinery, further successes can be hoped for and should result in an improved standard of public health. Already difficulties and weaknesses can be foreseen, but unless our aptitude and interest in central and local government deteriorate seriously opportunities lie ahead for greater achievements than in the past. In concluding I would like, as usual, to express my appreciation and thanks to all who have co-operated in the health services to the benefit of the public. These are too numerous to mention here but I must include special reference to the Senior Health Visitor for the steady and progressive work of her team and the assistance she has given in recording their work for this Report, and also to my late colleague and Chief Sanitary Inspector, Mr. Buxton. One could not have wished for a more loyal or pleasant colleague. His reliability, tact, humour and sound judgment were always a source of strength to the Department and I shall ever remember with gratitude and pleasure our 15 years of completely harmonious co-operation. In welcoming and thanking his successor for his assistance I can only hope that our relationship will be as equally happy as it promises to be. Finally, my thanks to my previous Chief Clerk and present part-time assistant who has not only worked very hard at preparing this Report but has cheerfully endeavoured to inspire efficiency, courtesy and loyal sympathetic service in the office during the almost complete double change of staff which has occurred these last two years. I am, Ladies and Gentlemen, Your obedient servant, F. R. EDBROOKE, Medical Officer of Health. HEALTH REPORT FOR 1946 The Urban District of Coulsdon and Purley was constituted by an Order of the Local Government Board, dated the 1st November, 1914, and came into existence on the 7th April, 1915. It has therefore been a separate District for just over 31 years. Situated on the North Downs immediately to the south of Croydon it is a well favoured "dormitory" suburb with a very considerable part of its area as yet undeveloped. Thanks to successful Town Planning Schemes there is comparatively little dense development, most of the houses being well spaced, while owing to the Abercrombie Scheme there is a probability that it will continue to possess very extensive open spaces, the Green Belt forming almost all its Southern and Eastern boundaries with large tongues of agricultural land or public open spaces protruding into the developed areas. While this has the advantages of preserving the appearance of the District and permitting easy access for residents to comparatively open country, it tends to the segregation of sections of the community and peculiar problems of local government. Communications between Selsdon and Farleigh and the remainder of the District are poor at present and the corporate sense is not as strong as in older towns with a natural civic and social centre. The majority of the residents who are employed work in London or Croydon, travelling to and fro daily. Locally there are no really large manufacturing or other industries, most of the residents employed in the District being connected with building and decorating, with the provision of food and the other wants of residents, or attached to the mental hospitals. The amount of unemployment, apart from temporary unemployment pending transfer from the services to industry, etc., was negligible in the district. Some improvement in the condition of property in the District was effected during the year, but owing to shortage of materials and the poor quality of many which are available the state of most houses is not what it was before the war. While comparatively few cases of statutory overcrowding were discovered, all properties are occupied unless used for other purposes and very many are undesirably crowded. The Council had, at the end of 1946, a list of some 2,000 applicants for houses, and had pressed forward as expeditiously as possible with rehousing. Approximately 300 houses had been requisitioned and fitted to provide accommodation for one or usually more families, but the number of houses actually constructed or reconstructed during 1946 was painfully inadequate. 8 AREA AND POPULATION. The District has an area of 11,142 acres, these being distributed among the wards as follows:— Coulsdon East 2,812 Coulsdon West 1,253 Kenley 1,292 Purley 685 Sanderstead 2,311 Selsdon and Farleigh 1,924 Woodcote 865 This is 2,507 acres more than in 1915, owing to revisions of the boundaries, the last of which was in 1933. The steady increase in population preceding the war is indicated by the following figures:— 1915 17,920 1921 census 21,493 1931 census 37,666 1938 (Registrar-General's estimate) 55,070 „ (Local estimate) 58,000 1939 (Registrar-General's estimate) 56,400 ,, (Local estimate) approximately 60,000 In 1945 the Registrar-General estimated that recovery from the wartime fluctuations had occurred to the extent that 53,460 persons were residing in the District, and by mid-1946 that the population had increased to 60,390. This number includes persons resident in Institutions in the District, the numbers of which at the end of 1946 were as follows:— Cane Hill Hospital 2,256 Netherne Hospital 2,195 Russell Hill School 219 Reedham Orphanage 252 In 1915 there were 4,141 occupied houses, chiefly in Purley and Woodcote, whereas in 1946 there were 16,692 occupied houses distributed as follows:— Coulsdon East 2,402 Coulsdon West 2,787 Purley 2,564 Woodcote 1,570 Sanderstead 4,121 Selsdon & Farleigh 1,764 Kenley 1,156 Hooley 328 This suggests an average of 3.6 persons per occupied house in 1946, compared with 3.5 in 1938 and 4.3 in 1915. It must, however, be remembered that this average is based on two estimates, neither of which is completely reliable; also that more houses classified as occupied are used for purposes other than dwellings than was the case before the war. 9 VITAL STATISTICS. The following table gives the average population, birth, death, maternal and other important mortality rates for the quinquennial periods 1915-1944, together with the actual figures for 1945 and 1946. Rates per 1,000 population. 19151919. 19201924. 19251929. 19301934. 19351939. 19401944. 1945. 1946. Birth rate 13.9 13.5 12.9 11.6 12.8 15.2 14.0 17.6 Percentage illegitimate 5.7% 3.4% 3 7% 2.8% 3.4% 3.9% 5.0% 3.4% Stillbirth rate — — — — 0.43 0.48 0.43 0.49 Death rate 8.5 7.4 7.0 7.4 8.3 11.4 10.2 9.8 Cancer death rate 1.18 0.96 1.15 1.35 1.19 1.70 1.75 1.93 Tuberculosis death rate (per 100,000 population) 72 57 36 38 35 48 29 44 Violence (including Suicide) 0.19 0.44 0.35 0.32 0.46 0.82 0.41 0.24 Maternal mortality rate (per 1,000 live and still births) 3.20 2.08 2.66 3.21 2.27 2.10 Nil 2.71 Infant mortality rate (per 1,000 registered births) 44 28 38 32 38 40 32 25 Neo-natal mortality rate — — — — 26 28 28 19 Estimated population 19,073 21,351 28,950 41,616 53,084 49,880 53,460 60,390 BIRTHS. During the year 1946, 1,065 births were registered as occurring in the District, of which 544 were male and 521 were female. It will be seen by reference to the above table that this is equal to an annual birth rate of 17.6 per 1,000 population, as compared with 14.0 in 1945, and that a considerable improvement in the local birth rate has occurred during the war years. This rate for 1946 was, in fact, the highest yet recorded in this District, the next highest being 17.4 in 1943 and 17.1 in 1942. The evidence to date suggests that this wartime and post-war tendency is continuing and it will be both interesting and important to note its future trend. The increase in 1946 would in part correspond with the return of men and women from the Forces but the absence of any tendency to decrease to date raises the question whether and to what extent it will continue into the future. The repercussions on social and economic life are obvious. The Birth Rate for England and Wales was 19.1 in 1946. Illegitimacy.—In 1946, of the births registered, 37 were illegitimate (12 males and 25 females), this being 11 less than in the preceding year and 2 less than in 1944. This post-war decrease in the percentage of illegitimate births corresponds with that which occurred after 1918 and is a tendency which it is hoped will continue. It forms one index of the attitude to marriage in the community, which, from other evidence, e.g. the greatly increased number of applications for divorce, has not appeared too healthy of recent years, and suggests that whatever the attitude in 10 the later years of life the sense of responsibility in respect of marriage and the resultant offspring continues to be strong during early adult life. Attention needs to be focused on all aspects of the marriage problem if the life of the community is to be a sound and happy one. Stillbirths.—The number of stillbirths registered during 1946 was 40 (22 males and 18 females), as compared with 18 in 1945 and 21 in 1944. All but one of the stillbirths occurred in legitimate children. The local stillbirth rate was thus 0.49 per thousand of population, as compared with 0.43 for the preceding year and 0.42 for the year 1944. It is, however, considerably lower than in 1942 and 1943 (0.56 and 0.66) and only slightly above the average for 1935-9. The implications of this rate can be best considered in conjunction with the infant mortality rate later in this Report. The stillbirth rate for England and Wales was 0.53 in 1946. DEATHS. The number of deaths registered during 1946 as belonging to this District was 591 (280 males and 311 females), as compared with 549 in 1945, and 651 in 1944. These numbers exclude deaths which, although occurring within the District, belonged to other districts, but includes deaths of residents who died outside the District and also non-residents dying in the District who have previously had no permanent place of abode, which latter group has increased of recent years. It will be seen from the table of vital statistics that the crude death rate for the year was equal to 9.8 per thousand of population, as compared with 10.2 in 1945 and 12.9 in the preceding year. The average death rate in the District was low in the inter-war years, ranging from 7.0 to 8.5, but even so there was a slight tendency for it to increase with the ageing population. During the war years the population at risk was a much older one, owing to the absence of large numbers of young adults in the services, etc. Until this influence has fully readjusted itself, the uncorrected death rate will remain of less significance. The crude death rate for England and Wales was 11.5 in 1946. The principal causes of death during 1946, together with the rates per cent. of total deaths, are shown in the following table:— Cause. Number of Deaths. Rate per cent. of Total Deaths. Bronchitis 12 2.03 Influenza 10 1.62 Tuberculosis of respiratory system 19 3.21 Cancer, malignant disease 109 18.44 Heart disease 163 27.58 Cerebral haemorrhage 67 11.33 Other circulatory diseases 22 3.72 Pneumonia 22 3.72 Violence (including suicide) 15 2.25 A full list of the causes of the deaths and the ages at which they occurred is given in Table IV in the Appendix. 11 HEART DISEASE, ETC. The death rate from heart and other circulatory diseases showed a slight decrease on last year's figure. As this group is largely composed of deaths occurring in elderly people from what is really old age, it is hoped that the proportion of deaths coming under this heading will remain relatively high. The slight decrease in 1946 is probably associated with a reduction in the average age of the population at risk in that year, compared with recent years. In 1946, 77 per cent. were over 65 years of age at the time of death, while 52 per cent. were over 75 years of age. CANCER. The cancer death rate for the year 1946 was 1.93 which is appreciably higher than the rate for 1945 though only slightly above the rates for 1941 and 1944. This rate has tended to increase more or less steadily since 1920, partly owing to better notification but in part due to a true increase in some forms of the disease. There was little difference in the distribution of the disease between 1946 and 1945, except that the pulmonary form of the disease, which is tending to increase nationally, particularly in males, accounted for fewer deaths. With the improvements in modern technique it is very unfortunate that more of the deaths from this disease are not prevented, particularly when the site is one aiding early diagnosis, e.g. in the breast. If only residents would report without delay any suspicious sign or symptom many more cases could be treated successfully, while others would be relieved of unnecessary anxiety. The points requiring attention are:— (1) the enlargement of any wart or other similar chronic skin defect; (2) the occurrence of any abnormal haemorrhage from any of the body orifices; (3) any lump persisting for more than a very short while, especially in a woman's breast; (4) persistent pain or swelling; (5) ulcers in the mouth or on the gums which do not quickly heal. 12 The following table gives the age, sex and distribution of the disease in the 118 deaths which occurred during 1946. 13 CANCER DEATHS, 1946. Localisation. 30-40. 40-50. 50-60. 60-70. 70-80. Over 80. Total. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Mouth and tongue — — — — — 1 1 — 1 — — — 2 1 Parotid 1 — — — — — — — — — — — 1 — Tonsil — — — — — 1 — — — — — — — 1 Pharynx — — — — — — — 1 — — — — — 1 Stomach 1 — — — 2 2 4 — 3 2 1 — 11 4 Intestines — — 2 1 2 2 1 1 10 1 1 2 16 7 Liver — — — — 1 — — 1 3 2 — — 4 3 Pancreas — — — — 1 — 1 1 2 — 1 1 5 2 Lungs — — 2 1 3 — 5 1 2 2 — — 12 4 Kidney — — — — — — — 1 — — — — — 1 Bladder — — — — — — 2 1 3 2 — 1 5 4 Prostate — — — — — — — — 2 — 1 — 3 — Uterus — 1 — — — 1 — 2 — 1 — 1 — 6 Ovary — — — 1 -— 2 — 1 — 3 — — — 7 Breast — — — 4 — 4 — 2 — 3 — 3 — 16 Bone — — — — — — — — 1 1 — — 1 1 Total 2 1 4 7 9 13 14 12 27 17 4 8 60 58 VIOLENCE. Deaths from Violence (including Suicide) again decreased during 1946, the Death Rate per thousand of population being 0.24 per thousand of population. This is appreciably lower than the average for the years 1920-39 and, as would be expected, very much below the average during the war years when enemy activity more than offset the reduction in road fatalities. The chief reduction in 1946 was in accidental deaths other than road accidents (which increased by 2 to 5) and suicide. The causes of death in this group in 1946 were train accidents (2), falls (3) and industrial accident (1). Road deaths resulted from or involved cycles (2), motor cycles (2) and a motor car (1). The suicide death rate was much lower than the average for the years before or during the war. TUBERCULOSIS AND PNEUMONIA. Deaths from Tuberculosis and Pneumonia are referred to in later sections of this Report. MATERNAL MORTALITY. There were 3 deaths associated with childbirth during 1946, compared with nil, 2, 1, 1, and 1 in the preceding 5 years. Two of the deaths were associated with septic abortions, and the other an unfortunate result of the anaesthetic used for instrumental delivery. While all were probably preventable this could not have been expected from any improvement in normal ante-natal care and supervision. Regrettable and challenging as these deaths always are, statistically the occurrence of 3 such cases in one year in part balances the absence of any maternal deaths in 1945. For 1946, however, the Maternal Mortality Rate must be recorded as 2.71 per 1,000 live and still births compared with 1.43 for England and Wales. INFANT MORTALITY. During 1946 there were 27 deaths among the children under one year of age, as compared with 25, 28, 32, 38 and 29 in the preceding 5 years. One of the deaths was in the case of an illegitimate child. The resultant Infant Mortality Rate was thus only 25 per thousand registered births, which is one of the lowest Rates recorded for this District, the years 1921, 1931 and 1933 being the only years with lower rates, viz. 17, 23 and 20. This Rate is very liable to fluctuation but if 10 yearly averages are taken it can be observed that, after a higher Rate during the 1915-18 period, this Rate remained at about 33-35 with a very slight tendency to increase. During the war there was an increase, particularly in 1941-2, but since that the Rate has steadily decreased, being 36, 33, 32 and 25 in the last 4 years. It is hoped that a lower average will be maintained in the future. The Infant Mortality Rate for England and Wales was 43 in 1946, and 46 in 1945. 14 The following table gives the causes of the 26 deaths which occurred during 1946 and of which records are available, together with the age at death. 15 INFANTILE MORTALITY DURING THE YEAR 1946. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total deaths under 1 year. Pneumonia 1 — — — 1 1 1 1 1 5 Meningitis (tubercular) — — — — — — — 1 — 1 Gastro-enteritis — — — — — — 1 — — 1 Birth injury 1 — — — 1 — — — — 1 Cerebral haemorrhage 2 1 — — 3 — — — — 3 Congenital malformation 2 1 — 3 — — — — 3 Atelectasis 3 — — — 3 — — — — 3 Premature birth 8 — — 1 9 — — — — 9 Totals 17 1 1 1 20 1 2 2 1 26 It will be noted that of the 26 children who died before they were 1 year old, only 6 were more than a month old. Of these 6, one, who was boarded out in the District as having tubercular parents, died of tubercular meningitis, one died of diarrhoea and 4 of pneumonia, thus emphasising the necessity for preventing infection in young babies. The relatively high number of deaths from respiratory infection indicates that the prevention of the spread of colds and coughs, particularly to young babies, is of the greatest importance. The 20 babies dying in the first month corresponds with a neo-natal mortality rate of 19 (i.e. deaths in the first month per 1,000 live births) and this is the lowest but one recorded since 1936 when mention was first made of this rate locally. Reviewing these 20 deaths it will be noted that only 1 occurred possibly owing to infection. The others were associated with birth and probably reflect in large measure the ante-natal condition of the mother. As such the neo-natal mortality rate should be considered in conjunction with the still birth rate. Fortunately both rates have tended to drop locally since the war. It should be noted that all the 9 deaths in premature babies occurred after the baby had been born in hospital, or in 1 case in a Nursing Home, and before their discharge home. Six of the babies were premature twins. This number suggests that 31 per cent, of the 29 babies notified as being premature at birth died. While this fact is to be regretted and regarded as a challenge to both the ante-natal and hospital services, it does not reflect on the special arrangements made locally for the assistance of mothers with premature babies which are referred to later in this Report. 16 COMPARATIVE CRUDE BIRTH-RATES, DEATH-RATES, ANALYSIS OF MORTALITY, MATERNAL DEATH-RATES, AND CASE-RATES for certain infectious diseases in the year 1946. England and Wales. 120 County Boroughs and Great Towns including London. 148 Smaller Towns (Resident Population 25,000— 50,000 at 1931 Census. London Administrative County. Coulsdon and Purley Urban District. Rates per 1,000 Civilian Population: Live births 19.1 * 22.2 21.3 21.5 17.6 Still births 0.53* 0.67 0.59 0.54 0.66 Deaths: All causes 11.5* 12.7 11.7 12.7 9.8 Typhoid and paratyphoid 0.00 0.00 0.00 0.00 — Scarlet fever 0.00 0.00 0.00 0.00 — Whooping cough 0.02 0.02 0.02 0.02 — Diphtheria 0.01 0.01 0.01 0.01 0.01 Influenza 0.15 0.13 0.14 0.12 0.16 Smallpox 0.00 0.00 0.00 — — Measles 0.00 0.01 0.00 0.01 — Notifications: Typhoid fever 0.01 0.01 0.01 0.01 0.05 Paratyphoid fever 0.02 0.02 0.01 0.01 0.01 Cerebro-spinal fever 0.05 0.05 0.04 0.06 0.05 Scarlet fever 1.38 1.51 1.33 1.42 1.54 Whooping cough 2.28 2.48 2.05 2.22 0.51 Diphtheria 0.28 0.32 0.31 0.24 0.13 Erysipelas 0.22 0.25 0.22 0.27 0.13 Smallpox 0.00 0.00 0.00 0.00 — Measles 3.92 4.73 3.70 7.35 2.33 Pneumonia 0.89 1.02 0.74 0.75 0.26 Rates per 1,000 live births: Deaths under 1 year of age 43† 46 37 41 25 Deaths from diarrhœa and enteritis under 2 years of age 4.4 6.1 2.8 4.2 0.9 Rates per 1,000 live and still births : Maternal mortality: Sepsis 0.31 1.81 Others 1.12 0.90 Notifications : Puerperal fever 8.50 10.35 7.63 1.62 1.81 Puerperal pyrexia 9.68 *Rates per 1,000 total population. †Per 1,000 related births. ‡Includes puerperal fever. A dash (—) signifies that there were no deaths. 17 INFECTIOUS DISEASE. In recording the changes which have occurred in the incidence of infectious disease in the District, the position is somewhat confused by the introduction of the compulsory notification of measles and whooping cough during the two war periods and the statistical influence of cases of infectious disease occurring among the inmates of the two mental hospitals. The residents in the latter have but little contact with the remainder of the District and for purposes of comparison it is advisable to exclude both the above factors. A full statement of the cases of infectious disease notified since 1917 is included in Table III in the appendix and it will be found that the incidence of infectious disease generally during 1946 compared very favourably with preceding years, particularly when the number of resultant deaths and amount of permanent injury is correlated. The following table relates to notifications received during 1946:– Disease. Numbers Notified. Removed to Hospital. Total Deaths. Diphtheria 8 5 1 Typhoid fever 3 3 – Paratyphoid fever 1 1 – Scarlet fever 93 71 – Erysipelas 8 2 – Puerperal pyrexia 2 2 – Pneumonia 16 2 22* Dysentery 82 – – Cerebro-spinal fever 3 3 1 Encephalitis 1 1 1 Poliomyelitis 1 1 – Measles 141 4 – Whooping cough 31 5 – Totals 390 100 25 * Includes deaths from all forms of pneumonia. Comments on the trend of individual diseases are included in the following sections. Suffice it here to state that, excluding the two abovementioned factors which prevent comparison, the number of cases of acute notifiable infectious disease occurring among the general population in 1946 was slightly less than 2.1 cases per 1,000 population. In 1945 this figure, which was 1.8, was slightly less than that in 1938, which in turn had one of the lowest rates for the pre-war years. Diphtheria. During 1946 a total of 8 notifications of diphtheria was received, compared with 15 in 1945. All the 8 cases in 1946 and 14 of the 15 in 1945 were adults. Of the 1946 cases 7 were adult patients at Netherne Mental Hospital, which hospital has had sporadic cases occurring over the last 3 years in gradually diminishing numbers. There was thus only one true case among the general population and this in a person of 20 years 18 who had been immunised 6 or 8 years previously. The illness which resulted was not severe and the patient recovered in hospital. In addition to the above, 3 children, members of one family, who had previously been well immunised, were found to be carrying diphtheria organisms as a result of routine swabbing for streptococci, which one of them had been carrying for several weeks. As a precautionary measure they were all removed to hospital, but were only carriers of the germ, not being ill themselves, and were not included among the notified cases of diphtheria. Similarly one member of the Forces was admitted to hospital with tonsilitis. When the history of diphtheria in the District is reviewed it is found that from 1915-1937 there was an average of 30 cases per annum notified and 31 deaths occurred. On the other hand, since 1937, the year in which diphtheria immunisation clinics were commenced in this District, there has only been an average of 12 cases per annum and a total of 2 deaths. In these 10 years not only has there been a saving of 12 lives compared with the preceding 20 years, but 18 cases per annum have not required treatment with all that involves in the way of expense, manpower and resultant ill-health. The complete absence of any cases among the child population in 1946 inspires the hope of even better records in the future providing the immunity of the children is maintained at its present high level. Scarlet Fever. During 1946 there were 93 notifications of scarlet fever, which was an increase of 26 on 1945, but only slightly above the average for recent years. The disease remained mild in type and was most prevalent among school children. Altogether 71 cases were removed to Hospital but no deaths occurred. Waves of increased prevalence of this disease occurred in 1920-21, 1928-29, 1934-36 and in 1943, but while there has been a tendency in recent years for the average number of cases to be rather higher than in the earlier years, the reduced severity of the disease has been its most marked feature. Between 1915 and 1932 there were 13 deaths from this cause in the District, whereas since 1932, in spite of an increase in the average number of cases, no deaths have occurred. The milder nature of the symptoms have, however, produced increased difficulties in control. With improved methods of bacteriological diagnosis, it has been possible to demonstrate the large percentage of the population which is carrying the germs of the disease at any one time. Of these a proportion suffer from slight symptoms from time to time, though to what extent these result from the streptococci or from other germs also present in the throat it is difficult to state. A much smaller proportion still show the typical rash which alone requires notification. W'ith this background it will be appreciated that it is impossible to eradicate the disease by isolation which can, however, be helpful in reducing contact with cases when they are in their most infective stages. It is fortunate that while preventive measures can thus of necessity only be partially effective, so long as the disease remains mild in type, there is no great cause for anxiety. 19 The treatment of the disease has improved very considerably with the introduction of the sulphonamides and penicillin, but it has appeared undesirable to use these drugs prophylactically as a routine measure for fear of encouraging the development of strains of streptococci which are resistant to them. Their future use for treatment might in this way be prejudiced. Occasionally, however, both drugs have assisted prevention of the spread of the disease. Erysipelas. A total of 8 cases was notified during 1946, compared with 4 in 1945, and of these 3 were mental hospital patients. Two cases were admitted to the Isolation Hospital for treatment and all recovered. This disease, although caused by a streptococcus, has never been very prevalent in the District and the slight increases which have occasionally occurred have tended to precede the waves of scarlet fever. It is very exceptional locally to meet cases which are associated directly one with another. Puerperal Pyrexia. While there were only 2 notifications of this disease received in this District during 1946, this being the same number as in 1945, a total of 9 residents was removed to the Isolation Hospital suffering from puerperal pyrexia during the year. The 2 notified cases were removed from a local Nursing Home, presumably having contracted the infection from a member of the staff who was carrying streptococci in her nose. The other 7 cases contracted the disease at Purley Hospital, 5 in May, 1 in July and 1 in August, but were notified to the Croydon Public Health Department as having developed the disease in that District. Fortunately all the cases recovered. There were comparatively very few cases of puerperal fever notified during the first 15 years of the history of this District but this may have been due to the failure to notify cases which would now be brought to the notice of the Department. In 1932 and 1937-8 there were increases to 6 or 7 cases per annum but since the beginning of the war the number of cases has been very low in spite of the prevalence of streptococci among the general population and the difficulties under which midwives have worked. Fortunately the introduction of the newer drugs has improved the outlook for actual cases during the last decade but it is hoped preventive measures will in future be more successful than in 1946. The overcrowding of maternity departments which is liable to occur with the relative reduction in accommodation and staff is, however, apt to increase the risks. Enteric Fever. Three cases of typhoid and 1 of paratyphoid were notified during 1946, compared with 2 of each during 1945. Of the cases of typhoid, 2 occurred in patients at one of the Mental Hospitals in February and the other was a child who contracted the disease in Ireland. The origin of the 1 case of paratyphoid could not be traced. Locally this group of diseases was much more prevalent in the first decade of the District's history than of late, when increased numbers 20 occurred only in 1937 and 1940-41. On almost every occasion in which increased numbers have occurred the majority of cases have been associated with the Mental Hospitals. The only outstanding exceptions were in 1925 when a large number of cases of paratyphoid due to a food infection originating in a Croydon bakery was the chief cause, and in 1937 when the well-known water-borne typhoid outbreak was the cause. Dysentery. While no less than 82 notifications of cases of dysentery were received during 1946 this is a big reduction on the 172 cases which occurred in 1945. As in that year, however, almost all the cases, 80 in fact, were patients in the mental hospitals, where the disease has increased very markedly during the war, but is now gradually diminishing with the return to a more desirable standard of accommodation. The two cases occurring among the general population were notified in February and June. One was definitely and the other probably suffering from Sonne dysentery. Cerebro-Spinal Fever. Three cases of cerebro-spinal fever were notified during the year, compared with one in 1945. None of the cases was in any way connected with the others nor with any known case. All were admitted to Redhill County Hospital, one dying on admission. The other 2 recovered. Apart from an increase during the war years, particularly during 1940/41, very few cases of this disease have occurred in the District during its history. Encephalitis Lethargica. One case of encephalitis lethargica was notified during 1946, this being the first case since 1943. It was impossible to trace the source of the infection from which the patient, an adult male, died in the Isolation Hospital. Only very occasional cases of this disease have occurred in the District. Poliomyelitis. Only 1 suspected case of poliomyelitis was admitted to the Isolation Hospital during the year but this was diagnosed as suffering from "Influenza," the temporary paralysis disappearing completely very shortly after admission. With the exception of 1937, when 3 cases of poliomyelitis and 2 of polio-encephalitis were notified, the maximum number of cases notified has been 3, with an average of about 1 case per annum. Pneumonia. Sixteen cases of acute primary or influenzal pneumonia were notified during the year, which is one less than in 1945 and about the average for the last 4 years. The greatest number notified in any one year was 52 in 1939. 21 Three-quarters of the cases in 1946 were in adults and two cases were admitted to the Isolation Hospital as suffering from the disease. A total of 22 deaths from all forms of pneumonia occurred, including two deaths in the Isolation Hospital in infants, one from croup and bronchopneumonia, the other following septic bronchitis. Measles. There was a marked drop in the number of notifications of measles from the record of 705 in 1945 to 141 in 1946, of which latter 4 cases were admitted to the Isolation Hospital where all recovered. No deaths from this disease occurred during the year and there has only been one death from measles during the last 8 years, compared with 16 in the 24 years before the war. Measles and whooping cough were made notifiable during the first world war and again since 1939. The arguments against the retention of their compulsory notification in a District such as this were stated fully in my last Annual Report. Whooping Cough. During 1946 only 31 notifications of whooping cough were received, compared with 100 in 1945. This is the lowest number of notifications since 1940, when the notification of this disease had only just commenced. No deaths occurred during 1946, compared with 5 in the period 1939-45, 4 in the preceding 14 years and 9 in the period 1915-24. Tuberculosis. The following table presents concisely the position with regard to ;uberculosis in the District during 1946:— Pulmonary. Nonpulmonary. Total. M. F. M. F. M. F. Number of cases on register, 1st January, 1946 159 119 16 29 175 148 Additions, 1946:— New cases notified 30 8 2 5 32 13 Cases removed into District 18 6 5 2 23 8 Restored to register 1 – 1 – 2 – Total Additions 49 14 8 7 57 21 Removals, 1946:— Deaths 13 16 2 2 15 17 Removed from District 6 4 1 3 7 7 Recovered 1 2 1 2 2 4 Non-tuberculous 3 1 – – 3 1 Total Removed from Register 23 23 4 7 27 29 Number of cases on register, 1st January, 1947 185 110 20 29 205 140 22 The following table shows the age-groups in which notifications and deaths occurred:— Age Periods. New Cases. Deaths. Pulmonary. Nonpulmonary. Pulmonary. Nonpulmonary. M. F. M. F. M. F. M. F. Under 1 year – – – – – – 1 – I and under 5 – – – – – – – 1 5 and under 10 – – – – – – – – 10 and under 15 2 – – – – – – – 15 and under 20 4 – – 1 – 1 – – 20 and under 25 5 – 1 – – 4 1 – 25 and under 35 3 – 1 1 – 2 – – 35 and under 45 6 1 – 1 4 3 – – 45 and under 55 4 5 – – 5 4 – – 55 and under 65 6 1 – – 2 2 – – 65 and over – 1 – 2 2 – – 1 Totals 30 8 2 5 13 16 2 2 The new cases were distributed amongst the wards as follows:— Localisation. Coulsdon East. Coulsdon West. Kenley. Purley. Sanderstead. Selsdon and Farleigh. Woodcote. Pulmonary 8 8 4 7 4 7 – Non- pulmonary 2 1 – 2 1 1 – Totals 10 9 4 9 5 8 In order to present a picture of the trend of this disease since the formation of the District the following table has been prepared:— Average Figures for the Quinquennial Periods 1915-1944. Annual Figures for 1945 and 1946. 19151919. 19201924. 19251929. 19301934. 19351939. 19401944. 1945. 1946. Pulmonary. New cases notified 23 21 20 38 31 40 44 38 Case rate per 100,000 population 132 98 71 94 58 79 82 63 Deaths 13 10 10 15 17 24 20 29 Death rate per 100,000 population 72 57 36 38 36 48 37 48 Non-Pulmonary. New cases notified 2 3 4 8 7 8 3 7 Case rate per 100,000 population 13 17 15 21 13 16 5 11 Deaths 3 2 2 3 1 3 1 4 Death rate per 100,000 population 20 9 7 8 3 6 1 6 23 Dealing first with the pulmonary form of the disease it will be noted that in spite of a temporary war-time increase the case rate has steadily declined since the formation of the District, the ten yearly averages being 115, 82 and 68 new cases per 100,000 population per annum. The corresponding figures for non-pulmonary tuberculosis are, of course, much lower and have remained fairly steady with ten yearly averages of 15, 18 and 14. In both the above rates, the figures for 1946 compared very favourably with those of previous years. In the death rates for both forms of tuberculosis there was a more or less steady decline before the war, a temporary set back in the early war years, followed by further improvement, but locally these death rates in 1946 were not so satisfactory as in 1945. This is probably, however, only a temporary fluctuation. Of the deaths which occurred in 1946, 22 were in previously notified cases, i.e. 66 per cent. Of the remainder 5 were notified posthumously. The Council is responsible for measures to prevent the spread of this disease, including rehousing where necessary. Arrangements have been made for the examination, free of charge, of sputa in cases or suspected cases of tuberculosis, 61 such examinations being made during 1946. Similarly disinfection and visitation are provided to secure the removal of unhygienic conditions, the examination of contacts, etc. The treatment of cases of tuberculosis is under the control of the Surrey County Council, which provides both sanatorium and dispensary treatment, but their resources continue to be strained owing to the lack of staff and other demands for hospital beds. The dispensary for the diagnosis and observation of cases is situated in Whytecliffe Road, Purley, and sessions are held there every Monday from 2-4 p.m. The County Council makes a very substantial contribution towards the financial resources of a Voluntary Care Committee, which serves the area of the Urban District and most of the Caterham and Warlingham Urban District. It does very useful work in helping individual cases and their dependants. The Council has been represented thereon by the Medical Officer of Health and, in addition, in 1945 appointed a member of the Council to serve on the Committee. PUBLIC HEALTH ACT, 1936, SECTION 172. PUBLIC HEALTH (PREVENTION OF TUBERCULOSIS) REGULATIONS, 1926. No action has been required under these powers during recent years. NON-NOTIFIABLE INFECTIOUS DISEASE. The group of non-notifiable infectious diseases accounts for very few deaths, with the exception of influenza, to which 10 deaths were attributed in 1946. The average number of deaths annually from influenza was 24 8 before and 9 during the war, with maxima of 24 in 1918 and 20 in 1927 and 1943. In addition 1 or 2 children under 2 years of age usually die each year from diarrhoea. Apart from the death returns the only information as to the presence of outbreaks of non-notifiable infectious disease is obtained from the returns from the nurseries and public elementary schools. As judged by these there was fairly extensive chicken pox in Sanderstead in January, and in Purley and Old Coulsdon in the Autumn, and a number of cases of mumps in Kenley in the Spring and in Sanderstead in the Autumn. Only 1 case of infective jaundice and 3 cases of ringworm were notified, the latter being scattered cases, 1 in the Spring and 1 each at Old Coulsdon and Kenley in October/November. Home visitation and exclusion from school are still the two chief methods relied upon to prevent or postpone the onset of the abovementioned diseases until the most favourable age is reached at which they can be withstood. Treatment in the Isolation Hospital is provided when required owing to social or physical complications being present, but only 1 case of German measles and 2 of influenza were so admitted in 1946. In addition some cases may have been admitted to the County Hospitals but of these no records are available. INFESTATIONS. (a) Scabies. During 1946 the number of persons treated at the Scabies Treatment Centre, lion Green, Coulsdon, was 250 of which number 79 were school children, 135 adults and children under 5 years of age, while 36 persons had preventative treatment only. Altogether 805 baths were given. Altogether 805 baths were given. The number of cases shows an appreciable reduction on previous years as shown by the following table:— Year. Number of Baths. Number of Persons treated. 1942 (May-December) 695 237 1943 1,217 326 1944 905 399 1945 768 349 1946 805 250 It is hoped that, as occurred after the war of 1914-1918, the steady decline in the prevalence of this disease already observable will be maintained. Theoretically the disease could be abolished quickly, but in practice its diagnosis is often delayed and not easy, while the interval of about 5 weeks which occurs between infection and the development of symptoms, and the difficulties in obtaining the treatment of non-co-operative families 25 are some of the additional reasons why eradication is likely to be protracted. During the year 7 sessions a week were held (2 being evening sessions), at some of which voluntary helpers from the original Civil Defence staff continued to assist the 2 part-time paid workers. With the reduction in the number of cases it has become practicable to reduce correspondingly the number of sessions, which are now only held on Tuesday, Friday and Saturday mornings and Tuesday and Saturday evenings. (b) Vermin. The number of cases of infestation was again very small and was mostly limited to cases of head lice discovered at the schools. One case with pubic and two with head infestations were treated at the Scabies treatment centre, which may in future be called upon to undertake more of this work as a result of the policy involved in the Education Act, 1944. No alteration was made during 1946 in the procedure for dealing with these cases as far as possible as a family unit. THE CONTROL OF INFECTIOUS DISEASE. The place of immunisation among the measures for the control of infectious disease was discussed in the 1945 Report and there has been no outstanding change in our knowledge or practice since that Report was completed. Diphtheria Immunisation. The following table shows the treatment given during the last 2 years and the proportion of children estimated to have been immunised in each:– 1945. 1946. Clinics. Number of sessions held during the year 74 59 Number of children who commenced treatment g66 476 Number who completed treatment 668 506 Number of Schick tests made 7 3 Number of "Booster" doses given 98 136 Total number of attendances 1,427 1,168 Schools. Number of visits made – 100 Number commencing treatment – 281 Number completed treatment – 292 Number of Schick tests made – 1,437 Number of " Booster doses given – 2,095 Proportion of children estimated to have been immunised: (a) from 1-5 years 56% 44% (b) from 5-14 years 90% 90% The smaller number of clinic sessions held during 1946. corresponds to the reduced demand which, in part at least, was attributable to the fall in the birth rate which occurred in 1945. The children attending the clinics 26 are chiefly young babies receiving their first course. On the other hand it will be observed that attention was focused on increasing the immunity of the school children. A questionnaire was sent to the parents of all children attending the public elementary, secondary and private schools in the District, from which up-to-date information was received as to the state of the children's immunity. Consent was also obtained to the vast majority being given reinforcing doses by the Medical Officer of Health when he considered this desirable. Others were encouraged by the enquiry to obtain further treatment from their own Doctors. By the end of the year a considerable proportion of the schools had been visited and by the middle of 1947 all schools which had more than an insignificant number of children had been visited, including private schools, isolated children being seen at the clinics. As a result of this enquiry and subsequent treatment it can be stated with a very reasonable degree of accuracy that at least 44 per cent. of children from 1 to 5 years of age and 90 per cent, of those 5-14 years of age have been immunised and the vast majority of the latter have received at least one reinforcing dose. In order to maintain this high degree of immunity of the children in the District it is very desirable that all children shall, if possible, have completed their first treatment by the time they are a year old, while older children should receive an extra dose at about 5 years, 10 years and possibly 15 years of age. Use can well be made of the Schick Test in the eldest children as revealing and at the same time increasing their immunity. No noteworthy alteration was made during the year on recent practice, A.P.T. being extensively used for children up to 9 years of age and T.A.F. for older children. Since the Diphtheria Immunisation Scheme was first introduced in this District a system of appointments in respect of all attendances at clinics has been maintained, a practice which is very exceptional if not unique. A fee of 1/- is payable for each notification of children immunised by General Practitioners, but since the offer was first made in December, 1945, no notification has been received, although doubtless an appreciable number of children are thus treated annually. This failure to assist the collection of accurate information is regretted. DIABETES. The supply of insulin at reduced cost or free of charge to residents unable to obtain such supply through other agencies was continued throughout the year. The number of cases remained small, only 6 being supplied in this way during 1946. AMBULANCES. For Infectious Disease Cases.—The Wandle Valley Joint Hospital Board has provided two motor ambulances for the removal of cases of infectious disease to hospital. The use of these ambulances is limited to the area served by the Hospital Board. 27 Accident and General Cases.— The three first-line ambulances, with one in reserve, continued to be manned continuously by whole-time, paid men, most of whom were ex-members of the Civil Defence forces. Until the end of the year they worked 24 hours on and off duty alternately, as they had in previous years, and continued to give most satisfactory service. They were directly responsible to the Medical Officer of Health. Through the courtesy of the National Fire Service the 3 ambulances on duty are based on the Purley and Sanderstead Fire Stations, as in the second half of 1945. Towards the end of the year the Council decided to conform to the recommendations of the National Joint Council for the Staff of Hospitals and Allied Institutions including the introduction of a 3-shift system and weekly day off for each man. This necessitated the appointment of approximately 50 per cent. more men and, in the interests of efficiency and to relieve the Medical Officer of Health of much of the detailed work he had undertaken since 1939, it was also decided to appoint an Ambulance Superintendent. It was moreover considered necessary to have only 2 ambulances on duty at night, care being taken, however, to see that the system of reinforcement by neighbouring Districts worked expeditiously and smoothly. The result of these changes has been that the high standard maintained throughout the war has not fallen and in fact the District can be proud to have what is probably the best service in the County. The system was continued of charging for removals, other than cases of accident or sudden illness, occurring in public places, but with modified charges for some maternity cases conveyed to and from hospital. HOSPITALS. Infectious Disease.—This Council is one of the constituent authorities of the Wandle Valley Joint Hospital Board, and cases of infectious disease (other than smallpox) occurring in this District are admitted to the Board's hospital at Beddington Corner, Mitcham. Although additional accommodation has been made available by the release of certain blocks previously reserved for war purposes, the actual bed accommodation has been seriously restricted, as in other hospitals, by the shortage of nursing and domestic staff. Smallpox.—Under arrangement with the Surrey County Council, cases of smallpox are admitted to the Smallpox Hospital at Clandon, but fortunately no cases of this disease have occurred in this District since 1932, although each year numerous contacts with the disease elsewh re are visited when arriving in this District. General Hospitals.'—The general hospitals chiefly serving this area are the Redhill County Hospital, Croydon General Hospital and the Purley War Memorial Hospital, but a considerable number of residents receive treatment at various London hospitals and other County hospitals. The position with regard to remedying the inadequacy of accommodation has remained very difficult. Maternity Hospitals.—There is an arrangement with the Purley War Memorial Hospital whereby the Council has the call on three beds, and if accommodation permits additional cases can be admitted. A large 28 proportion of cases from this District are admitted to the County Hospital at Redhill, while a considerable number of residents make arrangements with private nursing homes or more distant hospitals. An analysis showing the percentages admitted to institutions for their confinements is included in a later section of this Report. With the increased number of births and limitation of accommodation, the competition to obtain admission remained keen and the qualifications imposed upon the applicants would have had to be even more restrictive, but for the reduction in the average stay of normal maternity cases in most hospitals. While, as a result, more admissions have been arranged, this is a retrogade step which authorities have been forced to take. When considered in conjunction with the housing situation, which limits the proportion of expectant mothers who can conveniently arrange for their confinements in their own homes, the present position cannot be considered satisfactory, but the problem is a very complex one and is linked with other social and economic questions. BACTERIOLOGICAL AND CHEMICAL EXAMINATIONS. The examination of swabs for diphtheria and sputa for tuberculosis is carried out by the Medical Officers of the Wandle Valley Isolation Hospital, and during 1946 the following numbers of specimens were examined:— Swabs for diphtheria 77 Sputa for tuberculosis 61 In addition, specimens submitted to detect and classify streptococci are sent to the Emergency Medical Service Laboratory, Westhill House, Westhill Road, Epsom, while an arrangement existed whereby other pathological specimens, the examination of which was of importance to the public health, were examined by the Pathologist to the Croydon General Hospital. The scope of the Emergency Medical Service Laboratory has now been widened and most samples are sent there for examination. In 1946 the following specimens were examined:— At Epsom for streptococci 170 At Croydon General Hospital: Blood for Widal Test 7 Faeces for typhoid, paratyphoid, etc. 5 The bacteriological examination of all samples of milk and all water samples are carried out at the Emergency Medical Service Laboratory, Epsom, only water samples for chemical examination being sent elsewhere, viz. to the Clinical Research Association. DISINFECTION. The disinfection of bedding, etc., is undertaken by the Wandle Valley Joint Hospital Board, while the disinfection of premises is carried out by the Officers of the Public Health Department. For the convenience of ratepayers, the Council has decided to arrange disinfection even when this is not essential in the interests of public health, but in these cases the following charges are made: 10s. per load of 29 bedding, etc., 5s. for the first room, and 2s. 6d. for each additional room disinfected at the same time. During 1946 the following disinfections were carried out:— Free of cost. Upon payment Total. Loads of bedding, etc. 164 37 201 Houses disinfected 182 11 193 HEALTH PROPAGANDA. Steady use has been made of the opportunities for health propaganda at the clinics and centres arranged by the Council, and during the visitation of the Health Visitors and Sanitary Inspectors. The material provided by the Central Council for Health Education and other bodies has been extremely useful and is widely used. MATERNITY AND CHILD WELFARE. The Council has been responsible, since it was constituted, for the maternity and child welfare work of this District, and in its endeavours to minimise the risks of childbirth and secure the care and healthy development of all children born or residing in the area has taken the following measures:— Maternity Clinics. The policy of combining ante-natal and post-natal work at the same clinics was continued throughout 1946, the clinics being held from 2 to 4 p.m. as follows (a) 69, Brighton Road, Purley, each Monday and on the first and third Tuesdays in each month. (b) Methodist Church, Sylverdale Road, Purley, on the first and third Wednesdays in each month. (c) Baptist Church, Addington Road, Selsdon, on the second and fourth Wednesdays in each month. A system of appointments for seeing the Medical Officers has been reintroduced and, thanks to the assistance of members of the British Red Cross Society, has worked very successfully to the benefit of the mothers attending. Centre. New Cases. Number of A ttendances. Sessions. Average per session. Antenatal. Postnatal. T otal. Antenatal. Postnatal. Total. 69, Brighton Road, Purley 356 6 362 1,006 101 1,107 74 14.9 Sylverdale Road, Kenley 129 2 131 721 84 805 24 33.5 Selsdon 91 2 93 449 57 506 22 23.0 Totals 576 10 586 2,176 242 2,418 120 20.1 (Two Doctors attend all sessions at Sylverdale Road and the sessions held at 69, Brighton Road on Mondays.) 30 The following table compares the 1946 figures with those of 1945:— 1945. 1946. New ante-natal cases 391 576 Percentage of registered births 52% 54% Post-natal attendances 210 242 Number of sessions 120 120 Average attending per session 22 20.1 It will be seen that the proportion of Ante-natal mothers attending the clinics, which was 33 per cent. in 1939, still tends to increase, probably owing in part to many hoping institutional confinements will result. The proportion of mothers attending for post-natal examination is still regrettably small and shows no tendency to increase. Much physical inconvenience or ill health could be avoided by the greater use of the facilities provided. Maternity Cases. The following table presents concisely the position regarding institutional confinements and those attended by the Council's midwives or the Coulsdon Nursing Association, comparing 1939, 1945 and 1946. 1939. 1945. 1946. Admitted to Purley Hospital 64 72 72 ,, Redhill Hospital 98 129 220 Attended by Selsdon Midwife 38 33 53 ,, ,, Purley ,, 49 39 75 ,, ,, Coulsdon Nursing Association Midwives 96 Supplied with Home Help 18 142* 171 * Including Home and Domestic help. Midwifery Service. The Council, acting as agents for the Surrey County Council, appointed two midwives in December, 1937, to serve the Sanderstead/Selsdon and Purley/Kenley areas. In addition, the Coulsdon District Nursing Association has, for several years, employed two midwives to attend confinements in the homes of residents in the Coulsdon area. In 1946 the Council's midwives attended 128 cases, of which at least 49 were maternity cases attended also by a Doctor, while the Coulsdon Nursing Association midwives attended 96 cases, of which 40 were maternity cases. Only 2 other midwives were known to be registered to practise in the District, but neither engaged in much actual midwifery work. Hospital Accommodation for Maternity Cases. The only change of note since the 1945 Report has been the reduction in the average number of days during which normal maternity cases have 31 been retained at the majority of the hospitals from 14 to 10 days. This has resulted in a greater number, although not a larger proportion of the local births taking place at Redhill County Hospital. The following table shows the percentage of births confined by various agencies in 1939, 1940, 1945 and 1946:— Year. Nursing Homes. Midwives. County Hospitals. Purley Hospital. London Hospitals. Number of births registered. Council Others. Redhill. Others. 1939 30 12 30 13 – 14 1 762 1940 24 15.5 23.5 14 1.5 20.5 1 626 1945 35 8.5 12 23.5 – 19.5 1.5 750 1946 36 11 13.5 22.5 1 13 3 1,065 It will be noted that the domiciliary midwives have this year dealt with a greater proportion of the births in spite of the phenomenal increase in their number. Home Help Service. The Council instituted a Home Help Service in 1920 but until 1944 assistance was limited to maternity cases. Only one permanent Home Help was employed from 1920 to 1941 with occasional part-time assistance. During the second half of 1945 the number employed was increased to at least 17 and it became necessary to employ a part-time paid Organiser to relieve the Senior Health Visitor. During 1946 the work expanded very considerably and the number employed varied from 14 to 26, which number has since been exceeded. The number of cases assisted increased from 31 maternity cases in 1938 to totals of 142 in 1945 and 268 in 1946. The latter represents 171 maternity and 97 other cases who were helped owing to sickness in the family, or old age, the latter being unable otherwise to cope with their domestic affairs. It was only practicable to aid the majority for a period of 2 to 3 weeks, but in exceptional circumstances the period was extended, occasionally very considerably. It is impossible to summarise the assistance rendered in a short section of a report of this type, or even to illustrate the very appreciable benefit it has meant to many residents. Suffice it to say without fear of contradiction from well informed and unbiassed sources that this form of service has been amply justified and is one of which all concerned can be proud. It is unfortunate that the charge for the service, which has to include overheads, must inevitably cause financial strain to some families, with undesirable limitation of the period during which aid is sought, or even the rejection of this assistance in cases for which it is really needed. A sliding scale has been devised which assists those in poorer financial circumstances, and a quite generous attempt has been made to extend modified benefits over a wide range of incomes. It was also regrettable that all legitimate appeals for assistance could not be met owing to the limited number of Home Helps employed. The Organiser, however, did extremely well in spreading the available 32 assistance over the maximum number of cases, in holding together so many assistants, whose conditions of service often vary very considerably and are not always by any means easy or pleasant, and particularly in enthusing them with a real sense of service. While her assistants tend to come and go, she is succeeding in building up a good organisation with its own quite high standard and tradition. It is hoped that further expansion will be practicable as there can be no doubt of the need, particularly in this time of limited nursing and domestic assistance and shortage of hospital accommodation. The secret of its success undoubtedly lies in local and individual initiative and enthusiasm, which must not be permitted to become stifled when reorganisation of the Health Services takes place. Obstetric Specialists. During 1946 there was one Obstetric Specialist recognised under the Council's scheme upon whom local Doctors could call for assistance in relation to anticipated or realised obstetrical difficulties, and his services were only called upon on one occasion. Since the end of the year the number of Specialists has been increased to six. The Council has made no attempt to recover the fees of the Specialists from those benefiting by the Service since 1938. Emergency Unit. In 1938 an arrangement was made, thanks to the generosity of the County Borough of Croydon, whereby an Emergency Unit or "Flying Squad" based on Mayday Hospital, Croydon, was made available to residents in this District, but fortunately its services were not required during 1946. Care of Premature Babies. During 1944 additional arrangements were made to provide for the peculiar needs of premature babies, including the appointment of a Consultant Paediatrician, but his services were not called upon during 1946. Similarly the special cots, with electric blankets, etc., which have been provided were used for only one case. These figures suggest a lack of use of the facilities to the provision of which much thought has been given. In fact the total number of premature babies whose births were notified during 1946 was only 29 and of these only 3 were born in the District. All the deaths in premature babies which occurred during the year were in respect of babies who were born and died in the Hospitals or Nursing Homes before they were due for discharge. Care of Illegitimate Babies and Their Mothers. While the Health Visitors continue to give very considerable attention to the individual needs of cases of this type of which they become aware, no further action was taken during 1946 towards completing the plans considered by this and neighbouring Districts during 1944/5. With the reduction of the total number of these cases, of whom not more than one half come to the knowledge of the Health Department, it is unlikely that plans for the provision of special local accommodation, etc., will mature. 33 Family Planning. The Family Planning Clinic which was established in the District at the end of 1945 held sessions on the second Tuesday in each month throughout 1946. A total of 60 new cases was seen, 45 for advice on birth control, the latter being desirable on medical grounds only, and 15 owing to sub-fertility. A total of 110 attendances was made at the 12 sessions, all being by appointment. Health Visitation. In theory the Council continued to employ 5 Health Visitors during 1946 but, owing to sickness and a resignation, for more than half the year a maximum of 4 Health Visitors were doing their best to maintain the standard of the service. The following table of visits paid during the year reveals that statistically the work suffered as, in spite of the increased number of births the total number of visits dropped by 1,394. First visits to babies actually increased by 254, however, although the percentage visited dropped slightly from 94 per cent. to 90 per cent. It is when the revisits to babies, and particularly to the older children, are compared that it is seen with regret how these had to be reduced by over a thousand visits. Fortunately there was less need for visits to cases of infectious disease, otherwise the work would have had to suffer still more. 961 first visits to babies. 1,925 visits to babies under 1 year. 3,452 visits to children from 1 to 5 years. 252 ante-natal visits (176 first visits, 76 re-visits). 29 visits to cases of Whooping Cough (22 first visits, 7 re-visits). 34 visits to cases of Measles (24 first visits, 10 re-visits). 3 visits to cases of Puerperal Pyrexia. 18 investigations re infant deaths. 25 investigations re still births. 215 miscellaneous visits. 32 visits to cases of Tuberculosis (21 first visits, 11 re-visits). 6,946 Total visits. The following table shows the five-yearly averages for the period 1916-1946:— Number of Health Visitors. Total Visits. Birth Visits. Re-visits. Visits re Infectious Disease. 1916-1920 1 1,078 117 845 95 1921-1925 1 2,443 144 2,010 112 1926-1930 1 3,111 250 2,260 215 1931-1935 2 5,354 438 3,920 236 1936-1940 3 7,506 624 6,040 245 1941-1945 4 8,760 717 6,451 350 34 Infant Welfare Centres. Six Infant Welfare Centres were held regularly from 2-4 p.m. during 1946 as follows:– Methodist Church, Brighton Road, Coulsdon Every Thursday. Church of St. Francis, Rickman Hill, Coulsdon Every Tuesday. St. John's Hall, Bradmore Green, Old Coulsdon Every Wednesday. Methodist Church, Sylverdale Road, Purley Every Friday Baptist Church, Addington Road, Selsdon Every Monday. Congregational Church, Sanderstead Road, Sanderstead Every Friday. Since then a seventh Centre has been opened, sessions being held every other Thursday at the Whitgift Sports Pavilion, Lime Meadow Avenue, Sanderstead. The expansion of the Infant Welfare Centres since they were started in 1916 is indicated by the following tables:— Years. Number of Clinics. Average Number of Sessions. Average Annual Total Attendance. Average Attendance per Session. 1916 1 – 31 – 1917-27 2 93 2,484 27 1928 3 103 3,587 31 1929-36 4 173 8,099 47 1938 6 239 17,038 71 1939-45 6 259 12,408 49 1946 6 297 13,770 46 35 36 ATTENDANCES AT INFANT WELFARE CENTRES. 1935-1946. Brighton Road, Coulsdon. Rickman Hill, Coulsdon. Bradmore Green, Old Coulsdon. Sylverdale Road, Purley. Addington Road, Selsdon. Sanderstead Hill, Sanderstead. TOTALS. 1946. 1945. 1944. 1943. 1942. 1941. 1940. 1939. 1938. 1937. 1936. 1935. New cases 154 118 105 192 126 150 845 768 681 811 848 717 667 811 667 594 502 423 Other cases 2,187 1,288 2,491 2,108 2,664 2,084 12,818 12,348 10,130 13,093 12,328 10,315 10,245 13,093 16,371 14,064 12,017 10,309 Total attendances 2,337 1,516 2,593 2,300 2,790 2,234 13,770 13,116 10,811 13,904 13,176 11,032 10,912 13,904 17,038 14,658 12,519 11,732 Consultations with doctor 565 391 380 514 675 617 3,142 3,078 2,973 3,601 3,466 3,477 3,243 3,412 3,522 2,866 2,403 2,099 Referred to hospital 1 4 4 3 2 2 16 27 21 38 59 68 10 38 41 21 16 17 Number of sessions 50 48 52 50 47 50 297 288 277 261 243 244 237 261 239 220 195 191 Average attendance per session: 1946 47 32 50 47 59 45 46* 1945 49 33 48 42 51 49 45* 1944 49 29 40 31 42 40 38* 1343 65 38 57 44 59 56 53* 1942 65 43 53 44 63 53 53* 1941 52 31 43 46 51 45 44* 1940 48 40 38 43 50 53 45* 1939 65 38 57 44 59 56 53* 1938 81 67 51 69 81 62 71 * 1937 75 64 42 59 79 49 67* 1936 69 56 – 53 81 69 64* 1935 58 57 – 49 61 – * Average attendance per session for all Centres. 61 * It will be noted that in almost all respects the numbers increased in 1946 over 1945 and in fact the number of new cases was almost the highest experienced locally. On the other hand, while there was a slight increase in the total attendance, this total was far below that of the peak year in 1938. In part this may be accounted for by the change of habits on the part of mothers following their disturbance during the war, but the more important reason is that at five of the centres one session each month is devoted primarily to toddlers and the attendance of babies is discouraged. In so far as the average attendance per session has been reduced this is all to the good, as overcrowding is diminished and better work can be done by the staff. The reduction in the number of cases referred to hospital compared with 1938 (and especially with the war-time peak in 1941-2 when the District was most short of private Doctors) is satisfactory as suggesting that the real purpose of the centres is being appreciated, i.e. the observation of the development of the apparently healthy child together with the tendering of advice on how to keep it healthy. The centres are not intended for the treatment of those who are ill; these are encouraged to obtain treatment when necessary through their private Doctors. The Council continued to receive assistance from voluntary helpers at all centres and their steady and unspectacular help continues to be appreciated, as the Health Visitors are thereby enabled to concentrate on giving personal professional advice which, when coupled with that of the Doctors, constitutes the essence of the Service. Toddlers' Clinics. Since 1939 the Council has devoted regular monthly sessions at five of the infant welfare centres to supervising the health of children over two years of age ; previously these attended but were apt to be overlooked on account of the attention claimed by the newly born babies. The following table indicates the numbers of children who have been examined in this way since the inception of these clinics:— 1939. 1940. 1941. 1942. 1943. 1944. 1945. 1946. Number of toddlers sessions held 23 44 46 41 44 45 43 56 Number of children examined 247 237 164 198 241 165 169 257 Total number of examinations 276 450 404 459 564 454 469 553 The improved figures for 1946 are very welcome as suggesting an increased appreciation of the benefits of this service. This age group has also received increased attention in the Nurseries and Nursery Schools, where the majority are over 2 years of age and receive frequent medical inspections. 37 Eye Defects and Treatment. Arrangements were made during the year 1938 whereby children suffering from eye defects could be referred by appointment to special sessions for young children held at the Surrey County Council's Clinic in Whytecliffe Road, Purley, and these facilities have continued throughout the war years. In 1946 appointments were made for 16 children to attend, which is more than the average number referred annually since the inception of the scheme. Dental Treatment. The number of ante-natal and nursing mothers and children under 5 years of age who received dental treatment from the panel of private dental surgeons under the Council's Scheme increased to 121 in 1946 as compared with 47 in 1945. This was partly due to the reduced scale of charges in respect of children which the Council decided to adopt in 1945. Day Nurseries. The local Day Nurseries underwent very considerable changes during 1946. When the year commenced there was still accommodation for approximately 200 children in the 2 Voluntary Nurseries at Purley and Coulsdon and the 3 Wartime Day Nurseries at Selsdon, Purley and Old Coulsdon. The nett cost of the latter was being met entirely by the Government, and while the local Council was heavily subsidising the cost of the 2 Voluntary Nurseries, whose expenses had increased but whose incomes had dropped both very appreciably, a good proportion of these subsidies was also being met by the Government. When in December, 1945, the Government decided to reduce its grants on wartime nurseries from 100 per cent. to 45 per cent. there was a natural desire on the part of the Council to reduce the local expenditure on nurseries. Insofar as these were helping the adjoining Districts of Croydon and Caterham it was reasonable to request both the former, and the County Council on behalf of the latter, to meet the cost of their children attending the local Nurseries, which requests were acceded to. Upon an analysis being made of the position of local residents then using the nurseries and those on the waiting lists (all the nurseries were full with waiting lists, except Selsdon, which had up to about 50 children utilising its 60 places) it was considered that the Council would be fulfilling its obligations as a child welfare authority by providing a minimum of 60 places primarily for the following groups:—(1) children from birth to 2 or 3 years of age whose parents needed to work to exist; (2) children of 2 to 5 years whose parents similarly needed to work and whose needs would not be met by nursery school facilities and (3) children needing admission for health reasons. To achieve this reduction in local responsibility and expense (1) the County Council, as the Education Authority, was approached and it was • agreed to divide the accommodation as between nurseries and nursery schools, on the understanding that the latter would be open for the same hours and under the same conditions as the nurseries, and (2) the charges 38 asked of parents whose children attended the nurseries were increased from 1s. to 1s. 6d. per day. As a result of this arrangement and the desire of both Voluntary Nursery Committees to transfer their responsibilities to the Council, (1) the Selsdon and Old Coulsdon Wartime Nurseries were divided into Nurseries and Nursery Schools, the dividing line being at 3 years of age, i.e. 30 places at each for each age group; (2) the Purley Day Nursery was taken over by the local Council for children from birth to approximately 2 years; and (3) the Purley Wartime Nursery and Coulsdon Day Nursery became Nursery Schools under the County Council, both taking children from 2 years to 5 years of age. Owing to local pressure on behalf of the owners of three sites of bombed houses occupied by the Selsdon Wartime Nursery and Nursery School, countered far too belatedly by those benefiting or likely to benefit by this amenity, it was decided to close and demolish this building. While the number of those attending was gradually reduced the actual closure was postponed until 31st March, 1947. The co-operation between the staffs of the nurseries and nursery schools has, on the whole, been very commendable but it has become gradually though steadily more obvious that the purpose behind each organisation is fundamentally different. The nursery schools, drawing their teaching staff from and being controlled by the Education Authority, regard their problem as the education of the young child irrespective of its social background. Having once been admitted the child normally continues to attend until transferred to a primary school, the atmosphere of which it has already been absorbing to a varying degree, depending upon the background of the Head Teacher. By contrast the Nursery is chiefly aware of the social background of young children, though not unconscious of the need to train for life in the widest sense the children who come under their care. The mother's need of assistance in the care of her child, owing to the necessity for her to work, or because of. her health or that of the child, these are the factors, the urgency of which indicates the priority which should be given to her application for the admission of her child. As and when the necessity abates the child can return to its home, usually the fitter for its time in the Nursery, while another can replace it. Starting from these two opposite conceptions of service to the child, the Nursery School naturally tends to conform with educational practice and to adopt the normal school hours and holidays. Associating with a movement in this direction there is a danger that a Child Welfare Authority may forget its primary function to provide for the social, physical and mental needs of the mothers and children for which it is responsible. The year 1946 provided opportunities for experiments in cooperation and for gaining experience in these two forms of social service. It would now appear desirable for the Council as a Child Welfare Authority to concentrate on providing an adequate and distinct Nursery service which can continue to provide for the needs of the District in this direction, 39 and not be absorbed by a virile educational service when the transfer of responsibilities takes place under the National Health Service Act. There would appear likely to be always a need for a Nursery Service, though with reduced accommodation, even when the Country realises its responsibility to encourage mothers with young children to regard their care as being their chief duty, and to discourage their going out to work away from their children, if necessary by adequate subsidies. Even in those probably remote days there will be cases of physical or mental ill health occurring among mothers or children for whom the provision of Nurseries, some with residential accommodation, will be desirable. Nursery schools, by virtue of their house and holidays, apart from any other factor, must never be regarded as substitutes for Nurseries. There is a place and a need for both but they perform distinct and different functions. Child Life Protection. The Health Visitors are all Infant Life Protection Officers and during the year kept 20 foster mothers under supervision. This is about the average number for recent years, but the 54 children distributed among them were more numerous than in any previous year. As stated earlier in this Report, one of the foster children died while in the District, the infection having been contracted, however, before its removal into the District. It was thought that no blame could be attached to the foster mother. The Health Visitors have also paid a considerable number of visits with regard to the suitability of families which were proposing to adopt children. HOUSING. The following table is a statistical record of work carried out in respect of the sanitary condition of dwelling houses 1. Inspection of Dwelling Houses during the Year 1946. (1) (a) Total number of houses inspected for housing defects (under Public Health or Housing Acts) 768 (b) Number of inspections made for the purpose 2,694 (2) (a) Number of dwelling houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 Nil (b) Number of inspections made for the purpose Nil (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation Nil (4) Number of dwelling houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 528 2. Remedy of Defects during the Year Without Service of Formal Notices:— Number of defective dwelling houses rendered fit in consequence of informal action by the Local Authority or their officers 435 40 3. Action under Statutory Powers during the Year:— (a) Proceedings under sections 9, 10 and 16 of the Housing Act, 1936: (1) Number of dwelling houses in respect of which notices were served requiring repairs 4 (2) Number of dwelling houses which were rendered fit after service of formal notices: (a) By Owners 4 (b) By Local Authority in default of Owners Nil (b) Proceedings under the Public Health Acts: (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 55 (2) Number of dwelling houses in which defects were remedied after service of formal notices: (a) By Owners 61 (b) By Local Authority in default of Owners Nil (3) Proceedings under sections 11 and 13 of the Housing Act, 1936: (a) Number of dwelling houses in respect of which Demolition Orders were made Nil (b) Number of dwelling houses demolished in pursuance of Demolition Orders Nil (4) Proceedings under section 12 of the Housing Act, 1936 : (a) Number of separate tenements or underground rooms in respect of which Closing Orders were made Nil (b) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit Nil 4. Housing Act, 1936, Part IV—Overcrowding:– (a) (1) N umber of dwelling houses overcrowded at end of year 11 (2) Number of families dwelling therein 16 (3) Number of persons dwelling therein 67 (b) Number of new cases of overcrowding reported during the year 18 (c) (1) Number of cases of overcrowding relieved during the year 13 (2) Number of persons concerned in such cases 42 (d) Particulars of any cases in which dwelling houses have again become overcrowded after the Local Authority has taken steps for the abatement of overcrowding Nil Number of New Houses Erected during the Year:— By the Local Authority 108 By other persons 64 ( * Including 105 pre-fabricated houses.) The number of houses inspected for defects showed an increase of 43 per cent. compared with 1945 and 1939, and was almost double the average for the war years, while the number of visits paid showed an even greater increase. As might be expected the numbers found not to be in all respects fit for habitation and subsequently rendered fit increased proportionately. The number of Sanitary Inspectors engaged on this work did not excerd three, which was the number employed throughout the war, and 41 in fact during the last 2 or 3 months of the year this staff was reduced to 2 Inspectors. The Chief Sanitary Inspector undoubtedly took on far more than his share of this and the other work of his Department, bearing the brunt when his staff was depleted in the Autumns of 1945 and 1946. While relatively small, the number of cases of statutory overcrowding reported during the year was very considerably above the pre-war level, as also the number still waiting to be relieved at the end of the year, in spite of the fact that the proportion relieved had been fairly high. When it is remembered that the standard set by the Housing Acts is extremely low, not only is it obvious that a considerable amount of undesirable crowding can and does co-exist without appearing in these records, but the desirability of attention being focused on these, the worst cases, is equally apparent. If given the priority which would appear desirable, the majority could be relieved at an early date. WATER SUPPLY. As in previous years the water supply of the District was provided by the Sutton and District Water Company and the East Surrey Water Company with a private supply supplementing, as necessary, at Cane Hill Hospital. Routine quarterly samples were taken for bacteriological and chemical examination. No complaints were received during the year with regard to the quality or quantity of the water supplied by the Water Companies and there were no unsatisfactory samples. Owing to the heavy rainfall throughout the year no restrictions in the use of water for domestic or other purposes were imposed by the respective Companies. No samples of raw water were taken throughout the year. The results of two chemical examinations and two bacteriological examinations are given below and these are fairly typical of the reports:— Chemical Analysis. Sutton and District Water Company. East Surrey Water Company. Parts per 100,000. Grains per Gallon. Parts per 100,000. Grains per Gallon. Total solids (dried at 180°C.) 21.0 14.7 22.0 15.4 Combined chlorine (Cl) 1.50 1.05 1.50 1.05 equivalent to Sodium Chloride (Na Cl) 2.48 1.74 2.48 1.74 Nitric nitrogen (Nitrates) ... 0.44 0.31 0.50 0.35 Nitrous Nitrogen (Nitrites) a faint trace present a minute trace present Ammoniacal nitrogen 0.0042 0.0029 0.0048 0.0034 Albuminoid nitrogen 0.0022 0.0015 0.0024 0.0017 Oxygen absorbed in 4 hours at 27°C. 0.018 0.013 0.009 0.006 Lead or Copper Nil Nil Nil Nil Temporary hardness ( = to CaCO3) 9.5 6.7 7.8 5.5 Permanent hardness ( do. ) 1.5 1.1 2.5 1.8 Total hardness ( do. ) 11.0 7.8 10.3 7.3 42 Bacteriological Examination. Plate count. Yeastrel agar— 3 days 22°C. aerobically 0 per cc. 0 per cc. 2 days 37°C. aerobically 0 per cc. 0 per cc. Present. Absent. Present. Absent. Presumptive Coliform Reaction — 100 cc. — 100 cc. Bac. Coli. — 100 cc. — 100 cc. CI. Welchii Reaction — 100 cc. — 100 cc. The Water Companies also supply copies of reports on samples taken by them. There are no private wells in use in the District; all houses are provided with a mains supply laid into the house and there are no standpipes for common use. The statutory maximum limit for hardness was not exceeded, 36 samples being taken for this purpose and examined by the Department. RAINFALL. The rainfall registered by the rain gauge at the Refuse Destructor was 36.45 inches, this being an increase of 8.13 inches over the previous year and the highest rainfall recorded since 1939. The monthly totals throughout the year were as follows :— January 3.02 inches February 2.84 „ March 1.56 „ April 2.70 ,, May 3.38 „ June 3.41 July 2.32 „ August 4.79 „ September 3.68 ,, October 149 November 4.73 December 2.53 „ DRAINAGE AND SEWERAGE. Further extension of the sewer at Old Couldson was carried out during the year. 1,240 yards of 9" diameter outfall was laid in Town Planning Road 54 and Drive Road to drain the Tollers Lane housing site. In addition estate sewers were laid at the Old Coulsdon and Sanderstead Housing Estates. CLOSET ACCOMMODATION. The difficulties experienced during the previous year with regard to labour and materials were increased during 1946 and only works of essential nature were permitted on licence, thus restricting the work under this heading to general maintenance. The approximate number of each type of closet accommodation remaining at the end of the year was:— Premises with water closets drained to sewers 15,375 Premises with pail closets 52 Number of cesspools 162 43 The contents of pail closets at private premises are disposed of in the gardens by the occupiers of the houses. PUBLIC CLEANSING. The system of fortnightly collection of house refuse instituted in 1941 continued during the early part of the year and in the middle of May it reverted to the weekly collection. The general public have been most patient during the war years regarding the collection of house refuse. However the number of complaints received in 1946 regarding noncollection showed a decrease of 33 per cent. on the previous year. The charges for trade refuse collection and for cesspool emptying remain the same ; the contents of the latter are disposed of by the public sewers. SMOKE ABATEMENT. The chimneys of the small factories in the District give little trouble and observation of these and the few large chimney stacks has never resulted in any major problem. RIVERS AND STREAMS. From time to time inspections are made of the water courses in the District, but apart from clearing them as frequently as is necessary, no particular difficulty has arisen. CAMPING SITES. The Boy Scouts camping site at Featherbed Lane continues to exist but owing to the war and other difficulties has not been used to the same extent as in pre-war years. The licensed site for two caravans at Coulsdon has not been altered but the temporary licence granted for a period of six months in respect of a third caravan has expired. SWIMMING POOLS. The swimming bath at Reedham Orphanage has continued to be used on a modified scale and one sample of water was taken, which proved very satisfactory. SHOPS AND OFFICES. As far as possible inspections have been made of the sanitary accommodation, washing facilities, heating and ventilation of shops and offices and improvements have been effected as circumstances have permitted. FACTORIES AND WORKPLACES. In 1946 there were 175 factories and 21 workplaces in the District. These figures show a slight increase on the previous year and are only slightly greater than the number in existence in 1938. The number of premises used by outworkers in 1946 was 42. 44 All these premises have been inspected regularly and such defects as have been found have been dealt with satisfactorily. SANITARY INSPECTIONS, ETC. The following is a summary of the complaints received, visits made, notices served, and defects remedied during the year 1946. The number of complaints received by the Department during the year increased by over 50 per cent. This increase is attributable chiefly to overcrowding resulting from the shortage of houses and delays and difficulties experienced in obtaining repairs to dwellings due to shortage of building labour and materials. Complaints Received. Rats and mice 191 Overcrowding 49 Non-collection of house refuse 20 Choked drains 116 Defective drainage 47 Lack of or unsatisfactory water supply 15 Offensive smells 22 Dilapidated dustbins 27 Smoking chimneys, bon fires, etc. 10 Keeping of animals 14 Accumulations 16 Insanitary conditions 232 Offensive pig bins 7 Verminous premises 1 Insect pests, etc. 29 Unsound food 19 Miscellaneous 28 843 Summary of Visits Made. Number of houses inspected 768 Re-inspections and calls made 2,694 Inspections : Factories 199 Bakehouses 64 Cowsheds 28 Dairies and milkshops 84 Slaughterhouses 2 Meat and other foods 328 Stables and stable yards 37 Food premises 437 Yards, outbuildings, drains, etc. 792 Piggeries, fowls and other animals 89 Under Rats & Mice (Destruction) Act, 1919 602 Revisits under Rats & Mice (Destruction) Act, 1919 1,499 Inspections, Shops Acts 340 Drains tested with water 32 Drains tested with colour 5 Infectious disease enquiries 128 Infectious disease contacts 99 Disinfections carried out 143 Disinfestations of verminous premises 18 Miscellaneous 69 8,457 45 Notices Served. Preliminary notices 707 Statutory notices 72 Defects Remedied. Cesspools requiring to be emptied 6 Unclean walls and ceilings 42 Choked drains 129 Defective drains, inspection chambers and covers 89 Defective fresh air inlets 12 Defective plaster 52 Defective firegrates 34 Defective floors 15 Defective woodwork 33 Defective paintwork 1 Defective paving 6 Defective dustbin 83 Defective waste pipes 20 Defective kerbs around gullies 12 Defective water closet fittings 32 Defective water closet pedestals 40 Defective eaves guttering and rain water pipes 31 Broken sashcords 6 Dampness through roofs 71 Dampness through other causes 41 Animals so kept as to be a nuisance 15 Offensive accumulations 17 Verminous premises 8 Lack of domestic cleanliness 5 Burst water pipes 41 Brickwork and pointing 26 Absence of water supply 6 Insufficient ventilation beneath floors 4 Glazing 8 Unclean bakehouse walls 1 Overcrowding 13 Miscellaneous 2 Total 901 ERADICATION OF BED BUGS. The method used for the eradication of bed bugs, which has proved successful in the past, has not been varied and the work is still carried out by the Local Authority. During the year 4 houses were disinfested, of which 3 were properties requisitioned by the Council. Fumigation was carried out by sulphur candles and spraying by "Vermicine" Insecticide. If it is considered desirable the homes of applicants for Council houses are inspected with a view to obtaining some knowledge of their suitability as tenants and if the houses and furniture are found to be infested steps are taken, as indicated above, before entry is permitted. It was not found necessary to disinfest any bedding by steam during 1946. 46 RATS AND MICE DESTRUCTION ACT, 1919. INFESTATION ORDER, 1943. During the early part of the year work under these headings was carried out solely by the Sanitary Inspectors, mainly in an advisory capacity, as in previous years. In May, 1946, the Ministry of Food in Circular N.S/12 submitted proposals to Local Authorities for a Private Dwellings Special Scheme to be carried out, free of cost to the occupiers of private dwellings. The Council adopted the Scheme which was commenced in September and a full-time temporary Rodent Operative was appointed to assist in carrying out the work, which was still proceeding at the end of the year under review. The Scheme involved routine inspection and treatment as necessary of all houses in the area on a block control system with sewer treatment as a necessary requirement of the Scheme. Pre-baiting and poisoning in accordance with Ministry of Food recommendations were the methods used in treating infested premises in all cases. The following is a summary of the work carried out during the year:— Number of complaints received 191 Number of infested premises treated 291 Estimated total kill 982 Private Dwellings Special Scheme. During the period in which this scheme operated 3,589 houses were inspected and 68 houses were found to be infested and treated. Work on the public sewers involved the pre-baiting of 157 manholes, poisoning found to be necessary only at 4 points. LEGAL PROCEEDINGS. During the year a Nuisance Order made by the Justices in respect of a statutory nuisance under the provisions of the Public Health Act, 1936, was the subject of an appeal by the owner of the property concerned. The Appeals Committee of Quarter Sessions allowed the appeal but made no order as to costs. Proceedings were taken under the Foods and Drugs Act, 1938, against a milk retailer in respect of a sample of milk reported as deficient in milk fat to the extent of 7 per cent. The vendor was fined £1 and £1 Is. Od. costs. SCHOOLS. School Closure.—While the procedure with regard to the closure of schools on account of the prevalence of infectious disease amongst the scholars has remained unaltered, in effect no public elementary school was closed during 1946. 47 The Medical Officer of Health has also held the appointment of Divisional School Medical Officer since September, 1945, and closer liaison between the Public Health and Education Departments has existed as a result. Medical Inspection.—No alteration was made during 1946 in the medical inspection of school children at public elementary and secondary schools, which is the responsibility of the County Council as the Local Education Authority. School Clinics.—The County Council provides the following clinics for the treatment of school children at the Surrey County Dispensary, Whytecliffe Road, Purley:— General Medical Clinic : Thursdays, 9.30 to 11 a.m. School Dental Clinic : Fridays, 1.30 p.m. or by appointment. School Eye Clinic : By appointment. Sanitary Services.—The water supply, the drainage and the sanitary accommodation of the public elementary and secondary schools are kept under observation, advice being given when necessary. INSPECTION AND SUPERVISION OF FOOD. Milk. The following is a list of dairy farms which were in existence at the end of 1946 :— Hooley Farm, Woodplace Lane, Coulsdon. Dean Farm, Brighton Road, Hooley. Elm Farm, Farleigh. Moorcroft Farm, Farleigh. Elmgrove Farm, Old Lodge Lane, Kenley. Hayes Farm, Hayes Lane, Kenley. This is one less than the previous year. In addition, the hospitals at Netherne and Cane Hill are supplied chiefly by their own private farms, while a few, cows are kept by private individuals. Elm Farm, Farleigh, and Dean Farm, Hooley, are licensed as "Accredited," and Hayes Farm, Hayes Lane, Kenley, for the production of "Tuberculin Tested" milk by the Surrey County Council under the Milk (Special Designations) Order, 1936. At the end of the year there were 11 registered dairies, 6 registered cowkeepers, 13 registered retailers, of whom 4 were out of the District, and 4 shops registered to sell bottled milk. These numbers have steadily decreased during the war years owing to the milk distribution policy of the Government, e.g., there were 44 registered retailers in 1938 but only 13 in 1946. 48 77 samples were submitted for bacteriological examination with the results set out in the following tables:— Tests required by Milk (Special Designations) Regulations 1936 to 1946, and the Heat-Treated Milk (Prescribed Tests Order, 1944. Number of Samples. Methylene Blue. Phosphatase. Satisfactory. Unsatisfactory. Satisfactory. Unsatisfactory. Pasteurised: 19 17 2 18 1 Heat-Treated : 40 38 2 39 1 Examination of Raw Milk. Number of Samples. Methylene Blue. Coliform Bacillus. Satisfactory. Unsatisfactory. Satisfactory. Unsatisfactory. 14 13 1 9 5 Biological Examination. Number of Samples. Tubercle Bacilli positive. Tubercle Bacilli negative. 4 - 4 The results of the biological examinations were entirely satisfactory, as also, in almost every case, were the Pasteurised and Heat-treated samples. The condition of the raw milk was less satisfactory and steps were taken to improve conditions following each bad sample. Milk (Special Designations) Regulations, 1936/46. Licences to sell milk under the above Regulations were issued as follows:— Dealers: Tuberculin Tested 5 Pasteurised 10 Supplementary: Tuberculin Tested 3 Pasteurised 4 49 Ice-Cream. Twelve samples of ice-cream were examined bacteriologically, three of which were reported upon adversely. The unsatisfactory samples were obtained from two local manufacturers and in one case the substitution of a hot mix for the cold mix method previously used produced satisfactory results. In the remaining case representations were made with the object of improving future supplies. Meat. The two slaughterhouses in the District have not been licensed since 1940. In 1946 one licence was issued under the Slaughter of Animals Act, 1943, for the purpose of slaughtering at a public institution in the District. The only carcases examined were occasional cottagers' pigs and meat delivered to local butchers' shops from the Wholesale Meat Supply Association situated outside the District. Other Foods. Routine inspections were made to food premises, including bakehouses, provision shops, ice-cream shops, restaurant kitchens and cafés, etc., with regard to the provisions as to rooms and precautions to be taken against contamination of food. The following unsound foods were surrendered during the year:— Total. Item. Cwl. lbs. ozs. Canned meat — 94 3½ Meat, bacon and poultry 9 — 1 Fish 21 86 — Canned fish 1 90 15¼ Canned peas, beans and vegetables 1 76 ½ Canned milk 2 7 3 Sugar, jam, etc. 1 21 7 ½ Flour, bread and cereals 101 10¾ Canned fruit 1 49 8 Fresh fruit 12 56 Eggs — 43 14 Soups — 31 12 Pickles and sauces — 50 4 Butter and fats — 7 4 Tea, coffee, etc. — 3 12 Total 54 47 15¾ Wherever appropriate the Ministry of Food salvage organisation has disposed of foodstuffs suitable for animal feeding or industrial purposes. 50 FOOD AND DRUGS ACT. The following samples were taken during 1946 and submitted to he Public Analyst with the results shown:— Articles. Analysed. Adulterated or deteriorated. Prosecutions. Convictions. Formal Informal. Total. Formal Informal. Total. Baking powder 2 - 2 - - - - - Batter flour J - 1 - - - — — Beer 1 - 1 - - - - - Bread 7 1 8 - 1 1 Butter - 2 - - - - - Cake flour 1 - 1 - - - - - Caramel Cake Mixture 1 - 1 - - - - - Cheese - 1 - - - - - Cocoa - 2 - - - — Cocoa compound 1 - 1 - - - — — Coffee and chicorv - 2 - - - — — Condensed milk 1 - 1 - - - - - Cooking fat 1 - 1 - - - - - Dessert mould 1 - 1 - - - - - Desiccated soup 1 - 1 - - - - - Drinking chocolate 1 - 1 - - - — — Egg substitute powder 1 - 1 1 - 1 - - Egg Savoree 1 - 1 - - - - - Extract of beef - 1 - - - - - Essence of anchovies 1 - 1 - - - - - French coffee - 1 - - - - - Fruit squashes - 4 - - - - - Fish paste - 1 - - - - - Fruit sauce - 1 - - - - - Gelatine I - 1 - - - - - Ham and beef paste 1 - 1 - - - - - Jam - 8 - - - - - Jelly crystals 1 - 1 - - - - - Jelly making compound 1 - 1 - - - - - Lemonade powder 1 - 1 - - - - - Liver sausage 1 - 1 - - - - - Malt vinegar 1 - 1 1 - 1 - - Malted food 1 - 1 1 - 1 - - Marmalade 3 - 3 - - - - - Meat pies 2 - 2 - - - - - Milk 35 - 35 3 - 3 1 1 Minced beef 1 - 1 - - - - - Mustard 2 - 2 - - - - - Non-brewed vinegar 1 - 1 - - - - - Orangeade 1 - 1 - - - - - Piccalilli 1 - 1 - - - - - Pineapple flavour essence 1 - 1 - - - - - Pudding mixture 1 - 1 - - - - - Rissole mixture 1 - 1 - - - - - Salad dressing powder 1 - 1 1 - 1 - - Sauce 1 - 1 - - - - - 51 Articles. Analysed. Adulterated or deteriorated. Prosecutions. Convictions. Formal Informal. T otal. Formal Informal. Total. Sausage meat 7 — 7 - - - - - Sausage 1 — 1 1 — 1 — — Sedlitz powder 1 — 1 - - - - - Self-raising flour ... 1 — 1 - - - - - Semolina 2 — 2 - - - - - Scotts M.O.F. 1 — 1 - - - - - Shredded beef suet 1 — 1 - - - - - Sponge pudding ... 1 — 1 - - - - - Stewed steak 1 — 1 - - - - - Soup 2 — 2 - - - - - Tea 4 — 4 - - - - - Tomato Soup powder ... 1 1 1 - 1 - — Treacle pudding ... 1 — 1 - - - - - Tomato puree 1 — 1 - - - - - Vegetable salad ... 1 — 1 - - - - - Zubes cough cure... 1 — 1 - - - - - Totals 131 1 132 9 1 10 1 1 52 TABLE 1. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1946. Disease. Number of cases notified. At Ages—-Years. Total cases notified in each Ward. Total cases removed to Hospital. At all ages. Under 1 year. 1 and under 2. 2 and under 3. 3 and under 4. 4 and under 5. 5 and under 10. 10 and under 15. 15 and under 20. 20 and under 35. 35 and under 45. 45 and under 65. 65 and over. Coulsdon East. Coulsdon West. Purley. Kenley. Sanderstead. Selsdon and Farleigh. Woodcote. Diphtheria 8 - - - - - - 1 5 2 7 - - - - - 1 5 Typhoid fever 3 - - - - - 1 - - - — 1 1 1 — - — — 1 3 Paratyphoid fever 1 — - - — — — — - — - — — — — 1 - — — —- 1 Scarlet fever 93 — 3 3 13 4 46 14 2 5 3 — — 17 12 37 3 11 8 5 71 Erysipelas 8 — — — — — — — — 1 2 1 4 2 3 1 — 2 — — 2 Puerperal pyrexia 2 — — — — — — — — 2 — — — — — 2 — — — — 2 Pneumonia 16 — — — — — 3 1 — 3 1 5 3 1 3 2 2 4 2 2 2 Dysentery 82 — — — 1 — — — — 12 11 21 37 78 2 — — 1 — 1 — Cerebro-spinal fever 3 — 1 - - - - 1 - 1 - - - 2 - - 1 - - - 3 Encephalitis 1 - - - - - - - - - 1 - - - - 1 - - - - 1 Poliomyelitis 1 — — — — — 1 — — — — — — — — 1 — —- — — 1 Measles 141 3 9 21 17 8 77 3 1 1 — — 1 4 22 8 1 49 38 19 4 Whooping cough 31 4 2 6 3 6 7 1 — 2 — — — 5 — 6 — 10 5 5 5 Totals 390 7 15 30 34 18 135 20 3 28 20 32 48 117 43 59 7 77 53 34 100 53 TABLE II. THE MONTHLY INCIDENCE OF INFECTIOUS DISEASE, 1940. Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. Total. Diphtheria - - - 1 1 1 3 - - 2 8 Typhoid fever — 2 — — 1 - — - - — — 1 3 1 Paratyphoid fever — — — — — — — - - — — Scarlet fever 9 9 8 17 11 2 4 5 6 2 10 10 93 Erysipelas — — — — 1 1 1 — 1 1 1 2 8 Puerperal pyrexia — — — - — — - —- — — — 2 2 Pneumonia 2 3 — 1 1 2 2 — 1 1 1 2 16 Dysentery 12 2 1 4 6 1 19 2 3 2 16 14 82 Cerebro-spinal fever 1 — — 1 1 1 - - - - 3 1 Encephalitis — — — — — - 1 — — — — — Poliomyelitis — 1 — — — — — — — — — —- 1 Measles — 3 4 20 21 14 45 20 3 5 6 — 141 Whooping cough 2 1 1 1 6 2 4 1 - - 3 10 31 Totals 26 21 14 45 . 49 23 79 28 14 13 37 41 390 54 TABLE III. INFECTIOUS DISEASE NOTIFIED EACH YEAR SINCE 1917. Disease. 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 Small pox - - - - - - - - - - - - 2 2 3 4 - - - - - - - - - - - - - - Scarlet fever 20 10 55 129 136 59 40 58 35 48 74 94 125 69 45 29 69 119 124 117 62 71 65 61 39 45 184 88 67 93 Diphtheria 17 4 26 44 62 70 27 101 14 17 11 23 26 17 8 21 16 24 52 35 8 10 10 25 7 9 7 19 15 8 Erysipelas 12 8 12 5 8 9 2 12 10 4 13 8 3 11 8 11 23 17 11 12 14 13 10 17 27 22 5 9 4 8 Typhoid and Paratyphoid fever C erebro-spinal fever Puerperal fever.. 18 73 31 15 5 16 11 5 24 9 9 9 6 4 4 i 5 5 1 3 26 5 1 53 12 3 1 6 4 4 3 1 - - 1 - - - - - - - 1 - - - - - 1 1 - - 4 8 6 1 4 2 1 3 1 1 - - 2 — — — — 1 — — 1 — 1 1 - 1 1 1 5 — — Puerperal pyrexia 1 1 1 1 3 5 1 2 1 - 2 5 3 2 - 2 3 1 2 2 Poliomyelitis - - 1 1 - 1 - 1 - - 1 1 - 1 - 2 - 1 1 - 3 1 1 1 2 3 — — 2 1 Polio-encephalitis - - - - - - - - - - - - - - - - - - - - 2 - - - - - - - - 1 Encephalitis lethargica Ophthalmia neonatorum Pneumonia — — — 1 1 1 1 1 1 — 1 1 - - - 1 - - - - - - - - - - 1 - - - 1 1 — 1 — — 1 — — 12 — 3 — 1 1 2 — 1 — 1 1 1 _ 1 1 — 1 — 1 - — — 18 8 9 21 6 16 11 — 9 7 38 11 14 29 28 20 32 13 30 12 52 19 32 38 27 9 17 16 Malaria - - 5 - - - - - - - - - - - - - - - - - - - - - - - - - - -- Measles 468 33 12 - - - - - - - - - - - - - - - - - - - 2 11 214 479 275 52 705 141 Dysentery — — 4 7 i 7 17 — — 1 — — 5 — — — — — 6 — 1 2 10 85 224 121 21 42 172 82 Whooping cough 6 1 136 36 55 51 100 31 Tuberculosis:— Pulmonary 17 25 28 24 12 29 16 24 14 19 25 23 22 38 44 30 44 28 30 27 36 32 31 31 32 43 39 51 44 38 Other forms 4 2 2 2 3 5 3 6 5 2 9 4 2 7 4 6 10 17 5 3 7 10 12 8 11 7 9 7 3 7 Totals 561 158 194 237 246 218 124 224 114 113 153 174 232 162 135 154 196 235 265 213 197 162 207 323 743 809 632 337 1137 435 55 TABLE IV. DEATHS OCCURRING DURING THE YEAR 1946. Cause of death. Males. Females. Total. Under 1 year. 1 and under 2. 2 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. I 45 and under 65. | 65 and over. Typhoid fever, etc. - - - — — Cerebro-spinal fever 1 — 1 — — - — - 1 -— — Scarlet fever - - - - - - - - - - Whooping cough - - - - - - - - - - - Diphtheria - - - - - - - - - - - Respiratory tuberculosis Other tuberculosis 7 12 19 - — - — 3 10 4 2 5 3 8 1 — 1 — 1 2 3 — Syphilis 3 — 3 - - - - - - 1 2 Influenza 2 8 10 — — — — 1 — 3 6 Measles Encephalitis 1 — 1 — 1 — — — — — — Cance 59 58 117 - - - - - 4 44 69 Diabetes 2 3 5 - - - - - - 5 Intra-cranial lesions 28 39 67 - - - - - 4 16 47 Heart disease 67 96 163 — -— — 1 — 2 34 126 Other diseases of circulatory system 17 5 22 - - 1 - - 2 8 11 Bronchitis 6 6 12 — 1 — — — 1 I 9 Pneumonia 10 12 22 — 1 — — 1 1 5 14 Other respiratory diseases Ulcer of stomach or duodenum 3 4 7 - - - - - 2 3 2 11 3 14 - - - - - - 9 5 Diarrhoea under 2 years Appendicitis — 1 1 1 - - - - - - — — — — -— - — — —- — — Other digestive diseases 5 7 12 - - - - - 1 3 8 Nephriti. 6 7 13 - - - - - - 4 9 Puerperal sepsis — 2 2 - - - - - 2 — — Other maternal causes — 1 1 — -— — — — 1 — — Premature birth 2 7 9 9 - - - - - - Congenital debility, etc 9 5 14 14 - - - - - - - Suicide 3 1 4 - - - - - 2 1 1 Road traffic accidents 3 2 5 — — — 1 2 1 1 - Other violent causes 3 3 6 — — — 1 — 2 1 2 All other causes 27 26 53 — — 2 1 — 6 11 33 Totals 280 3ll 591 25 3 4 4 8 44 152 351 56 WANDLE VALLEY JOINT HOSPITAL BOARD. Cases Admitted to Hospital during the Year ended 31st December, 1940. Disease. Beddington and Wallington. Coulsdon and Pur ley. Merton and M or den. Mitch am.. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Diphtheria 3 — 5 — 9 — 32 — Scarlet fever 30 — 71 — 95 — 70 — Erysipelas 1 — 2 — 4 — 6 — Tonsilitis or quinsy 1 — 1 — 12 — 7 — Measles 2 — 4 — 3 — 6 — Influenza 1 — 2 — 1 — 6 — Whooping cough — — 5 — 2 — 9 — Rubella — — 1 — 2 — 4 — Typhoid and enteritis 5 1 3 — — — 3 — Meningitis, all types 1 — — — 2 2 2 — Puerperal fever (sepsis) 1 — 9 — 3 — 4 — Admitted with mother — — 8 — 3 — 4 — Infantile paralysis — — — — 2 — 1 — Dermatitis 1 — — — . 2 — 1 — Laryngitis — — 1 — 2 — 3 — Bronchitis 1 — — — 1 — — — Pneumonia — — 2 2* 1 1 5 — Nephritis - - - - - 1 — Glandular fever - - - - - 1 — Tumour of brain — — 1 1 — — — — Otitis media 1 — — — 1 — 1 — Cerebral haemorrhage — — — — 1 — — — Encephalitis lethargica — — 1 1 - — — — Erysipelas (admitted 21/12/45) — 1 - - - - - Anterior poliomyelitis and influenzal pneumonia (admitted 24/7/45) - - - — 1 - - - - - - 48 3 116 4 146 3 166 0 * 1 death septic bronchitis, 1 death croup and broncho-pneumonia. 57 INDEX. Page Ambulances 27, 28 Analysis of Mortality 11 Ante-natal Clinics 31 Area 5, 9 Bacteriological Work 29 Bed Bugs, Eradication of 46 Birth Rates 5, 10, 17 Births, Live, Illegitimate and Still 10, 11 Camping Sites 44 Cancer 12,13 Causes of Deaths 11,56 Cerebro-Spinal Fever 21 Child Life Protection40 Clinics Ante-natal 30 Diphtheria Immunisation 26 Family Planning 34 Infant Welfare 35, 36 Post-natal 30 School 48 Toddlers 37 Tuberculosis 24 Closet Accommodation 43 Dairies and Cowsheds 48 Day Nurseries 38 Deaths and Death Rates 11,17, 56 Dental Treatment 38 Diabetes 27 Diphtheria 18 Diphtheria Immunisation 26 Disinfection 29, 30 Drainage and Sewerage 43 Dysentery 21 Emergency Unit 33 Encephalitis Lethargica 21 Enteric Fever 20 Erysipelas 20 Eye Defects 38 Factories 44 Family Planning Clinic 34 Food and Drugs Act 51 Food Supply: Milk 48 Meat 50 Food Preparing Places 50 Health Visitation 34 Health Propaganda 30 Heart Disease, etc. 12 Home Helps 32 Hospitals 28 Houses, Inspection of 40 Houses, Inhabited 9 Housing 8, 40 Ice-Cream 50 Illegitimate Babies 10, 33 Immunisation 26 Infantile Mortality 14 Infant Life Protection 40 Infectious Disease : Cases notified 18, 53, 54, 55 Monthly incidence of 54 School Notifications 25 58 Page Inspection and Supervision of Food 48 Laboratory Facilities 29 Legal Proceedings 47 Maternal Mortality 14, 17 Maternity Cases 31 Maternity and Child Welfare : Services 30 Centres 35 Hospital Accommodation 26, 31 Measles 22 Meat 50 Midwifery Service 31 Milk (Special Designations) Regulations 49 Milk, Sampling of 49 Mortality : Analysis of 11, 56 Infant 14 Maternal 14 Mumps 25 Non-notifiable Infectious Disease 24,25 Obstetric Specialists 33 Paratyphoid Fever 20 Paediatrician 33 Pneumonia 14, 21 Polio-myelitis 21 Population 5, 9 Post-natal Clinic 30 Premature Babies 16, 33 Public Cleansing 44 Public Health Committee 3 Puerperal Pyrexia 17, 20 Rainfall 43 Rateable Value 4 Rats and Mice Destruction 47 Rivers and Streams 44 Sanitary Inspections, etc. 45 Scabies 25 Scarlet Fever 19 Schools 48 School Clinics 48 Sewerage 43 Shops 44 Slaughterhouses 50 Small Pox 17, 26 Smoke Abatement 44 Social Conditions 5, 8 Staff 3 Statistics : Housing 40 Vital 5, 10, 17 Still Births 5, 11, 16 Swimming Baths 44 Toddlers'Clinic 37 Tuberculosis 14,22 Tuberculosis Care Committee 24 Typhoid Fever 20 Violence, Deaths from 14 Vital Statistics 5, 10 Wandle Valley Isolation Hospital 26, 57 Water Supply 42 Whooping Cough 22 59