AC 4413(3) 1 In Meghna D 5B 2 Library HEALTH REPORT for 1956 for the COULSDON & PURLEY URBAN DISTRICT by the MEDICAL OFFICER OF HEALTH Printed by RAYNES PARK PRESS, Lambton Road, London, S.W.20. WHAT "IMPROVEMENT GRANTS" CAN DO.(See page 40.) Before After CONTENTS. INTRODUCTION. Part 1. THE DISTRICT- ITS NATURAL FEATURES, AREA, POPULATION AND GROWTH. Part 2. ASSESSMENT OF THE HEALTH OF THE DISTRICT. A. Vital statistics-(page 9). (a) Facts about its births and deaths. (b) The main causes of death and their prevention. B. Sickness in the District-(page 17). (a) Infectious diseases and their prevention. (b) Other illnesses,(page 30). Part 3. SERVICES TO HELP EACH RESIDENT TO BE HEALTHY,(page 32).(Mothers, and Babies, School Children, Other Adults, the Aged). Part 4. SERVICES AND MEASURES TO KEEP OUR SURROUNDINGS HEALTHY,(page 39). (Housing, Drainage, Cleansing, Workplaces, Pests, Water, Food). APPENDICES. 1 URBAN DISTRICT COUNCIL OF COULSDON AND PURLEY. 1956. Public Health Committee. Chairman: R N. Saunders. Councillor F. W. Purvis. Councillor W. H. Glanville, j.p. „ H. W. Hayden, „ Mrs. D. Pattison, b.a. j.p., f.b.o.a., f.s.m.c. „ Miss J. C. Simpson. „ S. E. Littlechild. m.a., j.p. „ D. M. Weightman. m.a. „ r.W. Kersey, „ Mrs. K. M. Platt. b.sc., a.r.i.c. Ex-officio: Councillor M. D. West, a.i.b., j.p. „ „ J. Corsie, a.s.a.a. Representatives on the South Eastern Divisional Health Sub-Committee. Councillor C. J. ffield, b.sc. Councillor Mrs. K. M. Platt. „ Mrs. F. K. Grover. „ R. W. Kersey, „ R. N. Saunders. b.sc., a.r.i.c. Public Health Department. STAFF: Medical Officer of Health: *F. R. Edbrooke, M.B., Ch.B., D.P.H. Deputy Medical Officer of Health: *T. R. Bennett., M.R.C.S., L.R.C.P., D.P.H. Chief Public Health Inspector: W. Haworth, f.a.p.h.i. Deputy Chief Public Health Inspector: W. Rice-Jones, m.a.p.h.i. Additional Public Health Inspectors: E. R. Rogers, m.a.p.h.i. G. H. Bourne, m.a.p.h.i. D. G. Stripp, m.a.p.h.i. Assistant to Public Health Inspectors: W. H. Sands. Rodent Operative: H. M. Key. Chief Clerk: *D. V. Prothero. Clerks: Mrs. G. Edmonston. *Mrs. J. M. Smyth. *Mrs. L. R. Proctor. F. J. Smith. (* Part-time appointment only to this Council.) 3 TO THE CHAIRMAN AND MEMBERS OF THE COULSDON AND PURLEY URBAN DISTRICT COUNCIL. Mr. Chairman, Ladies and Gentlemen, I have pleasure in presenting my Annual Report for 1956, this being my twenty-fifth report as your Medical Officer of Health. These Annual Reports have to be prepared mainly for the information of, and on the instructions of the Minister of Health, but they also provide information for the Council and the residents of the District. In the past they have tended to present an accumulation of facts, largely in tabular form, which have not made attractive reading for those unused to such fare. In spite of steady endeavour to write them more interestingly, considerable repetition has been inevitable in the small amount of space available between the tables. The opinion is growing that more use should be made of this opportunity to interest residents in health questions and widen their knowledge of the preventive measures which can be taken to improve the health of the District, and on this occasion the the experiment has been made of reducing the number of tables, devoting more space to positive advice and, as far as possible, simplifying the wording. It is hoped that, as a result, more residents, and particularly teenagers who are interested in 'Civics' will read this report and not find it too heavy going. If it is thought that even now sections could have been omitted to advantage, it must be remembered that these reports are valuable as works of reference in the years ahead, hence many facts have to be included which may not be very interesting to the lay reader. Most of the tables have been relegated to the Appendix while those of the least general interest have been omitted from the printed report but are available in duplicated form, on request. Experience alone will show to what extent it is practicable to meet the demands of a wide variety of potential readers in a single report. It is usual in these introductions to give a very brief assessment of the health of the District based on the vital statistics for the year under review, for the benefit of the vast majority who do not find time to read any further. Judged solely by this standard the health of the District was well maintained in 1956. The birth rate increased, the death rate remained stable while that for ordinary residents decreased. Most commendable and outstanding are the facts that again there was no maternal death, while the death rate among infants under one year was the lowest ever experienced. On the whole the infectious diseases were not very common, very few cases occurring of those which are liable to be most serious. Immunisation against poliomyelitis was instituted in 4 the early Summer and the proportion of the eligible asking to cooperate in this experiment was higher in this Division than in any other part of Surrey. Steady work was maintained in all branches of the personal and environmental health services. Those who have the interest and patience to read and reflect on the remainder of this report, will appreciate more fully how impossible it is accurately and concisely to deduce the health of a District. Much information which should be obtainable is not available particularly in regard to those sicknesses which are not notifiable and to absenteeism. One has constantly to recollect too, that health is not the mere absence of disease but a positive state involving complete physical, mental and spiritual fitness. An annual stocktaking and report on the part of each individual resident might be beneficial and revealing. With this wider conception of health as a background, the inevitable inadequacy of this attempted assessment of the state of the whole group stands out clearly but becomes of less significance. Ultimately, the responsibility rests with each of us as individuals to play our part if real health is to be known and enjoyed by the District as a whole. May I conclude by thanking the Council for its continued support and my colleagues, in the voluntary and official branches of the Health and Welfare Services for their full co-operation which, we hope, has been to the benefit of the District. I would wish to thank particularly those who have assisted in the preparation of this Report, and request their patience if, in attempting this revised edition. I have not given full enough recognition to their special activities. I am, Ladies and Gentlemen, Your obedient Servant, F. R. EDBROOKE, Medical Officer of Health. 5 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area(in acres) 11,142 Registrar-General's estimate of population, mid 1956 66,460 Population, Census 1931 37,666 Population, Census 1951 63,770 Number of occupied houses, December, 1956 . 19,591 Number of occupied houses, 1931 9,533 Number of occupied houses, 1951 18,071 Rateable Value, December, 1956 £1,283,180 Sum represented by a penny rate £5,225 VITAL STATISTICS FOR THE YEAR 1956. Total M. F. Birth Rate per 1,000 of the estimated resident population Live Births do. Legitimate 885 471 414 13.6 Illegitimate 21 7 14 906 478 428 Corrected Birth Rate 14-6 Rate per 1,000 (live and still)births. Still Births do. Legitimate 13 10 14.1 Illegitimate - - - 13 10 Crude Death Rate per 1,000 of the estimated resident population Death 931 392 539 14.0 Corrected Death Rate 9.1 Deaths from puerperal causes:— Rate per 1,000 (live and still) births. Puerperal Sepsis — - Other Puerperal causes - - Total - - Death Rates of Infants under one year of age:— All infants per 1,000 live births 9.9 Legitimate infants per 1,000 legitimate births 10.2 Illegitimate infants per 1,000 illegitimate births — Deaths from Cancer(all ages) 152 Deaths from Measles(all ages) Nil. Deaths from Whooping Cough(all ages) Nil. Deaths from Diarrhoea (under 2 years) Nil. 6 The Coulsdon and Purley Urban District The Urban District of Coulsdon and Purley has been officially recognised as a distinct Local Government unit since 1915, i.e. 42 years, prior to which it was part of the Croydon Rural District. The District, which has no natural boundaries, is part of the large dormitory area to the South of the County Borough of Croydon. 12-17 miles south of Charing Cross, and it is mainly situated on the plateaux and sides of the northerly spurs of the North Downs, together with the intervening valleys. The majority of the houses, which are in general very well spaced, have been built in the last 30 years, mainly on the chalk. There are caps of clay and flints of varying depths on the highest downs, while the comparatively narrow valleys present a light loam with pockets of sand, below which, along the Brighton and Godstone roads, run the bournes, or underground streams. The latter only appear above ground level in prolonged wet seasons. The southern part of the District forms part of London's "Green Belt" and tongues of this agricultural or undeveloped area run into the District to augment the many recreation grounds and public open spaces, which are among the features of the area. Thanks to its hilly nature, to good planning and the influence of its many garden lovers, the District is one of the most favoured of London's suburbs. There are no really large manufacturing or other industries in the District, the majority of the residents who work, doing so in London or Croydon, travelling to and fro daily. Those employed locally are mainly connected with the building trade, the retail supply of food and other daily wants of the inhabitants, or are attached to the two large mental hospitals in the Coulsdon area to the South of the District. For the last 20 years at least the amount of unemployment, apart from temporary unemployment pending transfer, has been negligible. AREA AND POPULATION The Growth of the District. Originally the District had an area of 8,457 acres, but from time to time variations in the boundaries have been made, especially in 1933 when 2,547 acres were added, mainly in Selsdon and Farleigh in the North East and in Coulsdon. The present area is 11,142 acres. The growth of the population in the last 40 years has been very considerable, being originally slightly less than 18,000 and now at least 66,460. 7 At the time of the 1921 Census, more than half of the 21,493 residents lived in Purley and Woodcote. Sanderstead housed nearly 4,000 and Kenley about 2,000; Coulsdon had only some 3,300 apart from Cane Hill Hospital. When the 1931 Census was taken, the total population had increased to 37,666 and, whereas the number of houses in Purley and Woodcote had only increased very slightly, the number in Sanderstead and Coulsdon was about four times as great. During the following eight years before the war. the rate of building increased still further. Whereas since 1922 the average annual increase was about 550 houses, after 1931 it reached an average of 850, and in the peak years of 1935/36 was over 1,000 and 1,200.(The increase in size of the area during 1933 due to the alteration of the boundaries brought in 2,547 more acres but only about 3,000 population). As might be expected the latest development chiefly affected Sanderstead and Coulsdon East, and to a less extent Selsdon and Coulsdon West. Meanwhile the average number of persons per occupied house, the Institutions being excluded, had decreased from 3.7 in 1915 and 3.9 in 1922, to 3.24 in 1951 and 3.13 in 1956. Since the war some 3,781 houses have been built, the number of occupied houses is 2,899 greater and the population must have increased by at least 9,275. As the 1951 Census population was 63,770 the present population should be quite 68,600 instead of the 66,460 estimated by the Registrar General. For record purposes, it is wise to include here the number of persons residing in the Institutions in the District at the end of 1956:- Cane Hill 2.400 Netherne 2.122 Russell Hill School 227 Reedham Orphanage 268 Further, in December 1956, the number of occupied houses was distributed as follows: Coulsdon East 3,282 Coulsdon West 3.183 Purley 2,628 Woodcote 1,778 Sanderstead North 2.354 Sanderstead South 2,919 Selsdon 1,890 Kenley 1,557 8 PART 2 - ASSESSMENT OF THE HEALTH OF THE DISTRICT. VITAL STATISTICS. For many years information has been collected nationally with a view to deducing whether the general state of the public health is satisfactory, to noting any tendencies to variation and to the introduction of any measures which appear desirable for its improvement. The following table is one way of presenting concisely what has been happening in the District since 1920. What the various 'Rates' mean will be dealt with in subsequent sections, but it should first be noted that in each of the first seven columns an average for the five years referred to has been given. Averages are desirable in order to even out the wide differences which are apt to occur from year to year when dealing with only relatively small numbers. An illustration of this will be included later. Rates per 1,000 population. 19201924. 19251929. 19301934. 19351939. 19401944. 19451949. 19501954. 1955. 1956. Birth rate 13.5 12.9 11.6 12.8 15.2 15.2 12.0 12.9 13.6 Percentage illegitimate 3.4% 3.7% 2.8% 3.4% 3.9% 3.4% 2.7% 2.5% 2.3% Stillbirth rate — — — 0.43 0.48 0.40 0.24 0.26 0.20 Death rate 7.4 7.0 7.4 8.3 11.4 9.7 12.1 14.0 14.0 Cancer death rate 0.96 1.15 1.35 1.19 1.70 1.75 2.02 2.19 2.29 Tuberculosis death rate (per 100,000 population) 57 36 38 35 48 36 25 21 23 Violence including Suicide 0.44 0.35 0.32 0.46 0.82 0.37 0.46 0.59 0.65 Maternal mortality rate per 1,000 live and still births 2.08 2.66 3.21 2.27 2.10 1.12 1.01 Nil Nil Infant mortality rate(per 1.000 registered births) 28 38 32 38 40 26 21 24 10 Neonatal mortality rate - - - 26 28 19 15 20 7 Estimated population 21,351 28,950 41,616 53,084 49.880 60,610 64.466 65,420 66,460 BIRTHS. For various reasons it is important to know how many babies are being born each year. For example, we want to know the total number of persons in the Country, how many places will be needed in the infants' schools five years hence and so on. 9 In 1956 there were 906 live babies born in Coulsdon and Purley,(478 boys and 428 girls) which was 63 more than in 1955. As the number will obviously depend in part on the number of people in the District, we find it best to speak of the number of births for every 1,000 residents and that figure is known as the Birth Rate. The preceding table shows what the recent Birth Rate has been and compares it with the averages since 1920. The most noticeable thing is that this rate was much higher for 1940-49, and that is why so many more schools have had to be built since the war. The Birth Rate of a District like this cannot be compared with, say Manchester, unless allowance is made for the proportion of the residents who are young married couples and therefore more likely to have babies. The Registrar General, who is responsible to the Country for dealing with these statistics, therefore decides each year on a "comparability factor" for each District, and if the simple or crude Birth Rate is multiplied by this, the "corrected Birth Rate" results. This should be comparable with the corrected rate for any other area or with that for the whole of England and Wales. The Birth Rate for the latter was 15.6 in 1956, whereas the corrected Birth Rate in this District was 14.6. Illegitimacy.—- The mothers of 21 babies(7 boys and 14 girls) born in 1956 were not married at the time the births occurred. This means that only 2.3% of the 1956 babies were illegitimate at birth. The smaller this proportion, the better the chance of a good start in life for the District's babies. Stillbirths.— Last year 13 babies were not born alive, (10 boys, 3 girls). The Stillbirth Rate is best expressed as the number born dead of every 1,000 born, whether alive or dead, and in 1956 this rate was 14.1 in this District and 22.9 in England and Wales. DEATHS. Just as every birth has to be registered by the Registrar, so too, since 1836 has every death, the doctor stating what caused the death. We note first that there were 931 deaths in this District during the year(392 males, 539 females) that being 14 more than in 1955. From this figure we calculate the Death Rate, i.e. the number of deaths per thousand population(14.0) and thanks to the Registrar General's "comparability factor" obtain the corrected Death Rate of 9.1 which should be comparable with the Death Rate of England and Wales of 11.7. It will be seen that the correction reduces the local Death Rate considerably and this is because the proportion of our residents who are elderly and thus more likely to die is greater than in the Country as a whole. This is also one of the reasons why in the 10 earlier table the Death Rate appears to have doubled in the last 30 years.(The Death Rates given in the table have not been corrected because the "comparability factor" was not recorded before 1934 nor supplied from 1938-49). Undoubtedly the average age of the residents of this District is higher now than it was before the war. Unfortunately there is another factor which has made it most difficult to compare the number and particularly the causes of death locally in recent years. Before 1953 the registrations of deaths of the people who died in the District but normally lived elsewhere, were transferred to their home towns. Now the rather large numbers who die in the two big Mental Hospitals count as if they had resided here permanently. As the inmates of these hospitals are included in our total population this is fair, but the alteration in the method of recording has complicated comparisons. When we come to consider the causes of death, it will be seen that an attempt is still being made to distinguish between ordinary residents and this special group, and here we record that, but for the new system, the crude Death Rate in Coulsdon and Purley in 1956 would have been 8.6 compared with 9.2, 8.6, 9.9 and 10.2 in the preceding four years. THE MAIN CAUSES OF DEATH AND THEIR PREVENTION. Ideally we would like everybody to live in good health until they wear out from old age. It is not our concern here to deal with how they employ their time while alive, although that is obviously of greater importance than the mere length of life. Our present concern is to observe what are the main causes of death and especially those which shorten life unduly. In Table IV in the Appendix, will be found a complete list of the official classifications of causes and the numbers affected divided into ordinary residents and mental hospital cases, and by sex and age. A number of the causes can be still further grouped together when it is found that, as usual, the commonest causes are heart and circulatory disease(54% of the total deaths of ordinary residents), cancer(21%), pneumonia and bronchitis(8%), accidents (3%) and tuberculosis(1%). HEART AND CIRCULATORY DISEASE. This large group is made up mainly of several quite different causes of failure of the heart and circulatory system. Some, but relatively few, commence life with structural defects, chiefly of the heart which, as a result, has to work against difficulties from birth. Advances in surgery in recent years are altering the outlook for these unfortunates. 11 Another diminishing group has the efficiency of the heart decreased as a result of infection, but the chief cause, rheumatic fever, has rapidly decreased in incidence during the last 30 years for some obscure reason. A substantial proportion of premature adult deaths from heart failure is due to damage originally due to this infection. By contrast, included in this group are those residents who have died virtually of old age, their hearts or arteries having eventually worn out. It is impossible to tell exactly from the brief death certificates which of the deaths can be attributed to old age and which to the larger group in which the primary cause of death appears to have been the same, except that it may be thought to have occurred prematurely. Some satisfaction can be gained if it is found that in general the average age at which death occurs is getting higher. During 1956 we find that 78% of the ordinary residents whose deaths were allocated to this group were over 65 years of age, compared with 80% in 1955 and an average of 79% in the previous five years, i.e. not much change has occurred. However, 56% of the group were over 75 years compared with 52% in 1955 and this is a welcome improvement. What can be done to diminish the appreciable proportion who die before 65 years of age? Unfortunately, the fundamental cause of clotting in the blood vessels, which underlies thrombosis, and of fracture of the vessels, which causes mainly cerebral haemorrhage, are not known. Evidence suggests on the one hand mistakes in diet, bearing in mind the occupation of the individual, and on the other, ways of life conducive to a permanent raising of the blood pressure. Of the first it may be said that in general the quantity of food, and especially the fats and carbohydrates, should be decreased the more sedentary the occupation. Of the second, the more even the tenor of life the better. Chief among the causes of raised blood pressure are drugs, including alchohol and tobacco, emotional stresses, including anger, fear and anxiety, and possibly over-eating and constipation. The cultivation of a cheerful, optimistic and philosophical way of life with ample mental and physical relaxation is to be commended. CANCER. The cancer death rate among ordinary local residents was 1.79(i.e. deaths in each 1,000 of the population) compared with 1.77 in 1955 and 1.87 in the previous 5 years. The latter is. however, about double what it was 30 years ago. In part, of course, this increase is due to the increase in the average age of the population, cancer being chiefly a disease of the more elderly; partly it may be due to better diagnosis, but it is generally believed that to some extent a true increase in prevalence has occurred, especially in lung cancer in men. Cancer is esentially the misbehaviour of certain cells of the body which, without notice, multiply in numbers causing a 'new 12 growth' which in turn is apt to spread, not only directly but by shedding parts which start 'secondary new growths' in other parts of the body. What exactly is the primary cause of this abnormal growth is still unknown. There may be underlying factors but almost certainly there is some form of direct irritation. The classical examples of the effect of irritation are the comparatively high number of cases which used to occur among chimney sweeps and tar workers, and those using rough ended clay pipes, badly fitting dentures or retaining jagged teeth. Turning to the following table in which the sites of the original growth are indicated and the ages and sex of the persons concerned, it will be seen that, as usual, the commonest sites affected are the stomach and intestines, the lungs,(especially in males), the genital-urinary system and the breasts in women. Unfortunately we know too little about the causal irritants except in the case of cancer of the lung where it is now generally suspected that heavy cigarette smoking over a long period may be a very important cause. In view of the many serious financial repercussions which would result if all cigarette smoking ceased, very considerable research is being undertaken to ascertain what chemical, if any, causes the irritation. While the results are awaited, adults who have become addicted to the habit would be well advised to reduce their use of cigarettes, while the younger generation would be wise to consider the unnecessary risk before they become addicted to what is, at least, a foolish and uneconomic habit and one which most probably contributes to other forms of ill health. If the scope for preventive measures is, unfortunately, limited, there is still hope of a cure being effected if operative or other measures are carried out early in the disease. The outlook is best in the accessible forms of the disease, e.g. the skin, mouth, breast and female genital organs. The prime necessity is for early recognition. Persistant ulcers, pain or swelling, the enlargement of any skin defect or unusual haemorrhage from any of the body orifices should be reported promptly to the patients' private doctor. The mental relief of a negative diagnosis is almost as important as the institution of early treatment. TUBERCULOSIS, PNEUMONIA AND BRONCHITIS. These diseases are referred to in later sections of this report. VIOLENCE. During 1956 there were 26 deaths among ordinary residents which were attributed to suicide or other forms of violence, the resultant death rate being 0.39 per 1,000 population which is the average since 1919, excluding the period of the war. Deaths on the road numbered 6(4 men and 2 women), which, although 2 less than in the previous year, was 1.5 more than the 13 14 CANCER TABLE 1956. 0-30. 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. M. F. P. H. P. H. P. H. P. H. P. H. P. H. P. H. P. H. P. H. P. H. P. H. P. H. P. H. P. H. P. H. P. H. Skin and Tongue - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Brain and Thyroid - - - - - - - - - - - - - 1 - - - 1 - - - - 2 - - - - - - 2 2 - Bone - - 1 - - - - - - - - - - - - - - - 1 - 1 - - - - - - - 1 - 2 - Oesophagus - - - - - - - - - - - - - - - - - - - - - 1 1 1 — — 1 — — 1 2 2 Stomach & Duodenum - - - - - - - - - - 1 — 6 1 1 — 2 — 1 1 1 — 3 1 — — 1 1 9 1 8 3 Intestines — — - — — — — — 1 — 1 — 1 — 1 — 1 1 2 — 3 — 2 2 2 2 2 8 1 8 4 Liver - - - - - - - - - - - - 1 - 1 - - - - - 1 - - - - - - - 2 - 1 - Pancreas - - - - - - - - - - - 1 - - - - - - - - - 1 - - - 1 — 1 - 2 - Lungs — — — — — — — — — — - - 10 1 - - 11 2 1 - 5 - 1 1 1 — — — 27 3 2 1 Bladder - - - - - - - - - - - - - - 1 - 4 - - - - - 1 - - - 2 — 4 — 4 — - - - - - - - - - - - - - - - - 2 - - - 2 1 — — 4 — — — 8 1 — — Uterus - - - - - - - - - - - - - - 2 - - - 2 - - 3 - - - 1 - - - 8 - Vagina and Ovary - - - - - - - - - - 1 - - - 1 - - - 2 1 - - 1 - - - 1 1 - - 6 2 Breast - - - - - - - - - - 1 - - - - - - - 3 1 - - 3 3 — — 1 2 — — 9 6 Kidneys - - - - - - - - - - - - 1 - - - - - - - - - - - - - - - 1 - - - Ill-defined - - - - - - - - - - 1 - - 1 1 - 1 - - 3 - - - 2 - 1 - - 1 2 2 5 TOTAL - - 1 - - - - - 1 - 5 - 20 4 9 - 21 4 12 7 13 2 18 10 7 1 11 6 62 11 56 23 average for the years since the war. Those killed were aged 21 to 60 years and at the time 2 were pedestrians, the others riding or driving a bicycle, motor-scooter, motor-cycle or car. By contrast other forms of accidental deaths, i.e. excluding those which occurred on the roads, numbered no less than 24, 10 being among ordinary residents. Unfortunately, this is about the average, 11 ordinary residents having died on the average each year since the war from "home accidents". In 1956, 3 young babies died through accidents, but the remainder with one exception, an elderly lady who was gassed, died following falls. One of these was a man of 40 years who fell after jumping for a train, one very old lady was knocked down by a train and the remaining 4 fell in their homes all being over 67 years of age. It seems ironical that so much emphasis and public expenditure is devoted to the prevention of road accidents and so very little by comparison to the avoidance of other forms of accidents, which consistently produce more fatalities. In part, the reason may be the different age groups affected. Road deaths concern all age groups but home accidents mainly result in the deaths of the elderly, particularly from falls. Locally since the war, however, an average of one pre-school child has died from a home accident each year and one school child every other year. The prevention of all forms of accidents obviously justifies continuous attention, as apart from the loss of life, there is a tremendous loss of working time, unnecessary suffering and absorption of the resources of the hospital and ambulance services. The number of deaths attributed to suicide was 10 among ordinary residents compared with an average of 7 since the war. The average age was 40 years, and in each case the Coroner found that the balance of the mind had been temporarily disturbed preceding death. MATERNAL MORTALITY. Deaths among women in association with childbirth are particularly regrettable, and it is therefore very pleasing to be able to report that on the whole the Maternal Death Rate has steadily decreased. This rate is usually expressed as the number of such deaths occurring in every 1,000 live and stillbirths, and if reference is made to the table at the beginning of this section, it will be seen that since 1945 this rate has been less than a half what it was on the average between 1920 and 1944, and that no such deaths occurred in this District in 1955 and 1956. In general there is still room for improvement and recently a renewed attempt has been made to ensure that every ante-natal mother gets the fullest advantage of our considerably increased knowledge of the earliest signs of abnormality and the associated preventive measures. 15 INFANT MORTALITY. Infant deaths are also almost universally deplored, hence we welcome the spectacular decrease in the Infant Mortality Rate (i.e. the number of deaths under 1 year which have occurred in every 1,000 live births) which has occurred nationally during this century. In 1900 the national Infant Mortality Rate was 154 but by 1927 is was 70 and in 1939 down to 50. Although it rose slightly during the war(60 in 1941) it has since fallen fairly steadily and in 1956 was only 23.8. As this Urban District was only constituted in 1915 and from the first concentrated on reducing the risks to young children, the effect on the local rate has been less dramatic. Even so, it is pleasing to note that, after remaining on the average about 36 from 1920 to 1944, during the last 10 years it has averaged 23. In 1953 it was 29, but in 1954 it was only 11; in 1955 this was again compensated for by 24 but in 1956 it was only 10. Incidentally this is a good illustration of the value of taking an average over a number of years if the numbers affected in any given year are small. The violent swings over the last 4 years even out to a much more reliable average of 18.5 and the still safer average of 23 in the last 10 years. The causes of death in the 9 babies who died locally in 1956 were prematurity and failure to start breathing(5), asphyxia(3) and pneumonia(1). Of the 3 cases of suffocation, one was a case of asphyxia of the newly born, one inhaled its stomach contents and the other was suffocated by its pillow. In general the greatest decrease in these deaths has occurred in children after the first month and the commonest causes in recent years have been prematurity, congenital defects and infections. While the actual numbers of those whose deaths have resulted from accidents and infections has greatly declined, constant watchfulness is obviously still very necessary. Even the common cold can be a most serious infection in the very young. During 1956 in this Division there were 6 deaths among babies in the first month of their lives, this corresponding with a Neo-natal Mortality Rate (i.e. deaths in the first month, per 1,000 live births) of 7, which is the lowest we have known. From 1935 to 1944 the average was 27 and in 1945 - 54 it fell to 17. As prematurity is the most important factor in this Rate, research has recently been concentrated upon its prevention, but the cause appears to be by no means a simple one. Every effort is, however, made to preserve the lives of these premature infants. During 1956, there were 39 "premature" babies(now interpreted as babies who weighed 5 lbs. 8 ozs. or less at birth) of which 11 were notified as being born at home and 28 in institutions. One of the former only lived 6 hours and of the lattter 3 infants died after living only 2 hours, 2 days and a week. This suggests that 10% of the premature babies died, compared with an average of 22% since 1945. 16 SICKNESS IN THE DISTRICT. (a) INFECTIOUS DISEASE. It was mainly because of the devastating effects of infectious diseases that Medical Officers of Health were first appointed just over 100 years ago and it is in the restriction of these diseases that the most spectacular results have been achieved. It is, therefore, understandable that consideration of their prevalence is given a rather conspicuous place in reports such as this. Fortunately during the century the picture has completely altered and some of the diseases which at times decimated the population, e.g. plague, cholera and smallpox, have now virtually disappeared from this Country, although still present and no less deadly in some parts of the world. Smallpox is, however, quite liable to reappear here, particularly in view of the speed of air transport of travellers from the tropics. It will be seen in the following notes that the majority of other infectious diseases which remain with us have also declined in prevalence or in their severity, and are, therefore, apt to be disregarded now as not having an important influence on the state of the public health. Unfortunately, however, the virulence of the organisms causing these diseases, has varied throughout history and we therefore have to be ever watchful lest they again become serious enemies. In order to present a picture of the position during 1956 the following table is included as usual, but a better perspective can be obtained by noting the variations over the last 20 years shown in Table III in the Appendix. Disease. Numbers Notified. Treated in Hospital. Total Deaths. Diphtheria — — — Scarlet fever 41 17 — Erysipelas 8 1 — Puerperal pyrexia 2 — — Pneumonia—primary 36 4 — Enteric fever 3 2 — Encephalitis, acute 1 1 1 Dysentery 81 18 2 Poliomyelitis 7 6 1 Measles 82 — — Whooping cough 93 — — Food poisoning 8 — — Malaria 2 — — Totals 364 49 4 It will be seen that tuberculosis is omitted from this list of acute infectious diseases, this chronic disease being dealt with separately later. Further, only 364 notifications were received compared with 1,283 in the preceding year, chiefly owing to the 17 relatively small number of cases of measles which occurred in 1956. Even so, whooping cough and measles were the commonest diseases to be notified, with dysentery close behind. The number of cases of dysentery and scarlet fever decreased slightly but those of pneumonia increased correspondingly. In comparison with earlier years it is better to omit reference to measles, whooping cough, and food poisoning, which were not notifiable from 1920-1939, and also the mental hospital cases of dysentery. The remaining acute infectious diseases then shown an incidence of 2.4 per 1,000 population which is just above the average of 2.2 since the war, but well below the averages of 6.7 (1915-24), 3.9 (1925-34) and 3.3 (1935-38). SMALLPOX. No case of this disease has occurred in this District since 1932, but in most years contacts with cases overseas and suspected cases have to be visited and kept under observation. In 1956. however, only one suspected case was visited for the purpose of diagnosis. The seriousness of the outbreak in Brighton in 1951 illustrated how important such preventive measures and vaccination still are. DIPHTHERIA. For the tenth year in succession no case of this disease has been notified in the District, but cases and deaths are still occurring in some parts of the Country. It is well to remember that from 1915-24 the average number of cases locally was 40 each year and from then until the end of the war the average was about 18, with 1 or 2 deaths resulting in most years. SCARLET FEVER. In 1860-70 this disease caused 70 deaths in every 100,000 population. In 1911-13 this number was decreased to 5, but it was still one of the more dangerous diseases. Locally until about 1932 it accounted for one death every other year, but during the last 20 years or so it has been very much milder, though liable to cause permanent damage from its complications. As it became known that the germ which caused the disease was much more wide spread than was originally thought, the attitude to preventive measures altered. (It so happened that treatment also became much more effective during the same period). The present attitude is that prevention by the isolation of cases is no longer likely to be effective and contacts of cases can continue to attend school or work providing they are well. On the other hand, as the virulence of the organism may increase again and there are still special circumstances in which it is very undesirable for the organism to be allowed to spread indiscriminately, 18 notification is still required, although there is evidence that this is being observed with decreasing stringency. The fact that only 41 cases were notified in 1956 is therefore of less significance, and it cannot be assumed that the disease was less prevalent. As has been noted in the last 13 years, the disease is almost entirely confined to school children and a smaller number of younger children. The proportion who were admitted to hospital, which until 1946 was at least three-quarters, decreased steadily until in 1953-54 it was only one quarter, but it is now about 40%. It is doubtful whether this increase is justified from the point of view of treatment: it certainly is not as a preventive measure. ERYSIPELAS. This disease, which is also due to a streptococcus has never been a major problem and since 1942 only a very few cases have been notified in any year. PUERPERAL PYREXIA. This complication of pregnancy, formerly also chiefly due to streptococcal infection and frequently very serious, has, fortunately, become of insignificant importance, thanks to aseptic technique and the effectiveness of newer types of drug treatment. In the two mild cases in 1956 the rises in temperature within 14 days of the confinement were due, in one instance to engorged breasts and in the other possibly to a mild infection resulting from a forceps delivery. Both responded rapidly to penicillin-like drugs. PNEUMONIA. Only cases of influenzal and primary pneumonia are notifiable, i.e. those due to a specific infection by the influenzal virus or pneumococci. It may be because of the uncertainty in differentiating between these types and the forms of pneumonia complicating other diseases that the notifications usually emanate from certain sources only. This year one doctor notified 14 cases, and another 9, while three notified 2 cases each and seven only a single case. In 1956 there were thus 36 cases notified, which is slightly above the average for the last 7 years and during the war period. The cases occurred mainly in the early months of the year and in the Purley area, but only 2 cases, i.e. a husband and wife, appeared to have any connection with each other. So far as is known, not a single death resulted. ENTERIC FEVER. During the year 1 case of typhoid and 2 of para-typhoid fever were notified which is about the average for the last 10 years. All recovered. The typhoid was Type E.1. and was probably contracted in Italy. The cases of paratyphoid originated in a child who presumably contracted the infection while an inpatient in a children's 19 hospital receiving treatment for another complaint. The father subsequently became infected, as did an aunt when visiting from another part of the Country. All had organisms of Type 3a. The source of para-typhoid infection is usually some food stuff but the food concerned in this case could not be traced. Typhoid is more often traceable to water and it should be noted that each year cases of one or other of these intestinal diseases occur in persons returning to this Country from the Continent. As so many residents now go overseas for their holidays, the desirability of prior inocculation against typhoid and para-typhoid should be considered, especially if going to countries in which the hygienic standards are inferior to ours. DYSENTERY. If reference is made to Table III in the Appendix, it will be noted that this disease first became prevalent during the war but that until 1955 there was a general tendency for the number of cases to decrease. In fact, until that year the cases were almost all due to the more severe Flexner type of the disease and were mental hospital cases. In 1955, however, only 32 of the 98 cases notified were of this type, the majority being of the very prevalent, though much milder Sonne form of dysentery. This disease was widely spread in this part of the Country. In 1956 there were 26 cases notified from the mental hospitals, (3 of the Flexner type) and 55 from among ordinary residents. This picture would have been quite different had it not been for 43 cases occurring in a large residential school. The epidemic there occurred in May and was abated in June. All the other cases were limited to one or more cases which occurred in individual families, mostly in the early months of the year. The prevention of the spread of Sonne dysentery is almost entirely a matter of practising hygienic habits and particularly those of cleansing the hands thoroughly after going to the W.C. and before handling food. FOOD POISONING. The preceding remarks apply also to the prevention of this group of infections, the prevalence of which increased with communal feeding during and after the war, but in respect of which public opinion has been steadily built up and supported by new legislation. In 1956 only 8 cases were notified locally and confirmed, all being members of the same household, but on 8 other occasions, suspicious symptoms prompted investigations into the food consumed by the families concerned with negative results. In the confirmed outbreak the organism (S.typhi murium) may have originated in some stale crab which had been eaten, or in incompletely cooked duck's eggs. In either case infection was not due to unhygienic practices but to the organisms which had 20 entered the food by natural means not having been destroyed. Ducks' eggs in particular should be boiled for a minimum of 10 minutes before consumption. Their use in sponge or cake making should be avoided as the interior of these foods is not sufficiently heated to destroy these germs. POLIOMYELITIS. It will be remembered that this disease first assumed major importance in this Country in the hot summer of 1947, since when, owing to the serious results which can occur, it has received considerable attention. Fortunately in 1956, relatively few cases were notified and in this District not more than 7 confirmed cases occurred, the diagnosis of one of these being doubtful. The first 4 cases were all of about school age and all were non-paralytic. One occurred in each of the months, June, July, August and October. In November, however, 3 paralytic cases of slight to moderate severity occurred, one being a child living in Coulsdon (as were 3 of the original 4) and the others being isolated adults resident in Sanderstead (as was the remaining original case). All recovered with a negligible amount of permanent paralysis if any. As usual, several cases were admitted to hospital as suspected of having poliomeylitis and the difficulty was again experienced of deciding between ill-defined non-paralytic cases of poliomyelitis and cases due to a variety of other organisms causing similar symptoms. A number of contacts with cases of poliomyelitis in other Districts had also to be kept under observation. ENCEPHALITIS. One case of a child was notified in June as suffering from encephalitis and as the hospital staff considered it was suffering from the "Royal Free" type of acute disseminated encephalomeningitis the notification was accepted. Unfortunately the child subsequently died as a result of a cerebral tumour which had caused the confusing symptoms. MALARIA. Two adult males were notified as suffering from malaria, but the disease had originally been contracted abroad. MEASLES. This most common infection is more prevalent in alternate years and, as over 1,000 cases had occurred in 1955 it was not surprising that only 82 new cases were notified in 1956. The disease was again of a mild type and, in fact, only two local cases with very exceptional complications have died from this disease since the war. 21 WHOOPING COUGH. There was a slight increase in the number of whooping cough notifications received, i.e. 93 compared with 64 in 1955 and an average of 110 per annum since 1941 when regular notification became the practice. Cases occurred in every month but the incidence was again highest in the summer months, with the peak in June. Most cases occurred in Selsdon, and about two-thirds were of school age with slightly less than one third under school age. As three babies were under 1 year when they were infected, it must be again emphasised that thIs disease can be very serious in babies and early immunisation is strongly recommended. No death due to whooping cough has occurred locally, however, since the war years. TUBERCULOSIS. The following table presents concisely the position with regard to tuberculosis in the District during 1956:- Pulmonary. Nonpulmonary. T otal. M. F. M. F. M. F. Number of cases on register 282 192 28 31 310 223 Additions:— New cases notified 25 16 1 2 26 17 Cases removed into district 21 13 4 2 25 15 Restored — 3 1 — 1 4 Total Additions 46 32 6 4 52 36 Removals:— Deaths from T.B. 8 4 1 3 9 7 Other causes — — — — — — Removed from district 24 17 2 3 26 20 Recovered 24 13 5 3 29 16 Not T.B 2 — — 1 2 1 Total Removed from Register 58 34 8 10 66 44 Number of cases on register, 1st January, 1957 270 190 26 25 296 215 Tables indicating the age groups and distribution of the new cases are included in the Appendix. The next table is helpful in showing the trend of this disease in Coulsdon and Purley since 1915. Average figures for the 5 to 10 yearly periods indicated have again been used to level out the fluctuations which are apt to occur between individual years. 22 The Rates given here and in the following notes are per 100,000 population.:- 19151924 19251934 19351944 19451949 19501954 1955 1956 Pulmonary— New cases notified 22 29 35 49 43 47 41 *Case rate 115 82 68 81 67 72 62 Deaths 12 13 21 27 16 11 12 *Death rate 65 37 42 44 22 17 17 Non-Pulmonary— New cases notified 3 6 7 8 5 3 3 *Case rate 15 18 15 13 8 5 5 Deaths 3 3 2 2 2 1 4 *Death rate 15 8 5 3 4 1 6 It is sometimes forgotten that tuberculosis is an infectious disease, mainly spread by droplets coughed into the air, the disease differing from the previous acute infections in that it tends to run a more chronic course. Skin testing suggests that about 13% of the local children have met the infection by the time they are 13 years of age. Their reaction probably depends on the doses they receive at any one time and on their general health and individual susceptibility. In most people the germs become sealed off in the lungs without obvious symptoms being noted. It is not yet clear whether the cases which are notified among older children and young adults, if and when the disease is active and tending to spread, are persons who have just received their first infection or who have become reinfected, or alternatively are persons in whom the original sealing off process has broken down, possibly due to subnormal general health combined with adverse circumstances. The latter is probably the cause of the increasing proportion of notifications of persons of 45-65 years of age, and particularly of males in the post war years. It will be seen from the last Table that apart from the war and immediate post war years, there has been a steady decline in the case rate, (i.e. the proportion of the population recognised annually as suffering from active disease whether pulmonary or nonpulmonary) and in the corresponding death rate. While this improvement, which is fortunately occurring throughout the Country as a whole, is welcomed, it must be remembered that the battle against this formidable disease still goes on, with relatively high casualities still occurring. Treatment has become increasingly successful, especially in those cases which are recognised early, but sufferers are out of action for quite long periods compared with those suffering from other infections. Undoubtedly the improvements in nutrition, housing and other factors affecting our standard of living, have made a major contribution to the success in dealing with this disease. The wider use of Mass X-ray Units in diagnosis has and does help in early diagnosis, while still more recently, skin testing combined with 23 B.C.G. immunisation has been used in an endeavour to increase immunity in groups who are especially exposed to heavy infection. All can assist in this battle, individual residents by maintaining their general health and accepting regular examinations, together, if necessary, with early treatment; the District Councils in their housing policy, the County Councils in their provision of clinics, after-care, etc., and the Regional Hospital Boards by their arrangements for treatment. The Mass X-ray Unit last visited this District in June, 1955 but many residents can and do avail themselves of facilities at their work or in London, Croydon and the surrounding Districts. The commencement of the erection of an ad hoc Chest Clinic at Purley Hospital, which has been long awaited, is most welcome, the present arrangements being very unsatisfactory for the public and staff. NON-NOTIFIABLE INFECTIOUS DISEASE. Less is inevitably known of infectious diseases which doctors are not required to notify because they are normally not very serious. Informal arrangements are, however, made each year for a few selected doctors to act as 'Spotters' in case influenza breaks out, and all are welcome to help in passing on information of any unusual outbreaks. The death returns and the sickness returns of the Ministry of Labour also help confirm the presence of influenza, but, fortunately, this disease was not prevalent in 1956. Head Teachers are also required to notify absences due to any infectious disease and as deduced from their returns, during 1956 chickenpox was mildly epidemic, mainly in Woodcote and Old Coulsdon, while a fair number of cases of mumps occurred in Woodcote with smaller numbers in Coulsdon and Purley. Small outbreaks of German measles were noted in Coulsdon and Old Coulsdon. The teachers are provided with instructions prescribing the minimum periods for which cases of infectious diseases must be excluded from school and. where necessary, these are supplemented by advice from the school doctors or Health Visitors who also visit the homes as and when desirable and practicable. INFESTATIONS. Although not in any way infectious, it is convenient to include here a note on the measures taken to reduce the commonest infestations :— (a) Scabies. Is due to a mite which lives on or in the skin; it was common during the war, but fortunately only one case came to the notice of the Health Department during 1956. Early notification of any case is very desirable in order that contacts may receive preventive treatment while the patient is being treated. 24 (b) Lice. Almost all school children are inspected by the Health Visitors each term to ensure the absence of lice and in 1956 only 17 were found to have head lice, usually following accidental or casual infestation. Such cases quickly respond to the treatment the parents are advised and assisted to provide. Only 2 or 3 families in this District seem permanently liable to harbour vermin. THE CONTROL OF INFECTIOUS DISEASE. The main lines along which attempts have been made to prevent the spread of infectious diseases have been (a) to prevent the organisms entering the body and (b) to increase the body's resistance to any which do enter. Isolation of the sufferer and disinfection of his excretions and surroundings can, in some instances, reduce the risks of others getting the germs, at least in very large numbers. These measures 'are most successful in those diseases, such as enteric fever, dysentery and possibly poliomyelitis, in which spread occurs mainly through the vomit, urine or faeces. The presumption underlying this historical approach to the problem is that only the obvious patient is carrying the germs. Increasing knowledge has shown, however, that in almost, if not in all cases the infection has spread to other persons before the first case is recognised, and a variable proportion of these can carry and thus spread the disease without themselves suffering much, if any, ill health. This consideration, which applies particularly to the large number of infections which are chiefly spread in the droplets the patient sprays around when speaking, coughing or sneezing, has resulted in less justification for following the practice of isolation or segregation and disinfection. There is still a place for excluding for 48 hours, persons starting to show signs of a 'cold', which may prove to be something even more serious. This will help to reduce the doseage others may receive. Nevertheless, it is obviously most desirable in all cases in which it is practicable, to increase the resistance of the population to those infections with which they will almost inevitably come into contact sometime, hence the steadily increasing emphasis on, and practice of immunisation. The following brief notes are an attempt to summarise the present position in regard thereto. SMALLPOX. Vaccination against this often deadly disease was historically the first attempt to provoke a mild attack which would reduce the chances of a severe reaction. Subsequently, vaccination with a milder but related vaccine was generally adopted and made 25 pulsory, but during this century, in this Country increasing advantage was taken of the ways in which this requirement could be avoided, with the result that only about a third of the population was being vaccinated. Under the National Health Service Act, 1946, vaccination against smallpox was left to voluntary acceptance, and for the last five years at least 60% of the babies in this Division have been vaccinated. In 1956 there were 282 primary vaccinations carried out in the Welfare Centres and 401 (including 39 of 15 years and over) by General Practitioners who also revaccinated 38 children under 15 years and 113 persons over 15 years. (The above figures include the primary vaccination of 521 babies under 1 year of age). ENTERIC, CHOLERA AND YELLOW FEVER. Immunisation against typhoid and paratyphoid was introduced successfully during the Boer War and has been used since, with the addition of vaccination against cholera and yellow fever when considered desirable, for the protection of troops and others proceeding abroad, the nature of the vaccine depending upon the Countries to be visited. Reference was made earlier to the desirability of certain of these forms of immunisation being more generally obtained by holiday makers going abroad. Private doctors will advise on how and where they can be secured. DIPHTHERIA. The situation with regard to this serious disease has completely changed since the national campaign to encourage immunisation against it began in 1941. No cases have occurred in this District for the last 10 years and it appears that the germ is rarely present in the throat of any resident. As natural immunity cannot, therefore, develop as a result of minute doses being picked up casually, it is all the more important that we should maintain an artificially produced immunity, especially among children. During 1956, the Authority arranged for 336 children to receive primary immunisation against diphtheria at Welfare Centres, Clinics and Day Nurseries and similarly treated 24 at their schools. They also arranged for 695 to get 'booster' doses (including 548 in the schools). In addition, private doctors gave 377 primary treatment and 469 'boosters'. The total receiving primary treatment was thus 63 less than in 1955, but 121 more had a 'booster' dose. WHOOPING COUGH. This form of immunisation was only officially adopted in 1952 and its effectiveness in preventing the occurence of the disease is not yet of as high a standard as is that against diphtheria. There 26 is, however, good clinical evidence that the severity of the attacks is reduced very considerably. While the vaccine can be used separately, it is usually combined with that against diphtheria. During 1956, at least 684 children received primary courses (333 at Infant Welfare Centres and 351 from private doctors) while 326 were given 'boosters', including 65 in the Centres. TETANUS. Of even more recent adoption officially, is a vaccine for active immunisation against tetanus, and this is normally given in combination with vaccines against diphtheria and whooping cough. Tetanus immunisation was used effectively in the Services throughout the last war and it has the advantages of not only producing some immunity against undetected infections resulting from minor injuries, but the necessity for using tetanus antitoxin following gross injuries can be avoided. This is important as the horse serum in the antitoxin contains antibodies which are apt to cause serious reactions in a proportion of the recipients. While tetanus is not such a common infection in Surrey as in some Counties, its results are often very grave and, for the reasons mentioned above, it would now appear wise to encourage the wider inclusion of this vaccine in the combined vaccine which it is the common practice to use for the primary immunisation of babies. TUBERCULOSIS. In some Countries, very general use is being made of a vaccine which it is claimed increases immunity against tuberculosis, but here a much more guarded approach has been adopted pending very careful observations of the results. For some years it has been used to help protect close contacts of open cases of pulmonary tuberculosis among the very young, nurses, etc., and in 1955 Ministerial approval was given to B.C.G. vaccine being offered to the parents of children aged 13 years. Originally confined to those attending Surrey County Council schools this treatment can now be given to the same age group attending any school in the District, and in fact 4 private schools have already co-operated. In 1956, in this Division 64% of those offered treatment accepted, of these 11% were shown by the Mantoux test not to need B.C.G. vaccination and 53% of the age group were inoculated. POLIOMYELITIS. As is widely known, 1956 was the first year in which a vaccine against poliomyelitis was introduced for use on a national scale in this Country. Instead of limiting the initial trial to certain areas as was done when trying out the whooping cough vaccines, the registration of all children born between 1947 and 1954 whose 27 parents wished them vaccinated against poliomyelitis was encouraged, and 4,570 children in this Division were registered. The amount of vaccine was very limited, however, and it was also thought advisable to confine treatment to the months of May and June, i.e. stopping it before poliomyelitis generally becomes prevalent. As a result, only registered children born in certain months were, in fact, called up for treatment, which was given only by selected doctors of the Local Authorities. In this Division 500 children each received two injections, with a minimum interval of three weeks between the doses, and hardly any immediate reaction was noted. Apart from that observation, however, owing to the small number treated and the comparatively low incidence of poliomyelitis in the Country in 1956, no reliable deductions as to its efficiency were reached. COMBINATIONS OF VACCINE. It will be seen from the above that the number of diseases against which vaccines can be used has steadily increased, although all have not been referred to in this Report, and also that a number have only recently been introduced as suitable for general use. Obviously the time has already come when the more they can be given in combination, the fewer the injections and the less the inconvenience to all concerned, with consequent greater popularity and wider acceptance. Unfortunately, there are a number of resultant problems which necessitate and are receiving considerable time absorbing research, in particular the question as to what extent combining various vaccines affects the efficiency of each. Rapid progress along these lines cannot be expected. Meanwhile the advice to parents has to be very carefully considered, not only in the interests of the individual child but bearing in mind the degree to which the advice will be acceptable as being convenient to the parent. At present the general use of anti-tuberculosis vaccination is not anticipated, while vaccination against poliomyelitis is limited by the quantity of vaccine becoming available. (At present this form of vaccination is only given providing a minimum interval of two or three weeks follows or precedes any other form of immunisation, and that the child is otherwise fit and not likely to be incubating any infectious disease). Vaccination against smallpox can be given as early as two months after birth in a healthy baby and, owing to the child's comparative immobility, there are advantages in carrying out this treatment as early as possible. Many think that it is wise to follow this by a course of combined diphtheria, whooping cough and tetanus prophylactics, commencing at the third month, particularly in view of the relatively high number of deaths from whooping cough in early infancy. On the other hand, there is evidence against such an early start in diphtheria immunisation, while the use of the triple vaccine may increase the risks of paralysis if and when poliomyelitis is occurring in the vicinity. 28 Ideally the whooping cough vaccine is best given on its own starting in the third month but as this would involve many injections in the first year, on balance it appears sound to advise the use of the triple antigen, starting at three months of age if no poliomyelitis is occurring in the immediate neighbourhood. If the risk of contracting poliomyelitis is greater than normal it is probably safer to give whooping cough vaccine alone, reserving the prophylatic treatment against diphtheria and tetanus until the following Spring. DISINFECTION. Residents are advised on the best methods of disinfection to adopt and where it is thought desirable they are assisted professionally. In general the efficient use of soap and water in cleansing the surroundings is adequate if coupled with the boiling of personal linen, after it has been soaked in a disinfectant solution, and the exposure to the sun of materials likely to be otherwise damaged. For the convenience of ratepayers, the Council has decided to arrange disinfection even when this is not essential to the public health, but in these cases the following charges are made:— £1 per load of bedding, etc., 5s. for the first room and 2s. 6d. for each additional room disinfected at the same time. During 1956 the following disinfections were carried out:- Free of cost. Upon payment. Total. Loads of bedding, etc 31 3 34 Houses disinfected 34 — 34 Parcels of clothing — — — Library books 493 — 493 BACTERIOLOGICAL AND CHEMICAL EXAMINATIONS. Many preventive measures depend upon an early and correct diagnosis which can only be made as a result of a bacteriological examination. The co-operation of the Public Health Laboratory at West Hill House. West Hill Road, Epsom, is often of paramount importance and their increasing efficiency and willing assistance is greatly appreciated. During 1956 they examined and reported on the following specimens:— Milk, ice cream, and water samples 434 Food utensils 106 Nose and throat swabs 18 Food 39 Faeces 196 Sputum 5 Ear swabs 1 Vaginal swabs 1 29 (b) OTHER ILLNESSES. It has previously been explained why so much space is devoted in these reports to the infectious diseases, although their influence on the public health has, fortunately, become of decreasing significance. Further reasons are, that at local level no statistics are available as to the prevalence of other forms of ill-health and, until recent times, it has been thought that but few preventive measures were practicable in relation to them. Nationally it is known that the chief causes of absenteeism are the respiratory diseases and especially chronic bronchitis, rheumatism, the so called 'psychosomatic' group of diseases and more obvious mental ill-health. RESPIRATORY DISEASES. The general principles outlined when considering the prevention of infectious diseases apply to the prevention of other respiratory diseases which are of an infectious nature, e.g. colds, influenza, acute bronchitis and pneumonia. The term 'Chronic Bronchitis' is one which calls for a clearer definition: it is generally applied to a collection of symptoms, possibly caused by a variety of circumstances or organisms, which recur time and again in the same patients. Much research is needed and is now being given to ascertain how and why this disease begins, as well as into the best treatment. All that can now be suggested to a layman is that he should try to avoid the acute respiratory infections; when he fails to do so he should see that the infections are completely cleared up before ceasing treatment and resuming work. Unfavourable climate, smoking, certain dusty occupations and poor housing conditions may all be conducive factors needing to be investigated. Meanwhile the sufferer should avoid, as far as practicable, these and other potential irritants and should learn to live within the capacity of his damaged lungs. 'Rheumatism' also covers a number of abnormal conditions, from the acute rheumatism, usually of childhood, to the osteoarthritis with permanently damaged articular surfaces of the joints. The former is now, fortunately, a much rarer sequel to throat infections, and the damaged hearts which frequently occurred should now be avoidable given adequate initial treatment coupled with graduated exercise when necessary. Rheumatoid arthritis, usually a disease of younger women, would be classified by some as a 'psychosomatic' complaint i.e. one in which it is the person's mental condition which, at least originally, causes the physical symptoms. If this is so the cultivation of a healthy mind would appear to be a logical preventive measure. Most people complaining of 'rheumatism' suffer from some form of muscular trouble which may have originated through such diverse causes as dampness or even prolonged mental tension and 30 strain. While direct treatment, e.g. by heat, electricity and drugs can assist, their handicap can be greatly reduced, as also in the case of osteoarthritis, by building up the general health, the reduction of anxiety and worry, and by using the parts affected fully, within reason. The 'Psychosomatic group' of diseases grows annually as the influence of the mind over the physical is more generally recognised. Asthma, duodenal ulceration, rheumatoid athritis and some cardiac diseases are those most widely attributed to a mental origin, but a much larger number are suspect. It is also recognised that the mind can very materially affect the course of other diseases, even possibly cancer, which are not yet thought to be originally caused by mental ill-health. 'Mental Ill-Health'. With these observations in mind and the increasing loss of manpower due to mental ill-health associated with negligible physical symptoms, the tremendous importance of mental hygiene is obvious. While good heredity is a very important and valuable asset, the period of training of the young child is a critical phase, but so also is that of the adolescent, while adults of all ages need knowledge and self discipline to adapt themselves adequately to their constantly changing environment. There is no short cut to mental health anymore than to physical well being, but absolute honesty and respect of truth, selflessness and the acceptance of a sound and practical philosophy of life appear to be some of the pre-requisites. As a nation, we should be well advised to concentrate more on the development of healthy minds than on trying to effect cures when symptoms of advanced derangement are noted. Instead of ever striving to quicken the speed of life and create distractions, surely more time for quiet meditation and clear thinking with subsequent logical action should be encouraged and the value of simplicity in individual lives stressed. We cannot 'put back the clock' but is the only alternative to allow time, the machine, atomic development and the like, to become our permanent masters ? 31 PART 3 - PERSONAL HEALTH SERVICES. Having presented such evidence as is available on the state of the public health locally and the measures taken to control the effects of infectious diseases, a brief account of the services provided to assist the individual resident to maintain health is desirable, if only for the purpose of information. Owing to the unfortunate division of the Health Service into three main branches, no mention is now normally made in the reports of Medical Officers of Health of the General Practitioner and Hospital Services, excepting insofar as they co-operate in the preventive services provided by the Local Authorities. Obviously, however, both contribute very substantially to the health of the public, though predominately by curing defects which have not been prevented. Owing to emphasis during the training of the personnel and the greater immediate satisfaction and appeal of spectacular cures, the question of prevention is, unfortunately, apt to be forgotten or relegated to a very minor role. In both Services there is, however, a very slowly growing appreciation of, and regard for the importance of the environment and the way of life of their patients, as a result of which more health education is being undertaken. Reports on the activities of these other services must be sought elsewhere. Here, attention must initially be confined to the main preventive Health Service — LOCAL AUTHORITY HEALTH SERVICES. Since 1948, the administrative responsibility for the personal Health Service has rested almost entirely on the County Councils and County Borough Councils. Fortunately, in South East Surrey, close liaison exists between the local Urban District Council and the County Council as the former has representatives on the Divisional Health Sub-Committee and the corresponding Divisional Education Executive, which bodies have certain specified powers and responsibilities for some of the allied Health Services. The Medical Officer of Health for this District and his Deputy, who hold similar positions in the Caterham and Warlingham Urban District, are the responsible officers for the Divisional Health Services and deal to a limited extent, among other things, with the maintenance and detailed organisation of the following branches. Maternity Clinics. Since the National Health Service Act has been implemented, prospective mothers wishing to take advantage of its provisions may arrange for their confinements with (1) a doctor providing midwifery service and a maternity nurse or (2) a midwife, the doctor of their choice being on call in emergency, or 32 (3) a hospital, where a bed may be reserved in certain circumstances. Expectant mothers making arrangements (2) or (3) usually attend the Council's Maternity Clinics but private doctors can also refer their cases for special purposes, e.g. blood tests for rhesus factor, etc. Normally every case has an X-ray examination of the chest, and a full examination including regular weighing and examination of the urine, blood, blood pressure, etc. Arrangements have been made in some instances for the District Midwives to assist general practitioners at ante-natal sessions in their surgeries. The results of the arrangement of alternative services under the Health Service Act are now being reviewed with the aim of ensuring that every ante- and post-natal mother gets the full advantage of modern knowledge, and that no gaps exist or inferior standards of practice are permitted, but that the closest co-operation between all branches of the Health Service is secured. During 1956, 279 residents had their babies in their own homes, some 273 at 7 hospitals in the County, including 255 at Redhill County, some 285 at 27 hospitals outside the County including 157 at Purley Hospital and 64 at Mayday, while about 69 were confined in private nursing homes. Only 31% arranging for home confinements is a low proportion but one for which there are a number of reasons. Official Maternity Clinics are now held at 62, Whytecliffe Road, 1st, 3rd and 5th Wednesday in each month, Purley. 10 a.m.—12 noon. and every Thursday, 2 p.m.—4 p.m. Westway, Caterham- Every Tuesday, 2—4 p.m. (For Old Coulsdon on-the-Hill. mothers). The Baptist Church, 2nd and 4th Wednesday Addington Road, in each month, 10 a.m. Selsdon. —12 noon. Mothercraft and Relaxation Classes. Classes covering these subjects were commenced in Purley at the end of 1953 and the numbers attending have increased very rapidly, hence it is hoped to extend the facilities in the near future. It is now necessary for expectant mothers wishing to join these classes to make application to the Divisional Health Visitor at 115 Brighton Road, Purley, who will inform them as soon as a vacancy occurs. Midwifery and Home Nursing Service. Almost all the midwifery attendance at home confinements and the general nursing in the District are provided by the midwives and district nurses appointed by the County Council. The equivalent of about 20 whole-time nurses is employed in this Division but 33 a fair amount of change occurs in the personnel from year to year, while, as they are part of a County Service, their services are not limited by local District boundaries and a system of reliefs operates over a wider area. The amount of 'cover' and the conditions of service of the individual nurses have, as a result, improved since the institution of the National Health Service, but there is apt to be less close association between the residents and their District Nurse than there was previously and less acceptance of direct responsibility for her well being. The demands on the midwives have varied considerably since 1948, and at present are on the increase. Further changes may result from the national review of the Maternity Services as a whole now being undertaken. As would be expected, with an ageing population the amount of District Nursing has steadily increased, while the greater number of persons being treated by injections of anti-biotics and the shortage of hospital accommodation for the elderly are additional factors involving still greater demands. The following figures give an idea of the amount of work done in 1956 in this Division, of which about two-thirds relates to Coulsdon and Purley:- 25,585 visits were paid to medical cases, 5,681 to surgical cases, 1,768 to the tuberculosis and 747 for a variety of other conditions, making a total of 33.781 visits. Home Help Service. This Service began locally on a small scale some 30 years ago initially to help mothers at the time of their confinements, but it grew rapidly during the war when its scope was widened. These Helps can only be provided in genuine cases of ill-health or old age and, as their number is limited by the supply of suitable women willing to undertake this work, the amount of help which can be provided has to be varied according to the physical and social circumstances of the applicants. Applications should be made to the Home Help Supervisor whose responsibility it is to make the day to day arrangements. During 1956, on the average the equivalent of 40 whole time Home Helps were employed in the Division; this at times necessitates the engagement of as many as 63 part or whole time Helps. A total of 903 cases were assisted, (i.e. 236 maternity, 23 tuberculosis, 281 chronic sick, aged or infirm and 363 acute cases) this being easily the highest number dealt with to date. Family Planning. Since 1945 a Family Planning Clinic has been provided for this District and it is now held at Westway, Caterham-on-the-Hill. Only married women whose health would be adversely affected if 34 advice were with-held can be seen and applications for appointments should be made to the Divisional Medical Officer at 115 Brighton Road, Purley. During 1956 only 93 persons were seen from the whole of the Division, the total attendance being 191. Health Visitation. The equivalent of about 8 whole time Health Visitors are employed in this District, and they visit in their homes the vast majority of ante-natal and nursing mothers and their children until these are of school age. They also are the School Health Visitors and attend most of the Clinics held in respect of their areas. They thus become the friends and advisors of the family from the earliest days until the end of school life. Of late their services have been extended to include supervision of the welfare of the aged. All have been trained as state registered Nurses and Midwives, and have additional qualifications for their special work. Their advice mainly relates to health matters but inevitably the field widens to include most social problems and they give valuable assistance by acting as liaison officers between residents and the variety of health and welfare organisations, both voluntary and statutory. Most of them are based on 115 Brighton Road and can be contacted there direct through the Divisional Health Visitor, between 9.0 a.m. and 10 a.m. daily. During 1956 the Health Visitors in this Division paid approximately 26,000 home visits. Infant Welfare Centres. Nine Infant Welfare Centres are held regularly throughout the District and here children under 5 years of age can be weighed and seen regularly by a doctor. The main object is not to treat children who are unwell, this being the responsibility of the private doctors, but to observe and advise on mental and physical progress. The mothers are taught normal child care and given personal advice on their many and varied problems, in a way which would otherwise not be available. The following 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 Wednesday. Whitgift Sports Pavilion, Lime Meadow Avenue, Every other Sanderstead Thursday. Church Hall. Mitchley Avenue, Purley 2nd and 4th day in each month. Community Centre. Hooley 1st and 3rd Wednesday in each month. 35 During 1956 the number of Infant Welfare Sessions held was 403 (406 in 1955), the total attendance was 15,580 (14,647) and the average attendance per session 38.6 (36). The Doctors' consultations numbered 4,620 (4,172) or 12.2 (10.8) per session. Nurseries and Child Minding. The County Council maintains two Day Nurseries situated as follows:- "Hazelglen" Day Nursery, Sanderstead Road, Sander- SANderstead 5329 stead. (Matron: Miss I. M. Bettridge) Old Coulsdon Day Nursery, Bradmore Green. Old Downland 4071. Coulsdon. (Matron: Mrs. L. C. Bryan, S.R.N.) They can only accept the children of residents on grounds of health in the widest sense, including bad home conditions, or when the mother is the sole wage earner. Applications for admission should be made to the Divisional Medical Officer, 115 Brighton Road, Purley. There are also two County Council residential establishments for children in the District under the supervision of the Children's Officer. In addition there are 17 registered Child Minders who accept children for care by private arrangement, usually for about 3 hours daily, and 8 registered foster mothers. The number in both groups varies from year to year. All are supervised by the Health Visitors or Children's Officer. School Health Service. The basis of this Service is the routine compulsory examination of all children attending the County Council's schools, at least four or five times during their school life, coupled with an annual dental inspection and an inspection each term for cleanliness, etc., of all except the most senior children by a Health Visitor. When defects are found these are either kept under observation or, if early treatment is needed, those concerned are referred to their private doctors or dentists. In some cases, subject to the private doctor's consent, they are referred for specialist advice or treatment; for others, special clinics are arranged, e.g. dental, eye clinics and clinics for speech therapy, remedial exercises and child guidance. The main groups of the commonest abnormalities found are visual defects, ears, nose and throat defects and postural or foot defects. Handicapped children receive very special attention, the objects being to see that they get any treatment they require and particularly to ensure that their education is adapted to their needs and is interrupted as little as possible. For certain groups, e.g. the blind, deaf and mentally sub-normal, special schools are provided but as far as practicable these children are brought up in a normal environment and not encouraged to think of themselves as being abnormal. 36 Services for other Adults. The curative services for all including adults have been made more widely available since the implementation of the National Health Service Act but the preventive services, other than those especially for the groups just mentioned, are very limited. The mass X-ray service is, of course, available to all and there is a preventive aspect to some hospital Out Patients Departments and treatment Clinics, e.g. the Chest Clinic and Ophthalmic Departments. Dental inspection is also encouraged, with special facilities for young adults, but of routine medical inspections there is very little apart from the military and similar services. Some hospital staffs are regularly supervised and many employees have an initial examination on appointment, which gives an opportunity for preventive advice. It is not suggested that it would be practicable at this time to introduce routine periodical examinations for all, but it is thought this gap should be mentioned in a survey such as this, for, until an extension of school medical examinations can be introduced, many of the earliest signs of abnormality will remain undiscovered and the tendency will be for ill-health to have advanced too far to be reversed, before it is first noted. As and when such extended supervision is contemplated, it will almost inevitably be found that Specialists in prevention will be needed to staff the service, for almost invariably a person responsible for both treatment and prevention is attracted to the former to the exclusion of the latter. Moreover, routine examinations and health education can be very boring and unattractive, hence some form of compensation will be required to attract suitable recruits for the medical profession and this in turn may prejudice the inauguration of such a service, but its potential importance is so great that the possibility of its introduction should not be forgotten. 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. There are 16 such establishments in the Urban District. Care of the Aged. With the increasing proportion of the population who live on until regarded as aged, considerable attention has been focussed on their health and welfare. Numerous Old People's Associations have been set up and the W.V.S. and Guild of Social Service also assist, their main object being to see that the aged have friends visiting them and have the food and amenities they need. Special social clubs have been organised and even one Home for the elderly has been opened in Purley, mainly through voluntary effort. The County Council has also provided two similar Homes just outside the District and the Urban District Council has organised and subsidised a 'Meals on Wheels' service for those who woul 37 benefit by the delivery of two hot meals a week, the actual distribution being made by members of the W.V.S. Gradually more geriatric specialists are being appointed, initially to deal with the treatment of the aged, sick and the priority of admission to hospital of those who need it. Advances in our knowledge in respect of the whole problem of ageing can be anticipated. National Assistance Act, Sections 47 and 50. The powers given under section 47 for securing the removal of aged persons from insanitary conditions were not utilised during 1956. Periodically border line cases occur in which the Welfare Officers seek advice, but every endeavour is made to find a satisfactory solution without resorting to compulsory powers, especially as the latter are so limited in their application. Under Section 50 the District Council is responsible for the disposal of the remains of any person dying in the District, where suitable arrangements would not otherwise be made, and during the year the Council dealt with no case of this type. Health Education. Constant attention is given to the opportunities for health propaganda at the Clinics and Centres in the area and during the visits made by the Health Visitors and Public Health Inspectors. In addition each year a number of talks are given by the Officers to various organisations who request their assistance. If time permitted doubtless more of these could be given to advantage. The material supplied by the Central Council for Health Education and other bodies is extremely useful. Welfare Services. The members of the Health Services work in close cooperation with the local representatives of the County Council's Welfare, Children's and Education Departments and such voluntary bodies as the Guild of Social Service, N.S.P.C.C. and Marriage Guidance Council. The Divisional Medical Officer has become responsible for co-ordinating the activities of all concerned with "Problem Families" and children neglected in their homes, and, in addition to emergency meetings, all current cases are reviewed at quarterly case conferences. Addresses of Health & Welfare Services. An up-to-date list of the addresses and telephone numbers of those mainly concerned in these official and voluntary services is obtainable on request at the Divisional Health Office, 115 Brighton Road, Purley. 38 PART 4 — ENVIRONMENTAL HEALTH. HOUSING. There are a number of ways in which housing influences the health of the public. First there is the question whether there are sufficient houses to meet the needs of residents. If there are not, and for a variety of reasons this is the present position, the problems of how to provide more rests with the Council through its Housing Committee and with private builders. The Health Committee is also very interested because too few houses means overcrowding somewhere, and this can have a bad effect on health, not only by increasing the risk of spread of airborne diseases, but by provoking mental ill-health owing to clashes in the family and between families, to disturbed rest, increased noise and lack of the privacy which everybody needs if they are to be able to relax or concentrate and think. Since the War the Council has caused 1,416 houses (including 105 prefabricated) to be built, while private builders have erected 2,365. Latterly the Council's annual contribution has decreased steadily and in 1956 they only saw 55 completed compared with 428 erected by private builders. Among the reasons for this slowing down of Council building, is the relatively small amount of land left which is thought suitable for Council house building, difficulties experienced by the builders in getting labour to erect these houses, and delay in agreeing with the Government the type of house which can be built. There is now only one very large site which has been bought by the Council and so far only about 50 of the 350 houses planned to be built on it have been completed. Smaller sites mean fewer new houses with relatively more time needed for their planning and erection, but the Council is pressing on in this way and in addition is making a very useful contribution by converting large old houses so as to provide more separate units for individuals or small families, which is increasingly important as there are now more elderly persons who need less accommodation than they previously did. Parallel with this problem of more housing units, is that of the fitness of the existing accommodation. The Public Health Inspectors are interested to ensure not only that gross defects like dampness are remedied but that the structure is well maintained, and as far as possible, that modern amenities like adequate hot and cold water supply, proper drainage, separate bathrooms and indoor sanitary accommodation are available. When properties are so old or defective, that they cannot be made reasonably fit for human habitation at reasonable expense, steps are taken to see that they are not inhabited and normally that they are pulled down. In a survey made in 1955, however, it was thought that only 27 needed to be dealt with in this way in the next 5 years, although a few more have since been added to the list. In 1956, in fact, 7 of these houses were demolished and the Council purchased by agreement the land on which a further 39 12 stand, preparatory to demolition and rebuilding. Closing orders on 2 unfit houses were cancelled after extensive repairs had been completed by the owners. This clearance of unfit houses is, however, obviously a relatively small problem locally, although nationally it is quite the reverse. What is very much more important is to ensure that the older houses do not get into this bad state. The Inspectors do what they can to encourage owners to take the necessary steps to prevent this, but the Rent Restriction Acts have handicapped them. Whatever the points for or against recent legislation, the necessity for encouraging the preservation of existing property is very obvious. Another measure with the same object is that of making "Improvement Grants" for the provision of modern amenities, but by December, 1955 only six applications of this type (including two in respect of rented properties) had been approved by the Council. Schemes for a further five houses were approved in 1956, and improvements to the value of £2,131 were completed in respect of four houses, 50% Grants being made in each case. Much more use could be made of these provisions. (See Frontispiece, etc.) As a guide to the remedial work carried out by the Public Health Inspectors during 1956, it should be mentioned that they inspected 321 houses for this purpose, making 1,850 inspections. Three were found unfit for habitation and 244 needed remedial action. Of these 216 were made fit without formal notice being required. In 47 cases notices had to be served and the work was subsequently carried out, on 44 occasions by the Council in default of the owners, mainly because the work was associated with the public sewers. Overcrowding as such has not received the concentrated attention it did in 1935/36 and only two houses (involving 3 families totalling 11 persons) were known to be overcrowded at the end of 1956, during which year 3 new cases were reported and 3 were relieved (involving 14 persons). This should not, however, be taken to be a complete picture of the amount of overcrowding now existing, and it should not be forgotten that the legal standard by which 'overcrowding' is judged is extremely low. One fairly frequent cause of severe crowding is the marriage of children in a family without their leaving the family roof, and in a recent example of this three families totalling 13 persons were existing in a 6 roomed house without causing "statutory overcrowding" requiring remedial action. PUBLIC HEALTH INSPECTIONS. It is probably opportune at this stage to introduce the work of the Public Health Inspectors, whose title was changed from 'Sanitary Inspectors' during 1956 in order to describe their duties more accurately and remove doubts arising from the present day interpretation of the word 'sanitary'. 40 Their duties are very varied but in general they inspect premises when they have reason to suspect that unhygienic conditions exist or are liable to occur and as a result, where necessary, help educate the persons concerned or require them to remedy any existing defects, if needs be by legal action. It is an anomaly that in this District they are the only Officers in the Health Service serving solely the local District Council, with the inevitable risk of it being thought that they constitute a sel contained unit. In practice they form a valuable part of a team and the closest co-operation has always occurred locally, although they can and do, on occasion, like other Health Officers, initiate and complete desirable courses of action without other branches of the Service necessarily being aware of their action. As anybody with experience will know, this is inevitable and need not be detrimental; complete liaison may be ideal and should be aimed at, but its achievement in this life is impossible. Mutual respect and trust, coupled with willing co-operation when possible is the best practical substitute. During 1956 the Inspectors received 866 complaints and altogether paid a total of 17,727 visits, details of which are obtainable. The nature of a number of these will be revealed in subsequent sections or have been previously referred to in relation to infectious disease enquiries and disinfection. Here it can be noted that over half the complaints related to rats and insect pests, about one third to the condition of property and some 50 complaints were about foodstuffs. Similarly a general impression of the causes of the visits can be given by the following main headings, i.e. the condition of properties (over 6,000); pests (4,500); shops and workplaces (about 1,250); food preparation and sampling, (about 1,750); infectious diseases (251). Some 2,500 visits can only be described as interviewing for various purposes and the remaining 1,000 or so as touching a miscellaneous variety of subjects. As a result of these visits, some 568 drainage or sanitary fittings were dealt with, 451 other housing defects remedied, and in 277 instances defects were remedied in food premises. Other results will be deduced subsequently, e.g. in the sections on vermin and food. The growth of this section of the Health Services is clearly shown in the following table. Years Complaints Received Visits Paid Preliminary Notices Qualified Staff 1921-25 av. 97 1,919 1½ inspectors* 1926-30 „ 133 2,720 1½ Inspectors* 1932-34 „ 163 3,495 1½ Inspectors* 1935-38 „ 393 7,137 656 2½ Inspectors* 1939-45 „ 404 8,968 549 2½ Inspectors* 1947 „ 956 5,735 364 3 Inspectors* 1948-53 „ 923 14,922 769 4 Inspectorst 1954-56 „ 914 18,083 539 5 Inspectorst * plus ½ - 1 assistant. † plus 2 assistants. 41 LEGAL PROCEEDINGS, ETC. Compliance with public health requirements including the repair of insanitary houses is normally enforced by verbal request or preliminary notice to the person responsible. If necessary this is followed up by the service of a Statutory or Legal Notice with Court proceedings as the final means of appeal. Over the years fewer and fewer cases have necessitated referral to a Court and this is illustrated by the figures for 1956. Of 645 Preliminary Notices served, only 78 were followed by Statutory Notices and only one case was heard in Court when the Magistrates at Wallington made a 'Nuisance Order' under S.94 of the Public Health Act, 1936 requiring the defendant to carry out all the specified works within six weeks. No fine was imposed but it was pointed out that a continuing penalty of £1. per day would be required if the works were not complete in the six weeks. The owner, who had to pay £2 costs to the Council, did, in fact, do all that was required in that time. DRAINAGE AND SEWERAGE. During the year, 524 yards of new sewer were constructed in the District, mainly to deal with new development. The majority of the sewerage drains into Croydon's sewers and is treated at Beddington before the effluent enters the river Wandle. Sewers from this and neighbouring districts converge on Purley Corner where, periodically, nuisance and dislocation is caused by flooding, particularly following heavy rainfall. Two particularly severe incidents occurred after thunderstorms in July, when a number of premises including 17 food shops and a public house were affected and considerable quantities of foodstuffs were rendered unfit for human consumption. Negotiations have been proceeding for years with a view to preventing this trouble and at last a procedure has been laboriously evolved which should result in general agreement between the Authorities concerned and subsequently in the required remedial works. CLOSET ACCOMMODATION. It is the policy of the Council to abolish pail closets and cesspools, substituting water closets connected to the public sewers. During the year 10 houses and a Girl Guides' Hut were connected to the sewer and 15 cesspools abolished. By 1957 only 6 pail closets remained, the contents of which are disposed of in their gardens by the occupiers, and some 106 cesspools. Most of these are situated in outlying parts of the District. PUBLIC CLEANSING. The Council arranges for a weekly collection of all house refuse, but makes a charge for the removal of trade refuse and for 42 cesspool emptying. The latter provides for the first 12 loads a year being removed at 7/6d. a load from any private dwelling (15/- for each subsequent load) and at £1.5.0 a load from any commercial premises. Part of the house refuse is incinerated at the Kenley Disposal Plant and part is tipped and covered with soil. The cesspool contents are emptied into the sewers. SMOKE ABATEMENT. This District is fortunate in not having been troubled by 'smog' while problems associated with smoke abatement have been minor in character. The chimneys of the small local factories have given very little trouble but doubtless they, and particularly our domestic chimneys contribute to some extent to other Districts' worries. All who are interested in the preservation of health and particularly those large numbers of our residents who work in London, will have welcomed the Clean Air Act as a contribution towards ameliorating this national problem. RIVERS AND STREAMS. The clearance of the local watercourses is also a minor matter, but surface water flooding associated with heavy rainfall and the increasing area of impervious road surfaces, has received and is still receiving attention. The policy is to direct the maximum amount of rainwater into the chalk subsoil for our future benefit and normally the existing arrangements are satisfactory. CAMPING SITES. These have to be supervised to avoid contamination of the water supply and other nuisances arising. The permanent Boy Scouts' Camp at Selsdon is conducted satisfactorily and the Caravan Camp Site near Hooley has produced no major public health problems. The Planning permission for the latter which was granted by the Ministry of Housing and Local Government on appeal in 1953, expired in November, but before that date the owners of the Camp applied for permission to continue its use for a further 15 years with an increase in the permitted number of caravans from 140 to 250. The Council refused permission, considering that the development infringed the Green Belt, but the Minister, on appeal, recognising the unsuitability of the site granted a final extension of 3 years for a maximum of 140 caravans, subject to certain conditions. At the time of the appeal 199 caravans were on the site and the Council has since taken steps towards reducing this number. 43 In 1951 the Council took action under S.57 of the Surrey County Council Act, to obtain prohibition orders in respect of certain areas in the District and this has continued to be successful in preventing nuisance arising from gipsy encampments. SWIMMING BATHS. There is one swimming bath at Selsdon, which is on occasion made available to the public, and another at Reedham Orphanage in respect of which official arrangements are made in order that a large number of school children can benefit from its use. Frequent inspections are made to supervise and ascertain the degree of chlorination. During 1956, 16 samples were submitted for chemical and bacteriological examination and two from one of the baths were unsatisfactory in that there had been insufficient chlorination. Following representation to the owners subsequent samples were 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 affected as circumstances have permitted. Surveys are carried out to see that the Shops Act is being complied with in respect of general closing hours, half day closing and Sunday trading, and individual inspections are made as necessary in respect of the conditions of employment of young persons. In addition, advice is given to traders on the operation of the Shops Act as related to specific trades. FACTORIES AND WORKPLACES. An official report, copies of which are available, has been submitted to the Minister in relation to the local implications of the Factories Acts, 1937 and 1948. In brief, 208 factories needing to be dealt with by this Local Authority are registered, 325 inspections were made and as a result 7 written notices were sent. The defects found numbered 27, of which one was a case of overcrowding and 24 had unsuitable or defective sanitary conveniences. The first was referred to H.M. Inspector, while 14 of the sanitary defects together with the 2 miscellaneous defects were remedied. In addition, 66 outworkers were supervised, 33 making wearing apparel and 23 carding buttons, but none were working in unwholesome premises. HAIRDRESSING ESTABLISHMENTS. Draft Byelaws in respect of hairdressing establishments have been agreed with the Ministry of Housing and Local Government and the Council has submitted the Byelaws to the Minister for final confirmation. 44 SCHOOLS. Matters affecting adversely the hygienic conditions of the schools are normally reported by the Divisional Medical Officer to the Divisional Executive or, in the case of the canteens, to the Central Committee concerned. Gradually improvements are being effected. Close co-operation exists between the School Health and Public Health Services in relation to the above and the prevention of the spread of disease. DISINFESTATION. No case of bed bug infestation was recorded during 1956, but the Inspectors or their assistants dealt with 68 cases of pests such as flies and wasps, a proprietary insecticidal spray being used in the majority of cases. The Council continues to undertake the routine disinfestation of local schools and school canteens owned by the County Council, as and when necessary, on a contract basis. PREVENTION OF DAMAGE BY PESTS ACT. 1949. During the year 164 visits were paid to the Council's depots and tip, to Millstock, and land at Littleheath Woods, Selsdon. With regard to rats and mice, 533 properties were inspected, including 393 dwelling houses and 99 business premises. Of these, 237 were infested by rats and 57 by mice, and a total of 198 treatments for rats and 55 for mice were carried out by the Inspectors' Assistants, by arrangement with the occupier but no notices were served under the Act. Eight occupiers subsequently rat-proofed their premises. The Council make a flat rate charge of 5/- in respect of the disinfestation of private dwellings and 10/- per hour plus cost of materials in all other cases. The Minister of Agriculture and Fisheries, as in 1954 agreed that biannual routine test baiting of the sewers together with maintenance treatment as required was sufficient to keep this aspect of the problem under control. Sewer treatment thus only necessitated 114 visits but the total number of rats and mice destruction visits was 4,249. THE PROTECTION OF FOOD. WATER. The water supply of the District is provided by the Sutton District Water Company and the East Surrey Water Company, with a private supply supplementing, as necessary, at Cane Hill Hospital. 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. 45 As contaminated water can cause disease, all the water is now chlorinated to destroy any harmful organisms and the public supply softened to about a half its original hardness, mainly for economic reasons. Routine samples of the treated water in public supply were submitted quarterly for bacteriological and chemical examination. In addition, six further samples were obtained for various reasons, making 22 samples in all. In addition, both the Water Companies and the Local Authorities sharing these public supplies provided the Department with copies of the reports on the samples taken by them. No complaints were received during the year with regard to the quality or quantity of water supplied by the Companies. Only one unsatisfactory report was received and that on a bacteriological sample the defect in which was attributed to the use by the consumer of an obsolete water softener, which was subsequently abolished on the advice of the Department. Forty-eight samples were taken from the supplies of the two Companies and examined for hardness by the Department, all of which were satisfactory in that adequate softening had been carried out as required by Statute. Typical chemical and bacteriological reports on the Companies' water as in public supply are available on request. Coming from deep wells in the chalk the fluoride content is low. The Cane Hill Hospital Management Committee has made arrangements with the Public Health Department of the London County Council for routine sampling and supervision of the water supply from the relatively shallow well in their grounds, which is used exclusively by this Hospital. Adequate chlorination is essential and steps have been taken to ensure this and to effect closer co-operation between the officers of the three authorities interested in the standard of this supply. It appears opportune to record here that the rainfall registered by the automatic rain gauge installed at Alderstead Heath, was 2917 inches in 1956, this being an increase of 0-41 inches compared with the previous year. The monthly totals throughout the year were as follows ] inches January 4.57 February 0.49 March 0.86 April 2.12 May 0.39 June 3.10 July 4.72 August 3.39 September 2.95 October 1.57 November 0 96 December 4.05 RAINFALL. 46 THE FOOD AND DRUGS ACT, 1955. THE FOOD HYGIENE REGULATIONS, 1955. While this District has always adopted a progressive attitude to food hygiene, as witness the powers it obtained in its private Act of 1937, and my previous Reports, the passage of the above mentioned legislation, which came into force on 1st January, 1956, has given a new impetus to food hygiene generally. The Food and Drugs Act, 1955 is a consolidating and amending Act and repeals a number of Acts formerly administered by the Council, the most important being the Food and Drugs Act, 1938 and the Food and Drugs (Milk, Dairies and Artificial Cream) Act, 1950. The law relating to food and drugs administration has been amended considerably as a result. The Act's provision of extended powers to enable the Ministers concerned to make Regulations or Orders as to the composition, labelling and description of food, food hygiene and the registration of any food business of a specified class is very useful as permitting relatively quick adaptation in the light of new knowledge and changing circumstances. The Food Hygiene Regulations, 1955, are a first contribution in the exercise of these powers and set a new standard in the control of food preparation and sale. The scope of the Regulations is extended to include canteens, clubs, schools, hospitals, etc., whether carried on for profit or not, and thus brings in all places where food is handled. The Chief Public Health Inspector reports that "as a first step in the enforcement of the new law, it was decided to carry out a completely new survey of all premises to which the Regulations apply. A start was made with catering premises, including clubs, canteens and private schools". "As a preliminary, the Council agreed to purchase for distribute the persons concerned, 500 copies of an explanatory memorandum summarising the principal requirements of the Food Hygiene Regulations, and posters drawing attention to the principal requirements, to be put up in food premises." "The work of inspection and recording is still proceeding, conditioned by other demands on the staff, but it can be said with a sense of satisfaction that, generally, the approach has met with a ready response and willingness to comply with the requirements. A reasonable interpretation of the Regulations is being enforced, having regard to the circumstances of each case." "Apart from general requirements, particular attention is being paid to the provision of adequate facilities for washing food and equipment as distinct from hand washing facilities, with adequate supplies of hot and cold water in each case." "The provision of suitable and sufficient cupboard or locker accommodation for staff clothing and footwear not worn during 47 working hours, and the prohibition of smoking are new requirements to which particular attention is given." "This work has affected the normal routine inspection of food shops, but this has continued on modified lines in the course of food sampling and inspection." A new register of all premises coming within the scope of the Food Hygiene Regulations is being made and at the present time includes the following:- Confectioners 61 Butchers 31 Fishmongers (wet and dry) 13 Fishmongers (fried) 6 Bakers 27 Greengrocers and Fruiterers 50 Cafes and Restaurants 56 Grocers 76 Hospitals, Nursing Homes, Guest Houses, Hotels 9 Canteens. Clubs, Halls, etc 38 Private Schools 26 Five grocers' shops and one baker's premises are registered for the preparation of preserved meat, etc., and all the fish friers' premises are similarly registered in respect of fish frying. On the 1st July, 1956 the Coulsdon & Purley Urban District (Food) Order 1956, came into force, thus finalising steps taken by the Council to effect a substitution of the powers in S.64. Coulsdon and Purley U.D.C. Act, 1937 (Registration of premises used in connection with the sale of ice cream or preserved food) by similar powers in S.16 of the Food and Drugs Act, 1955. MILK. As milk is not only an excellent food for humans, and especially children, but also for germs to thrive and multiply in, its production and handling has received a great deal of attention and separate legislation. It was formerly probably the chief contributor to non-pulmonary tuberculosis in children, and the reduction in prevalence of that disease bears evidence of the beneficial effect of supervision of the milk supply. Milk and Dairies Regulations, 1949-1954. As a result of these Regulations, the supervision of the production of milk passed out of the hands of Local Authorities in 1949, but the handling, distribution and sale of milk after leaving the point of production is carefully supervised by the local Inspectors. A register has to be kept, and entered therein in 1956 were 19 distributors of milk in the District but only one registered dairy 48 at which milk is processed. This is equipped with pasturising plant which is licensed by the Council under the provisions of the Milk (Special Designation) (Pasteurised and Sterilised Milk) Regulations, 1949-1953. Most of the milk now consumed in the District is produced and processed outside the District and retailed by the large dairy companies. Under the Milk (Special Designations) (Specified Areas) Order, 1951, only milk bearing a special designation is permitted to be sold in the District. Milk Sampling. A total of 247 samples was submitted to the methylene blue (keeping) test and the phosphatase (pasteurisation) test, 198 being 'Pasteurised' milk, 23 'Tuberculin tested' (raw) and 26 'T.T. (Pasteurised)'. Three of the 'Pasteurised' and 4 of the raw 'T.T.' did not pass the keeping test. Of 27 samples of 'Sterilised' milk, only 1 failed the turbidity test. In addition 25 samples of T.T. and 12 of ungraded milk were injected into guinea pigs for the biological test for tuberculosis and all were negative, which is very satisfactory. As similar results have been recorded throughout the County, decreased biological sampling of T.T. milk is now thought justifiable. Milk (Special Designation) Regulations, 1949 - 1954. Licences to sell milk under the above Regulations were issued as follows:- Dealers: Tuberculin Tested 14 Pasteurised 15 Sterilised 16 Pasteuriser's 1 Supplementary: Tuberculin Tested 10 Pasteurised 10 Sterilised 8 ICE CREAM. As this product has also caused cases of gastro intestinal diseases in the past, its production and sale is kept under close review. In 1956, 96 premises in the District were registered for its sale, and a further 3 for its manufacture and sale. In a further 24 premises it is sold but these premises are exempt from registration. One registration for sale was cancelled owing to a change in character in the general business carried on at the premises concerned. One of the results of close supervision has been centralised production, and with one exception, all the ice cream retailed in 49 the District was obtained by the vendors, prepacked, from large scale manufacturers whose premises are situated outside the District. A total of 132 samples of ice cream was examined for bacterial quality by submission to the methylene blue reduction test, and placed in the following provisional grades Grade I 126 Grade II 5 Grade III 1 Grade IV — Grade I and II samples can be considered satisfactory; only about a fifth of the samples taken from any dealer should be of Grade III quality, and none of Grade IV. As judged by these standards the general position can be considered very satisfactory. MEAT. There are no slaughtering facilities in the District, apart from those at Cane Hill Hospital, which did not function during 1956, and at Netherne Hospital where the carcases and offals of the 6 cattle and 4 calves killed were inspected for disease with negative results. Animals slaughtered at these hospitals are solely for the consumption of the inmates. One slaughterman's licence was issued under the Slaughter of Animals Act, 1933, for the purpose of slaughtering at a Public Institution in the District. There are 31 butchers' shops in the District, all registered for the preparation or manufacture of sausages or potted, pressed, pickled or preserved meat under the provisions of Section 16 of the Food and Drugs Act, 1955. Retailers now obtain supplies of fresh and imported meat from the Croydon Abattoir and Meat Market and the Smithfield Market, and in addition small quantities of fresh meat direct from Scotland. Frequent inspections of meat shops are carried out, and during the year 91 visits were made for this purpose. UNSOUND FOOD. The following unsound foods were surrendered during 1956, mostly a result of the Purley flooding. The total bulk has only been twice exceeded in the. last 10 years. With minor exceptions, all unsound food is disposed of at the Council's destructor. cwts. lbs. ozs. Canned Soups — 14 11 Canned Meat 1 27 0 Canned Fish — 5 14½ Canned Vegetables — 106 3½ 50 Canned Fruits — 77 1½ Canned Milk and Cream — 10 12 Meat, Bacon, Poultry etc. 6 51 4 Fish 2 41 4 Fresh Vegetables 14 101 10 Fresh Fruit 4 107 3 Butter, Fats and Cheese 3 87 2 Sugar, Jam, etc. 5 62 7 Meat and Fish Pastes — 3 7¼ Coffee — 27 — Flour, Bread, Cereals and Biscuits 5 98 10½ Pickles and Sauces 4 42 10½ Dried Fruit 3 68 10 Eggs — 75 2 Miscellaneous — 99 11¾ Total 56 99 2½ Wines and Spirits, Beer and Soft Drinks 76 gallons FOOD AND DRUGS ACT, 1955. A list of the very varied articles of which samples were submitted to the Public Analyst is available. Altogether 168 samples (including 6 informal ones) were examined of 78 products. Samples of milk (59) were much the most numerous, the next highest being sweets (7) spirits (6) and soup (4). Only 5 samples were reported as not being genuine, i.e. of the nature, substance and quality of the article demanded. The following are the substances concerned and the result of the action taken Cough Mixture The Analyst criticised the labelling and the manufacturers accepted his suggested alteration. Pork Sausages: The Public Analyst reported that this sample contained a meat content including fat of 57%, and observed that in his experience pork sausages of ordinary commercial quality contained not less than 65% of meat including fat. Having regard to the price being charged for this commodity, and in view of recent High Court decisions on similar cases, it was decided to take no action in the matter. Fresh Cream: The Analyst criticised the labelling and accompanying leaflet and the Company agreed to make the necessary modifications. Icing Sugar: A minor labelling offence was amended. Assorted Swiss Cheeses: The Public Analyst reported that a portion of this processed cheese described on the label as "Cream Gruyere Cheese" was deficient in milk fat. In view of the representations made, the manufacturers decided to omit, in future, the cream cheese portion from the assorted box. 51 TABLE I. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1956. Disease. At all ages. Number of cases notified. At Ages—Years. Total cases notified in each Ward. 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 tinder 65. 65 and over. Coulsdon East. Coulsdon West. Purley. Kenley. Sanderstead. Selsdon and Farleigh. Woodcote. Scarlet fever 41 - 1 1 2 2 27 7 - 1 - - - 6 1 14 1 8 10 - Pneumonia 36 3 - 9 1 — 3 — 4 — 2 11 12 3 6 16 6 2 1 2 Measles 82 3 3 7 22 10 29 6 - - - - - 20 22 19 2 12 5 2 Whooping cough 93 3 3 - 9 8 64 2 2 — - — — 9 4 7 1 14 54 4 Erysipelas 8 — — — — — 1 — — — 1 3 3 2 — 1 5 — — — Dysentery 81 — — — 1 l 14 29 6 1 6 21 6 26 4 - 2 — 43 (Flex.=3) (Sonne=78) Poliomyelitis 7 - - - - l 1 3 - 1 - 1 - 3 1 - - 3 - - (n.p.=4) (p=3) Paratyphoid 2 - - 1 - - - - - 1 - - - - - - - - - 2 Typhoid 1 - - - - - - - - - - 1 - - 1 - - - - - Puerperal Pyrexia 2 — — — — — — — — 2 - — - - 1 1 — — — — Malaria 2 — — — — — — — —. 1 - 1 — — .— 2 — — — — Encephalitis 1 - - - - - 1 - - - - - - - 1 - - - - - Food Poisoning 8 — — — — — 1 2 4 — 1 — — — — — 8 — — — Totals 364 9 7 13 35 22 141 49 16 6 5 23 36 49 63 64 23 41 70 53 52 TABLE II. THE MONTHLY INCIDENCE OF INFECTIOUS DISEASE, 1956 Disease. Jan. Feb. Mar. A pril May June July Aug. Sept. Oct. Nov. Dec. Total Scarlet fever - 3 3 2 7 5 7 2 3 1 5 3 41 Pneumonia 5 12 7 5 2 — — 2 2 — 1 — 36 Measles 1 2 5 1 2 6 13 12 3 1 13 23 82 Whooping cough 2 1 1 13 16 31 5 7 10 4 2 1 93 Erysipelas 2 — — 2 — 1 — — 2 1 - - 8 Dysentery 10 12 — 4 27 24 2 — — — 2 — 81 Poliomyelitis - - - - - 1 1 1 — 1 3 - 7 Paratyphoid — — 2 - - - - - - - - - 2 Typhoid fever — — — — — — 1 — — — — 1 Puerperal pyrexia — — — — — — — 1 — — 1 2 Malaria 1 — — 1 - - - - - - - - 2 Encephalitis — — — — — 1 — — — — — — 1 Food poisoning - - - - - - 8 - - - - - 8 Totals 21 30 18 28 54 69 37 25 20 8 27 27 364 53 TABLE III. INFECTIOUS DISEASE NOTIFIED EACH YEAR SINCE 1926. Disease 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 Small pox - - - 2 2 3 4 - - - - - - - - - - - - - - - - - - - - - - - - Scarlet fever 48 74 94 125 69 45 29 69 119 124 117 62 71 65 61 39 45 184 88 67 93 78 62 138 149 90 80 118 68 46 41 Diphtheria 17 11 23 26 17 8 21 16 24 52 35 8 10 10 25 7 9 7 19 15 8 - - - - - - - - - - Erysipelas 4 13 8 3 11 8 11 23 17 11 12 14 13 10 17 27 22 5 9 4 8 5 8 4 4 3 - 3 4 4 8 Typhoid and paratyphoid fever 9 9 9 6 4 4 7 5 5 1 3 26 5 1 53 12 3 1 6 4 4 2 2 2 1 11 1 - 1 3 3 Meningococcal infections - - - 1 - - - - - 1 1 - - 4 8 6 1 4 2 1 3 1 1 - - - 1 - - - - Puerperal fever 1 — — 1 — 1 1 — 1 1 1 5 - - - - - - - - - - - - - - - - - - - Puerperal pyrexia — 1 1 1 1 3 5 1 2 1 - 2 5 3 2 - 2 3 1 2 2 1 2 2 2 3 2 3 - 3 2 Poliomyelitis - 1 1 - 1 - 2 - 1 1 - 3 1 1 1 2 3 - - 2 1 11 2 9 10 - 8 9 1 17 7 Polio-encephalitis - - - - - - - - - - - 2 - - - - - - - - 1 - - - - - - - - - - Acute encaphalitis — 1 1 - - - 1 - - - - - - - - - - 1 - - - - - - - - 1 - 1 - 1 Ophthalmia neonatorum 12 - 3 - 1 1 2 - 1 - 1 1 1 - 1 1 - 1 - 1 - - - - 1 - - - - - - Pneumonia — 9 7 38 11 14 29 28 20 13 13 30 12 52 19 32 38 27 9 17 16 20 13 5 23 51 21 44 20 31 36 Malaria — — — - - - - - - - - - - - - - - - - - - - - - 1 - - - - - 2 Measles 2 11 214 479 275 52 705 41 218 567 600 477 810 170 1319 9 1012 82 Dysentery 1 — — 5 - - - - - 6 - 1 2 10 85 224 121 21 42 172 82 43 71 14 28 22 48 Whooping cough 6 1 136 36 55 51 100 31 115 201 42 242 204 196 66 131 64 93 Food poisoning 2 6 2 5 2 71 5 8 Tuberculosis:— Pulmonary 19 25 23 22 38 44 36 44 28 30 27 36 32 31 31 32 43 39 51 44 38 59 48 57 47 60 42 37 31 47 41 Other forms 2 9 4 2 7 4 6 10 17 5 3 7 10 12 8 11 7 9 7 3 7 11 13 5 7 4 4 3 7 3 3 Totals 113 153 174 232 162 135 154 196 235 265 213 197 162 207 323 743 809 632 337 1137 335 564 990 880 998 I2<0 579 1617 359 1333 408 54 TABLE IV. DEATHS OCCURRING DURING THE YEAR, 1956. Cause of death. Private Residents Hospital Cases Total. 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. Males Females Males Females Males Females Respiratory tuberculosis 6 1 2 1 8 2 - - - - - - 5 4 Other tuberculosis — — 1 1 1 1 - - - - - 1 1 — Syphilitic disease — — 1 2 1 2 - - - - - - - 3 Diphtheria — — — — —- — - - - - - - — — Whooping cough - - - - - - - - - - - - - - Meningococcal infections - - - - - - - - - - - - - - Poliomyelitis — 1 — — — 1 - - - - - 1 — — Measles - - - - - - - - - - - - - - Other infective and parasitic diseases - 1 - 2 - 3 - - - - - - 1 2 Cancer 62 56 11 23 73 79 - - - - 1 - 59 92 Leukaemia — 5 — 1 — 6 - - 1 - - 1 2 2 Diabetes — 4 — — — 4 - - - - - - - 4 Vascular lesions of nervous system 28 49 13 25 41 74 - 1 - 1 - 2 21 90 Coronary disease, angina 57 34 21 27 78 61 - - - - - 2 37 100 Hypertension with heart disease 9 11 2 10 11 21 - - - - 1 - 1 30 Other heart disease 31 52 14 29 45 81 - - - - - 3 7 116 Other circulatory disease 12 22 8 18 20 40 - - - - 1 - 14 45 Influenza 1 3 — — 1 3 - - - - - — — 4 Pneumonia 9 16 22 47 31 63 1 1 - - - 4 12 76 Bronchitis 13 6 4 3 17 9 - - - - - 1 4 21 Other respiratory diseases 2 — 3 9 5 9 - - - - - — 2 12 Ulcer of stomach and duodenum 3 1 - 2 3 3 - - - - - - 2 4 Gastritis, eneritis 2 — 1 2 3 2 - - - - - — 2 3 Nephritis 1 3 — 1 1 4 - - - 1 1 — 1 2 Hyperplasia of prostate 5 — 2 — 7 — - - - - - - — 7 Pregnancy — - - - - - - - - - - - - - Congenital malformation — — — 2 — 2 - 2 - - - — — — Other defined and illdefined diseases 15 16 15 26 30 42 5 1 1 2 - - 14 49 Motor vehicle accidents 4 2 — — 4 2 — — - — 1 1 4 — All other accidents 5 5 3 11 8 16 3 — - — - 3 16 Suicide 2 8 2 1 4 9 - - - - - 4 9 — Homicide - - - —— — - - - - - - — - - Totals 267 296 125 243 392 539 9 6 2 4 5 22 201 682 55 TABLE V. TUBERCULOSIS - WARD DISTRIBUTION OF NEW CASES NOTIFIED 1956. Localisation. Coulsdon East. Coulsdon West. Kenley. Purley. Sanderstead. Selsdon. Woodcote. Pulmonary 8 9 3 8 8 4 1 Nonpulmonary — 3 - - - - - Totals 8 12 3 8 8 4 1 TABLE VI. TUBERCULOSIS - AGE GROUPS OF NOTIFICATIONS AND DEATHS, 1956. Age Periods. New Cases. Deaths. Pulmonary Nonpulmonary. Pulmonary. Nonpulmonary. M. F. M. F. M. F. M. F. Under 1 year - - - - - - - - 1 and under 5 - - - - - - - - 5 and under 10 1 - - - - - - - 10 and under 15 — 2 - - - - - - 15 and under 20 — 1 - - - - - - 20 and under 25 3 1 - - - - - — 25 and under 35 4 5 — 1 — — - — 35 and under 45 6 5 1 — 1 — - 1 45 and under 55 6 2 — 1 3 1 1 — 55 and under 65 5 — — — 2 1 - — 65 and over - - - - 2 2 - 2 Totals 25 16 1 2 8 4 1 3 56 FACTORIES AND WORKPLACES. FACTORIES ACTS, 1937 and 19k8. PART 1. 1. INSPECTIONS. Premises Number on Register Number of Inspections Written Notices Occupiers Prosecuted. (i) Factories in which Sections 1,2,3,4 and 6 are to be enforced by Local Authorities 39 36 1 - (ii) Factories not included in (l) in which Section 7 is enforced by the Local Authority 155 267 6 - (iii) Other premises in Which Section 7 is enforced by the Local Authority (excluding out-workers' premises) 14 22 — - TOTAL 208 325 7 - 2. Oases in which defects were found. Particulars, Number of Cases in which defects were found. No. of Cases in which prosecutions were instituted Found Remedied Referred To H,M, Inspector, By H.M. Inspector, Want of cleanliness (S.1.) - - - - - Overcrowding (S.2). 1 - 1 - - Unreasonable temperature (S.3). - - - - - Inadequate ventilation (S.4). - - - - - Ineffective drainage of floors (S.6) - - - - - Sanitary conveniences (S.7.) (a) Insufficient — - - - - (b) Unsuitable or defective 24 14 - - - (c) Not separate for sexes - - - - - Other offences against the Act (Not including offences relating to outwork) 2 2 - - - TOTAL 27 16 1 - - PACT VIII Outwork (Sections 110 and 111). NATURE OF WORK. Section 110 i Section 111 ! No. of Outworkers in August list required by Sect. 110(1)(c). No. of cases of default in sending lists to the Council. No. of Prosecutions for failure to supply lists. No. of instances of work in unwholesome premises. Notices Served, Prosecutions. Wearing apparel Making etc. 33 - - - - - Gleaning & washing - - \- - - - Umbrellas, etc. 1 - - - - - Making boxes 1 - - - - - Carding, etc, of buttons, etc. 23 - - - - - Duster Dolls 5 - - - - - Cosaques,Christmas crackers, Christmas stockings, etc. 3 - - - - - TOTAL 66 - - - - - HOUSING. The following is a statistical record of work carried out in respect of the sanitary condition of dwelling houses, as required by the Minister* 1. Inspection of Dwelling Houses during the year 1956- (1) (a) Total number of houses inspected for housing defects (under Public Health or Housing Acts) 321 (b) Number of inspections made for the purpose 1,850 (2) (a) Number of dwelling houses (included under sub-head (l) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 and 1932 22 (b) Number of inspections made for the purpose 324 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 3 (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 244 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 216 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 1 (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 3 (b) Proceedings under the Public Health Acts- (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 46 (2) Number of dwelling houses in which defects were remedied after service of formal notices- (a) By owners 3 (b) By Local Authority in default of owners 41 (c) Proceedings under Sections 11 and 13 of the Housing Act, 1936- (1) Number of dwelling houses in respect of v/hich Demolition Orders were made 4 (2) Number of dwelling houses demolished in pursuance of Demolition Orders 7 (d) Proceedings under Section 12 of the Housing Act, 1936- (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made Nil. (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit Nil. (e) Local Government (Miscellaneuous Provisions) Act, 1953- (1) Closing Orders made under Section 10 (l) Nil. Housing Act, 1936. Part IV-Overcrowding (a) (l) Number of dwelling houses overcrowded at the end of year 2 (2) Number of families dwelling therein 3 (3) Number of persons dwelling therein 11 (b) Number of new cases of overcrowding reported during the year 3 (c) (l) Number of cases of overcrowding relieved during the year (2) Number of persons concerned in such cases 14 (d) Particulars of any causes 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 55 By other persons 428 SUMMARY OP VISITS MADE. Number of houses visited 349 Number of reinspections and calls made 1,924 Verminous premises11 Insect pests 197 Water supply 15 Tents, vans and sheds 30 Schools 6 Places of entertainment 2 Licensed premises 32 Storage of refuse 43 Accumulation 130 Piggeries, fowls and other animals 90 Stables 51 Rodent control 4,249 Drainage inspected 2,831 Drainage tested 259 Pail closets 6 Cesspools 260 Urinals 6 Sewers and stree gullies 262 Cowsheds, dairies and milkshops 60 Ice-cream premises 24 Meat shops 91 Pood preparing premises 602 Other food shops 331 Bakehouses -Power 26 Other 1 Slaughterhouses 10 Pood Inspection-Meat 31 „ „ -Other Food 111 Factories-Power 241 -Other 19 Workplaces 38 Outworkers 56 Heating Appliances (Fireguards) Act 37 Rag flock and Other Pilling Materials Act 1 Pet Animals Act 8 Shops Act 882 Mines & Quarries Act 2 Hairdressing Establishments 7 Infectious disease enquiries 150 Infectious disease contacts 9 Pood poisoning enquiries 17 Disinfection 75 Disinfestation 27 Swimming Baths 70 Sampling-Pood and Drugs Act, 1955 216 " Ice Cream 137 " Milk (Bacteriological) 234 " Milk (Biological) 38 " Water Interviews 2,495 Miscellaneuous Visits 927 TOTAL 17,727 WORK CARRIED OUT AND DEFECTS REMEDIED, Drainage and Sanitary Fittings: Drains repaired or reconstructed 92 Flood valves inserted in drainage systems 2 Blocked drains cleared 196 Soil and vent pipes repaired or renewed 11 Inspection chambers provided or repaired 66 Fresh air inlets repaired or renewed and/or stoppers provided 32 New W. C. pans fixed and/or new seats provided 24 W.C. flushing cisterns repaired or renewed 10 Cesspools abolished and filled in 5 Cesspools cleansed, repaired or renewed 8 Cesspools abolished and drains connected to sewer 10 Soakaways reconstructed or provided 12 Eaves gutters & stack pipes renewed or repaired 50 New lavatory basins fixed 4 Baths provided or repaired 2 Glazed sinks renewed or repaired 3 Waste pipes trapped, repaired or renewed 12 Sink gully dishings repaired 22 Pail closets abolished and houses connected to sewer 3 Pail closets abolished (houses demolished) 3 Urinals cleansed 1 General Housing Repairs: Defective roofs repaired 31 Chimney stacks repaired or rebuilt 21 External walls repaired 23 Yards paved, or paving repaired 8 Steps repaired or renewed 2 Dampness in walls remedied 18 Dampproof courses repaired or provided 10 Additional sub-floor ventilation provided 2 Walls and ceilings repaired 49 New ceilings provided 18 Walls of rooms cleansed and/or redecorated 50 Ceilings of rooms cleansed and/or redecorated 41 Floors repaired or renewed 27 Ventilation and lighting of rooms improved 1 Staircases repaired or renewed 1 Windows repaired or renewed 57 Doors repaired or renewed 15 Firegrates repaired or renewed 13 Domestic boilers repaired or renewed 6 Service water pipes repaired or renewed 15 External paintwork renewed 4 Boundary fences and gates repaired or renewed 1 Additional ventilation and light provided to W.C's 2 Walls and ceilings of W.C's cleansed and/or redecorated 8 Portable dustbins provided 14 Electricity supply repaired or renewed 1 Coal sheds repaired or renewed 2 Derelict buildings demolished 1 Miscellaneous 10 Pood Premises: Hot water supply provided for ablution purposes 11 Notices re washing of hands provided 5 Lavatory basins provided 8 New sinks provided 14 Hot water supply provided to sinks 1 Draining boards provided 7 Waste pipes repaired 1 First-aid equipment provided 4 Staff sanitary accommodation repaired 11 Staff sanitary accommodation cleansed 12 Staff sanitary accommodation provided 1 Lockers for clothing required 7 Walls and ceilings cleansed and repaired 97 Doors repaired 3 Floors repaired, relaid, recovered or cleansed 6 New equipment installed 3 Equipment cleansed and repaired 11 Staircases repaired 3 Additional ventilation provided to food premises 4 Windows repaired or cleansed 9 Food stores provided or enlarged 2 Food vehicles cleansed 1 Yards paved 5 External walls repaired 2 Blocked drains cleared and drains repaired 2 Dustbins provided 13 Accumulations removed 22 Miscellaneous 12 Ratproofing: Work carried out by occupiers, of premises after completion of treatment 8 Heating Appliances (Fireguards) Act, 1952, Fires altered or withdrawn from sale 44 NOTICES SERVED. Preliminary Notice 645 Statutory Notices 78 FOOD AND DRUGS ACT, 1955. The following samples were token during 1956 and submitted to the Public Analyst, with the results shown- Article Analysed TOTAL Non-Genuine TOTAL Formal Informal Forinal Informal Amplex 1 - 1 - - - Almonds, ground 1 - 1 - - - Apples, liquid 1 - 1 - - - Butter Beans 1 - 1 - - - Butter 1 - 1 - - - Bread 2 - 2 - - - Beer 3 - 3 - - - Biscuits - 1 1 - - - Buns 1 - 1 - - - Bi-carb. Soda 1 - 1 - - - Cough Mixture 1 - 1 1 - 1 Cockles 1 - 1 - - - Camphorated Oil 1 - 1 - - - Cream 1 1 2 1 - 1 Crumbs, cooking 1 - 1 - - - Cake Mix 1 - 1 - - - Cheese 1 1 2 - 1 1 Coffee 1 - 1 - - - Compound, Whipping 1 - 1 - - - Custard Powder 1 - 1 - - 1 Chicken Puffs 1 - 1 - - - Chicken Sjcread 1 - 1 - - - Cake 1 - 1 - - - Dripping 1 - 1 - - - Fruit, Tinned 3 - 3 - - - Fruit, Dried 1 - 1 - - - Flavouring 1 - 1 - - - Gelatine 1 - 1 - - - Gravy Powder 1 - 1 - - - Honeycomb Mould 1 - 1 - - - Ice Cream 1 - 1 - - - Iodine 1 - 1 - - - Jam 1 - 1 - - - Liver Pate 1 - 1 - - - Lard 3 - 3 - - - Lemon Juice 1 - 1 - - - Lemonade Powder 1 - 1 - - - Mustard 1 - 1 - - - Mint in Vinegar 1 - 1 - - - Mincemeat 2 - 2 - - - Marzipan 1 - 1 - - - Milk 59 - 59 - - - Mineral Water 1 - 1 - - - Margarine 2 - 2 - - - Orange Juice 2 1 3 - - - Ostermilic 1 - 1 - - - Pepper, Ground White 2 - 2 - - - Pickle 1 - 1 - - - Peas 2 - 2 - - - Pie, Steak & Kidney _ 1 1 - - - Pudding 1 - 1 - - - Pudding, Black 1 - 1 - - - Rennet, Essence of 1 - 1 - - - Rice, Flaked 1 - 1 - - - Sausages, Pork 3 - 3 1 - - Sugar 3 - 3 1 - 1 Salt 1 .- 1 - - 1 C/F 129 5 134 4 1 5 2 - Article Analysed ' TOTAL Non-G-enui tie TOTAL Formal Informal ! Formal Informal b/f 129 5 134 4 1 5 Shrimps 1 - 1 - - - Sauce 1 - 1 - - - Soup 3 1 4 - - - Spirits 6 - 6 - - - Stuffing 1 - 1 - - - Seidlita Powder 1 - 1 - - - Sardines in Oil 1 - 1 - - - Sweets 7 - 7 - - - Sherry 1 - 1 - - - Stout 1 - 1 - - - Suet, Beef 1 - 1 - - - Salad Cream 1 - 1 - - - Saccharin 1 - 1 - - - Tapioca 1 - 1 - - - Tea 2 - 2 - - - Tomato Juice 1 - 1 - - - Vitamin Capsules 1 - 1 - - - Vinegar 2 - 2 - - - TOTAL 162 6 163 4 1 5 SANITARY INSPECTIONS, ETC. The following is a summary of the complaints received and visits made, together with details of work carried out and defects remedied as a consequence of notices served during the year 1956:- COMPLAINTS RECEIVED, General disrepair and insanitary conditions 31 Dampness 5 Overcrowding 3 Defective drainage systems 33 Blocked drainage systems 188 Defective drainage fittings 7 Defective W.C. Pans and flushing apparatus 11 Defective service water pipes 10 Defective hot water systems 3 Defective chimney stacks 1 Absence of, or defective dustbins 1 Accumulation of refuse, etc. 14 Hats and mice 350 Keeping of animals 2 Insect pests, etc. 19 Wasps Nests 82 Smoke nuisance 2 Contaminated food 17 Unsound food 36 Miscellaneous 51 TOTAL 866 INFANT MORTALITY DURING THE T3AB 1956. Cause of death. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. ! ! Total under 4 week. 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. ASPHYXIA NEONATORUM 1 - - - 1 - - - - 1 PNEUMONIA - - - - - 1 - - - 1 PREMATURITY AND ATELECTASTS 4 1 - - 5 - - - - 5 ACCIDENT - - - - - - - 2 _ 2 TOTALS 5 1 - - 6 - - 2 - 9 PREVENTION OP DAMAGE BY PESTS ACT. 1949. The following table is a tabular statement indicating the action taken in 1956 Type of Property. Number of properties inspected by the Local Authority as a result of Number of properties found to be infested by Number of treatments carried out by Department by arrangement with Occupier. Number of Notices served under Section 4. Number of Inspections made. Notification.. wise Total Eats Mice Rats Mice Treatment Structural works, i.e. proofing. Primary and reinspections. Sewer treatment. TOTAL. local Authority 4 19 23 11 2 11 2 - - Dwelling Houses 302 91 393 208 32 173 30 - - Business Premises 48 51 99 17 23 13 23 - - 4,135 114 4,249 Agricultural 2 16 18 1 — 1 - - - TOTAL 356 177 533 237 57 198 55 - -