HEALTH REPORT FOR 1947 FOR THE COULSDON AND PURLEY URBAN DISTRICT BY THE MEDICAL OFFICER OF HEALTH REDHILL : Surrey Fine Art Press, Ltd., Cavendish Road. HEALTH REPORT FOR 1947 I OR THE COULSDON AND PURLEY URBAN DISTRICT BY THE MEDICAL OFFICER OF HEALTH REDHILL : Surrey Fine Art Press, Ltd., Cavendish Road, URBAN DISTRICT COUNCIL OF COULSDON AND PURLEY. 1947 Public Health Committee. Chairman : Councillor S. E. Littlechild, J.P: Councillor Mrs. G. M. Bluett Councillor Mrs. M. Mayes A. J. Crisp ,, Mrs. L. J. Nesbitt F. Jobbins ,, E. R. Nicholson Mrs. D. May ,, R. H. Pullen R. N. Saunders 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. J obbins S. B. Gillespie, J.P. (ex-officio Member). Representatives on the Purley War Memorial Hospital Committee. Councillor F. H. Glogg. F. G. L. Moir, M.M.I.Struct.E., I.Mar.E. Public Health Department. STAFF: Medical Officer of Health: F. R. Edbrooke, M.B., Ch.B., D.P.H. *Medical Officers of Ante-Natal Clinics : Sylvia E. Collingwood, M.B., Ch.B. Gladys Lenanton, 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., D.Obst.R.C.O.G. *AIedical Officers of Child Welfare Centres : Sylvia E. Collingwood, M.B., Ch.B. Gladys Lenanton, M.R.C.S., L.R.C.P. 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., D.Obst.R.C.O.G. Janet E. D. Michael, M.D., M.R.C.P., M.R.C.S. *Medical Officer of Family Planning Clinic : Gwyneth M. Cotterell, M.B., Ch.B. (resigned July, 1947). Joan Llewellyn, M.B., B.S., M.R.C.S., L.R.C.P. (appointed October, 1947). *Medical Officers of Wartime Nurseries : Sylvia E. Collingwood, M.B., Ch.B. Isabel May, M.B., B.S., M.R.C.S., L.R.C.P., D.C.H., D.Obst.R.C.O.G. 3 *Considting Obstetric Specialists : j. B. Blaikley, F.R.C.S., F.R.C.O.G. Douglas Lindsay, M.D., Ch.B., F.R.F.P.S. J. H. Peel, F.R.C.S. Miss M. Salmond, F.R.C.S. Miss G. M. Sandes, F.R.C.S. Vincent O'Sullivan, F.R.C.S. *Consulting Paediatrician : J. N. O'Reilly, D.M., M.R.C.P. Chief Sanitary Inspector : H. Buxton, M.R.S.I, (deceased 24th March, 1947). W. Haworth, M.S.I.A. (appointed 21st July, 1947). Additional Sanitary Inspectors : S. E. Crisp, C.R.S.I. V. Ribbons, M.S.I.A. 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. Mrs. M. I. Pointer, S.R.N., S.C.M., H.V.C. Miss E. V. Bell, S.R.N., S.C.M., H.V.C. Miss Evans, S.R.N., S.C.M., H.V.C. (appointed August, 1947). 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. Chief Clerk: G. A. Lee (resigned 10th May, 1947). A. A. Edwards (appointed 30th June, 1947). Clerks: J. R. Richardson (sick leave 15th July, 1946—7th March, 1947, and 28th April, 1947 onwards). Mrs. G. Edmonston (appointed 28th April, 1947). Miss P. Jenner. , *Mrs. J. E. Hodge. *Miss E. Cope (appointed 11th August, 1947). Mrs. B. F. Brook (appointed 1st September, 1947). Mrs. K. M. Owen (appointed 29th December, 1947). (* Part-time officials.) 4 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 11,142 Registrar-General's estimate of population, 1947 62,440 Population, Census 1931 37,666 Number of occupied houses, December, 1947 16,999 Number of occupied houses, 1931 9,533 Rateable Value, December, 1946 £754,493 Sum represented by a penny rate £3,113 VITAL STATISTICS FOR THE YEAR 1947. Total. M. F. Birth Rate per 1,000 of the estimated resident population. Live Births—Legitimate 1,030 511 519 do. Illegitimate 33 21 12 1,063 532 531 17.0 Rate per 1,000 Hive and still) births. Still Births—Legitimate 30 12 18 do. Illegitimate 1 1 — 31 13 18 28.3 Death Rate per 1,000 of the estimated resident population Deaths 672 329 343 10.8 Deaths from Puerperal causes :— Rate per 1,000 {live and, still) births. Puerperal Sepsis — — Other Puerperal causes 1.83 1.83 Total 1.83 1.83 Death Rates of Infants under one year of age :—• All infants per 1,000 live births 23 Legitimate infants per 1,000 legitimate births 23 Illegitimate infants per 1,000 illegitimate births — Deaths from Cancer (all ages) 118 Deaths from Measles (all ages) Nil Deaths from Whooping Cough (all ages) Nil Deaths from Diarrhoea (under 2 years) Nij 5 COULSDON AND PURLEY URBAN DISTRICT COUNCIL. Ladies and Gentlemen, I beg to present to you my Annual Report for 1947, this being my sixteenth report as your Medical Officer of Health. It is regretted that it has not proved possible to produce this report earlier in the year, chiefly owing to the requests for other reports and the demands resulting from the implementation of the National Health Service Act. It is hoped that by next year reorganisation will have taken place, with a redistribution of duties, which will permit time being given to the preparation of this report when it is most needed, i.e., early in the year and particularly in June and July, after the Registrar-General's statistics are received. Much will, however, depend on the adequacy and ability of the staff then available, the most important members of which have yet to be recruited. It will be found that in this report I have concentrated more on the health of the District during the year 1947 and not reviewed so liberally the preceding years, as in my last two reports, which covered the war period and the 30 years during which this District has been a separate Local Government unit. It will be unique in one respect in that it records the services provided by your Council during the last complete year before the National Health Service Act caused the transfer of certain of your most important responsibilities to the County Council. Future reports will, of course, reflect these changes. The year 1947 will be remembered by most of us for its phenomenal weather, with the coldest early months experienced for many years, and the equally remarkable dry and sunny summer. It was, however, on the whole a very satisfactory one in so far as the health of your District was concerned. The Birth Rate remained high, though a trifle lower than in 1946; the Death Rate rose slightly, but was chiefly attributable to increases in deaths of the more elderly sections of the community; the Infant Mortality Rate was one of the lowest this District, with its normally good record, has ever known; while the incidence of infectious disease was also one of the lowest recorded locally, and this in spite of the epidemic of poliomyelitis which affected the whole country. Fortunately, the number of cases of this disease which occurred locally was relatively small. It is most pleasing to be able to report also that for the first time a year has passed without a single case of diphtheria being notified in your District. While the Doctors, Midwives, Health Visitors and others engaged in Maternity and Child Welfare work must gain satisfaction in considering the saving in infant lives represented by the low Infant Mortality Rate, so, too, can those responsible for Diphtheria Immunisation, with the consideration that, compared with the average years preceding its introduction, no notifications in 1947 represented the 6 saving of at least one life, and the temporary incapacity, with the possibility of permanent defect, in some 30 others. Such is the favourable impression gleaned from a review of the facts collected and classified under the heading of the Vital Statistics for 1947. In the introduction to my last Annual Report 1 tried to show how difficult it is to assess more accurately the true state of health of the community. When the National Health Service is operating smoothly and efficiently, it may be possible to obtain further carefully collected data showing the degree to which definite physical and mental sickness exists amongst the population, but even with this information it is very doubtful whether a wholly satisfactory assessment will be practicable, chiefly because this would omit evidence regarding their psychological state or morale. Health in a community, as in an individual, consists not merely in the absence of physical disease, but in the vitality, the energy and the creative impulse which is shown in the normal and exceptional responses to life and the changing conditions of environment. At the present time there is abundant evidence, at least of a quantitative character, of this vitality in such varied spheres as sport, literature and the Arts, research, and in legislation, but when we turn to ordinary work or to voluntary service there is less to suggest widespread superabundant energy. That this is not due to shortage of, or lack of variety in food supplies appears clear from the satisfactory examples just given, and from the vitality shown in post-war reconstruction in some other countries with less favourable food supplies than ours. Maybe the partial failure to stimulate a desire to work is attributable in part to the increasing complexity of life, which makes it more difficult to make many jobs really interesting and to connect immediate action with the final result, while the present justifiable emphasis on satisfactory working conditions is liable to lead to introspection in the beneficiaries and others, with enervating effect. Similarly, the latter tendency is also apt to produce a reaction against voluntary work, while many potential voluntary workers are perplexed by the reorganisation of our social services now taking place, with the community accepting responsibility for much which formerly depended on voluntary effort. In both cases clarity is lacking as to the way improvement can be effected, and doubt as to the possibility of success, while possibly at times there is also absence of desire or impulse. The present need would appear to be for the constant and able expression of a simple ideal, which is both practicable and certain of immediate satisfactory results. In the past the essentials of Christianity have provided the clue, both to the motive power and the method of rendering constructive service. It would seem that this or a similar message is needed to-day, if, as a community and nation, we are to show the vitality of the Elizabethan and other peak periods of our history. Our vital statistics far surpass those of former days, and we should, therefore, be capable of producing superior results. Unsolicited and disinterested service brings early reward, and can generally be rendered in all spheres of life, given a sincere desire and resolution. Perhaps 7 by such means the individual and community will be able to awaken further potential sources of energy and find real health, which will attract men and women of all ideologies. In conclusion, Ladies, and Gentlemen, may I again express my appreciation of the assistance I have received from my colleagues and staff, and of the sympathetic consideration shown by those Councillors who have appreciated the difficult period through which we are passing and some of its implications. In this expression of appreciation the Chief Sanitary Inspector wishes to be associated. My thanks are due to him and the Senior Health Visitor for their assistance in preparing this report. I am, Ladies and Gentlemen, Your obedient servant, F. R. EDBROOKE, Medical Officer of Health. 8 HEALTH REPORT FOR 1947 The Urban District of Coulsdon and Purley was constituted by an Order of the Local Government Board dated the ist November, 1914, and came into existence on the 7th April, 1915. It has therefore been a separate District for just over 32 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 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, is negligible. 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. In 1947 the Register-General estimated that 62,440 persons were residing in the District, compared with 60,390 in 1946. 9 This number includes persons resident in Institutions in the District, the numbers of which at the end of 1947 were as follows: — Cane Hill Hospital 2,427 Netherne Hospital 2,156 Russell Hill School 240 Reedham Orphanage 260 In 1947 there were 16,999 occupied houses, distributed as follows: — Coulsdon East 2,439 Coulsdon West 3,052 Purley 2,651 Woodcote 1,653 Sanderstead 4,250 Selsdon and Farleigh 1,664 Kenley 1,290 This suggests an average of 3.7 persons per occupied house in 1947. 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 1946 and 1947: — Rates per 1,000 population. 19151919. 19201924. 19251929. 19301934. 19351939. 19401944. 1946. 1947. Birth rate 13.9 13.5 12.9 11.6 12.8 15.2 17.6 17.0 Percentage illegitimate 5.7% 3.4% 3.7% 2.8% 3.4% 3.9% 3.4% 3.1% Stillbirth rate — — — — 0.43 0.48 0.49 0.49 Death rate 8.5 7.4 7.0 7.4 8.3 11.4 9.8 10.8 Cancer death rate 1.18 0.96 1.15 1.35 1.19 1.70 1.93 1.89 Tuberculosis death rate (per 100,000 population) 72 57 36 38 35 48 44 37 Violence (including Suicide) 0.19 0.44 0.35 0.32 0.46 0.82 0.24 0.56 Maternal mortality rate (per 1,000 live and still births) 3.20 2.08 2.66 3.21 2.27 2.10 2.71 1.83 Infant mortality rate (per 1,000 registered births) 44 28 38 32 38 40 25 23 Neo-natal mortality rate - - - - 26 28 19 15 Estimated population 19,073 21,351 28,950 41,616 53,084 49,880 60,390 62,440 BIRTHS. During the year 1947, 1,063 births were registered as occurring in the District, of which 532 were male and 531 were female. It will be seen by reference to the above table that this is equal to an annual birth rate of 17.0 per 1,000 population, as compared with 17.6 in 1946, which latter was the highest birth rate experienced in this District. It will be very interesting to see whether the slight fall which occurred in 1947 10 represents a downward trend or is just one of the slight fluctuations to which all such rates are liable. The birth rate for England and Wales was 20.5 in 1947, which was an increase of 1.4 compared with 1946. Illegitimacy.— In 1947, of the births registered, 33 were illegitimate (21 males and 12 females), this being four less than in the preceding year. 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. Stillbirths.— The number of stillbirths registered during 1947 was 31 (13 males and 18 females), as compared with 40 in 1946 and 18 in 1945. All but one of the stillbirths occurred in legitimate children. The local stillbirth rate was thus 0.49 per thousand of population, which is the same as in the preceding year, compared with 0.43 in the year 1945. The stillbirth rate for England and Wales was 0.50 in 1947. DEATHS. The number of deaths registered during 1947 as belonging to this District was 672 (329 males and 343 females), as compared with 591 in 1946 and 549 in 1945. These numbers exclude deaths which, although occurring within the District, belonged to other districts, but include 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, being 32 in 1947 compared with 29 in 1946. It will be seen from the table of vital statistics that the crude death rate for the year was equal to 10.8 per thousand of population, as compared with 9.8 in 1946 and 10.2 in the preceding year. While this rate still compares favourably with the crude death rate for England and Wales, which was 12.0 in 1947, the increase calls for some explanation. The principal causes of death during 1947, 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 30 4.46 Influenza 3 0.45 Tuberculosis of respiratory system 23 3.42 Cancer, malignant disease 118 17.56 Heart disease 187 27.82 Cerebral haemorrhage 85 12.65 Other circulatory diseases 23 3.42 Pneumonia 34 5.06 Violence (including suicide) 28 4.17 11 (A full list of the causes of the deaths and the ages at which they occurred is given in Table IV in the Appendix.) On analysis it is found that the chief causes of the increased number of deaths in 1947 compared with 1946 were heart disease, etc. (43), bronchitis and pneumonia (30) and violence (22). HEART DISEASE, ETC. The death rate from heart and other circulatory diseases showed a slight increase on last year's figure, but as this group is largely composed of deaths occurring in elderly people from what is really old age, it is hoped that the proportion coming under this heading will remain relatively high. The slight increase in 1947 is probably associated with a corresponding increase in the average age of the population at risk in that year, compared with recent years, and this factor has also doubtless influenced the deaths from other causes. In 1947, 81 per cent, of deaths from heart disease, etc., were over 65 years of age at the time of death (an increase of 4 per cent, on 1946), while 51 per cent, were over 75 years of age. Similarly, of deaths from all causes, 64 per cent, were over 65 years of age, compared with 59 per cent, in 1946. CANCER. The cancer death rate for the year 1947 was 1.89, which is slightly less than the rate for 1946. 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. The following table gives the age, sex and distribution of the disease in the 118 deaths which occurred during 1947. Only a slight difference is noticeable in the distribution of the disease when comparing the fatal cases in the last two years. 12 CANCER DEATHS, 1947. 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. Brain - - - - - - - - - - - - 1 — Mouth and tongue — — — — — — 1 - 1 - - - 2 — Glands—lymph and thyroid - - - - - - - - 2 — — 1 2 1 Pharynx and oesophagus - — 1 — — - 1 2 — 1 — 4 1 Stomach and duodenum 1 - - - - - 3 1 2 7 - 1 6 9 Intestines - — 1 1 2 3 4 4 3 6 2 4 12 18 Liver - - - 1 - - - - - 1 2 — 2 2 Pancreas - - - - - - - - - 1 - - - 1 Gall bladder - - - 1 - - - 1 - - - - - 2 Lungs 1 - 1 — 2 2 5 — 1 1 — — 10 3 Kidney — — 1 — — 1 2 — 1 — — — 4 1 Bladder - - - - - - 1 1 1 1 — — 2 2 Prostate — — — — — — 1 — 3 — 1 — 5 — Testicles — — 1 - - - - - 1 - - - 2 — Uterus — — — 2 — 2 — 1 — 1 — — 6 Ovary - - - 3 - - - - - 1 - - - 4 Breast — — — 7 — 3 —■ 2 — 2 — 1 — 15 Bone — 1 - - - - - - - - - - - 1 Totals 2 1 5 15 4 11 18 11 17 21 6 7 52 66 13 VIOLENCE. Deaths from violence (including suicide) showed an appreciable increase during 1947, the death rate being 0.56 per thousand of population, compared with 0.24 last year and an average of 0.39 for the interwar years. The chief cause of this increase was the unfortunate train accident in October, which resulted in the deaths of 14 local residents. There was an increase also in deaths following falls in the more or less elderly (8), which again reflects the increasing age of the population. Deaths on the road were again less than in pre-war years, being three compared with five last year. All resulted from motor car accidents, and in two instances the persons killed were pedestrians. The suicide death rate was slightly less than in 1946 and well below 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 2 deaths associated with childbirth during 1947, compared with 3, nil, 2, 1 and 1 in the preceding five years. One death really resulted from pre-existing heart and kidney disease which was accelerated by pregnancy. In the other case of a very elderly lady, whose death followed operative treatment to rectify the result of childbirth which had occurred at least 40 years previously, it was most unfortunate that this had to be classified as a maternal death. As a result the local Maternal Mortality Rate was 1.83 per 1,000 live and stillbirths compared with 1.17 for England and Wales, which was the lowest yet recorded. INFANT MORTALITY. During 1947 there were 24 deaths among the children under one year of age, as compared with 27, 25, 28, 32 and 38 in the preceding five years. None of the deaths was in respect of illegitimate children. The resultant Infant Mortality Rate was thus only 23 per 1,000 registered births, which is one of the lowest recorded for the District, the only years which had lower rates being 1921 '(17) and 1933 (20). The Infant Mortality Rate for England and Wales was 41 in 1947, this being the lowest on record. 14 The following table gives the causes of the deaths which occurred during 1947 and of which records are available, together with the age at death. INFANTILE MORTALITY DURING THE YEAR 1947. 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. Polio-encephalitis — — — — — — — 1 — 1 Pneumonia — I — — 1 — 1 — — 2 Otitis media — — — — — — 1 — — 1 Birth injury 1 — — — 1 — — — — 1 Congenital mal-formation 5 — — — 5 1 — — — 6 Hernia — — — — — 1 — — — 1 Prematurity and marasmus 8 1 — — 9 1 — — — 10 Asphyxia due to misadventure — — — — — 1 — — — 1 Asthma — — — — — — — — 1 1 Totals 14 2 — — 16 4 2 1 1 24 15 The relatively high number of deaths from respiratory infection emphasises that the prevention of the spread of colds and coughs, particularly to young babies, is of the greatest importance. The 17 babies dying in the first month correspond with a Neonatal Mortality Rate of 16 (i.e., deaths in the first month per 1,000 live births). This is the lowest recorded in this District since 1936, when this rate was first noted, the previous lowest being 18 in 1944, and the average for the 11 years being 26.5. During the year 3 premature babies were notified as being born at home and 34 in institutions. Of the former, 1 died within a few hours of birth and another died when two months old in hospital. Altogether 10 deaths occurred in premature babies, and 8 of them were in respect of babies born in hospital or in a nursing home outside the District, and before their discharge home. (Two of the babies were premature twins.) These numbers suggest that 27 per cent, of the premature babies died. Their deaths present a challenge to the ante-natal and hospital services, but do 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 OMPARATIVE CRUDE BIRTH-RATES, DEATH-RATES, ANALYSIS OF MORTALITY, MATERNAL DEATH-RATES, AND CASE-RATES FOR CERTAIN INFECTIOUS DISEASES IN THE YEAR 1947. England and Wales. 126 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 20.6* 23.3 22.2 22 7 17.0 Still Births 0.50* 0.62 0.54 0.49 0.49 Deaths All causes 12.0* 13.0 11.9 12.8 10.8 Typhoid and paratyphoid 0.00 0.00 0.00 0.00 - Scarlet fever 0.00 0.00 0.00 0.00 0.02 Whooping cough 0.02 0.03 0.02 0.02 — Diphtheria 0.01 0.01 0.01 0.01 — Influenza 0.09 0.09 0.08 0.08 0.05 Smallpox 0.00 0.00 0.00 — - Measles 0.01 0.02 0.02 0.01 — Notifications : Typhoid fever 0.01 0 01 0.00 0.01 0.02 Paratyphoid fever 0.01 0 01 0.01 0.01 0.02 Cerebro-spinal fever 0.05 0.06 0.05 0.05 0 02 Scarlet fever 1.37 1.54 1.37 1.31 1.25 Whooping cough 2.22 241 2.02 2.80 1.84 Diphtheria 0.13 0.15 0.14 0.14 — Erysipelas 0.19 0.21 0.18 0.22 0.08 Smallpox 0.00 0.00 0.01 0.00 — Measles 9.41 9.13 9.58 5.29 3.49 Pneumonia 0.79 0.89 0.68 0.64 0.32 Rates for 1,000 Live Births : Deaths under 1 year of age 411 47 36 37 23 Deaths from diarrhoea and enteritis under 2 years of age 5.8 8.0 3.7 4.8 — Rates for 1,000 Live and Still Births : Notifications : Puerperal fever 7.16 8.99 6.27 1.21 0.91 Puerperal pyrexia 6-941 Maternal Mortality : Coulsdon and Purley England and Wales Rates per 1,000 Total (Live and Still) Births, Rates per million women aged 15-44. Urban District. Rates per 1,000 Total (Live and Still) Births. Abortion with sepsis 0.10 9 — Abortion without sepsis 0.06 5 Puerperal infections 0.16 — — Other maternal causes 0.85 1.83 * Rates per 1,000 total population, †Per 1,000 related births. ‡ Including Puerperal fever. A dash (—) signifies that there were no deaths. 17 INFECTIOUS DISEASE. In previous reports, when commenting on variations in the incidence of infectious disease, attention has been drawn to the confusion resulting from 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 local mental hospitals. The residents in the latter have but little contact with the remainder of the District, and it is therefore advisable to exclude both the above factors when comparing annual returns. A full statement of the cases of infectious disease notified since 1918 is included in Table III in the Appendix, and it will be found that the incidence of infectious disease generally during 1947 compared very favourably with preceding years, particularly when the number of resultant deaths and amount of permanent injury are correlated. The following table relates to notifications received during 1947: — Disease. Numbers Notified. Removed to Hospital. Total Deaths. Diphtheria — — — Typhoid fever 1 — — Paratyphoid fever 1 — — Scarlet fever 78 47 1 Erysipelas 5 2 — Puerperal pyrexia 1 1 — Pneumonia 20 — 34* Dysentery 43 — -— Cerebro-spinal fever 2 2 1 Poliomyelitis 11 10 1 Measles 218 2 — Whooping cough 115 3 — Totals 495 67 37 * Includes deaths from all forms of pneumonia. Comments on the trend of individual diseases are included in the following sections, but in general it can be stated that, excluding the two above-mentioned factors which disturb comparison, the number of cases of acute notifiable infectious disease occurring among the general population in 1947 was slightly less than 1.9 cases per 1,000 population, which is one of the lowest rates for infectious disease the District has experienced. Diphtheria. For the first time since the formation of the District a year has passed without a single notification of a case of diphtheria. One adult suffering from tonsilitis was admitted to hospital in January as a suspect, but all findings were negative. This absence of cases represents a saving of 30 cases and at least one life compared with the average for the years preceding 1937, when 18 diphtheria immunisation was introduced locally, while even compared with the improved average for the last 10 years, II fewer cases have needed to be admitted to hospital. Apart from the financial economy and the reduction in the loss of health and working time which this absence of cases has meant, the saving in manpower has been very considerable, and particularly welcome at a time when the hospital has had such difficulty in finding sufficient nurses. Scarlet Fever. A total of 78 cases of scarlet fever was notified during 1947, which is 15 fewer than in the previous year and about the average for the last 15 years. The disease continued to be mild in character, but unfortunately was the underlying cause of death in one middle-aged adult male. Three-quarters of the cases were schoolchildren, while 3 of the 10 adult cases were associated with school cases, as were also 3 of the 9 children below school age who suffered from the disease. Thirty of the cases were treated at home and in only one instance did a second member of the family contract scarlet fever, which might well have happened even if the primary case had been admitted to hospital. One secondary case of this type did, in fact, occur during the year, while in one or two instances infection followed the discharge from hospital of the primary case. Undoubtedly, however, school life, including the voluntary activities associated therewith, appears to produce the greatest risk of infection and, as it is coupled with the susceptibility of the age groups in attendance, results in the majority of cases. It is very difficult, however, to eradicate infection, particularly during the present mild phase of the disease. Erysipelas. Five cases of erysipelas were notified during the year, this being 3 less than in 1946 and fewer than in the majority of preceding years. One case was treated in the Isolation Hospital and one at Redhill County Hospital, the others being treated at home. All recovered. Puerperal Pyrexia. One maternity case only was notified as suffering from puerperal pyrexia, which had developed while the patient was resident in the District, and she recovered after treatment at the Isolation Hospital. Information was also received regarding a resident who developed but recovered from puerperal pyrexia while in Redhill County Hospital. Enteric Fever. One case of typhoid fever was notified in September and, the diagnosis having been made in Redhill County Hospital, the patient was 19 treated and recovered in Redhill Isolation Hospital. The cause of the disease could not be traced. One case of paratyphoid B was notified in August in respect of an inmate of one of the mental hospitals, who subsequently recovered. The above represent a slight reduction on the number of cases experienced in recent years. Dysentery. There were 43 notifications of cases of dysentery received in 1947 and 40 of these were inmates of one of the mental hospitals, the remaining 3 cases being inmates of the other mental hospital. These numbers are appreciably lower than the corresponding totals for the last two years, and it is hoped the improvement will be maintained. Three of the cases died of the disease during the year. Cerebro-Spinal Meningitis. One case of cerebro-spinal meningitis was notified during April, and he recovered completely in the Isolation Hospital. Another case suspected of suffering from the same disease was admitted to an isolation hospital, where she died the same day. Death was believed to have been caused by septicaemia. Poliomyelitis. No little concern was caused by the publicity given to the widespread outbreak of poliomyelitis which affected the country chiefly during the second half of the year. It had previously been generally recognised that obvious cases of this disease were usually associated with a high proportion of contacts showing no symptoms and a much smaller percentage who had transitory symptoms, which latter were by no means peculiar to this disease, e.g., tonsilitis, headache and diarrhoea, usually accompanied by a varying degree of pyrexia. With a widespread outbreak, coupled with Press and wireless publicity, a large proportion of the population became concerned lest they were suffering from the disease, and the doctors were unusually harassed by enquiries. The general policy was adopted of advising all persons suffering from indispositions accompanied by a temperature who had been in probable contact with a case to isolate themselves as far as possible for a week, definite contacts among schoolchildren or those associating with young children being excluded for three weeks. The lack of an easily applied and definite means of diagnosis also complicated decisions upon which suspected cases should be admitted to hospital and what final diagnosis should be assigned to them. In 20 general, the more definitely suspected cases, e.g., those whose symptoms included some rigidity of the neck muscles, were admitted freely to hospital and as expeditiously discharged for isolation at home if no signs of paralysis developed within a week or so, the limited resources of the hospitals having to be used to the greatest advantage. Fortunately, only 15 persons were notified in the District, all being admitted to or already in hospital. Three of these were definitely diagnosed as suffering from other diseases, and a fourth was almost certainly not a case of poliomyelitis. Of the remaining II definite or most probable cases, 4 males and 7 females, only 8 developed paralysis, one of whom unfortunately died after a prolonged illness. Three were discharged without permanent defect, having probably had the disease but no paralysis, and 4 had only slight paralysis which had disappeared on or shortly after discharge. In addition, 2 residents developed the disease outside the District, while two further but unnotified cases have since come to light, both in young children, one of whom has recovered completely, the other having some slight residual paralysis. Residents were recommended, through the Press and other means, to keep out in the open air as much as possible, to avoid crowds as far as practicable, and not to indulge in very strenuous activities to which they were not accustomed. Individual advice was also given to numerous persons and groups who sought guidance before taking holidays, etc. Bearing in mind the profound influence of the Press, wireless, etc., on public opinion, the time appears opportune for a concerted policy and practice to be evolved by leading representatives of these institutions and the medical profession, whereby, in the face of epidemics, public morale can be maintained, and only sound advice given from the earliest phase of the outbreak. Well organised propaganda can be a very useful weapon, but indiscriminate publicity can lead to undue alarm and ill-considered actions, many of which latter may be unwise or unreasonably restrictive. Co-operation in the public interest appears to be needed. Pneumonia. During the year 20 notifications of acute primary or influenzal pneumonia were received, this being very slightly more than in the last three years, but less than in many preceding years. The very abnormal weather conditions of the early spring had no marked effect on the number of these cases, which were scattered over the District and occurred chiefly in January, February and December. No cases were admitted to the Isolation Hospital. By contrast 34 deaths occurred from all forms of pneumonia and 30 from bronchitis, being a total increase of 30 deaths from this group of diseases compared with the previous year. 21 Measles. There was a slight increase in the number of cases of measles notified during the year, from 141 in 1946 to 218 in 1947, but this was well below the record total of 705 in 1945. Two cases were admitted to the Isolation Hospital, one being a baby of 10 weeks and the other a young child with both measles and whooping cough. Both recovered, and, in fact, no deaths from this disease occurred. The arguments against the compulsory notification of measles and whooping cough in a District such as this were fully stated in the Annual Report for 1945, but the views then expressed have produced no result. As a result, further increases in notifications can be expected, involving increased expenditure in notification fees without any resultant benefit. It is regretted that it was not made optional for each District to decide whether these diseases should be compulsorily notifiable, as in the case of chicken pox. Whooping Cough. During 1947 there were 115 cases of whooping cough notified, compared with 31 in 1946 and 100 in 1945. Four cases were admitted to the Isolation Hospital, one being the case of measles referred to above. The others were children of 5 years, 2 months (with convulsions) and 11 months. All recovered, there being no deaths from this disease during the year. Tuberculosis. The following table presents concisely the position with regard to tuberculosis in the District during 1947:— Pulmonary. Nonpulmonary. T otal. M. F. M. F. M. F. Number of cases on register, 1st January, 1947 186 1ll 20 30 206 141 Additions, 1947:— New cases notified 34 25 5 6 39 31 Cases removed into District 10 13 — 3 10 16 Restored to register — 1 — ' — — 1 Total Additions 44 39 5 . 9 49 48 Removals, 1947:— Deaths 14 11 - -. 14 11 Removed from District 17 11 - - 17 11 Recovered 7 1 2 2 9 3 Non-tuberculous 1 - - - 1 - Total Removed from Register 39 23 2 2 41 25 Number of cases on register, 1st January, 1948 191 127 23 37 214 164 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 and under 5 — — — 1 — — — — 5 and under 10 — — 2 — — — — — 10 and under 15 - - - - - - - - 15 and under 20 2 2 — 2 — — — — 20 and under 25 9 5 1 1 — 1 — — 25 and under 35 5 4 — 1 2 3 — — 35 and under 45 5 8 2 — 1 2 — — 45 and under 55 5 1 — — 5 1 — — 55 and under 65 7 3 — — 4 2 — — 65 and over 1 2 — 1 2 2 — — Totals 34 25 5 6 14 11 — — The new cases were distributed amongst the wards as follows: — Localisation. Coulsdon East. Coulsdon West. Kenley. Purley. Sanderstead. Selsdon and Farleigh. Woodcote. Pulmonary 11 15 3 11 9 7 3 Non- pulmonary 1 3 - 2 3 2 Totals 12 18 3 13 12 7 5 Dealing first with the pulmonary form of this disease, it is noted that while more cases were notified in 1947 than in either of the two preceding years, the case rate has on the whole tended to drop, although of recent years there has been a reverse tendency, probably owing to a larger number of early and unsuspected cases being detected through examination for military service and the wider use of mass radiography. The more important fact is that the death rate, which was diminishing steadily before the war only to rise during that period, is, if anything, again tending to decrease. Nationally this trend is even more marked than locally. Turning to non-pulmonary tuberculosis, although again there was an increase in the number of new cases notified and in the case rate, there were no deaths recorded last year, and the average death rate is definitely decreasing. The Council is responsible for measures to prevent the spread of this disease, including rehousing, disinfection and the examination of 23 sputa of cases or suspected cases of this disease, 47 specimens being examined for this purpose in 1947. The County Council is responsible for the treatment of cases and the examination of contacts, sanatorium accommodation and dispensaries being provided for the purpose. The majority of home visitation is undertaken by their Health Visitor appointed specifically for this purpose. The appointment of Care Almoners has also been of great help to the patients and to the Voluntary Care Committee, which, supported by very substantial contributions from the County Council, does very useful work in helping in many varied ways individual cases and their relatives. 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 3 deaths were attributed in 1947. There were no deaths in children under two years of age from infantile 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 were a few scattered cases of mumps in all parts of the District in January, but this infection died down except at Sanderstead, where 10 cases occurred in May, and in Selsdon, where, cpmmencing in April, the numbers steadily increased throughout the remaining months of the year, a total of 50 cases being notified from this one school. A few cases of chicken pox were scattered over the District during the early months, e.g., 12 at Roke in January and 12 at Sanderstead in February, but with the exception of Kenley, where 25 cases occurred in July, only a very few cases were notified during the remainder of the year. Similarly, only odd cases of German measles and 1 case of infective jaundice were reported. There was an extensive outbreak of cat ringworm at Old Coulsdon from June to October inclusive, which extended over the nearby Caterham boundary. Fifteen cases were reported, all being from one school. Segregation and treatment of the cases was accompanied by a widespread and voluntary destruction of feline and other pets, the disease eventually dying out before the end of the year. Home visitation and exclusion from school are still the two chief 24 methods relied upon to prevent or postpone the onset of the majority of the above-mentioned 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 no case was so admitted in 1947. A few cases may have been admitted to the Count}' Hospitals, but of these no records are available. INFESTATIONS. (a) Scabies. During 1947 the number of persons treated at the Scabies Treatment Centre, Lion Green, Coulsdon, was 172, of which number 29 were schoolchildren, 103 adults and children under 5 years of age, while 40 persons had preventative treatment only. Altogether 805 baths were given. the number ot 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 1947 316 172 After the war of 1914-1918, a steady decline in the prevalence of this disease occurred, and a similar decrease in the number of cases is occurring at the present time. At the commencement of the year seven sessions a week were held (two being evening sessions), at some of which voluntary helpers from the original Civil Defence staff continued to assist the two part-time paid workers. With the reduction in the number of cases, it became practicable to reduce correspondingly the number of sessions, which are now only held on Tuesday, Friday and Saturday mornings and Tuesday and Saturday evenings. A further reduction in the number of sessions or an alteration in the arrangements will probably be introduced in the near future. (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. No cases needed to be treated at the Scabies Treatment Centre, which may, however, be called upon to undertake this work under the Education Act, 1944, if required to do so. As far as possible, these cases are dealt with as family units. 25 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 1947, and the proportion of children estimated to have been immunised in that year:— Clinics. Number of sessions held during the year 56 Number of children who commenced treatment 505 Number who completed treatment 477 Number of Schick tests made 1 Number of "Booster" doses given 292 Total number of attendances 1,295 Welfare Centres. Number of children who commenced treatment 121 Number who completed treatment 119 Number of " Booster " doses given 34 Total attending for immunisation 275 Schools. Number of visits made 13 Number commencing treatment 17 Number completed treatment 5 Number of Schick tests made 38 Number of " Booster " doses given 282 Proportion of children estimated to have been immunized:— (a) from 1-5 years 48% (6) from 5-14 years 91% The number of clinic sessions held during 1947 was almost exactly the same as in 1946, the number of children commencing treatment being, however, slightly higher. In addition, the experiment was made of giving treatment at certain of the less busy Child Welfare Centres, the doctor normally attending the Centre giving the injections. At the schools less treatment was given than in the previous year and was confined to completing the very thorough review of all children attending both private and public schools. The position in the latter has since received further attention, and it is hoped in future to maintain the high degree of immunity of primary school children, extending the scope of the treatment if found practicable and desirable. As a result of the enquiry and subsequent treatment during 1946-47, it can be stated with a very reasonable degree of accuracy that at least 48 per cent. of children from 1 to 5 years of age and 91 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. 26 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. No noteworthy alteration was made during the year on recent practice, A.P.T. being extensively used for children up to 7 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 is. was payable for each notification of children immunised by general practitioners, but during 1946 and 1947 no notifications were received, although doubtless an appreciable number of children are thus treated annually. DIABETES. The supply of insulin at reduced cost or free of charge to residents unable to obtain it through other agencies was continued throughout the year. The number of cases remained small, only 8 being supplied in this way during 1947. AMBULANCES. For Infectious Disease Cases.—The Wandle Valley Joint Hospital Board provided two motor ambulances for the removal of cases of infectious disease to hospital. The use of these ambulances was limited to the area served by the Hospital Board. Accident and General Cases.—The three first-line ambulances provided by the Council, with one in reserve, continued to be manned by whole-time paid men, under the very able leadership of the Ambulance Superintendent. The service remained the responsibility of the Medical Officer of Health and maintained its very high standard throughout the year. Through the courtesy of the National Fire Service the three ambulances on duty continued to be based on the Purley and Sanderstead Fire Stations. 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 was one of the constituent authorities of the Wandle Valley Joint Hospital Board, and cases of infectious disease (other than smallpox) occurring in this District were admitted to the Board's hospital at Beddington Corner, Mitcham. The 27 bed accommodation was seriously restricted, as in other hospitals, by the shortage of nursing and domestic staff. Smallpox.— An arrangement with the Surrey County Council existed whereby any cases of smallpox could be admitted to the Smallpox Hospital at Clandon, but fortunately no cases of this disease have occurred in this District since 1932, although each year contacts with the disease elsewhere are visited when arriving in this District. General Hospitals.— The general hospitals which chiefly served this area were the Redhill County Hospital, Croydon General Hospital and the Purley War Memorial Hospital, but a considerable number of residents received treatment at various London hospitals and other county hospitals. Maternity Hospitals.— An arrangement existed with the Purley War Memorial Hospital whereby the Council had the call on three beds, and if accommodation permitted additional cases could be admitted. A large proportion of cases from this District was admitted to the County Hospital at Redhill, while a considerable number of residents made 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 retrograde 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. MASSAGE ESTABLISHMENTS. The provisions of Part IV of the Surrey County Council Act, 1931, relating to the registration and management of massage establishments, are in operation. Eleven such establishments are situated within the Urban District. BACTERIOLOGICAL AND CHEMICAL EXAMINATIONS. The examination of swabs for diphtheria and sputa for tuberculosis was carried out by the Medical Officers of the Wandle Valley Isolation Hospital, and during 1947 the following numbers of specimens were examined:— Swabs for diphtheria 43 Sputa for tuberculosis 47 28 In addition, specimens submitted to detect and classify streptococci were sent to the Emergency 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 1947 the following specimens were examined:— At Epsom for streptococci 272 At Croydon General Hospital: Blood for Widal Test 1 Faeces for typhoid, paratyphoid,etc. 2 The bacteriological examination of all samples of milk and all water samples is carried out at the Emergency Medical Service Laboratory, Flpsom, only water samples for chemical examination being sent elsewhere, viz., to the Clinical Research Association. DISINFECTION. The disinfection of bedding, etc., is undertaken at the Wandle Valley Hospital, 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 bedding, etc.; 5s. for the first room; and 2s. 6d. for each additional room disinfected at the same time. During 1947 the following disinfections were carried out:— Free of cost. Upon payment. T otal. Loads of bedding, etc. 146 18 164 Houses disinfected 135 — 135 HEALTH PROPAGANDA. Steady use was 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 1915, for the maternity and child welfare work of this District, and in its attSmpt to minimise the risks of childbirth and encourage the care and healthy development of all children born or residing in the area, has taken the1 following measures:— 29 Maternity Clinics. Combined ante-natal and post-natal clinics are held as follows:— (a) 69, Brighton Road, Purley, each Monday and on the first and third Tuesdays in each month from 2-4 p.m. (b) Methodist Church, Sylverdale Road, Purley, on the first and third Wednesdays in each month from 2-4 p.m. (c) Baptist Church, Addington Road, Selsdon, on the second and fourth Wednesdays in each month from 10 a.m.-noon and 2-4 p.m. A system of appointments for seeing the Medical Officers is in use and, thanks to the assistance of members of the British Red Cross Society, has worked very successfully to the benefit of the mothers attending. The following attendances were made in 1947: — Centre. New Cases. Number of Attendances. Sessions. Average per session. Antenatal. Postnatal. T otal. Antenatal. Postnatal. Total. 69, Brighton Road, Purley 257 2 259 1,581 144 1,725 76 22.7 Sylverdale Road, Kenley 83 3 86 504 56 560 22 25.5 Selsdon 94 — 94 585 39 624 22 28.4 Totals 434 5 439 2,670 239 2,909 120 24.2 (Two Doctors attended all sessions at Sylverdale Road and the sessions held at 69, Brighton Road, on Mondays.) The following table compares the 1947 figures with those of 1945 and 1946: — 1945. 1946. 1947. New ante-natal cases 391 576 434 Percentage of registered births 52% 54% 41% Post-natal attendances 210 242 239 Number of sessions 120 120 120 Average attending per session 22 20.1 24.2 While the total number of ante-natal cases decreased, the attendances at the Selsdon Ante-Natal Clinics remained high; hence extra sessions had to be arranged. This is offset by only one doctor attending the majority of the sessions at 69, Brighton Road, Purley, latterly. The proportion of mothers attending for post-natal examination is 30 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 during the year compared with 1939, 1945 and 1946:— 1939. 1945. 1946. 1947. Admitted to Purley Hospital 64 72 72 72 ,, Redhill Hospital 98 129 220 263 Attended by Selsdon Midwife 38 33 53 60 ,, Purley 49 39 75 67 ,, Coulsdon Nursing Association Midwives 96 85 Supplied with Home Help 18 142* 171 215 * Including Home and Domestic help. The only change of note in the arrangement for hospital accommodation for maternity cases since the 1946 Report has been the reduction in the average period during which normal maternity cases have been retained at Purley Hospital from 14 to 10 days. This alteration was effected towards the end of the year, and did not influence the number of admissions to that hospital in 1947. For the last two years this change in policy has resulted in a greater number of the local 'births taking place at Redhill County Hospital. 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 1947 the Council's midwives attended 127 cases, of which 50 were maternity cases attended also by a doctor, while the Coulsdon Nursing Association midwives attended 85 cases. One other midwife was known to be registered to practise in the District, but did not engage in much midwifery work. 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 31 Visitor. During 1946 the work expanded very considerably and the number employed varied from 14 to 26. In 1947 the average number employed was about 28, with a maximum of 31 or 32. The number of cases assisted increased from 31 maternity cases in 1938 to totals of 142 in 1945, 268 in 1946 and 414 in 1947. The latter represents 215 maternity and 199 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 two to three weeks, but in exceptional circumstances the period was extended, occasionally very considerably. 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 regretted that all legitimate appeals for assistance could not be met owing to the limited number of Home Helps employed. The Organiser, however, again did extremely well in spreading the available assistance over the maximum number of cases, in holding together so many assistants, whose conditions of service often vary considerably and are not always by any means easy or pleasant, and particularly in inculcating a real sense of service. While her assistants tend to come and go, she has succeeded in building up a good organisation, with its own quite high standard and tradition. Towards the end of the year further limited expansion became practicable and is tentatively being explored. Uncertainty regarding the effect of the National Health Service Act limited the progress which might otherwise have been achieved, coupled with doubt as to the financial responsibility which should be accepted by the community. Obstetric Specialists. During 1947 the number of Obstetric Specialists recognised under the Council's scheme, upon whom local doctors could call for assistance in relation to anticipated or realised obstetrical difficulties, was increased to six. Altogether 17 local residents were seen by one or other of the specialists, and in 6 cases minor or major operations were performed. 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 have not been required during the last two years. 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 have not been called upon during the last two years. The special cots, with electric blankets, etc., 32 which have also been provided, were used for only one case during 1947. This suggests a lack of use of the facilities, but only 3 babies were born prematurely at home, and of these one did not want it, the other failing to obtain it owing to the lack of knowledge of a temporary midwife. Care of Illegitimate Babies and Their Mothers. The Health Visitors continue to give very considerable attention to the individual needs of cases of this type of which they become aware, but 110 further action has been taken 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. 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 1947. A total of 91 new cases was seen, 75 for advice on birth control, the latter being desirable solely on medical grounds, and 16 owing to sub-fertility. A total of 166 attendances was made at the 12 sessions, all being by appointment. These figures represent an increase of about 50 per cent, on those for 1946, the chief expansion being in the number of cases being recommended by doctors to obtain advice on birth control on grounds of health. Health Visitation. For the second year in succession, the Council theoretically employed 5 Health Visitors, but, owing to sickness and a resignation, for more than half the year a maximum of 4 Health Visitors were rendering active service. The following table of visits paid during the year reveals that statistically the work again suffered as, in spite of the increased number of births, the total number of visits decreased. First visits to babies, which increased by 254 in 1946, again increased by a further 53. The number of revisits to babies was maintained, but the older children had to receive far less attention, the visits to these being reduced by a further thousand visits. Fortunately visits to cases of infectious disease could be reduced, otherwise the work would have had to suffer still more. 1,014 first visits to babies. 1,947 visits to babies under 1 year. 2,643 visits to children from 1 to 5 years. 186 ante-natal visits (139 first visits, 47 re-visits). 23 visits to cases of Whooping Cough (21 first visits, 2 re-visits). 120 visits to foster children. 31 visits to cases of Measles (30 first visits, 1 re-visit). 1 visit to a case of Puerperal Pyrexia. 4 investigations re infant deaths. 16 investigations re still births. 92 miscellaneous visits. 45 visits to children received for adoption. 6,122 Total visits. 33 The following table compares the 1946 and 1947 work with the fiveyearly 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 1946 4-5 6,946 961 5,377 98 1947 . 4-5 6,122 1,014 4,590 55 Infant Welfare Centres. The following seven Infant Welfare Centres are held regularly from 2-4 p.m.:— 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. Whitgift Sports Pavilion, Lime Meadow Avenue, Sanderstead Every other Thursday. It is anticipated that an eighth Centre will be opened shortly, sessions being held every other Tuesday at the Estate Office, Mitchley Avenue, Purley. 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 1947 7 315 14,819 47 34 OJ Ln attendances at infant welfare centres. 1937-1947. Brighton Road, Coulsdon. Rickman Hill, Coulsdon. Bradmore Green, Old Coulsdon. Sylverdale Road, Purley. Addington Road, Selsdon. Sanderstead Hill, Sanderstead. Whitgift Pavilion, Sanderstead. TOTALS. 1947. 1946. 1945. 1944. 1943. 1942. 1941. 1940. 1939. 1938. 1937. New cases 200 94 133 160 166 109 122 984 845 768 681 811 848 717 667 811 667 594 Other cases 2,264 2,036 2,545 2,171 2,371 1,573 875 13,835 12,818 12,348 10,130 13,093 12,328 10,315 10,245 13,093 16,371 14,064 Total attendances 2,464 2,130 2,678 2,331 2,537 1,682 997 14,819 13,770 13,116 10,811 13,904 13,176 11,032 10,912 13,904 17,038 14,658 Consultations with doctor 528 442 435 642 667 396 304 3,414 3,142 3,078 2,973 3,601 3,466 3,477 3,243 3,412 3,522 2,866 Referred to hospital 4 1 7 3 4 2 3 24 16 27 21 38 59 68 10 38 41 21 Number of sessions 48 46 49 50 48 50 24 315 297 288 277 261 243 244 237 261 239 220 Average attendance per session : 1947 51 46 55 47 53 34 42 47* 1946 47 32 50 47 59 45 — 46 * 1945 49 33 48 42 51 49 - 45* 1944 49 29 40 31 42 40 - 38* 1943 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 * Average attendance per session for all Centres. 67 * It will be noted that the number of new cases attending the Centres during 1947 was the highest yet recorded, while the total number of attendances was the highest, with the one exception of 1938. These increases were not quite uniform throughout the District, the number of new cases showing a decrease at Rickman Hill, Sylverdale Road and Sanderstead Hill, the first being compensated for by the increase in reattendances and the latter by the very satisfactory numbers attending the newly-opened Centre off Limpsfield Road, Sanderstead. The fact that the total number of sessions held is not only the largest yet recorded but considerably greater than before the war explains partly why the Health Visitors have been unable to pay so many home visits, especially if it is remembered that the number of Ante-Natal Clinic sessions is also almost double the number it was in 1938. To a slight extent the Health Visitors have been helped when very short-handed by the employment of a part-time experienced Assistant Nurse to weigh the children at certain of the Centres, thus saving a second Health Visitor from being present at some of the larger Centres. While it is naturally preferable to have a second Health Visitor when two are required at a Centre, when it becomes, as at present, a choice between a serious drop in the number of home revisits and additional trained help at the Centres, it is probably more advantageous to the scheme to give relief in the Centres, and this might be extended to advantage. The voluntary helpers at these Centres, the Ante-Natal Clinics and Diphtheria Immunisation Clinics continued to give valuable assistance, which is greatly appreciated, and which it is hoped they will cofttinue to render after the reorganisation in 1948. 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. 1947. Number of toddlers sessions held 23 44 46 41 44 45 43 56 56 Number of children examined 247 237 164 198 241 165 169 257 180 Total number of examinations 276 450 404 459 504 454 469 553 462 It was disappointing to note a fall in the number of these attendances in 1947 after an improvement in the previous year. This age group also receives attention in the Nurseries and Nursery Schools, where the 36 majority are over two years of age and have frequent medical inspections, but the total numbers involved are not large. Further propaganda is needed to impress on parents the value of these annual overhauls. Eye Defects and Treatment. Arrangements have been made whereby children suffering from eye defects can be referred by appointment to special sessions for young children held at the Surrey County Council's Clinic in Whytecliffe Road, Purley, and in 1946 appointments were made for 14 children to attend. Dental Treatment. The number of ante-natal and nursing mothers and children under five years of age who received dental treatment from the private dental surgeons assisting under the Council's scheme decreased from 121 in 1946 to 88 in 1947. The reduced scale of charges in respect of children which the Council decided to adopt in 1945, improved the number of acceptances for that age group, but, there being no corresponding variation in the scale for mothers, the percentage of those who refused treatment increased, especially as the maximum charges for treatment had meanwhile been raised. Day Nurseries. The year commenced with accommodation for about 18 children under the age of 2-2 J years at the Purley Day Nursery and for not more than 30 children under 3 years of age at the Old Coulsdon Day Nursery, which latter shares the Wartime Nursery premises with a Nursery School for 30 children over 3 years of age. The relationship between the Day Nurseries and Nursery Schools was dealt with fully in the 1946 Annual Report. The view then expressed that as soon as practicable the two organisations should be dissociated was supported by experience during 1947. While the staffs co-operated closely, the difference in outlook, and particularly in the normal nursery school hours and holidays, towards which the staff of Nursery Schools are naturally and constantly aiming, emphasised the impracticability of continued close association. During the summer and Christmas holidays the Old Coulsdon Nursery School only closed for the same periods as the Nurseries, but these were permitted to close for longer stretches than in previous years as a compromise. The remaining Nursery Schools closed for the normal school holidays, and an effort was made to transport and accommodate at Old Coulsdon the maximum number of children of the mothers whose domestic circumstances made this action most desirable. During August, thanks to the numbers taking their holidays, it was possible to accommodate all the children of parents who really urgently needed this assistance without permitting overcrowding, which it was most necessary to avoid, particularly owing to the wave of poliomyelitis then being experienced. Over half the applicants for places had to be refused, however. 37 The position was much more difficult at Christmas, when the only vacant places were due to illness. As the latter cannot be foreseen accurately, but on the other hand the parents require some notice both of vacancies and the possibility of transporting their children, in practice full use could not be made of the unexpected vacancies which did occur. It is pleasing to be able to report that throughout the year the health of the children in the Nurseries and Nursery Schools was relatively satisfactory, and no cases of poliomyelitis occurred in any of these institutions, thus justifying the insistence on the avoidance of overcrowding. A further problem which has arisen of late in the Nurseries has related to the training of students. At the Purley Nursery the ages of the children do not usually exceed 2\ years; hence the students can only train for and take Part A Certificate of the National Nursery Examination Board. At Old Coulsdon the children are aged up to 3 years, and the students would naturally desire to take the full Certificate, but it is impracticable for them to obtain sufficient experience with the children of 3-5 years of age in the Nursery School, although they get plenty of time with the 2-3 year-olds. It would seem obvious that an exchange of staff should be effected between the Nursery and Nursery School to encourage this training, but owing to the differences in the numbers of students employed in the two Departments, this has so far been impracticable. Towards the end of 1947 the Council received notice to quit the Purley Day Nursery premises, and thanks to the offer of a local resident took the preliminary steps towards acquiring the use of more commodious and suitable premises in Lower Sanderstead. It was hoped that it would be practicable to effect this before the transfer of responsibility for child welfare to the County Council in July, 1948, and also that with an increase in the amount of accommodation, all the children under 5 years of age of parents who really need Nursery as opposed to Nursery School assistance, and who reside in the District (other than in Coulsdon or Old Coulsdon), would be able to be met. This Nursery should, moreover, provide a training establishment for the full National Nursery Nurses' Certificate for a larger number of students than has hitherto been possible, which is of importance, bearing in mind the need for recruitment of embryo nurses. The Council also explored the possibility of establishing a Nursery in the Kenley/Whyteleafe part of the District. While there is a very extensive need for Nursery School accommodation in the District, which is unlikely to be met fully for years owing to the difficulties in providing new building, it is hoped that the demand for Day Nurseries will gradually diminish with the fall in the illegitimacy rate, improved social conditions, etc., as Nurseries are an expensive form of social service. Child Life Protection. The Health Visitors are all Infant Life Protection Officers, and during the year kept 20 foster mothers under supervision, which is the 38 same number as in 1946. There were 74 children distributed among them, which is 20 more than in the previous year. The Health Visitors also paid a considerable number of visits to ascertain 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 1947. (1) (a) Total number of houses inspected for housing defects (under Public Health or Housing Acts) 524 (b) Number of inspections made for the purpose 2,482 (2) (a) Number of dwelling houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 3 (b) Number of inspections made for the purpose 6 (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 377 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 275 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 Nil (2) Number of dwelling houses which were rendered fit after service of formal notices : (a) By Owners Nil (b) By Local Authority in default of Owners 1 (b) Proceedings under the Public Health Acts : (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 49 (2) Number of dwelling houses in which defects were remedied after service of formal notices : (a) By Owners 30 (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 39 (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) Number of dwelling houses overcrowded at end of year 16 (2) Number of families dwelling therein 18 (3) Number of persons dwelling therein 94 (b) Number of new cases of overcrowding reported during the year 13 (c) (1) Number of cases of overcrowding relieved during the year 8 (2) Number of persons concerned in such cases 30 (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 66 By other persons 165 The number of houses inspected for defects was 244 less than in 1946, although the number of inspections made for the purpose was only 214 less. This decrease was largely due to the depleted number of Sanitary Inspectors on the staff of the Council, preceding and following the sudden death of the Chief Sanitary Inspector at the end of March. Lack of building materials and shortage of labour again restricted this side of their work, which had to be confined to those defects of a more urgent nature. An increasing reliance has been placed on them by the public in order to distinguish between building works considered essential for the maintenance of public health and other less urgent works. Close co-operation with the Council's Licensing Department has been maintained thereon. The number of cases of statutory overcrowding increased from 11 to 16 during the year, although 8 were relieved. The Council continued to provide new housing and housing units as rapidly as circumstances permitted, and altogether 231 new houses and 55 other new housing units resulted. A scheme for reconditioning three cottages which were in need of extensive repair, the conversion of pail closets and the proper disposal of waste water, was presented by the Department, approved by the Council and subsequently confirmed by the Ministry of Health. The houses could not be repaired at '' reasonable cost,'' but in view of the present-day shortage of houses and the costs incurred in rehousing persons displaced from houses considered as unfit, the Council agreed to purchase the houses by agreement at site value and carry out the 40 necessary improvements and repair. A scheme of road widening is also incorporated in the proposals. When the works are completed, three useful housing units will be retained at a cost in the region of £1,140, excluding road charges. 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. No samples of raw water were taken during the year, but routine samples were taken for bacteriological and chemical examination of the treated water. The water companies also supply copies of reports on samples taken by them. No complaints were received during the year with regard to the quality or quantity of water supplied by the water companies, and there were no unsatisfactory samples. 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 Grains per Parts per Grains per 100,000. Gallon. 100,000. Gallon. Total solids (dried at 180°C.) 17.0 11.9 16.0 11.2 Combined chlorine (C1) 1.7 1.2 1.7 1.2 equivalent to Sodium Chloride (Na C1) 2.8 2.0 2.8 2.0 Nitric nitrogen (Nitrates) 0.42 0.29 0.56 0.39 Nitrous nitrogen (Nitrites) a faint trace present a faint trace present Ammoniacal nitrogen Nil Nil 0.0004 0.0003 Albuminoid nitrogen Nil Nil Nil Nil Oxygen absorbed in 4 hours at 27°C. 0.002 0.001 0.003 0.002 Lead or Copper Nil Nil Nil Nil Temporary hardness ( = to CaC03) 10.0 7.0 5.0 3.5 Permanent hardness ( do. ) 3.0 2.1 4.0 2.8 Total hardness ( do. ) 13.0 9.1 9.0 6.3 Bacteriological Examination. Plate count. Yeastrel agar— 3 days 22°C. aerobically 4 per ml. 2 per ml. 2 days 37°C. aerobically 6 per ml. 2 per ml. Probable number of coliform bacilli, MacConkey 2 days, 37°C. 0. per 100 ml. 0. per 100 ml. 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 Analyst's reports suggested that the statutory maximum limit for hardness was exceeded by a small margin on three occasions, but the method of estimation used exaggerated the degree of hardness, and was not that required by statute. Forty-five samples were taken and 41 examined for hardness by the Department, one showing excess. Representations were made on all occasions to the company concerned. RAINFALL. The rainfall registered by the automatic rain gauge installed at Alderstead Heath was 25.42 inches, this being a decrease of 11.03 inches compared with the previous year. The monthly totals throughout the year were as follows:— January 2.57 inches February 1.68„ March 5.56„ April 2.13„ May 1.79 June 2.79 July 2.38 August .29 September 1.56„ October .46„ November 1.33 December 2.88„ DRAINAGE AND SEWERAGE. New sewers were constructed during the year to an extent of 847 yards in conjunction with the development of Council Housing Estates. CLOSET ACCOMMODATION. The approximate number of each type of closet accommodation remaining at the end of the year was:— Premises with water closets drained to sewers 15,605 Premises with pail closets 42 Number of cesspools 163 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 weekly collection, recommenced in 1946, continued during most of the year, but unfortunately it was found necessary, owing to labour and transport difficulties, to revert to a fortnightly collection in October. The charges for trade refuse collection and for cesspool emptying remain the same. 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 watercourses in the District, but apart from clearing them as frequently as is necessary, no particular difficulty has arisen. 42 CAMPING SITES. The Boy Scouts' camping site at Featherbed Lane continues to be used, and is conducted in a very satisfactory manner. Tents and caravans are not a serious problem in the District, but constant supervision is necessary to prevent undesirable conditions arising through uncontrolled development. 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 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. There were 12 factories in the District in which Sections 1-4 and Section 6 of the Factories Act, 1937, are enforced by local authorities, and 89 others in which Section 7 is enforced, 46 inspections being made of the latter, but no notices served as a result. The total on the register was thus 101 factories. On three occasions want of cleanliness was found, on one occasion insufficient conveniences and once unsuitable or defective conveniences. On all five occasions the defects were remedied. The number of outworkers in the August list was 3, these being engaged on making wearing apparel, etc. Part IV of the Act (Section 53): Underground Workroom. H.M. Inspector of Factories made representations regarding the suitability or otherwise of an underground workroom in the District used for the repair of wireless sets and the charging of batteries. Owing to dampness and lack of ventilation, the room was considered unfit for use as a workroom. H.M. Inspector of Factories was informed accordingly, with a view to the issue of a certificate of unsuitability. SANITARY INSPECTIONS, ETC. The following is a summary of the complaints received, visits made, notices served and defects remedied during the year 1947. The number of complaints received increased by 113, and were chiefly in respect of rats and mice, difficulties with water, resulting from the severe weather in the early part of the year, and by complaints of unsound food, offensive pig bins, etc., during the exceptionally 43 hot summer. There were decreases in the number of complaints from almost all other causes, including those relating to overcrowding. The number of inspections carried out decreased in almost all sections owing to the staff deficiencies previously noted. The number of drains tested increased slightly, and there was a very considerable increase in work arising from the destruction of rats, which is reported upon more fully later. Complaints Received. Rats and mice 231 Overcrowding 17 Non-collection of house refuse 14 Choked drains 87 Defective drainage 66 Defective water supply pipes and fittings 29 Defective washbasins and w.c.'s 80 Offensive smells 30 Dilapidated dustbins 10 Smoking chimneys, bonfires, etc. 5 Keeping of animals 5 Accumulations 13 General defects and insanitary conditions 225 Offensive pig bins 17 Verminous premises 6 Insect pests, etc. 13 Unsound food 67 Miscellaneous 41 956 Summary of Visits Made. Number of houses inspected 524 Re-inspections and calls made 2,482 Inspections : Factories 32 Bakehouses 14 Cowsheds 6 Dairies and Milkshops 26 Meat and other foods 127 Stables and stable yards 2 Food premises 427 Yards, outbuildings, drains, etc. 762 Piggeries, fowls and other animals 67 Under Rats & Mice (Destruction) Act, 1919 239* Revisits under Rats & Mice (Destruction) Act, 1919 621* Inspections, Shops Act 7 Drains tested 73 Infectious disease enquiries 117 Infectious disease contacts 36 Disinfections carried out 116 Disinfestations of verminous premises 5 Tents, vans and sheds 8 Water supply 2 Vermin 3 Miscellaneous 39 5,735 * Exclusive of visits made in connection with the Private Private Dwellings Special Scheme, 1946/47. 44 Notices Served. Preliminary notices 364 Statutory notices 49 Defects Remedied. Cesspools requiring to be emptied 3 Unclean walls and ceilings 41 Choked drains 86 Defective drains, inspection chambers and covers 73 Defective plaster 45 Defective firegrates 36 Defective floors 24 Defective woodwork 43 Defective paintwork 6 Defective paving 4 Defective dustbins 27 Defective waste pipes 17 Defective kerbs around gullies 8 Defective water closet fittings 33 Defective water closet pedestals 71 Defective eaves guttering and rain water pipes 23 Broken sashboards 4 Dampness through roofs 61 Dampness through other causes 35 Animals so kept as to be a nuisance 4 Offensive accumulations 6 Verminous premises 4 Lack of domestic cleanliness 1 Burst water pipes 23 Brickwork and pointing 35 Insufficient ventilation beneath floors 7 Glazing 26 Unclean bakehouse walls 3 Overcrowding 7 Sinks and lavatory basins 14 Miscellaneous 4 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 7 houses were disinfested, of which 3 were Council properties. Disinfestation was carried out by spraying with proprietary insecticides. It was not found necessary to disinfest any bedding by steam during 1947. RATS AND MICE DESTRUCTION ACT, 1919. INFESTATION ORDER, 1943. In 1946 the Council adopted the Ministry of Food Private Dwellings Special Scheme, as described in Circular N.S. 12, involving the routine inspection and treatment as necessary of all houses in the District. Treatment was carried out free of cost to the occupiers of private 45 dwellings, the duration of the scheme being for a period of twelve months ending on 30th September, 1947. The following table shows the work carried out under the Scheme:— Number of houses inspected 16,117 Infestations found on routine inspection and treated 270 Complaints received and resultant primary inspections 177 Additional infestations thus found 98 Sewer treatment was a necessary requirement of the scheme, and in this respect 388 sewer sections were inspected and 423 manholes were pre-baited, but poison was found necessary in 20 cases only. During the year under review 91 visits were made to Council Depots, including the Refuse Disposal Works. At the conclusion of the Private Dwellings Special Scheme, the Council reviewed their Rodent Control arrangements and agreed to implement Ministry of Food Scheme F/2 in regard to rodent control in the Urban District as from 1st October, 1947. A full-time Rodent Operative was appointed, who had already given excellent service. It was agreed that a charge of 3s. 6d. per hour, with a minimum charge of 5s., be made to occupiers of premises for services rendered by the Council in the destruction of rats and mice. The following is a record of the work carried out for the three months ending 31st December, 1947:-— Number of complaints received 69 Number of complaints investigated 69 Number of premises inspected 102 Number of premises found infested 75 Number of premises treated by Council 65 Number of premises treated privately 10 During this period 18 visits were made to the Council Depots at Millstock, Purley Oaks and Kenley. LEGAL PROCEEDINGS. Public Health Act, 1936. Section 75. A statutory notice was served under the above, requiring the provision of a dustbin for the reception of house refuse, a:nd was the subject of an appeal by the owner of the property concerned. The appeal was dismissed and the Council were awarded 10s. costs. SCHOOLS. The Medical Officer of Health has also been the Divisional School Medical Officer since September, 1945, and close co-operation between the Public Health and School Health Services results, particularly in regard to the prevention of the spread of infectious disease. The hygienic condition of the schools is kept under observation, advice being given when necessary. 46 School Clinics. — The County Council provide the following Clinics at their Clinic premises in Whytecliffe Road, Purley:— General Medical Clinic : Thursdays 9.20—11 a.m. School Dental Clinic : Fridays 1.30 p.m. or by appointment. School Eye Clinic : By appointment. Speech Therapy Clinic : By appointment. Remedial Exercise Clinic : By appointment. INSPECTION AND SUPERVISION OF FOOD. MILK. Milk and Dairies Order, 1926. The entries in the registers required to be kept in accordance with the Order were as follows:— Cowkeepers 6 Dairymen and Retail Purveyors with premises in the District 4 Retail purveyors with premises outside the District 5 Retail purveyors of bottled milk only sold in general shops 12 Dairies (including 1 Receiving Depot) 4 The following is a list of dairy farms in the District: — 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. 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) Regulations, 1936/46. Milk Sampling. 76 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 : 24 22 2 22 1 Heat-Treated : 37 34 3 37 — 47 Examination of Raw Milk. Number of Samples. Methylene Blue. Coliform Bacillus. Satisfactory. Unsatisfactory. Satisfactory. Unsatisfactory. 9 9 — 8 1 Biological Examination. Number of Samples. Tubercle Bacilli positive. Tubercle Bacilli negative. 6 1 5 Adverse reports on samples of milk were investigated with a view to improvement of future supplies, and in this respect six bottle rinses were examined to ascertain the efficiency or otherwise of bottle washing. Biological examination revealed one sample of milk to be T.B. positive. As a result of investigations made by the Divisional Inspector of the Ministry of Agriculture and Fisheries, one cow from the herd concerned was slaughtered under the Tuberculosis Order, 1938. A further bulk sample of milk submitted for biological examination was certified non-tuberculous. 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 7 Pasteurised 7 Ice-Cream. Twenty-four samples of ice-cream were examined for bacterial quality, 12 of which were reported as unsatisfactory and indicating various degrees of contamination. The high percentage of unsatisfactory samples was chiefly due to repeat samples from the same source, four retailers in all being involved. In one instance the product sold was chocolate ice (prepacked) purchased by the vendor in bulk from outside the District, and upon 48 which four unsatisfactory reports were received. On representations made to the vendor, he eventually closed down the business. Another trader who manufactured his product locally was also responsible for four unsatisfactory reports. Investigation into the methods employed and facilities available revealed scope for improvement. A technical adviser was employed and a plan for reorganising the premises and equipment was approved, which was proceeding at the close of the year. The third instance concerned a retail vendor purchasing ice-cream in bulk from outside the District; three adverse reports were received on this product. Following representations, the trader concerned temporarily stopped the sale of ice-cream and has since obtained supplies from another source. In the remaining case a local manufacturer was responsible for one adverse report. A subsequent sample proved satisfactory. Meat. The two slaughterhouses in the District have not been licensed since 1940. In 1947 one licence was issued under the Slaughter of Animals Act, 1933, 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. As far as possible routine inspections were made to food premises, including bakehouses, provision shops, ice-cream shops, restaurant kitchens and cafes, etc., with regard to the provisions as to rooms and precautions to be taken against contamination of food. The condition of many of these premises leaves much to be desired, due in the main to the accumulation of defects and neglect during the war years, unavoidable lack of supervision, difficulties experienced in obtaining labour and materials to carry out alterations and repairs, and restrictions on civil building. At the close of the year efforts were being made to overtake the arrears of work under this heading. A public awareness of the necessity for a high standard of food hygiene is becoming more apparent, and in those cases where representations have been made, the traders concerned have generally expressed willingness to fall in with the suggestions made by the Inspectors. Unfortunately difficulties and delays have been experienced by owners in obtaining building licences from the Ministry of Works, even when applications have been supported by the Public Health Department. 49 The following unsound foods were surrendered during the year:— Cwt. lbs. ozs. Soups, etc. — 66 8½ Canned Meat 1 8 ½ Meat, Bacon, Poultry 21 33 10 Fish 44 5 ½ Canned fish 1 39 12¼ Canned beans, peas, etc. 1 91 ½ Canned milk 3 74 7 Sugar, jam, etc. 2 87 12½ Flour, bread, cereals 4 50 10½ Canned fruit — 60 6 Eggs 2 — 3 Fresh fruit and vegetables 7 31 — Pickles and Sauces — 17 — Butter and fats 1 29 7½ Tea, coffee, etc. — 3 3 Meat paste — 4 9¾ Drugs and spices — 29 14 Total 92 72 9½ 5' FOOD AND DRUGS ACT. The following samples were taken during 1947 and submitted to the Public Analyst, with the results shown: — A rticles. A nalysed. Adulterated or deteriorated. Prosecutions. Convictions. Formal Informal. T otal. Formal Informal. T otal. Bread 2 - 2 - - - - Baking powder 4 — 4 - - - - - Bi-carbonate of soda 1 — 1 - - - - - Butter 3 — 3 - - - - - Cake flour 8 — 8 3 — 3 — — Cooking fat 4 — 4 - - - - - Curry powder 3 — 3 1 — 1 — — Coffee and chicory- 3 — 3 - - - - - Cocoa 4 — 4 - - - - - Cinnamon 1 — 1 - - - - - Essence of anchovies 1 —, 1 - - - - - Flour 1 — 1 - - - - - Fruit squash 2 — 2 - - - - - Fish paste 5 — 5 - - - - - Fruit pepsin 1 — 1 - - - - - Gelatine 2 — 2 - - - - - Gravy cubes 1 — 1 1 — 1 — — Hors d'ceuvre 1 — 1 - - - - - Jam 7 — 7 - - - - - Jelly making compound 2 — 2 - - - - - Jelly crystals 1 — 1 — - - - - Lemonade powder 1 — 1 - - - - - Liviar (cod liver) 1 — 1 - - - - - Milk 28 — 28 - - - - - Malt vinegar 4 — 4 - - - - - Margarine 2 — 2 - - - - - Oatmeal 1 — 1 - - - - - Potted Meat 2 — 2 - - - - - Pudding mixture 4 — 4 - - - - Potato powder 1 — 1 - - - - - Sauce 6 — 6 - - - - - Soup 1 — 1 - - - - - Soup powder 2 — 2 - - - - - Sardines 1 — 1 - - - - - Sausage meat 1 — 1 1 — 1 — — Spinach 1 — 1 - - - - - Semolina 1 — 1 - - - - Savora 1 — 1 - - - - - Tea 1 — 1 - - - - - Tomato juice 1 — 1 - - - - - Total 117 — 117 6 — 6 — — It will be noted that six samples were reported as being adulterated or otherwise unsatisfactory. Three of these related to defects in labelling and no action was taken on the firms concerned agreeing to withdraw the products and revise the wording of the labels. Similarly, in another case where flour was considered unfit for human consumption owing to the presence of flour mites, all remaining stocks were withdrawn from sale. No action other than warning letters was taken in the other cases owing to the impossibility of obtaining favourable legal decisions. 51 52 TABLE 1. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1947. 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. Sander stead. Selsdon and Farleigh. Wood cote. Diphtheria - - - - - - - - - - - - - - - - - - - - - Typhoid fever 1 - - - - - - - - 1 - - - 1 - - - - - - - Paratyphoid fever 1 - - - - - - - —. 1 — — — — 1 — — — - — - Scarlet fever 78 1 1 2 4 2 37 17 6 5 2 1 — 10 4 24 10 12 10 8 47 Erysipelas 5 - - - - - - - - 1 - 3 1 - 1 2 1 - - 1 1 Puerperal pyrexia 1 - - - - - - - - 1 - - - - - 1 - - - - 1 Pneumonia 20 - - — — — 1 — — — 5 6 8 3 1 8 1 4 2 1 — Dysentery 43 - - — — — 1 — 1 4 5 17 15 40 3 - - - - - - Cerebro-spinal fever 1 - - - - - - - - - 1 - - - - 1 - - - - 1 Encephalitis - - - - - - - - - - - - - - - - - - - - - Poliomyelitis 11 - - — — — 2 — 3 5 1 — — 1 1 5 1 1 — 2 Measles 218 4 20 17 25 21 112 10 3 4 1 1 — 41 9 57 25 74 7 5 2 Whooping cough 115 12 16 10 23 16 34 — 1 1 2 — - 5 6 29 16 23 27 9 3 Totals 494 17 37 29 52 39 187 27 14 23 17 28 24 101 26 127 54 114 46 26 55 53 TABLE II. THE MONTHLY INCIDENCE OF INFECTIOUS DISEASE, 1947. Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. Total. Diphtheria - - - - - - - - - - - - — Typhoid fever - - - - - - - — 1 - — — 1 Paratyphoid fever - - - - - - - 1 - - - — 1 Scarlet fever 8 7 10 5 13 7 7 5 2 2 4 8 78 Erysipelas - - - - - 1 - 2 -. — — —- 5 Puerperal pyrexia - - - - 1 - - - - - — 1 Pneumonia 7 5 - 2 - 1 — 1 — 1 — 3 20 Dysentery - - - - - - 2 - 7 1 3 2 43 Cerebro spinal fever - - - - - - - - - — — 1 Poliomyelitis - - - - - - 3 3 5 - — —. 11 Measles 6 55 56 29 11 13 35 10 1 1 — 1 218 Whooping cough 12 1 3 23 18 20 20 5 8 1 4 115 Totals 52 71 72 64 44 42 67 27 24 6 7 18 494 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 1947 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 78 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 5 Typhoid and Para— 18 73 31 15 5 16 11 5 24 9 9 9 6 4 4 7 5 5 1 3 26 5 1 53 12 3 1 6 4 4 2 C erebro—spinal fever 3 1 — — 1 — — — — — — — 1 — — — — — 1 — — 4 8 6 1 4 2 1 3 1 Puerperal fever 1 1 — — 2 — — — — 1 — — 1 — 1 1 — 1 1 1 5 — — — — — — — — — — Puerperal pyrexia — — — — — — — — — — 1 1 1 1 3 5 1 2 — — 2 5 3 2 —— 2 3 1 2 2 1 Poliomyelitis — — 1 1 — 1 — 1 — — 1 1 — 1 — 2 — 1 1 — 3 1 1 1 2 3 — — 2 1 11 Polio—encephalitis — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Encephalitis lethargica — — — 1 1 1 1 1 1 — 1 1 Ophthalmia neonatorum 1 1 — 1 — — 1 — — 12 — 3 — 1 1 2 — 1 — 1 1 1 — 1 1 — 1 — 1 — — Pneumonia — — 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 20 Malaria — — 5 — — — — — — — — — — — — — — — — — — — — — — — — — — — — Measles 468 33 12 — — — — — — — — — — — — — — — — — — — 2 11 214 479 275 52 705 141 218 Dysentery — — 4 7 7 7 17 — — — — — — — — — — — 6 — 1 2 10 85 224 121 21 42 172 82 43 Whooping cough — — — — — — — — — — — — — — — — — — — — — — 6 1 136 36 55 51 100 31 115 Tuberculosis:— Pulmonary 17 25 28 24 12 29 16 24 14 19 25 23 22 38 44 36 44 28 30 27 36 32 31 31 32 43 39 51 44 38 59 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 11 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 435 564 TABLE IV. DEATHS OCCURRING DURING THE YEAR 1947. Cause of death. Males. Females. Total. 1 Under 1 year. 1 and, under 2. 2 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and over. Typhoid fever, etc. Cerebro-spinal fever — i i - — — — •— i —- — Scarlet fever 1 — 1 - - - - - - 1 — Whooping cough - - - - - - - - - - - Diphtheria - - - - - - - - - - - Respiratory tuberculosis 11 12 23 - - - - - 7 13 3 Other tuberculosis - - - - - - - - - - - Syphilis 1 — 1 - - - - - - 1 — Influenza 2 1 3 - — — — — — 2 1 Measles - - - - - - - - - - - Poliomyelitis and polioencephalitis 1 - 1 1 - - - - - - - Ac. Inf. encephalitis 2 1 3 - — — — 1 1 — 1 Cancer 52 66 118 - - - - - 12 43 63 Diabetes — 2 0 - - - - - 1 — 1 Intra-cranial lesions 33 52 85 - - - - - 10 75 Heart disease 95 92 187 - — — — — 2 36 149 Other diseases of circulatory system 11 12 23 - - - - 1 3 5 14 Bronchitis 16 14 30 - - - - - - 9 21 Pneumonia 17 17 34 2 — I — 2 6 3 20 Other respiratory diseases 4 7 11 — — — 1 — — 4 6 Ulcer of stomach or duodenum 6 1 7 - - - - - - 1 6 Diarrhoea under 2 years - - - - - - Appendicitis 2 1 3 — — 1 — — — 1 1 Other digestive diseases 8 10 18 — — — 1 1 — 6 10 Nephritis 7 6 13 - - - - - 1 5 7 Puerperal sepsis - - - - - - - - - - - Other maternal causes — 2 2 - - - - - 1 — 1 Premature birth 8 2 10 10 - - - - - - - Congenital debility, etc. 6 4 10 10 - - - - - - - Suicide 2 2 4 - - - - - - 3 1 Road traffic accidents i 1 3 - - - - - - 2 I Other violent causes 15 13 28 1 — — — 3 6 7 11 All other causes ;.. 27 24 51 — 1 —. — — 4 8 38 Totals 329 343 672 24 I 2 2 8 45 160 430 55 WANDLE VALLEY JOINT HOSPITAL BOARD. Cases Admitted to Hospital during the Year ended 31st December, 1917. Disease. Beddington and Wallington. Coulsdon and Pur ley. Merton and Morden. Mitcham. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Diphtheria 2 — — 3 — 5 — Scarlet fever 51 — 47 1(a) 98 — 44 — Erysipelas 4 1(b) 1 — 1 — 2 — Tonsilitis or quinsy 3 — 7 — 10 — 9 — Measles 1 — 2 — 5 — 3 — Influenza 2 — 1 — 4 — — — Whooping cough 3 1(f) 3 — 4 — 8 Rubella — — — — — 6 — Typhoid and enteritis — 3 1(c) 1 — Meningitis, all types, including T.B. meningitis 3 1(d) 1 - 3 1(d) 3 3(e) Pneumonia 1 Puerperal fever (sepsis) — - 1 — 1 — — - Admitted with mother — - 1 — — — - Poliomyelitis . 9 - 10 — 16 — 10 - Dermatitis 3 - — — 1 — — - Laryngitis — - — — 1 — 1 Angio-neurotic oedema — - 1 — — — — - Pneumococcal peritonitis - - 2 - - - - - Chicken pox 1 - — — 3 — — — Myalgia — - — — 3 — 3 — Sub-arachnoid haemorrhage - - - — 1 1 1 — Cystitis - - - - - - 1 — Urethral stricture — - — — , 1 — — - 82 3 77 1 160 3 98 3 (a) 1 death cerebral embolus, cardiac failure, septica?mia with scarlet fever. (b) 1 death erysipelas of face and heart disease. (c) 1 death gastro enteritis. (d) 2 deaths T.B. meningitis. (e) 2 deaths T.B. meningitis, 1 death meningitis from brain abscess. (/) 1 death broncho-pneumonia and whooping cough. 56 INDEX. Page Ambulances 27 Analysis of Mortality 11, 12 Ante-natal Clinics 30 Area 5,9 Bacteriological Work 28 Bed Bugs, Eradication of 45 Birth Kates 5, 10, 17 Births, Live, Illegitimate and Still 10, 11 Camping Sites 43 Cancer 12, 13 Causes of Deaths 11,55 Cerebro-Spinal Fever 20 Child Life Protection 38 Clinics : Ante-natal 30 Diphtheria Immunisation 26 Family Planning 33 Infant Welfare 34, 35 Post-natal 30 School 47 Toddlers 36 Tuberculosis 24 Closet Accommodation 42 Dairies and Cowsheds 47 Day Nurseries 37 Deaths and Death Rates 11, 17, 55 Dental Treatment 37,47 Diabetes 27 Diphtheria .. 18 Diphtheria Immunisation 26 Disinfection 29 Drainage and Sewerage 42 Dysentery 20 Emergency Unit 19 Erysipelas 19 Eye Defects 37, 47 Factories 43 Family Planning Clinic 33 Food and Drugs Act 51 Food Supply : Milk 47 Meat 49 Food Preparing Places 49 Health Visitation 33 Health Propaganda 29 Heart Disease, etc. 12 Home Helps 31 Hospitals 27 Houses, Inspection of 39 Houses, Inhabited 10 Housing 10, 39 Ice-Cream 48 Illegitimate Babies 11, 33 Immunisation 26 Infantile Mortality 14 Infant Life Protection 38 Infectious Disease : Cases notified 18,52,53,55 Monthly incidence of 53 School Notifications 24 Inspection and Supervision of Food 47 57 Page Laboratory Facilities 29 1 -egal Proceedings 46 Massage Establishments 28 Maternal Mortality 14, 17 Maternity Cases 31 Maternity and Child Welfare : Services 30 Centres 34, 35 Hospital Accommodation 28, 31 Measles 22 Meat 49 Midwifery Service 31 Milk (Special Designations) Regulations 48 Milk, Sampling of 47 Mortality : Analysis of 11, 55 Infant 14 Maternal 14 Mumps 24 Non-notifiable Infectious Disease 24 Obstetric Specialists 32 Paratyphoid Fever 20 Paediatrician 32 Pneumonia 21 Polio-myelitis 20 Population 5, 9 Post-natal Clinic 30 Premature Babies 16, 32 Public Cleansing 42 Public Health Committee 3 Puerperal Pyrexia 17, 19 Rainfall 42 Rateable Value 5 Rats and Mice Destruction 45 Rivers and Streams 42 Sanitary Inspections, etc. 43 Scabies 25 Scarlet Fever 19 Schools « 46 School Clinics 47 Sewerage 42 Shops 43 Slaughterhouses 49 Small Pox 17, 28 Smoke Abatement 42 Social Conditions 5, 9 Staff 3 Statistics : Housing 39 Vital 5, 10, 17 Still Births 5, 11 Swimming Baths 43 Toddlers' Clinic 36 Tuberculosis 22 Tuberculosis Care Committee 24 Typhoid Fever 20 Violence, Deaths from 14 Vital Statistics 5, 10 Wandle Valley Isolation Hospital 27, 56 Water Supply 41 Whooping Cough 22 58