4413(3) 1 Div 5B 2 Library cou 25 HEALTH REPORT for 1957 for the COULSDON & PURLEY URBAN DISTRICT by the MEDICAL OFFICER OF HEALTH Printed by RAYNES PARK PRESS, Lambton Road, London, S.W.20. 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 illness, (page 29). 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 40). (Housing, Drainage, Cleansing, Workplaces, Pests, Water, Food). APPENDICES. 1 URBAN DISTRICT COUNCIL OF COULSDON AND PURLEY. 1957. Public Health Committee. Chairman: r. N. Saunders. Councillor B. E. Eastoe, a.c.a. Councillor H. O. Faircloth. „ H. W. Hayden, „ Mrs. D. Pattison, b.a. f.b.o.a., f.s.m.c., j.p. „ pattison, b.a. „ 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. F. Simpson, f.i.a.c. Ex-officio: Councillor j. Corsie, a.c.a., j.p. 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. (until 1/12/57) Assistant to Public Health Inspectors: W. H. Sands. Rodent Operative: H. M. Key. Chief Clerk: *D. V. Prothero. Clerks: Mrs. G. Edmonston. *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, It is with pleasure that I present this my Annual Report for 1957, it being my 26th report as your Medical Officer of Health. It is accompanied, however, by some degree of regret in that it will be my last Report in this capacity. With the passage of time, it is increasingly difficult not to get stale and, in my opinion, it is then usually wiser to transfer those particular responsibilities to a new generation while seeking opportunities for further but different service elsewhere. I am very glad to be able to report that there has been no retrogression in the standard of the Public Health in this District but that, as will be observed, further preventive measures were introduced in 1957, the results of which should be noticeable in subsequent Reports. As judged by the usual standards, the inadequacy of which is again indicated, the health of the District remained reasonably satisfactory during 1957. Once more the Birth Rate increased while the percentage of illegitimate births decreased to a very low level. The corrected Death Rate was still well below that of the nation as a whole and it is particularly pleasing to observe the big decrease in the tuberculosis death rate and even a slight but steady decline in the cancer death rate in recent years. Unfortunately, one maternal death occurred after two clear years, and the Infant Mortality Rate was higher than the record low level of 1956; it was still well below the recent average, however, and as is stressed throughout the Report, more attention has to be given to general trends than to spectacular fluctuations in any given year. Apart from measles, the local incidence of infectious disease was reasonably satisfactory, although there were a few more cases of poliomyelitis than the average in recent years, including unfortunately, 2 fatal adult cases. In spite of the limited quantities of vaccine available, immunisation against this disease progressed, a further 3,540 children receiving their two injections, and evidence as to the efficacy of this measure on a national scale as deduced by an analysis of the statistics for 1957 is awaited with interest. It is commendable that despite the attractions of this latest form of immunisation, acceptance of the earliest form of vaccination, i.e. that against smallpox, did not decline but probably achieved a record in that about 75% of the babies under 1 year were vaccinated. At last it is possible to report some slight but real progress towards the solution of the problem of the flooding near Purley Fountain. Although fortunately this has not affected the Public Health, it has been a potential danger which should be removed as soon as possible. May my successor have the satisfaction of reporting its termination in an early Report. 4 The Health Inspectors have recorded another full and very useful year's work, considerable progress having been made particularly in improving food hygiene. They have also been very interested in the implications of the Rent Act, 1957. While the Housing Department may have been more involved in anticipating the immediate effects, the Health Department is more concerned in ensuring that real progress results in the improvement and preservation of the older houses in the District. Many undertakings have been given that improvements will be made in justification of the higher rentals. The results cannot yet be assessed but they will be keenly supervised in the future. Readers will note that, in accordance with your wishes, and as a result of the general appreciation of the simpler terminology of my 1956 Report, this has been adhered to, and it is hoped that not only will public interest in the Health Services increase but that still more students and older school children will find these Reports of help in their study and understanding of "Civics". One final word to them and one which I have tried to emphasise throughout the last 26 years. Real health, which is finally an individual responsibility, involves not only fine physical fitness but an equally important wholesome state of mind and spirit. We need to maintain a balance between these contributory factors in the development of our personality and to strive to achieve the highest level of which we are capable for the benefit of mankind, the happiness and health of which must surely be our ideal. In concluding, Mr. Chairman, Ladies and Gentlemen, may I express my thanks to the vast majority of the members of the present Council and its predecessors for their interest and support throughout the years. May the anticipated reorganisation of Local Government result in greater opportunities for responsible and enlightened decisions by the local representatives of the residents, with a corresponding increase in their happiness and health. Finally I would express my indebtedness to those of my colleagues in the voluntary and official health, welfare, education and other social services who have favoured me with their advice, co-operation and, frequently, real friendship, which has increased our effectiveness and happy relations. My Deputies have given loyal support; may they experience decreasing frustration in the years ahead. I have been particularly fortunate in the cordial goodwill of the two Chief Public Health Inspectors I have worked with in this District and would wish the present Chief and his colleagues further happiness and success. Similarly, as I have no other opportunity of expressing publicly my appreciation of the valuable assistance I have received from the Health Visitors, Nurses, Home Helps, my Chief and other clerical assistants, and many others, who have contributed of their best in the local team, may I do so now. I hope they will flourish as a recognisable, efficient and progressive unit in the years ahead. I am, Mr. Chairman, 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 1957 67,830 Population, Census 1931 37,666 Population, Census 1951 63,770 Number of occupied houses, December, 1957 20,142 Number of occupied houses, 1931 9,533 Number of occupied houses, 1951 18,071 Rateable Value, December, 1957 £1,292,112 Sum represented by a penny rate £5,346 VITAL STATISTICS FOR THE YEAR 1957. Total M. F. Birth Rate per 1,000 of the estimated resident population Live Births—Legitimate 938 476 462 14.1 do. Illegitimate 19 12 7 Corrected Birth Rate 957 488 469 15.7 Rate per 1,000 (live and still) births. Still Births—Legitimate 17 9 8 18.4 do. Illegitimate 1 1 - 18 10 8 Crude Death Rate per 1,000 of the estimated resident population Deaths 1,001 422 579 14.8 Corrected Death Rate 9.4 Deaths from puerperal causes Rate per 1,000 (live and still) births. Puerperal Sepsis - - Other Puerperal causes 1 1.0 Total 1 1.0 Death Rates of Infants under one year of age:— All infants per 1,000 live births 16.7 Legitimate infants per 1,000 legitimate births 17.0 Illegitimate infants per 1,000 illegitimate births — Deaths from Cancer (all ages) 154 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. 43 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 67,830. 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 1957. Since the war some 4,109 houses have been built and the number of occupied houses has increased by at least 3,450. The 1951 Census revealed that the population was 63,770 and since that event the number of occupied houses has increased by 2,071, hence the present population is probably about 70,250 compared with the 67,830 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 1957:- Cane Hill 2,360 Netherne 1,993 Russell Hill School 226 Reedham Orphanage 260 Further, in December, 1957. the number of occupied houses was distributed as follows : Coulsdon East 3,442 Coulsdon West 3,205 Purley 2,692 Woodcote 1,794 Sanderstead North 2,391 Sanderstead South 3,060 Selsdon 1,916 Kenley 1,642 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. 1956. 1957. Birth rate 13.5 12.9 11.6 12.8 15.2 15.2 12.0 13.6 14.1 Percentage illegitimate 3.4% 3.7% 2.8% 3.4% 3.9% 3.4% 2.7% 2.3% 2.0% Stillbirth rate — — — 0.43 0.48 0.40 0.24 0.20 0.26 Death rate 7.4 7.0 7.4 8.3 11.4 9.7 12.1 14.0 14.8 Cancer death rate 0.96 1.15 1.35 1.19 1.70 1.75 2.02 2.29 2.27 Tuberculosis death rate (per 100,000 population) 57 36 38 35 48 36 25 23 7 Violence including Suicide 0.44 0.35 0.32 0.46 0.82 0.37 0.46 0.65 0.46 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 1.00 Infant mortality rate (per 1,000 registered births) 28 38 32 38 40 26 21 10 17 Neo-natal mortality rate 26 28 19 15 7 14 Estimated population 21,351 28,950 41,616 53,084 49,880 60,610 64,466 66,460 67,830 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 1957 there were 957 live babies born in Coulsdon and Purley, (488 boys and 469 girls) which was 51 more than in 1956. 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 16.1 in 1957, whereas the corrected Birth Rate in this District was 15.7. Illegitimacy.—The mothers of 19 babies (12 boys and 7 girls) born in 1957 were not married at the time the births occurred. This means that only 2.0% of the 1957 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 18 babies were not born alive, (10 boys, 8 girls). The Stillbirth Rate is best expressed as the number born dead of every 1,000 born, whether alive or dead, and in 1957 this rate was 18.4 in this District and 22.4 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 1,001 deaths in this District during the year, (422 males, 579 females) that being 70 more than in 1956. From this figure we calculate the Death Rate. i.e. the number of deaths per thousand population (14.8) and thanks to the Registrar General's "comparability factor" obtain the corrected Death Rate of 9.4 which should be comparable with the Death Rate of England and Wales of 11.5. 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 earlier table the Death Rate appears to have doubled in the last 10 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 1957 would have been 9.6 compared with an average of 9.3 in the preceding five 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 (51% of the total deaths), cancer (15%), pneumonia and bronchitis (16%), accidents (3%) and tuberculosis (½%) 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 out look for these unfortunates. Another diminishing group has the efficiency of the heart decreased as a result of infection, but the chief cause, rheumatic fever, 11 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 1957 we find that 72% of the ordinary residents whose deaths were allocated to this group were over 65 years of age, compared with an average of 79% in the previous seven years, i.e. no marked change has occurred. (For interest sake 34% of the group were over 75 years, 4.4% over 90 years and the eldest 101 years). 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 animal 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 1.76 (i.e. deaths in each 1,000 of the population) compared with 1.79 in 1956 and an average of 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 essentially the misbehaviour of certain cells of the body which, without notice, multiply in numbers causing a 'new growth' which in turn is apt to spread, not only directly but by 12 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 on page 14, 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 breasts in women, the lungs, (although much less than in 1956) and the genital-urinary system. 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 1957 there were 16 deaths among ordinary residents which were attributed to suicide or other forms of violence, the resultant death rate being 0.25 per 1,000 population which is well below the average of about 0.39 since 1919, excluding the period of the war. 13 CANCER TABLE 1957. * 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 1 — — — — 1 — — — — — — 1 1 1 1 Bone — — — — — — — — — — — — — — — — — — — — — — — — — — — — 2 — 1 — Oesophagus — — — — — — — — — — — — — — — — — — — — 2 1 — — — — — — 2 1 — 4 Stomach & Duodenum — — — — — — — — 1 — 1 — 1 — — — 4 — 1 — 3 2 1 2 1 — 1 — 10 2 4 2 Intestines — — — — — — 1 — — — 1 — 3 — 2 — 4 — 2 1 6 — 4 1 1 1 6 2 14 1 16 4 Liver — — — — — — — — — — — — — — — — — — — — 1 1 1 — — — 1 — 3 1 3 — Pancreas — — — — — — — — — 1 — — 1 1 — — — — 1 1 1 — — — — — — — 2 2 1 1 Lungs — — — — — — — — — — 1 — 4 1 1 1 4 — — — 1 2 2 2 — 1 — — 9 4 4 3 Bladder — — — — — — — — — — — — 3 — — — — — — — — 1 — 4 1 — 1 — 4 1 1 4 Prostate — — — — — — — — — — — — — — — — — — — — 1 — — — 1 — — — 2 — — — Uterus — — — — — — — — — — 1 — — — 2 — — — — — — — — — — — — — — — 3 — Vagina and Ovary — — — — — — — — — — 1 — — — 3 — — — 1 — — — — 1 — — 1 — — — 6 1 Breast — — — — — — 2 — — — 2 1 — — 3 — — — 4 — — — 3 3 — — 3 — — — 17 4 Kidneys — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Ill-defined — — — — 2 — — — — — — — — — 1 — — 2 1 — 1 3 — — 1 — — — 4 5 2 — TOTAL — — — — 2 — 3 — 1 1 7 1 14 2 13 2 15 2 12 2 16 11 11 17 5 2 13 2 53 18 59 24 *H = Hospital cases. P = normal residents. 14 Deaths on the road numbered 3 (all males), which, was 3 less than in the previous year, and 1.5 less than the average for the years since the war. All 3 were pedestrians when knocked down by four-wheeled motor vehicles, one aged 25 years and the other two over 70 years. By contrast other forms of accidental deaths, i.e. excluding those which occurred on the roads, numbered no less than 20, 7 being ordinary residents. Seven is less than usual, 11 ordinary residents having died on the average each year since the war from "home accidents". In 1957, 5 were elderly persons, 3 of whom fell while indoors and 2 were suffocated while they were unconscious. One young adult's death resulted from an air accident and the other from drowning. 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 6 among ordinary residents compared with an average of 7 since the war. The average age was 47 years, and in 4 cases 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. No such deaths occurred in this District in 1955 and 1956, but unfortunately there was one maternal death in 1957 due to an embolism following a forceps delivery. 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 it 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 1957 was only 23.0. 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 just under 23. In 1953 it was 29, but in 1954 it dropped to 11; in 1955 it again rose to 24, falling in 1956 to only 10. The rate of 17 in 1957 was thus below the recent average. 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 5 years even out to the much more reliable average of 18, while it is still safer to consider the local average to be the 22.6 of the last 10 years. The causes of death in the 16 babies who died locally in 1957 were prematurity and failure to start breathing (13), congenital abnormalities (2), meningococcal meningitis (1). The origin of the infection in the latter was not discovered. Nationally 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 have greatly declined, constant watchfulness is obviously still very necessary. Even the common cold can be a most serious infection in the very young. During 1957 in this District there were 13 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 13.5. From 1935 to 1944 the average was 27 and in 1945 to 1954 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 1957, there were 61 "premature" babies born (now interpreted as babies who weighed 5 lbs. 8 oz. or less at birth) of which 14 were notified as being born at home and 47 in institutions. Seven of the latter lived less than 24 hours and a further 3 died between the 2nd and 7th day. This suggests that nearly 20% 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 1957 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 47 7 — Erysipelas 1 — — Puerperal pyrexia 4 1 — Pneumonia — primary 26 6 — Enteric fever — — — Encephalitis, acute 1 1 — Dysentery 2 1 — Poliomyelitis 13 11 2 Measles 1,184 16 — Whooping cough 58 1 — Food poisoning 3 — — Totals 1,339 44 2 It will be seen that tuberculosis is omitted from this list of acute infectious diseases, this chronic disease being dealt with separately later. Further, 1,339 notifications were received compared with 364 in the preceding year, chiefly owing to the 17 very large number of cases of measles which occurred in 1957, this being much the commonest disease to be notified. While the number of cases of whooping cough and dysentery decreased considerably and pneumonia decreased slightly they did not affect the total number of notifications materially. When comparing these figures with those of 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 show 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. The seriousness of the outbreak in Brighton in 1951 illustrated how important such preventive measures and vaccination still are. DIPHTHERIA. For the eleventh 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 had 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, notification is still required, although there is evidence that this is being observed with decreasing stringency. The fact that only 47 cases were notified in 1957 is therefore of less significance, and it cannot be assumed that the disease remained less prevalent. 18 As has been noted in the last 14 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. In 1956 it rose to about 40%, but in 1957 only 15% were admitted, without any obvious increase in secondary cases resulting. The admission of some cases may be justified in order that they shall receive better treatment, but 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, which was also usually due to a 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 four mild cases notified in 1957 the rises in temperature within 14 days of the confinement were mostly due to a mild infection which 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 by pneumococci, and in 1957 there were 26 cases notified, which is only one above the average for the last 12 years. The cases occurred mainly in the early months of the year with a secondary increase in October. As usual the majority were in the Purley area, but only in 2 sets of twins did the cases appear to have any connection with each other. So far as is known, 8 were admitted to hospital and not a single death resulted from this infection. ENTERIC FEVER. During the year no case of typhoid or para-typhoid fever was notified whereas since the war about 3 cases have occurred on the average each year. The source of para-typhoid infection is usually some food stuff, while typhoid is more often traceable to water. As it is not uncommon for these intestinal diseases to occur in persons returning to this Country from the Continent, the desirability of prior inoculation against typhoid and para-typhoid should be considered, especially if going to countries in which the hygienic standards are inferior to ours. 19 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. The facts are, that 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 that type, the majority being of the very prevalent, though much milder Sonne form of dysentery, which was widely spread in this part of the Country. In 1956, 26 cases of dysentery were notified from the mental hospitals, (3 of the Flexner type) and 55 from among ordinary residents, but in 1957 only a total of 2 cases were notified and the diagnosis confirmed, both being of the Flexner type. They occurred in one of the mental hospitals during the Summer. In 7 other instances suspected cases or contacts had to be followed up and investigated. The prevention of the spread of 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, and in 1957 only 3. One of the latter was due to a staphylococcal infection spread through custard which caused a Croydon School outbreak. The other two were due to S. typhi-murium, one being an isolated case, forming part of an outbreak in a large laboratory in another County and the other probably contracted the disease on the Continent. All three recovered. 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. In this District, the average number of cases which has occurred annually since 1946 is 8, hence the 13 notified in 1957 was slightly above the average, but three of the cases were nonparalytic; they included one adult case who was later diagnosed as having had a virus meningitis of an unknown type. Of the 10 paralytic cases, 7 were children of whom at least 2 had only mild attacks and were treated at home. One of the children had just received his first immunising dose of vaccine which could not have had time to act. All recovered with very slight to moderate residual paralysis. On the other hand, of the 3 adults, both the males had very severe attacks and died. 20 As usual, several cases were admitted to hospital as suspected of having poliomyelitis and difficulty was again experienced in 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 school child was notified. He was admitted to The Grove Hospital and recovered. MEASLES. This most common infection is more prevalent in alternate years and, as over 1,000 cases occurred in 1955, followed by only 82 in 1956, it was not surprising that the number of new cases notified in 1957 was 1,184. 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. WHOOPING COUGH There was a slight decrease in the number of whooping cough notifications received, i.e. 58 compared with 93 and 64 in the two previous years and an average of 110 per annum since 1941 when regular notification became the practice. TUBERCULOSIS. The following table presents concisely the position with regard to tuberculosis in the District during 1957 Pulmonary. Nonpulmonary. Total. M. F. M. F. M. F. Number of cases on register 270 190 26 25 296 215 Additions:— New cases notified 27 18 2 — 29 18 Cases removed into district 13 12 1 1 14 13 Restored 3 1 — — 3 i Total Additions 43 31 3 1 46 32 Removals:— Deaths from T.B. 8 1 — — 8 1 Other causes — — — — — —. Removed from district 23 22 — — 23 22 Recovered 10 9 3 3 13 12 Non T.B. 2 1 — 2 1 Total Removed from Register 43 33 3 3 46 36 Number of cases on register, 1st January, 1958 270 188 26 23 296 211 21 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. The Rates given here and in the following notes are per 100,000 population. 19151924 19251934 19351944 19451949 19501954 1956 1957 Pulmonary— New cases notified 22 29 35 49 43 41 45 *Case rate 115 82 68 81 67 62 66 Deaths „. 12 13 21 27 16 12 5 *Death rate 65 37 42 44 22 17 7 Non-Pulmonary— New cases notified 3 6 7 8 5 3 2 *Case rate 15 18 15 13 8 5 4 Deaths 3 3 2 2 2 4 — *Death rate 15 8 5 3 4 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 not more than 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 decline in the case rate, (i.e. the proportion of the population recognised annually as suffering from active disease, whether pulmonary or non-pulmonary) and an even more marked decrease 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 22 tively high casualties 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 has helped in early diagnosis, while still more recently, skin testing combined with B.C.G. immunisation has been used in an endeavour to increase immunity in those groups which 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 visited this District in September 1957, when 3,937 residents attended which was a disappointingly low total, but many residents can and do avail themselves of facilities at their work or in London, Croydon and the surrounding Districts. The opening early in 1958 of the ad hoc Chest Clinic in Purley Hospital was most welcome, as it will not only provide better accommodation for patients and staff, and liberate needed space at the County Council Clinic, but give opportunities for improved diagnosis and treatment facilities. 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, as do those of the Head Teachers, who are also required to notify absences due to any infectious disease. The latter were especially valuable in 1957, for they indicated the arrival of "Asian Flu" in this District in September. This outbreak, which originated in the Far East and first appeared in the North of England earlier in the year, appeared to attack primarily children of school age among whom there was a high absentee rate. A variety of other ill-defined forms of sickness contributed to this, however. Among this age group the influenza was not severe, but the results were sometimes more serious towards the end of the year when adults chiefly suffered. Fortunately, the epidemic could not be compared in extent or severity with the notorious 1919 pandemic. 23 The Head Teachers' returns in 1957 also indicated that mumps was widely epidemic in the early months when a fair number of cases of German measles occurred in Reedham, Sanderstead and Old Coulsdon. Small outbreaks of chicken-pox were noted in Woodcote. Roke and Reedham in April, with scattered cases in Sanderstead and Old Coulsdon at the end of the year. 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 no case came to the notice of the Health Department during 1957. Early notification of any case is very desirable in order that contacts may receive preventive treatment while the patient is being treated. (b) Lice. Almost all school children are inspected by the Health Visitors each term to ensure the absence of lice and in 1957 only 10 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. 24 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 compulsory, 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 District have been vaccinated. In 1957 there were 294 primary vaccinations carried out in the Welfare Centres (and 28 revaccinations, including adults) and 568 (including 48 of 15 years and over) by General Practitioners, who also revaccinated 48 children under 15 years and 163 persons over 15 years. As the above figures include the primary vaccination of 732 babies under 1 year of age, no less than about 76% of the babies born in that period were vaccinated, which is most commendable. ENTERIC, CHOLERA AND YELLOW FEVER. Immunisation against typhoid and paratyphoid fevers 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. 25 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 eleven 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 1957, the Authority arranged for 374 children to receive primary immunisation against diphtheria at Welfare Centres, Clinics and Day Nurseries and similarly treated 18 at their schools. They also arranged for 722 to get 'booster' doses (including 613 in the schools). In addition, private doctors gave 540 primary treatment and 538 'boosters'. The total receiving primary treatment was thus 195 more than in 1956 while 94 more had a 'booster' dose. WHOOPING COUGH. This form of immunisation was only officially adopted in 1952 and its effectiveness in preventing the occurrence of the disease is not yet of as high a standard as is that against diphtheria. There 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 1957, at least 902 children received primary courses (368 at Infant Welfare Centres and 534 from private doctors) while 379 were given 'boosters', including 82 in the Centres. There was thus an increase of 218 primary treatments and 53 in those receiving 'boosters'. 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. 26 In 1957 at least 334 children had primary courses in this District, 313 being treated by private doctors who also gave 138 boosting doses. 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 1954 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 5 private schools have already co-operated. In 1957, in this Division 59% of those offered treatment accepted; of these 6.5% were shown by the Mantoux test not to need B.C.G. vaccination and 49% 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 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 500 registered children born in certain months were, in fact, called up for treatment, which was given only by selected doctors of the Local Authorities. During 1957 the treatment of the remainder was proceeded with as rapidly as the supply of vaccine permitted, only a temporary halt being called in the immediate neighbourhood of any case of poliomyelitis. The private doctors also assisted, and by the end of the year 4,041 had received two injections. In May, the age group was extended to include children born in 1955/6 and in November ante-natal mothers, babies of six months or over and groups at special risk were added. The year 1958 thus began with a waiting list of about 5,748 but with little anticipation that the complications hitherto introduced, some unnecessarily, were to be intensified as the year progressed. 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 27 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 has been 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. During the Spring months and possibly when poliomyelitis is not occurring in a district, this can be followed 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. There is evidence, however, 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 neighbourhood. Ideally, therefore, the whooping cough vaccine is best given on its own, starting in the third month, and reserving the prophylatic treatment against diphtheria and tetanus until the following Spring, but this would involve many injections in the first year, including 2 injections against poliomyelitis after the child is 6 months old. The practice followed and advice being given now varies from District to District, and further variations can be expected. Meanwhile the local practice has been to continue the use of the triple antigen in children of 3 months upwards unless a case of poliomyelitis occurs in any given part of the District, and then to suspend treatment locally for as short a time as possible; this appears to be justified in view of the almost negligible number of cases of paralytic poliomyelitis which have occurred in Surrey during the last 10 years following injections of the triple vaccine. 28 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 1957 the following disinfections were carried out Free of cost. Upon payment. Total. Loads of bedding, etc ... 27 2 29 Houses disinfected 42 — 42 Parcels of clothing 2 1 3 Library books 893 — 893 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 1957 they examined and reported on the following specimens:— Milk, ice cream, and water samples 418 Food utensils 118 Nose and throat swabs 10 Food 6 Faeces 47 Sputum 8 (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. 29 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 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, 30 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 be stressed. 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 have recently been reviewed and are being kept under supervision with the aim of ensuring that every anteand 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 1957, 303 residents had their babies in their own homes, some 222 at 7 hospitals in the County, including 205 at Redhill County, some 360 at 29 hospitals outside the County including 163 at Purley Hospital and 126 at Mayday, while about 72 were confined in private nursing homes. Only 32% 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. With the decreased attendances at all the Council's Maternity Clinics the Selsdon sessions may be discontinued in the near future and the Purley sessions reduced to the Thursday afternoons only. Mothercraft and Relaxation Classes. Classes covering these subjects were commenced in Purley at the end of 1953 and the numbers attending have steadily increased hence it is hoped to extend the facilities in the near future. Meanwhile it is 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. 33 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 just over 20 whole-time nurses is employed in this Division but changes in the personnel occur each 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. While the amount of 'cover' and the conditions of service of the individual nurses have improved since the institution of the National Health Service, there is unfortunately 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, but have been on the increase in recent years. 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 1957 in this Division, of which about two-thirds relates to Coulsdon and Purley The Midwives delivered 475 cases and attended 92 other maternity cases, while the General Nurses paid 24,929 visits to medical cases, 5,860 to surgical cases, 2,602 to the tuberculous and 712 visits for a variety of other conditions, making a total of 34,103 visits, an increase of 322 compared with 1956. 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, at 115 Brighton Road, Purley (UPLands 7014 or 9277) if possible between 9.30 and 10.30 a.m. During 1957, on the average the equivalent of just over 40 whole-time Home Helps were employed in the Division; this at times necessitated the engagement of as many as 63 part or whole time Helps. A total of 1,032 cases were assisted, (i.e. 301 maternity, 17 tuberculous, 398 chronic sick, aged or infirm and 316 acute cases) this being easily the highest number dealt with 34 to date due to increases in the number of maternity and chronic sick cases. A recent development has been the training and employment of specially selected "teaching Home Helps" for use in suitable cases, who are mainly "Problem Families". 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 advice were withheld can be seen and applications for appointments should be made to the Divisional Medical Officer at 115 Brighton Road, Purley. During 1957 only 119 persons including 50 new cases were seen from the whole of the Division, the total attendance being 225. 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 or through the Divisional Health Visitor, be tween 9.0 a.m. and 10 a.m. daily. During 1957 the Health Visitors in this Division paid approximately 24,000 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.:- 35 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 Tuesday in each month. Community Centre, Hooley 1st and 3rd Wednesday in each month. During 1957 the number of Infant Welfare Sessions held was 402 (403 in 1956), the total attendance was 17,127 (15,580), and the average attendance per session 42.8 (38.6). The Doctors' consultations numbered 4,498 (4,620) or 12.8 (12.2) per session. Nurseries and Child Minding. The County Council has maintained two Day Nurseries situated as follows:- "Hazelglen" Day Nursery, Sanderstead Road, Sanderstead. (Matron: Miss I. M. Bettridge) SANderstead 5329. Old Coulsdon Day Nursery, Bradmore Green, Old Coulsdon. (Matron: Mrs. L. C. Bryan, S.R.N.) Downlands 4071. The children of residents have only been accepted on grounds of health in the widest sense, including bad home conditions, or when the mother is the sole wage earner, applications for admission being made to the Divisional Medical Officer, 115, Brighton Road, Purley. In general, owing to the very restricted conditions justifying admission, the average number of children in attendance at all Surrey Day Nurseries has diminished and the cost per head increased proportionately. Towards the end of the year consideration was being given to the possibility of closing one or both of the local Nurseries and it has since been decided to close the Old Coulsdon Day Nursery from 1st October, 1958. The future of the Sanderstead Day Nursery is also in doubt. In addition to the Day Nurseries, there are two County Council residential establishments for children in the District under the supervision of the Children's Officer, while there are 16 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 compulsory routine examination of all children attending the County Council's schools, at least four or five times during their school life, coupled with an 36 annual dental inspection and an inspection each term for cleanliness, etc., of all except the most senior children by a Health Visitor. The commonest abnormalities found are visual defects, ears, nose and throat defects and postural or foot defects. 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. 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. Services for other Adults. Since the implementation of the National Health Service Act the curative services for all, including adults, have been made more widely available 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 adults but 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. 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. 37 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 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 would 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 only utilised once during 1957. The person concerned has since been living under greatly improved conditions in a private nursing home at her own expense. 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 one 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. 38 The Divisional Medical Officer is 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. 39 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 1,444 houses (including 105 prefabricated) to be built, while private builders have erected 2,665. Latterly the Council's annual contribution has decreased steadily and in 1957 they only saw 28 completed compared with 300 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 but at the end of 1957 only 64 of the 350 houses planned to be built on it had 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 it was thought that only 27 needed to be dealt with in this way in the next 5 years. In 1956 when a few more were added to the list, 7 of these houses were demolished and the Council purchased by agreement the land on which a further 12 stand, preparatory to demolition and rebuilding. 40 In 1957 the Council decided to demolish 4 houses in Whytecliffe Road, Purley, which they owned, as being unfit for human habitation and incapable of being rendered fit at reasonable expense, and the Ministry agreed. In addition an undertaking was accepted that one house at Netherne would no longer be used for human occupation while the closure of a house in another part of the District was agreed, and a further one has been demolished. 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, and the Inspectors have done what they could to encourage owners to take the necessary steps to prevent this, but until 1957 the Rent Restriction Acts have handicapped them. The Chief Public Health Inspector now writes:- "The Rent Act, 1957, which came into force on 6th July, 1957, can truly be acknowledged as one of the most important and far-reaching events occurring in the sphere of housing during the post-war years. It had been apparent for some time that the rent provisions of the Housing Repairs and Rents Act, 1954 did not go far enough in providing an incentive to owners to increase the rents of small cottage property and at the same time accept the obligations of putting the houses in good repair. The new provisions allow of increases in rent more in line with present day values and costs and have as their main objective the repair and proper maintenance of rented houses and flats together with the increase and better use of such accommodation. The fairly substantial increases in rent allowed under the Act are subject to the tenant's right to demand a standard of repair commensurate with the age, character and locality of the dwelling. A criticism which might be levelled against these provisions is that of the tedious and complicated machinery for enforcing the obligations of landlord and tenant in the event of failure to agree. If. however, the number of Certificates of Disrepair issued by a Local Authority can be accepted as the yardstick by which the Act can be judged, then so far as this District is concerned, it can be said to have been a success. Only six Certificates had been issued at the end of the year, with one refusal, and in thirteen further cases, undertakings were given by landlords to carry out repairs within the prescribed period. Very few complaints have come to the notice of the Department and it is the impression that rent increases have been 41 generally accepted as a logical and realistic adjustment of an important item of domestic expenditure. What is not quite so clear is the extent to which landlords have taken advantage of the right to increase the rent and tenants to see that repairs are carried out. It will be the duty of Local Authority Officers to observe whether the "repair and maintenance" objective is achieved in due course and consider in the light of experience whether greater use of the statutory powers contained in the Housing and Public Health Acts is necessary. Landlords cannot now plead "unreasonable expense" when asked to carry out essential repairs to otherwise structurally sound property." Another measure with the same object is that of making "Improvement Grants" for the provision of modern amenities, but by December, 1956 only eleven applications of this type had been approved by the Council. Schemes for a further five houses were approved in 1957 and improvements to the value of £1,652 were completed, 50% Grants being made in each case. Much more use could be made of these provisions especially by owners of rented property. To date all but 2 of the grants have been made to owner/occupiers. As a guide to the remedial work carried out by the Public Health Inspectors during 1957, it should be mentioned that they inspected 324 houses for this purpose, making 3,153 inspections. Five were found unfit for habitation and 293 needed remedial action. Of these 224 were made fit without formal notice being required. In 39 cases notices had to be served and the work was subsequently carried out, on 29 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 no houses were known to be overcrowded at the end of 1957, during which year 3 cases were relieved (involving 16 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. PUBLIC HEALTH INSPECTIONS. The duties of the Public Health Inspectors, whose housing activities have just been referred to are very varied. In genera! 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 self contained unit. In practice they form a valuable part of a team and 42 the closest co-operation has always existed 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 1957 the Inspectors received 831 complaints and altogether paid a total of 18,172 visits, details of which are obtainable on request. 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 they received 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 5,500); pests (5,600); shops and workplaces (about 1,500); food premises (about 2,000); infectious diseases (250). Some 3,250 visits can only be described as interviewing for various purposes or as touching a miscellaneous variety of subjects. As a result of these visits, some 616 drainage or sanitary fittings were dealt with, 624 other housing defects remedied, and in 675 instances defects were remedied in food premises. Other results will be deduced subsequently, e.g. in the sections on vermin and food. 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 1957. Of 644 Preliminary Notices served, only 55 were followed by Statutory Notices (23 less than in respect of a similar number of cases in 1956) and no case was taken to Court. DRAINAGE AND SEWERAGE. During the year 273 yards of new sewer were constructed in the District, mainly to deal with new development. The majority of the sewage 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. 43 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 5 properties were connected to the sewer and 11 cesspools abolished. By 1958 only 6 pail closets remained, the contents of which are disposed of in their gardens by the occupiers, and some 101 cesspools, most of which are situated in outlying parts of the District. Eight years ago there were 17 pail closets and 180 cesspools, while in 1933 there were over 100 closets and about 530 cesspools, mostly in the outlying parts incorporated in the District as a result of the review of the Boundary. 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 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. CLEAN AIR. By virtue of an Order made by the Minister of Housing and Local Government, certain provisions of the Clean Air Act, 1956 came into force on the 31st December, 1956, dealing with the installation of new furnaces, the height of chimneys, smoke control areas, research, publicity and the making of building byelaws. The Council gave consideration to these matters and decided to take no action at the present time to establish a "Smoke Control Area" within the Urban District or to make byelaws requiring the provision in new buildings of appliances capable of burning smokeless fuels. This District is, of course, fortunate in that little or no nuisance is experienced from the small number of industrial chimneys in the area. MINES AND QUARRIES ACT, 1954. This Act came into force on the 1st January, 1957 and Section 151 provides that the following shall be deemed to be a statutory 44 nuisance, i.e. "A quarry (whether in course of being worked or not) which (i) is not provided with an efficient and properly maintained barrier so designed and constructed as to prevent any person from accidentally falling into the quarry, and (ii) by reason of its accessibility from a highway or a place of public resort constitutes a danger to members of the public." A survey was accordingly carried out of all the quarries in the District to which this Section applies, and as a result a considerable amount of new fencing was provided. RIVERS AND STREAMS. From time to time inspections are made of the local watercourses but their clearance is a minor matter. 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 very satisfactorily and no major public health problems have arisen as a result of the caravan camp site near Hooley. The latter continues to operate subject to a final extension of permission granted by the Ministry of Housing and Local Government for a period of 3 years from the 28th January, 1957. The action taken by the Council in 1951 under S.57 of the Surrey County Council Act, to obtain "prohibition orders" in respect of certain areas in the District has continued to be effective in preventing nuisance arising from gypsy 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 try to ensure an adequate degree of chlorination. During 1957, 20 samples of the water in these baths were submitted for chemical and bacteriological examination and four from one of the baths showed that there had been insufficient chlorination. Following representations to the owners subsequent samples were satisfactory. 45 SHOPS AND OFFICES. As far as possible inspections have been made of the sanitary accommodation, washing facilities, heating and ventilation of shops and offices, and improvements have been effected as circumstances have permitted. Surveys are carried out to see that the Shops Act is being complied with in regard to 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, 214 factories needing to be dealt with by this Local Authority are registered, and during 1957, 252 inspections were made following which two written notices were sent. In 13 cases defects were found, three relating to insufficient and ten to unsuitable or defective sanitary conveniences. (Two of the former and two of the latter were referred by H.M. Inspector). Two cases with insufficient conveniences were remedied as were 21 cases of unsuitable or defective conveniences. In addition, 83 outworkers were supervised, 47 of whom were making apparel and 24 carding buttons. (One of the latter was working in unwholesome premises). The remaining 12 outworkers were engaged on household linen (1), umbrellas etc., (1), making boxes (1), duster dolls (5), Christmas stockings, etc. (4). HAIRDRESSING ESTABLISHMENTS. During the year the Ministry of Housing and Local Government confirmed the draft byelaws submitted by the Council for approval and these came into force on 1st August, 1957. The byelaws provide for securing the cleanliness of premises and the instruments, towels, equipment and materials used in the premises. Copies of the byelaws were sent to all hairdressing establishments in the District, and 24 visits were made to ensure compliance. 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, and many improvements have resulted. 46 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. Three cases of bed bug infestation were dealt with during the year and action was taken in respect of 75 cases of infestation with pests such as flies and wasps. In the majority of cases disinfestation was carried out by spraying with a proprietary insecticide. PREVENTION OF DAMAGE BY PESTS ACT, 1949. During the year 123 visits were paid to the Council's depots and tip, to Millstock, and land at Littleheath Woods, Selsdon. With regard to rats and mice, 609 properties were inspected, including 418 dwelling houses and 88 business premises. Of these, 263 were infested by rats and 60 by mice, and a total of 233 treatments for rats and 58 for mice were carried out by the Inspectors' Assistants, by arrangement with the occupier and no notices were served under the Act. Eleven occupiers subsequently rat-proofed their premises. The Council make a flat rate charge of 5/- in respect of the disinfestation of private dwellings and 10/8 per hour plus cost of materials in all other cases. In accordance with the requirements of the Minister of Agriculture and Fisheries, a routine test baiting of the sewers was carried out, but only minor infestations were detected. This sewer treatment necessitated 1,148 visits but the total number of rats and mice destruction visits was 5,413. 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. 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. 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. 47 Routine samples of the treated water in public supply were submitted quarterly for bacteriological and chemical examination. 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 unsatisfactory report was received and no complaints were received during the year with regard to the quality or quantity of water supplied by the Companies. 48 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. RAINFALL. It appears opportune to record here that the rainfall registered by the automatic rain gauge installed at Alderstead Heath, was 28 93 inches in 1957, this being a decrease of 0.24 inches compared with the previous year. The monthly totals throughout the year were as follows inches January 2.55 February 4.27 March 1.74 April 0.23 May 1.70 June 1.11 July 3.69 August.2.75 September 3.18 October 2.14 November 2.94 December 2.63 48 RECONSTRUCTION AND IMPROVEMENT OF SMALL DAIRY PLANT BEFORE RECONSTRUCTION LOADING BAY AFTER RECONSTRUCTION (See page 50) RECONSTRUCTION AND IMPROVEMENT BEFORE RECONSTRUCTION MILK PASTEURISING EQUIPMENT AFTER RECONSTRUCTION (See page 50) OF SMALL DAIRY PLANT BEFORE RECONSTRUCTION BOTTLE FILLING PLANT AFTER RECONSTRUCTION (See page 50) RECONSTRUCTION AND IMPROVEMENT OF SMALL DAIRY PLANT BEFORE RECONSTRUCTION STEAM RAISING EQUIPMENT AFTER RECONSTRUCTION (See page 50) THE FOOD AND DRUGS ACT, 1955. THE FOOD HYGIENE REGULATIONS, 1955. 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, but the passage of the above mentioned legislation, which came into force on 1st January, 1956 gave a new impetus to food hygiene generally. The Food and Drugs Act, 1955 is a consolidating and amending Act and one of its chief contributions is that it provided 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. This is very useful as permitting relatively quick adaptation in the light of new knowledge and changing circumstances. The Food Hygiene Regulations, 1955, were the first contribution in the exercise of these powers and set a new standard in the control of food preparation and sale. All places where food is handled come within their scope, including canteens, clubs, schools, hospitals, etc., whether carried on for profit or not. In 1956 the Chief Public Health Inspector reported 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." "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 working hours, and the prohibition of smoking are new requirements to which particular attention is given." In respect of 1957, the Chief Public Health Inspector reports:- "The survey of all food premises continued during the year. This further drive to obtain a higher standard of Food Hygiene in such premises has met with a good response." "An indication of the public interest in the subject is the number of complaints received in respect of contaminated food and/or containers. During the year, 12 cases of this nature were fully investigated and the necessary representations made in each case. Individual cases are reported to the Public Health Committee with a view to statutory proceedings if the circumstances merit such action." 49 The new register of premises coming within the scope of the Food Hygiene Regulations at present includes the following Confectioners 58 Butchers 31 Fishmongers (wet and dry) 13 Fishmongers (fried) 6 Bakers 22 Greengrocers and Fruiterers 41 Cafes and Restaurants 41 Grocers 70 Chemists 18 Licensed premises 30 Hospitals, Nursing Homes, Guest Houses, Hotels 14 Canteens, Clubs, Halls, etc. 47 Schools 45 Six 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. 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. 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 1957 were 19 distributors of milk in the District but only one registered dairy at which milk is processed. This is equipped with pasteurising plant which is licensed by the Council under the provisions of the Milk (Special Designation) (Pasteurised and Sterilised Milk) Regulations, 1949 - 1953, and has just been completely rebuilt and reequipped with the latest High Temperature Short Time Pasteurisation Plant, Cold Storage and Steam Raising Equipment. From a somewhat cramped and obsolete building the new premises provide a complete contrast as will be seen in the photographs included in this Report, (for which I am again indebted to Mr. G. H. Bourne, additional Public Health Inspector), and it is pleasing to record the satisfactory degree of co-operation and consultation established with proprietors in a joint effort to get a dairy more in line with present day standards. 50 Apart from the output of this dairy, the bulk of the milk now consumed in the District is produced and processed outside the District and retailed by the large dairy companies. By virtue of 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 243 samples was submitted to the methylene blue (keeping) test and the phosphatase (pasteurisation) test, 194 being 'Pasteurised' milk, 19 'Tuberculin tested' (raw) and 30 'T.T. (Pasteurised). Only six of the 'Pasteurised' samples did not pass the keeping test. Of 17 samples of 'Sterilised' milk submitted, none failed the turbidity test. These results reflect the high standard now achieved and particularly the efficiency of modern pasteurisation. Biological In view of the widespread attestation of dairy herds supplying milk for the liquid market, it has been considered unnecessary to continue biological examination of milk to the same extent as hitherto, and only one sample was taken during the year, with a negative result. Milk (Special Designation) Regulations, 1949- 1954. Licences to sell milk under the above Regulations were issued as follows Dealers: Tuberculin Tested 13 Pasteurised 15 Sterilised 15 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 1957, 99 premises in the District were registered under the Food and Drugs Act, 1955, Section 16, for its sale, and a further 2 for its manufacture and sale, although, in fact, no manufacture was carried on. It was also sold from 23 premises which were exempt from registration. One registration for sale and one for manufacture were cancelled owing to a change in character of the general business carried on at the premises concerned. Some 52 visits of inspection were made to these premises. 51 One of the results of close supervision has been centralised production, and all the ice cream retailed in the District is obtained by the vendors, prepacked, from large scale manufacturers whose premises are situated outside the District. A total of 129 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 117 Grade II 10 Grade III 1 Grade IV 1 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 reasonably satisfactory. MEAT. There are no slaughtering facilities in the District, apart from those at Cane Hill Hospital, which did not function during 1957, and at Netherne Hospital where the carcases and offals of the 11 cattle, 1 calf and 2 pigs killed were inspected for disease. A number of the cattle slaughtered were found to be suffering from parasitic bronchial pneumonia and a quantity of offal was condemned. 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 99 visits were made for this purpose. 52 UNSOUND FOOD. The following unsound foods were surrendered during 1957, the total quantity being very much less than in the previous year. With minor exceptions, all unsound food is disposed of at the Council's destructor.  cwts. lbs. ozs. Canned Soup — — 10 Canned Meat 1 69 8 Canned Fish — 3 11 Canned Vegetables — 30 2½ Canned Fruits — 38 0½ Canned Milk and Cream — 11 6 Meat, Bacon, Poultry, etc. 5 87 0 Fish 5 42 4 Miscellaneous - — 8 Total 13 59 2 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 11 informal ones) were examined of 73 products. Samples of milk (64) were much the most numerous, the next highest being confectionery (7) and spirits (5). Only 6 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. Buttered Bread The Public Analyst reported that this was a sample of bread spread with a mixture of butter and margarine, the proportion of butter in the mixture being not more than 60 per cent. A warning letter was sent to the person concerned. Cheese Spread There was a discrepancy in the labelling of this product in that the ingredients disclosed on the outside carton were different from those disclosed on the cheese portions inside the packet. The manufacturers were asked to make the necessary amendments. Gluco Juice Vitaminised Plus Glucose The Public Analyst objected to the claim made in the description of this article that it contained added glucose when the actual substance used was liquid glucose, which is a partially hydrolised starch product of very different composition to glucose. As, however, the term "Glucose Beverage" is used in the Food Standards (Soft Drinks) Order, 1953 to include either substance, it was felt that no useful purpose would be served at the present time by pursuing the matter further. 53 Jelly Fruit Salad This sample consisted of a complete table sweet in a can, comprising water, sugar, gelatine and various fruits and flavouring, which failed to set to a firm jelly sweet when cooled to and maintained at 16°C. Representations were made to the manufacturer concerned and the product was withdrawn from the market pending a full investigation of the complaint. Hot Milk This sample contained 44 per cent added water, but in view of all the circumstances, it was considered that a warning letter would meet the case. Meringues This sample was contaminated with particles of rust or oxide of iron, from the appearance of which they could have been particles of scale picked up on the under surface of the meringues from the baking sheet. Action was taken in the bakery concerned to prevent a recurrence. 54 55 TABLE I. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1957. 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 under 65. 65 and over. Coulsdon East. Coulsdon West. Purley. Kenley. Sanderstead. Selsdon and Farleigh. Woodcote. Scarlet fever 47 - - 1 5 3 28 8 1 - - 1 - 5 2 9 5 10 16 - Pneumonia 26 — — — 1 3 5 — 1 3 2 5 6 — 3 12 4 2 3 2 Measles 1184 13 43 97 128 147 706 41 4 3 2 — — 164 249 375 66 249 74 7 Whooping cough 58 2 6 5 4 4 28 6 — 3 — — — 6 7 15 1 16 12 1 Erysipelas 1 - - - - - - - - - - 1 - 1 - - - - - - Dysentery (Flexner) 2 — — — — — — — — 1 — 1 — 2 — — — — — — Poliomyelitis (Paralytic) 10 1 — 2 1 1 1 1 — 2 1 — — 2 — 4 1 1 2 — Poliomyelitis (Non para.) 3 — — — — 1 1 — — 1 — — — — 1 1 — — 1 — Typhoid — - - - - - - - - - - - - - - - - - - - Puerperal pyrexia 4 — — — — — — — — 3 1 — — — 2 2 — — — — Encephalitis 1 - - - - - 1 - - - - - - - - 1 - - - - Food poisoning 3 — •— — — — — — 1 2 — — — — — 1 — — 2 — Totals 1339 16 49 105 139 159 770 56 7 18 6 8 6 180 264 420 77 278 110 10 56 TABLE II. THE MONTHLY INCIDENCE OF INFECTIOUS DISEASE, 1957. Disease. Jan. Feb. Mar. A pril May June July Aug. Sept. Oct. Nov. Dec. Total Scarlet fever 9 8 14 7 2 1 - - - 3 2 1 47 Pneumonia — 9 6 3 — — 1 — 1 5 - 1 26 Measles 103 402 421 212 18 1 13 14 - - - - 1184 Whooping cough 4 3 7 7 2 3 21 5 2 - - 4 28 Erysipelas — — — 1 - - - - - - - - 1 Dysentery — — - - - 1 - 1 - - - - 2 Poliomyelitis 2 — 1 - 1 - - 5 1 3 - - 13 Typhoid fever — — — — — — - - - - - - - Puerperal pyrexia — 1 1 1 — — - 1 - - - - 4 Encephalitis — 1 — — — — - — — - — - 1 Food poisoning - — 2 — — — 1 - - — — — 3 Totals 118 424 452 231 23 6 36 26 4 11 2 6 1339 57 TABLE III. INFECTIOUS DISEASE NOTIFIED EACH YEAR SINCE 1927. Disease 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 1957 Smallpox _ — 2 2 3 4 — — — — — — — — _ _ _ Scarlet fever 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 47 Diphtheria 11 23 26 17 8 21 16 24 52 35 8 10 10 25 7 9 7 19 15 8 — — — — — — — Erysipelas 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 1 Typhoid and typhoid fever 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 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 4 Poliomyelitis 1 1 — 1 — 2 — 1 1 — 3 1 1 1 2 3 — — 2 1 11 2 9 10 — 8 9 1 17 7 13 Polio-encephalitis .. Acute encaphalitis . . 1 1 1 1 Ophthalmia neonatorum — 3 — 1 1 2 — 1 — 1 1 1 — 1 1 — 1 — 1 — — 1 — — — Pneumonia 9 7 38 11 14 29 28 20 32 13 30 12 52 19 32 38 27 9 17 16 20 13 5 23 51 21 44 20 31 36 26 Malaria — — — — — — — — — — — — — — — — — — — — — 1 — — — 2 Measles 2 11 214 479 275 52 705 41 218 567 600 477 810 170 1319 9 1012 82 1184 Dysentery — — 5 — — — — — 6 — 1 2 10 85 224 121 21 42 172 82 43 71 14 28 22 48 13 12 98 81 2 Whooping cough . . 6 1 136 36 55 51 100 31 115 201 42 242 204 196 66 131 64 93 58 Food poisoning .. 2 6 2 5 2 74 5 8 3 Tuberculosis :— Pulmonary 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 45 Other forms 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 2 Totals 153 174 232 162 135 154 196 235 265 213 197 162 207 323 743 809 632 337 1137 335 564 990 880 998 1260 579 1617 359 1333 408 1386 TABLE IV. DEATHS OCCURRING DURING THE YEAR, 1957. Cause of death. i2 £ 2 a "3 3 K v. s: £ ci c 3 c a <0 v. c -a <3 vo CJ v. R "*3 C <3 *0 Tt V. T3 K 3 C a >0 cn *0 vo K. "a c 3 "a s a VI ■<* k.* u > 0 -a c a W-v "a § »1 "a 5 ft, <>5 -Si § 0 5 ft. "3 § "3 s ft. "3 Respiratory tuberculosis 2 3 5 3 2 Other tuberculosis Syphilitic disease 2 5 — — 2 5 — — 1 6 Diphtheria — — — — — — — Whooping cough — — — — — — — — Meningococcal infections 1 — — — 1 1 — — Poliomyelitis 2 — — — 2 — — 2 — Measles — — — — — — — — Other infective and parasitic diseases 1 1 Cancer 53 59 18 24 71 83 — — 8 51 95 Leukaemia 3 3 — 3 3 — 1 3 Diabetes 2 2 2 2 4 — 2 4 Vascular lesions of nervous system 34 65 9 10 43 75 1 3 18 96 Coronary disease, angina 69 39 13 21 82 60 — 39 6 103 35 Hypertension with heart disease 3 9 6 23 9 32 Other heart disease 32 44 20 51 52 95 — 1 2 16 128 Other circulatory disease 15 35 5 6 20 41 — 1 6 54 Influenza 4 1 4 6 8 7 — — 2 2 11 Pneumonia 11 11 26 60 37 71 1 1 2 14 90 Bronchitis 11 6 13 2 24 8 — — 1 1 1 3 26 Other respiratory diseases 2 1 6 1 8 2 — — 1 3 6 Ulcer of stomach and duodenum 4 2 1 _ 5 2 7 Gastritis, enteritis — 4 — — — 4 — 2 2 Nephritis 5 1 — 1 5 — — 2 1 4 Hyperplasia of prostate 1 — 1 Pregnancy — 1 — — — 1 — — 1 — Congenital malformation 5 1 — 1 5 2 1 — 1 1 3 1 Other defined and illdefined diseases 21 24 7 35 28 59 13 2 3 3 15 51 Motor vehicle accidents 3 — — — 3 1 2 All other accidents ... 2 5 2 11 4 16 1 5 14 Suicide 2 4 2 2 6 4 3 1 Homicide — ■— — — — — — — Totals 287 322 135 257 422 579 16 3 2 7 2 35 194 742 58 TABLE V. TUBERCULOSIS - WARD DISTRIBUTION OF NEW CASES NOTIFIED 1957. Localisation. Coulsdon East. Coulsdon West. Kenley. Purley. Sanderstead. Selsdon. Woodcote. Pulmonary ... 7 16 7 6 5 3 1 Nonpulmonary 1 - - 1 - - - Totals 8 16 7 7 5 3 1 59 TABLE VI. TUBERCULOSIS - AGE GROUPS OF NOTIFICATIONS AND DEATHS, 1957. Age Periods. New Cases. Deaths. Pulmonary Nonpulmonary. Pulmonary. Nonpulmonary. M. F. M. F. M. F. M. F. Under 1 year - - - - - - - - 1 and under 5 2 - - - - - - - 5 and under 10 - - - - - - - - 10 and under 15 - - - - - - - - 15 and under 20 2 3 1 - - - - - 20 and under 25 — 1 - - - - - - 25 and under 35 4 3 — — 1 — — — 35 and under 45 5 7 - - - - - - 45 and under 55 6 3 1 — 1 — — — 55 and under 65 5 1 — — 3 — — — 65 and over 3 — — — 3 1 — — Totals 27 18 2 — 8 1 — — HOUSING. The following is a statistical record of work carried out in respeot of the sanitary condition of dwelling houses, as required by the Minister. 1. Inspection of Dwelling Houses during the year 1957 - (1) (a) Total number of houses inspected for housing defects (under Public Health or Housing Acts) 324 (b) Number of inspections made for the purpose 3,153 (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 24 (b) Number of inspections made for the purpose 126 (3) Number of dwelling bouses found to be in a state so dangerous or injurious to health as to be unfit for human habitation. 5 (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 293 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 224 3. Action under Statutory Powers during the year - (a) Proceedings under Sections 9> 10 and 12 of the Housing Act, 1957 - (1) Number of dwelling houses in respect of which notices were served requiring repairs Nil (2) Number of dwelling houses which were rendered fit after service of formal notices (a) By owners Nil (b) By Local Authority in default of Owners Nil (b) Proceedings under the Public Health Acts - (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 39 (2) N umber of dwelling houses in which defects were remedied after service of formal notices - (a) By owners 2 (b) By Local Authority in default of owners 29 (c) Proceedings under Sections 17 and 23 of the Housing Act, 1957 - (1) Number of dwelling houses in respect of which Demolition Orders were made 1 (2) Number of dwelling houses demolished in pursuance of Demolition Orders 1 (a) Proceedings under Section 18 of the Housing Act, 1957 - - 2 - (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made 1 (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 Housing Act, 1957, Part IV - Overcrowding - (a) (l) Number of dwelling houses overcrowded at the end of the year Nil (2) Number of families dwelling therein Nil {3) Number of persons dwelling therein Nil (b.1 Number of now cases of overcrowding reported during the year 1 (c) (l) Number of cases of overcrowding relieved during the year 3 (2) Number of persons concerned in such cases 16 (d) Particulars of any cases in which dwelling houses have again become overcrowded after the Local Authority has taken steps for the abatement of overcrowding Nil Number of New Houses erected during the year - By the Local Authority 28 Ey other persons 300 FACTORIES AND WORKPLACES. FACTORIES ACTS, 1937 and 192,8. FART I. 1. INSPECTIONS. Premises Number on Register Inspections Number of Written Notices Occupiers Prosecuted (i) Faotories in which Sections 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 39 29 - - (ii) Factories not included in (l) in which Section. 7 is enforced by the Local Authority 158 181 2 - (iii) Other premises in which Section 7 is enforced by the Local Authority (excluding outworkers' premises) 17 42 - - TOTAL 214 252 2 - 2. Cases 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). - - - - - Unreasonable temperature (S,3). - - - - — Inadequate ventilation (S„4). - - - - - Ineffective drainage of floors (S,6). - - - - - Sanitary conveniences (S,7). (a) Insufficient 3 2 - 2 — (b) Unsuitable or defective 10 21 - 2 - (c) Not separate for s^ces - - - Other offences against the Act (Not including offences relating to cutwork) - 1 - - - TOTAL 13 24 - 4 - PART VIII Outwork (Sections 110 and 111), NATURE OF WORK. 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 (Making etc. 47 - - - - - apparel (Cleaning & (washing - - - - - - Household linen 1 - - - - - Umbrellas, etc. 1 - - - - - Making boxes 1 - - - - - Carding, etc, of buttons, etc. 24 - - - Duster Dolls 5 - - - - - Coeaques,Christmas crackers, Christmas stockings, etc. 4 - - - - - TOTAL 63 - - 1 1 - PREVENTION OP DAMAGE BY PESTS ACT, 1949. The following table is a tabular statement indicating the action taken in 1957. 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. Otherwise Total Rats Mice Rats Mice Treatment Structuaal works i.e. proofing Primary and reinsepctions. Sewer treatment Total local Authority 5 16 21 .6 1 6 1 - - telling Houses 327 91 418 224 40 199 - - - Business Premises 36 52 88 28 16 25 16 - - 4,265 1,148 5,413 Agricultural - 82 82 5 3 3 1 - - TOTAL 368 241 609 263 60 233 58 - - V 1 * 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 1957 - Complaints Received. General disrepair and insanitary conditions 21 Dampness 14 Defective drainage systems 24 Blocked drainage systems 181 Defective drainage fittings 4 Defective W.C. pans and flushing apparatus 6 Defective service water pipes 4 Defective chimney stacks 1 Absence of, or defective dustbins 3 Insanitary pig waste bins 3 Accumulation of refuse, etc 15 Hats and mice 369 Keeping of animals 3 Insect pests, etc. 28 Wasps nests 67 Smoke nuisance 4 Contaminated food 11 Unsound food 38 Miscellaneous 35 TOTAL 831 WORK CARRIED OUT AND DEFECTS REMEDIED. Drainage and Sanitary Fittings: Drains repaired or reconstructed 110 Blocked drains cleared 211 Disused drains sealed off 7 Soil and vent pipes repaired/renewed 7 Inspection chambers provided or repaired 91 Fresh air inlet repaired or renewed 19 Stoppers to interceptors renewed 18 New W.G. pans fixed 21 W.0o cisterns repaired or renewed 8 Cesspools abolished and filled in 10 Drainage disconnected from cesspool and connected to sewer 5 Cesspools cleansed,5 Soakaways provided or reconstructed 12 Eaves gutters and rainwater pipes renewed/repaired 40 Lavatory basins renewed or provided 7 Baths renewed or provided 2 Sinks renewed or provided 3 Waste pipes renewed or repaired 7 Sink gully curbs and dishings renewed 29 Miscellaneous 4 General Housing Repairs: Defective roofs repaired 28 Chimney stacks repaired or rebuilt 20 External walls repaired 28 Yards paved or paving repaired 11 Steps repaired or renewed 3 External paintwork renewed 11 Boundary fences & gates repaired or renewed 2 Coalsheds repaired or renewed 1 Dampness in walls remedied 58 Dampproof courses provided 23 Walls and ceilings repaired 60 New ceilings provided 4 Walls of rooms cleansed or redecorated 68 Ceilings of rooms cleansed or redecorated 49 Floors repaired or renewed 30 Internal woodwork cleansed or redecorated 14 Additional sub-floor ventilation provided 4 Staircases repaired or renewed 2 Windows repaired or renewed 76 Doors repaired or renewed 11 Firegrates repaired or renewed 16 Domestic hot water systems repaired or renewed 3 Water storage tanks repaired or renewed 1 Water service pipes repaired or renewed 10 Additional ventilation or light provided to W.C. compartments 2 Walls and ceilings of W.C. compartments repaired 11 Walls and ceilings of W.C. compartments cleansed 7 Floors to W.C. compartments repaired or renewed 4 Portable dustbins provided 29 Miscellaneous 38 624 B/fd 624 Food Promises: Premises reconstructed 1 Premises altered and improved structurally 10 Floors repaired/renewed/recovered 19 Walls and ceilings of rooms repaired 48 Walls of rooms cleansed or redecorated 105 Ceilings of rooms cleansed or redecorated 77 Windows repaired or renewed 8 Doors repaired or renewed 4 Woodwork cleansed or redecorated 37 Roofs repaired 2 Rainwater pipes and gutters repaired or renewed 4 External walls repaired 1 Yards paved or paving repaired 2 Pood stores provided 7 Sinks renewed or new sinks provided 43 Draining boards provided 6 Hot water supply provided for personal ablution purposes 32 Hot water supply provided for cleansing purposes 15 Waste pipes repaired or renewed 3 Towels, soap, nailbrushes supplied 7 First-aid equipment supplied 24 Lockers for clothing provided 9 Equipment cleansed 9 Equipment renewed or repaired 16 New equipment provided 5 Additional lighting provided 7 Additional ventilation provided 11 Sanitary accommodation provided for staff*.3 Sanitary accommodation repaired 16 Sanitary accommodation cleansed 42 Staff rooms provided 1 Lavatory basins provided 27 •Miscellaneous 74 675 Ratproofing: Work carried out by occupiers of premises after completion of treatment 11 Heating Appliances (Fireguards) Act, 1952: Fires altered or withdrawn from sale 2 Shops Act: Heating provided 1 Additional sanitary accommodation provided 1 Wasihing facilities provided 1 NOTICES SERVED. Preliminary Notices 644 Statutory Notices 55 SUMMARY OF VISITS MADE. Number of houses visited in respect of improvement and repair 326 Number of reinspections made to above houses in respect of improvement and repair 2,831 Verminous premises 19 Insect posts 181 Water supply 8 Tents, vans and sheds 39 Schools 12 Places of entertainment 38 Licensed, premises 36 Storage of refuse 58 ACCmulatlOn 140 Piggeries, fowls and other animals 66 Stables 9 Rodent control 5,413 Drainage inspected 1,517 Drainage tested 285 Cesspools 126 Urinals 10 Sewers and street gullies 110 Cowsheds., dairies and milkshops 81 Ice cream premises 52 Meat shops 99 Pood preparing premises 505 Other food shops 528 Bakehouses Power 37 Slaughterhouses 22 Food inspection - Meat 31 Food inspection - other food 51 Factories - Power 144 " Other 15 Workplaces 56 Outworkers 111 Heating Appliances (Fireguards) Act 6 Merchandise Marks Act 5 Pet Animals Act 10 Shops Act 931 Mines and Quarries Act 27 Clean Air Act 9 Hairdressing Establishments 24 Infectious disease enquiries 116 Infectious disease contacts 9 Food poisoning enquiries 13 Disinfection 114 Disinfestation 39 Swimming baths 74 Sampling - Food and Drugs Act, 1955 192 " Ice Cream 135 " Milk (Bacteriological) 225 " Milk (Biological) 2 " Water 13 Interviews 2,298 Miscellaneous Visits 974 Total 18,172 ' . . - FOOD AND DRUGS ACT, 1955. The following samples were taken during 1957 and submitted to the Public Analyst, with the results shown - Article. Analysed Non-Genuine Formal Informal Total Formal Informal Total. Aspirin 3 - 3 - - - Almonds, Ground 1 - 1 - - - Baking Powder 1 - 1 - - - Bread 2 - 2 - - - Broad, Buttered 1 - 1 1 - - Butter 2 - 2 - - - Boracic Ointment - 1 1 - - - Beer 2 - 2 - - - Biscuits 1 - 1 - - - Cloves 1 - 1 - - - Confectionery 6 1 7 - - - Cordial 2 1 3 - - - Coffee, Ground 2 - 2 - - - Cream 2 - 2 - - - Crab, Dressed 1 - 1 - - - Cake 1 - 1 - - - Cake Decorations 1 - 1 - - - Cheese 2 - 2 - - - Cheese Spread 2 1 3 1 - 1 Fruit, Dried 2 - 2 - - - Fruit, Tinned 1 - 1 - - - Fruit, Loaf 2 - 2 - - - Fish Cakes 1 - 1 - - - Fish Paste 1 - 1 - - - Fat,Cooking 1 - 1 - - - Gluco Juice 1 - 1 1 — 1 Horseradish Sauce 1 - 1 - - - Icing Sugar 1 - 1 - - - Ice Cream 1 - 1 — - — Ice Cream Powder 1 - 1 - - - Jelly, Table 1 - 1 - - - Jelly Fruit Salad 1 - 1 1 - 1 Jam 1 - 1 — — - Lozenges, Throat 3 - 3 - - — Lemon Flavouring 1 - 1 — — - Lemonade Crystals 1 - 1 - — - Milk 60 4 64 - - - Milk, Hot 1 - 1 1 - 1 Marmalade 1 - 1 - — — Meat Paste 1 - 1 - - — Meat, Minced 1 - 1 - - - Meringues 1 - 1 1 - 1 Marzipan 1 - 1 - — — Onion Salt l - 1 - - - Pep-Up Tablets 1 - 1 - - - Peas, Tinned 1 - 1 - — — Pepper, Cayenne 1 - 1 - - - Paraffin, Liquid 1 - 1 - - - Pudding Mixture 1 - 1 - - - Pasties 1 - 1 - - - Peel, Mixed 1 - 1 - - - Peanuts, Salted 1 - 1 - - - Rice 2 - 2 - - - Ravioli 1 - 1 - - - Steak, Tinned 1 - 1 - - - Steak, Frozen 1 - 1 - - - Salts, Health 2 - 2 - - - Sausages, Pork 1 - 1 - - - Stuffing - 1 1 - - — Spam - 1 1 - — — C/f 137 10 147 6 - 6 - 2 - Article Analysed Non-Genuine Formal Informal Total Formal Informal Total B/fd 137 10 147 6 - 6 Salmon Steak,Frozen - 1 1 - - - Sal Volatile 1 - 1 - - - Sugar 1 - 1 - - - Soup 1 - 1 - - - Suet, Beef 1 - 1 - - - Spirits 5 - 5 - - - Soda Mint Tablets 1 - 1 - - - Tapioca Flakes 1 - 1 - - - Tomatoes, Tinned 3 - 3 - - - Vinegar 1 - 1 - - - Vitamin Tablets 3 - 3 - - - Vermicelli 1 - 1 - - - Wine 1 - 1 - - - 157 11 168 6 - 6 INFANT MORTALITY DURING THE YEAR 1957. Cause of death. Under 1 week 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total deaths under 1 year. ASPHYXIA NEONATORUM PNEUMONIA PREMATURITY AND ATELECTASIS 13 13 1 14 ACCIDENT • MENINGOCOCCAL MENINGITIS 1 1 CONGENITAL MALFORMATIONS. 1 1 TOTALS. 13 13 1 1 1 16