MER 5 library Merton and Morden Urban District ANNUAL REPORT OF THE Medical Officer of Health FOR THE YEAR 1943 AND REPORT OF The Sanitary Inspector Merton and Morden Urban District ANNUAL REPORT OF THE Medical Officer of Health FOR THE YEAR 1943 AND REPORT OF The Sanitary Inspector PREFACE. To the Chairman and Members of the Merton and Morden Urban District Council. Mr. Chairman, Ladies and Gentlemen, I have the honour to present my Annual Report for the year 1943. It is my intention to endeavour to keep this report as concise as possible, but as the annual report serves to a large extent as a reference, it is often necessary to include descriptions of public health activities even though they have been fully dealt with in previous years. In this way, while repetition is inevitable, the risk of the report losing much of its value for reference purposes is avoided. The vital statistics for the year 1943 are in every respect satisfactory. The birth rate has risen again above last year's highest figure since 1927, and is, in fact, the highest recorded since 1923. This is a remarkable and noteworthy fact, that to find a comparable birth rate we have to go back to the years after the last war twenty years ago. The total number of live births has made a new record. The 1942 figure of 1,069 was then the highest recorded until now, the figure for 1943 is 1,146. The infant mortality rate at 23.5 deaths of children under one year per 1,000 live births is another record. As has been mentioned in previous reports, the infant mortality figure is always anxiously watched. This figure follows closely the progress in infant care and management. It has been mentioned before that during the past thirty years the infant mortality figure for England and Wales as a whole has dropped from 130 to 50. The figure for Merton and Morden is even more remarkable. In 1898 the rate was 212 per 1,000 births. This was before the amalgamation of Merton and Morden and represents the figure for Merton alone. For the ten years up to 1907 the average was 108. In 1908 it suddenly dropped to 48, and it is recorded as a matter for congratulation, at the same time pointing out that the lowest figure recorded for the previous ten years was 85. Our present figure is the lowest ever recorded and, with one exception, this figure for the district has been at or below 40 for the past ten years. Sixty per cent. of these deaths occurred in the first month of life. Of the total deaths of infants under one year, 18 occurred in the first month. This, as I have remarked in previous years, points to the fact that until the hazards to the 2 infant of ante-natal development, and of parturition, are reduced, no further diminution of infant mortality comparable with that achieved over the past two or three decades by improvement in infant care, is possible. The remaining statistics present no features to arouse comment, and are satisfactory. Among the notifiable infectious diseases Measles during the year assumed epidemic proportions, and there was high incidence of Whooping Cough, and to a less extent, Scarlet Fever. Information from other sources suggests also that there has been, during the year, an increase in non-notifiable diseases and in milder infections. Returns from the schools and information from medical practitioners show that a mild form of gastro-enteritis was fairly widespread at certain periods during the year, not adequately revealed probably by dysentery notifications. Towards the end of the year, influenza threatened to assume epidemic proportions. The all-out production effort and the consequent absence of the usual sources of domestic assistance gave rise to some anxiety, so much so that the Ministry of Health sought the aid of the Women's Voluntary Service to secure that ill people should be able to remain in bed. Fortunately the epidemic was of very limited extent and the arrangements made were not extensively required. It remains for me to place on record my appreciation of the loyal and unstinting labours of my staff. Through a period of great difficulty the members of the Public Health staff have carried on, and what success the department may have achieved is largely due to them. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient Servant, A. WALLACE JOHNS, Medical Officer of Health. September, 1944. 8 URBAN DISTRICT COUNCIL of MERTON and MORDEN 1943 NO. 3 COMMITTEE (SERVICES). Chairman: Mrs. H. Cobbett. Mr. F. H. Brinkworth. Mrs. L. A. Doel. Mr. Roberts Brown. Mr. W. E. Gibson. Mrs. E.' M. Clifton, J.P. Mr. J. R. Leggett. Mr C. C. Cockbain. Mr. W. S. Le Gros Clark. Mr. G. F. Coleman. Mrs. S. A. Lodge. Mr. A. E. Davison. Mr. A. T. Piner. Mr. E. Young. Mr. S. F. Franklin, J.P. (ex-officio). Mr. S. W. Billingiham (ex-officio). REPRESENTATIVES ON THE WANDLE VALLEY JOINT HOSPITAL BOARD. Mrs. H. Cobbett. Mr. F. J. Grimme. Mr. W. S. Le Gros Clark. REPRESENTATIVES ON THE WANDLE VALLEY JOINT SEWERAGE BOARD. Mrs. E. M. Clifton, J.P. Mr. S. F. Franklin. Mr. D. Shadbolt. REPRESENTATIVES ON NELSON HOSPTAL COUNCIL. Mr. V. H. Auger. Mr. W. H. Glasscock. Mr. F. J. Grimme. 4 ERRATA NO. 3 COMMITTEE (SERVICES) Add Mr.S.Beven, and substitute for ex-officio members Mr.W.S.Le Gros Clark,J.P. (ex-officio) Mr.S.F.Franklin (ex-officio) REPRESENTATIVES ON WANDLE VALLEY JOINT HOSPITAL BOARD. Add Mr.G.F.Coleman, and the letters 'J.P.' after Mr.W.S.Le Gros Clark's name. REPRESENTATIVES ON WANDLE VALLEY JOINT SEWERAGE BOARD Add Mr.W.S.Le Gros Clark, J.P. (ex-officio) REPRESENTATIVES ON NELSON HOSPITAL COUNCIL Substitute Mr.P.Hill for Mr.V.H.Auger. PUBLIC HEALTH STAFF, 1943. Medical Officer of Health: A. Wallace Johns, M.E.C.S., L.R.C.P., D.P.H. Assistant Medical Officer of Health: Evelyn B. G. Ewen, M.B., Ch.B. Edin., D.P.H. Chief Sanitary Inspector: a J. B. Pointon, M.S.I.A. Deputy Chief Sanitary Inspector: a b F. C. Thomas, M.S.I.A. Sanitary Inspectors: a d C. Jones, M.S.I.A. a c N. Smith, M.S.I.A. Senior Health Visitor: Miss E. M. Sperry. Health Visitors: Miss A. R. Taylor. Miss M. E. Black. Miss A. Howard. Miss V. M. Evans. Senior Clerk: H. J. Herbert. Clerks: Mrs. E. Lang. A. J. Fletcher. R. A. Connolly. Assistant Medical Officer for Maternity Clinics: Up to September, 1943— Dr. Stanley Bond, M.B., Ch.B., M.R.C.O.G. From September, 1943— Dr. Anthony Partridge, M.R.C.S., L.R.C.P. Bacteriologist: F. Deas, M.R.C.S., L.R.C.P. Consulting Obstetrician under the Puerperal Pyrexia Regulations and Public Health Act, 1936—Part VII.: Aubrey Goodwin, O.B.E., M.D., F.R.C.S., Panel of Honorary Staff of Queen Charlotte's Hospital. Anesthetist to Maternity and Child Welfare Dental Clinics: Mary M. Tulloch, M.B., B.S. Dentist to Maternity and Child Welfare Dental Clinics: H. W. Fynn, L.D.S., R.C.S. (Eng.). a Meat and Food Inspector's Certificate, Royal Sanitary Institute. b Sanitary Science Certificate, University of Liverpool. c Smoke Inspector's Certificate, Royal Sanitary Institute. d Meat and Food Certificate, Royal Sanitary Association of Scotland. 5 SECTION A. STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 3,238 Number of inhabited houses according to Rate Books 21,160 Rateable value at 31st December, 1943 £644,510 Sum represented by Id. rate £2,615 approx. Industry. The number of factories registered under the Factories Act at the end of 1943 was:— Factories with mechanical power:— Employing more than 40 persons 43 Employing less than 40 persons 93 Factories without mechanical power 16 152 Public Assistance. The following information as to Public Assistance is supplied by the courtesy of the Chief Public Assistance Officer of the Surrey County Council. Medical Relief. Number of persons admitted to Public Assistance hospitals from Merton and Morden 74 (These figures do not include those admitted direct to Hospitals by the local doctors) Number of persons admitted to mental hospitals 42 Average number of persons in receipt of Medical Relief only 4 Total number of persons in receipt of domiciliary assistance on:— 1st January, 1943 319 1st July, 1943 253 31st December, 1943 229 Total amount of domiciliary assistance granted in Merton and Morden in the year 1943 £9,002 5 4 The figures above relating to the number of admissions to hospitals is only in respect of those patients who were referred to hospital by the Relieving Officer. In this connection it should be observed that several of the hitherto Public Assistance Institutions have been appropriated by the County Health Department and consequently numerous admissions to hospitals have been made direct under public health arrangements which are not shown in these figures. 6 Climatic Conditions. Rain gauges are installed at the Joseph Hood Recreation Ground and West Barnes Pumping Station. The monthly recordings are as shown below:— RAINFALL, 1943. JOSEPH HOOD RECREATION GROUND WEST BARNES PUMPING STATION Inches. Inches. January 5.11 5.16 February 1.88 2.10 March .33 .31 April .78 .84 May 1.85 1.90 June 1.04 1.28 July 1.30 1.57 August 1.49 1.31 September 1.44 1.69 October 2.76 2.75 November 1.14 1.22 December 1.50 1.64 Total 20.62 21.77 VITAL STATISTICS. Reference has been made in the Preface to the satisfactory record revealed by the vital statistics for the year 1943. The birth rate was 17.4 per 1,000 population with a total number of live births of 1,146. The death rate was 8.7 per 1,000 population compared with the corresponding figure for England and Wales as a whole of 12.1 per 1,000 population. The infant mortality rate was 23.5 per 1,000 live births as compared with a figure of 49 for England and Wales. These figures establish three records for the district, the lowest infant mortality rate ever recorded, the highest total number of births ever recorded, and the highest birth rate since 1923. 7 The infant mortality rate is the number of deaths of infants under one year per thousand live births. They are set out in the appended table:— England and Wales. Merton and Morden. 1940 55 34.3 1941 59 42.5 1942 49 33.9 1943 49 23.5 It will be observed that the number of illegitimate births at 57 is the highest ever recorded for the district, and while the absence of any deaths of illegitimate infants under one year of age gives an illegitimate infant mortality rate of nil, this does not by any means convey a true picture. Appended is a table to illustrate this fact. It compares the mortality rate of illegitimate infants with legitimate infants for the previous ten years. Year. Infant Mortality Rate among Legitimate Infants. Infant Mortality Rate among Illegitimate Infants. 1933 48.1 105 1934 39 90.9 1935 38.8 40 1936 35.4 55.5 1937 39.4 142 1938 39.3 161 1939 30.3 185 1940 34.3 172 1941 40.7 75 1942 32 51 Average 37.8 Average 107.7 It will be seen that the chances of survival during the first year of life are three times better for a legitimate child than for an illegitimate one. 8 SUMMARY OF VITAL STATISTICS. (Registrar General's Figures), Population: Registrar General's Estimate ... ... 65,880 Births: M. F. Total Live (Leg.) 563 526 1,089 (IIIeg.) 25 32 57 588 558 1,146 Still Births 17 9 26 Birth Rate 17.4 per 1,000 population Still Birth Rate 23.5 per 1,000 births Deaths: M. F. Total 304 271 575 Death Rate 8.7 per 1,000 population Infant Mortality: Total deaths under 1 year 27 Infant Mortality Rate per 1,000 Live Births 23.5 Deaths of Legitimate infants under 1 year 27 Death Rate per 1,000 live births 23.5 Deaths of Illegitimate infants under 1 year Nil Maternal Mortality: Deaths from Sepsis 1 Deaths from other principal causes — Maternal Death Rate 0.85 Zymotic Deaths: Deaths from Measles 1 Whooping Cough 1 Diarrhoea (under 2 years) 2 7 Principal Zymotic Diseases 5 Zymotic Death Rate (per 1,000 population) 0.076 Deaths from Tuberculosis: All Forms 39 Rate per 1,000 population 0.59 Phthisis 35 Rate per 1,000 population 0.53 Deaths from Cancer 116 Rate per 1,000 population 1.7 9 Table I. COMPARATIVE STATISTICS, 1943. (Registrar General's Figures with Corresponding Figures for Merton and Morden added). England and Wales. 126 County Boro's and Great Towns including London. 148 Smaller Towns (Residential Populations 25,000 to 50,000 at Census). London Adminis- tive County. Merton and Morden. Rates per 1,000 Population. Births:— Live 16.5 18.6 19.4 15.8 17.4 Still 0.51 0.63 0.61 0.45 0.39 Deaths:— All causes 12.1 14.2 12.7 15.0 8.7 Typhoid and Paratyphoid fevers 0.00 0.00 0.00 0.00 0.00 Scarlet fever 0.00 0.00 0.00 0.00 0.00 Whooping Cough 0.03 0.03 0.03 0.03 0.01 Diphtheria 0.03 0.04 0.04 0.02 0.01 Influenza 0.37 0.36 0.37 0.27 0.28 Smallpox — — — - — Measles 0.02 0.02 0.02 0.02 0.01 Notifications:— Typhoid Fever 0.01 0.01 0.02 0.01 0.01 Paratyphoid fever 0.01 0.01 0.01 0.01 0.00 Cerebro-spinal fever 0.08 0.10 0.06 0.09 0.04 Scarlet fever 3.01 3.29 3.54 3.80 4.13 Whooping Cough 2.54 2.82 2.25 2.68 3.82 Diphtheria 0.88 1.12 0.77 0.74 0.24 Erysipelas 0.31 0.35 0.27 0.42 0.16 Smallpox -— — — — — Measles 9.88 9.23 9.77 9.17 6.58 Pneumonia 1.34 1.62 1.16 1.27 1.24 Rates per 1,000 Live Births. Deaths under 1 year of age 49 58 46 58 23.5 Deaths from Diarrhoea and Enteritis under 2 years of age 5.3 7.9 4.4 10.4 1.7 Rates per 1,000 Total Births (Live and Still). Maternal Mortality (excluding Abortion) Puerperal Infection No. 147 0.39 Not av ailable 0.84 Others 1.45 — — Total 1.84 0.84 Notifications:— Puerperal fever 11.68 15.11 9.26 3.05 7.6 Puerperal pyrexia 15.23* " Including Puerperal Fever. 10 Population. The Registrar General's Estimate of the mid-year population for 1943 is 65,880. The practice of providing separate population figures for calculation of birth rates and death rates, and incidence of infectious disease has been discontinued. Similarly the attempt to secure comparability between local death rates by the use of areal comparability factors has been abandoned. Two special population estimates have been made by the Registrar General for 1943 to assist in obtaining uniformity in the Diphtheria immunisation figures. These are the under five population and the five to fifteen population. The figure for the age group 0—4 inclusive is 4,939, and for the age group 5—14 inclusive 9,855. The estimated population of the Wards is as follows:— Wards. Dwellings at mid. 1943. Estimated Population mid. 1943. Abbey 1,407 7,384 Bushey Mead 2,137 8,064 Central 3,026 8,163 Morden 3,117 10,867 Park 2,845 5,374 Ravensbury 1,832 6,988 Raynes Park 2,111 10,906 St. Helier 2,855 11,906 West Barnes 1,933 11,559 21,263 81,211 BIRTHS. The registered live births totalled 1,146, an increase of 77 over the previous year; and the birth rate has shown a corresponding rise from 16.05 to 17.4 per 1,000 of the population. Of the total live births 588 were males and 558 females. There were 57 illegitimate births, the highest figure ever recorded for the district; of these 25 were males and 32 females. There were 26 stillbirths; seventeen males and nine females. Institutional and Domiciliary Births. The appended table shows a further increase in institutional births, and a decrease in domiciliary births. This trend of recent years has been accelerated by the difficulties of providing help in the home, and absence of husbands, and absence, in consequence, of any company in the house—a factor which no home help scheme can entirely cover. It will be seen that 325 mothers from our district had their babies in St. Helier Hospital. It would seem that the 11 availability of beds for some time yet will be the only limitation on this tendency to institutional confinements. It is to be hoped that this obstacle will be removed, lor it is difficult to see what arguments can be adduced for attempting to restrain this desire for in-patient accommodation. Many of us are heartily in favour of the institutional delivery of as many as may desire the accommodation, and would insist that all mothers with their first baby should be confined in hospital. Institutional births for the year were as under:— Nelson Hospital 236 St. Helier Hospital 325 Kingston County Hospital 43 Other hospitals, institutions and nursing homes 187 791 TABLE II. Showing Births and Deaths with Rates since the Amalgamation of Merton with Morden. Year. Estimated population. Total Births. Birth Rate. Total Deaths. Death Rate. 1913 16,767 400 23.5 166 9.9 1914 17,500 420 24 142 8.2 1915 17,500 402 22.9 169 10.4 1916 16,000 348 27.75 134 8.3 1917 17,000 271 15.75 145 9.0 1918 17,552 241 14 204 13.0 1919 18,100 257 14.2 210 11.8 1920 18,200 359 19.8 171 9.4 1921 18,000 322 17.8 138 7.0 1922 18,500 365 19.7 198 10.7 1923 18,750 341 18.1 153 8.1 1924 18,710 311 16.6 170 9.1 1925 18,960 307 16.2 187 9.9 1926 19,980 333 16.7 179 9.0 1927 21,850 352 16.13 200 9.2 1928 25,780 392 15.2 224 8.7 1929 27,430 442 16.1 281 10.2 1930 35,000 452 12.9 241 6.9 1931 41,610 628 15.1 333 8.0 1932 48,550 770 15.8 352 7.2 1933 52,130 644 12.3 416 7.9 1934 55,550 770 13.8 484 8.7 1935 57,440 721 12.5 433 7.5 1936 61,000 789 12.9 443 7.2 1937 65,530 812 12.3 487 7.4 1938 68,980 990 14.3 509 7.3 1939 72,150 1,005 13.9 516 7.2 1940 68,540 971 14.2 714 10.4 1941 64,920 848 13.06 557 8.58 1942 66,590 1,069 16.05 588 8.8 1943 65,880 1,146 17.4 575 8.7 12 DEATHS. The number of registered deaths after adjustment by transferable deaths, is given below:— 575 total deaths, of which 304 were males and 271 females. The Seasonal mortality is indicated by the deaths for each quarter of the year, which were:— First quarter 166 Second quarter 166 Third quarter 131 Fourth quarter 167 Inquests. Inquests were held in the district on 16 deaths. Verdicts were as follows:— (1) Natural causes 5 (2) Suicide by— Coal gas poisoning 2 3 Drowning 1 (3) Accidental deaths— Electrocution on railway 1 6 Bullet wound in chest 1 Collision with object while leaning out of train 1 Fall from scaffolding 1 Collision with lorry while riding pedal cycle 1 Fall in home 1 (4) Misadventure— Hemorrhage into a cyst adenoma of thyroid gland accelerated by administration of Sodium Amytal and paraldehyde for acute melancholia 1 2 Hæmorrhage following dissection of tonsils 1 — 16 Road accidents were responsible for 3 of the total deaths compared with 4 in 1942. CAUSES OF DEATH. Diseases of the heart as usual head the list of causes of death, and second place is taken by Cancer, which again shows a slight increase. Deaths from Tuberculosis, however, have fallen this year compared with the figures for the previous nine years. 18 The appended tables show the number of deaths from Cancer during the past ten years and the corresponding death rates. CANCER DEATH RATE. No. of deaths from Cancer for past 10 years. 1934 66 1939 91 1935 50 1940 76 1936 74 1941 85 1937 93 1942 103 1938 89 1943 116 Year. Death Rate per 1,000 population. Year. Death Rate per 1,000 population. 1934 1.2 1939 1.1 1935 1.0 1940 1.2 1936 1.2 1941 1.3 1937 1.4 1942 1.5 1938 1.2 1943 1.7 TABLE III. Deaths from Respiratory Diseases, 1925-43. Year Bronchitis Pneumonia Other Respiratory Diseases Total Death Rate 1925 6 16 1 23 1.2 1926 6 8 5 19 0.9 1927 10 11 5 26 12 1928 8 14 2 24 0.9 1929 11 20 4 35 1.2 1980 2 10 3 15 0.4 1931 8 24 4 36 0.8 1932 11 27 8 41 08 1988 12 32 6 50 0.9 1934 7 88 4 49 08 1935 9 22 6 37 0.6 1936 2 35 2 89 0.6 1987 14 31 6 51 0.8 1938 15 27 7 49 0.7 1939 5 20 9 84 0.4 1940 38 40 15 93 13 1941 30 30 6 66 0.9 1942 9 12 20 41 0.62 1943 25 36 9 70 1.05 Respiratory Diseases. It will be seen from the Table that there was an unusually high death rate from respiratory diseases. These rates follow closely influenza incidence, and it will be noted in Table IV on page 15 that there were 19 deaths from influenza, an unusually high number. 14 TABLE IV. Causes of Death during the Year 1943. No. Cause of Death. Males Females Total 1 Typhoid and Paratyphoid Fevers - - - 2 Cerebro spinal fever 1 1 2 3 Scarlet Fever — — — 4 Whooping Cough — 1 1 5 Diphtheria 1 — 1 6 Tuberculosis Respir. System 22 13 35 7 Other forms of Tuberculosis 3 1 4 8 Syphilitic diseases 1 2 3 9 Influenza 6 13 19 10 Measles — 1 1 11 Ac. Polio-myel. and polioencephalitis - 1 1 12 Ac. inf. encephalitis — — — 13 Cancer of buc. cav. and oesoph. (M) uterus (F) 4 5 9 14 Cancer of stomach and duodenum 10 7 17 15 Cancer of breast 1 15 16 16 Cancer of all other sites 42 32 74 17 Diabetes 3 3 6 18 Intra-cranial vascular lesions 18 19 37 19 Heart disease 72 63 135 20 Other dis. of circ. system 10 11 21 21 Bronchitis 17 8 25 22 Pneumonia 20 16 36 23 Other respiratory diseases. 4 5 9 24 Ulcer of stom. or duodenum 5 2 7 25 Diarrhoea under 2 years 1 1 2 26 Appendicitis 2 1 3 27 Other digestive diseases 6 16 22 28 Nephritis 7 4 11 29 Puer. and post abort, sepsis — 1 1 30 Other maternal causes — — — 31 Premature birth 5 1 6 32 Con. mal. birth inj. inf. dis. 7 5 12 33 Suicide 2 2 4 34 Road traffic accident 3 — 3 35 Other violent causes 6 5 11 36 All other cause 25 16 41 Total all causes 304 271 575 15 MATERNAL MORTALITY. One death only occurred in the year from maternal causes. The maternal mortality rate was 0.85 and reference to the appended Table will show this is the lowest recorded for the past two decades. While this is eminently satisfactory it will be appreciated that with small numbers such as local statistics provide, a single unfortunate death can convert the maternal mortality for that particular year from a satisfactory level to an abnormally high level. Hence it is essential for comparison to examine the figures over a period of years. Such scrutiny none the less reveals a very satisfactory rate for the district. In the single death which occurred, actually not in the district, a post mortem examination was done and the cause of death was certified by the Coroner to be:— Hæmorrhage from Placenta Prævia and Multiple fibroids of uterus. TABLE V. Maternal Mortality, 1924-43. Year Death rate per thousand total births. Sepsis Other causes Total 1924 - 3.2 3.2 1925 — 6.5 6.5 1926 — — — 1927 — 2.8 — 928 — — — 1929 2.2 — 2.2 1930 — 2.2 2.2 1931 1.6 3.1 4.7 1932 5.1 2.5 7.7 1933 2.9 1.4 4.3 1934 2.5 2.5 5.0 1935 — 2.6 2.6 1936 2.4 — 2.4 1937 1.2 1.2 2.4 1938 0.98 1.96 2.95 1939 — 3.93 3.93 1940 1.04 — 1.04 1941 — 2.3 2.3 1942 0.93 1.87 2.80 1943 0.85 - 0.85 Maternal deaths occurring within the area are enquired into personally by the Medical Officer of Health and a 16 fidential report in each case is forwarded to the Maternal Mortality Committee of the Ministry of Health in accordance with the recommendation contained in the Committee's report on Maternal Mortality. INFANT MORTALITY. In the introduction to this report attention has been drawn to the satisfactoriness of the infant mortality, and the comfort that may be derived from the implication of these figures. There were 27 deaths of infants under one year of age, of whom 15 were male and 12 female. None of these were illegitimate infants. The appended details of causes of neonatal deaths illustrates well the observations made in the introduction to this report, and shows clearly enough where any further saving of infant life will have to take place. Neonatal Deaths with Causes of Death. Sex. Age. Cause. Male 10 minutes Erythroblastosis Fœtalis. Female 6 days Patent interventricular Septum. Male 2 days Atelectasis and Prematurity. Male 1 day Congenital Heart Disease. Female 4 hours Prematurity. Female 6 weeks Intussusception. Female 1 day Atelectasis. Male 2 weeks Malnutrition—Cleft Palate. Male 2 hours Prematurity. Male 1 month Septicæmia—Gastro-enteritis. Female 20 minutes Atelectasis. Male 14 hours Prematurity—Maternal Eclampsia. Male 1 day Atelectasis—Prematurity. Male 7 hours Cyanotic attacks—Prematurity. Male 15 minutes Atelectasis. Prenatal inspiration of meconium and Liquor Amnii. Male 1 month Marasmus. Gastro Enteritis. Male 6 hours Prematurity—Atelectasis. Female 5 minutes Multiple Congenital Malformations. It is interesting to analyse these causes of death, bearing in mind the two before-mentioned broad groups, developmental faults and birth hazards. It will be seen that out of the 18 deaths 12 occurred within 24 hours of birth and actually 14 within the first week. This reveals that 40 per cent. of our infant mortality is due to deaths within 24 hours of birth. Five deaths are clearly attributable to the second group alone—developmental errors. Prematurity figures as a cause in 7 of these deaths and the new requirement of the birth notification to indicate where the infant is less than 5½ lbs. will shed a 17 valuable light,on the significance of this cause, and Atelectasis is given as the cause of 6, without associated prematurity in 4 of the cases. SECTION B.—HEALTH SERVICES. Nursing in the Home. Three voluntary associations provide nursing facilities in the District. The Council makes an annual contribution to the funds of each and arrangements have been agreed for nursing assistance to be available for cases referred through the Council's Health Services. (1) The Merton Parish Nurse Fund employs one nurse for general nursing; no midwifery or maternity nursing is undertaken. The district served is approximately the ecclesiastical parish of St. Mary's. A total of 150 cases involving 1,787 visits were attended during the year 1943, of these 77 cases were children under 5 years of age to whom 96 visits were made. (2) The St. Helier District Nursing Association employs one nurse for general nursing. No midwifery nor maternity nursing is undertaken. Its activities cover the whole of the Merton and Morden portion of the St Helier Estate and in addition that part situated in the Carshalton Urban District lying to the North of Reigate Avenue. During 1943, 169 eases were dealt with by the St. Helier District Nursing Association, 26 of these were children under 5. The total number of visits made was 1,995, of which 184 were in respect of children under 5 years. (3) The Wimbledon District Nursing Association serves Wimbledon and the western part of this District. Nurses are employed for general nursing in Merton and Morden. The figures relating to cases and visits in Merton 'and Morden during 1943 are as follows:— Cases. Visits. Children under 5 yrs. 47 333 Maternity 8 59 Midwifery — — Other cases 281 3,679 336 4,071 Laboratory Facilities. The arrangements with the Nelson Hospital for carrying out such bacteriological examinations as swabs and sputa continue to work satisfactorily. In addition, the Emergency Medical Service Laboratory at Kingston has 18 proved of great assistance in carrying out more complicated investigations such as material from suspected food poisoning and isolation of the typhoid dysenteriæ group in food or fæces. The following examinations were made during the years under review:— Examinations. No. performed. Positive result. Swabs for diphtheria bacilli 306 2 Sputum for tubercle bacilli 88 6 Blood for Widal test — — Fasces 57 8 Swabs for Meningococci 3 — AMBULANCE FACILITIES. Infectious Cases. For the removal of infectious cases two ambulances are provided by the Wandle Valley Joint Hospital Board for use within its administrative area including this district. No difficulties have been experienced in securing the prompt removal of any infectious case. Non-Infectious Cases. For the removal of non-infectious and maternity cases, the district council provides one ambulance. This vehicle will accommodate two stretcher cases and two sitting cases. It used to be housed at the Fire Station in Kingston Road, but on the formation of the National Fire Service it was handed over to the Civil Defence to be manned by their personnel and a garage has been built at the Morden Recreation Depot, where it has been kept since. Authority has now been given for the use of Civil Defence Ambulances and Ambulance cars for ordinary civilian cases. This should relieve the ordinary Ambulance Service, which with the increasingly large number of calls and the increased distances, owing to the transference of so many of the London Hospitals to the Home Counties, was becoming so fully occupied that an unnecessary number of calls were being transferred to other authorities, under the mutual arrangements with other authorities in operation. The authority given for the use of these sitting case cars for maternity cases has eased the situation as a certain proportion of cases are capable of being transported by motor car and do not demand the use of an ambulance. It is true that this inevitably places a discretionary responsibility on whoever is in charge at the ambulance station, but experience has shown that this has worked very well. Now that the authority for using Civil Defence vehicles is extended to the use of two vehicles, the position should be fairly easy, especially as we now have ex-army ambulances in place of some of the original civil defence converted ambulances which were damaged at the Morden Depot. 19 AMBULANCE CALLS. Month Calls received from Public Calls received from neighbouring Brigades Total Calls Received Calls transferred to other Brigades Calls answered by Own Ambulance Jan. 68 - 68 68 - Feb. 83 - 83 45 38 March 92 3 95 5 90 April 67 - 67 10 57 May 87 1 88 8 80 June 81 - 81 6 75 July 68 3 71 7 64 Aug. 67 - 67 4 63 Sep. 82 7 89 5 84 Oct. 84 2 86 7 79 Nov. 83 7 90 6 84 Dec. 112 5 117 26 91 Total 974 28 1002 197 805 Time taken in executing the calls (from leaving Station to return) 705 hours Mileage covered 7,489 Average time per call 52.56minutes Average distance per call 8.6 miles The Ambulance was out of commission until February, 1943. CLINICS AND TREATMENT CENTRES. 1.—Maternity and Child Welfare Clinics (provided by the Council). Centre Clinic Times of Clinics Sports Pavilion, 216, Grand Drive, Raynes Park Infant Welfare Mondays 10— 12 noon. ,, 2— 4 p.m. Wednesdays 10—12noon Ante-Natal Thursdays at 2 p.m. by appointment. Health Centre, Middleton Road, Morden Infant Welfare Tuesdays 10—12 noon. ,, 2— 4 p.m. Fridays 2—4 p.m. Ante-Natal Thursdays 9.45 a.m. by appointment. Dental Thursdays 10—12 noon First Aid Post, Blakesley House, 246, Kingston Rd. Merton Infant Welfare Thursdays 2—4 p.m. Ante-Natal Saturdays at 9.45 a.m. by appointment. Health Centre, Aston Road, Raynes Park Infant Welfare Wednesdays 2—4 p.m. Fridays 10—12 noon Dental Fridays 10—12 ,, Hope Mission Hall Rodney Place, Merton Infant Welfare Thursdays 10—12 noon 20 DIPHTHERIA IMMUNISATION. 2.—Diphtheria Immunisation Clinics (provided by the Council). During 1943, 758 children under 5 were immunised and 328 between the ages of 5 and 15. The number of children immunised at the end of 1943 in the district was 10,018, of whom 2,816 were under 5 and 7,202 of school age. These figures represent an estimated percentage of 57 per cent. of under fives and 73 per cent. of the five to fifteen group. Access to the school age group will always make for greater success among these children, but it should be born in mind that immunisation of children between birth and one year of age is rarely done, and the 2,816 immunisations of children under five are really immunisations of children between one year and five years, that is, of four not five age groups. To compare the success rate therefore of the two age groups the total number of immunisations 2,816, should be expressed as a percentage of the population 0—4 not 0—5. This is estimated at 3,823, and 2,816 is 73.8 per cent. Therefore of the available under fives 74 per cent. have been immunised. Immunisation Clinics. Sports Pavilion, 216, Grand Drive, Raynes Park Mondays at 0.45 a.m. Health Centre, Middleton Road, Morden Fridays at 2 p.m. Hope Mission Hall, Rodney Place, Mer on Thursdays at 9.45 a.m. Health Centre, Aston Road, Raynes Park Fridays between 10—11 am. In addition to these sessions specially set aside for immunisation injections are given at the ordinary Infant Welfare Sessions. 21 3.—School Clinics (provided by The Surrey Education Committee). Middleton Road, St, Helier, Morden General Medical Mon. & Wed. 9.30-12 noon Eye Wed. 1.30—4 p.m. Dental Tues. & Wed. 9.30-12 noon & 1.30—4 p.m. Sat. 9.30-12 noon except 3rd Sat. in each month Thurs. 1.30—4 p.m. Aston Road, Raynes Park General Medical Tues. & Thur. 9.30-12 noon Dental Mon. Tues. & Thurs. 9.30-12 noon & 1.30—4 p.m. Wed. & Sat. 9.30-12 noon Fri. 1.30—4 p.m. Eye 2nd, 4th & 5th Wed. in each month 9.30-12 noon 4.—Tuberculosis Dispensaries (provided by Surrey County Council). St. Helier County Hospial, Mon. 10 a.m. Wrythe Lane, Carshalton 2nd Mon. in month 5.30 p.m. Morden Patients Fri. 1.30 p.m. 5.—Venereal Diseases. The County Council administers the Venereal diseases Regulations and participates in the London and Home Counties scheme. Under this arrangement treatment is available at the principal London Hospitals. The sessions are numerous and in some cases continuous, whilst many of these institutions provide in-patient as well as out-patient treatment. HOSPITALS. Smallpox. The Surrey County Isolation Hospital, Clandon—accommodation 28 beds. These premises provide the hospital accommodation for smallpox for the whole of the administrative County of Surrey, and is administered as a County Service. No cases were admitted during 1943. 22 Infectious Diseases. The Wandle Valley Joint Hospital situated at Beddington Corner, Mitcham, maintained conjointly by the following districts:— Beddington and Wallington Borough; Coulsdon and Purley Urban; Merton and Morden Urban; Mitcham Borough. This hospital suffered a reduction in accommodation owing to the discontinuance of a cubicle block which reduced the available accommodation under war conditions, to 122 beds. In addition to a numerical reduction of beds this is liable to impose a special strain on isolation facilities. Another factor governing hospital accommodation which has operated to the disadvantage of the Wandle Valley Isolation Hospital has been the shortage of nursing staff. Even under these difficulties however the hospital has maintained its previous service. One ward has been altered to provide for admission of 10 cases of Typhus, in the event of an outbreak of that disease, and arrangements for the delousing and cleansing of contacts for the district has also been provided at the hospital. In 1943, 238 cases were admitted from this district compared with 247 in 1942. TABLE VI. Cases admitted to the Wandle Valley Isolation Hospital during the Year 1943. Disease. Cases Deaths Diphtheria 12 1 Scarlet Fever 189 — Erysipelas 1 — Tonsillitis 5 — Measles 8 — Influenza 2 — Whooping Cough 5 — Rubella 5 — Mumps 1 — Chicken Pox 2 — Rheumatism 1 — Meningitis 2 — Puerperal Sepsis 2 — Admitted with Mother 1 — Castro Enteritis 1 — Poliomyelitis 1 — Total 238 1 23 General and Maternity. 1. The Nelson Hospital for Wimbledon, Merton and District. The bed complement at this hospital is now termed as 100 casualty beds (with permission to use these for civilian sick patients) plus 21 maternity beds (reserved for civilian patients only). The following information relating to the hospital's activities during the year under review is supplied by the courtesy of the Secretary:— (a) General Medical and Surgical Treatment. Total in-patients admitted 2,586 Number from Merton and Morden 542 Total number of new out-patients 8,042 Number from Merton and Morden 3,504 (b) Maternity Services. Number of patients admitted from all districts during the year:— (1) General Wards 319 (2) Private Wards 168 487 Number of patients admitted from Merton and Morden:— (1) General Wards 163 (2) Private Wards 85 248 2. The County and Public Assistance Hospitals. Under existing arrangements, patients from this district receiving treatment in County Hospitals are admitted, in most instances to the Kingston County Hospital at Wolverton Avenue. Tuberculosis. The County Sanatorium, Milford—300 beds. The Surrey County Council is responsible for the AntiTuberculosis Scheme in the district. The County Sanatorium at Milford constitutes the main institutional provision, and 17 persons were admitted from Merton and Morden during 1943, whilst 115 other persons received treatment in other institutions. 24 MATERNITY AND CHILD WELFARE. Public Health Act, 1936, Section 203—Notification of Births. The births notified under Section 203 as adjusted by transferred notification were:— Live Births 1,122 Notified by midwives 506 Still Births 20 Notified by doctors and parents 30 Transferred from other districts 606 Total. 1,142 Total 1,142 The Work of the Centres. During the year 1943 the scope of the welfare activities at the centres was well maintained. The number of sessions held—ante-natal and infant welfare— was 655. This figure—the same as last year—is the greatest number of sessions per year operated in the service. The total attendances continue at a high level. There was an increase in the primary attendances of infants, which was to be expected as the number of births has gone up, and the attendances of infants is the highest recorded since 1939. The number of ante-natal mothers attending the clinics has fallen slightly from last year's figure, and this is due to the establishment of the St. Helier Hospital Ante-Natal Clinic. It will be observed that during 1943, 325 of our mothers were delivered in St. Helier Hospital. While the actual number of mothers on the Ante-natal Clinic Register has fallen, it will be seen that there has been a considerable increase in the number of attendances. This is due to attendance earlier in pregnancy, so that the value and scope of the service has been well up to the standard of previous years. 25 TABLE VII. Attendances at Maternity Clinics. Centre No. on Register Attendances Sessions Average Attendance per Session Primary Total Grand Drive Ante-Natal 223 183 784 52 15.6 Post-Natal 25 1 25 — Individuals 248 184 809 morden Ante-Natal 228 181 673 52 13.2 Post-Natal 15 — 15 — Individuals 243 181 688 Blakesley House Ante-Natal 175 134 564 46 12.6 Post-Natal 15 1 15 — Individuals 190 135 579 All Centres Ante-Natal 626 498 2021 150 13.2 Post-Natal 55 2 55 — Individuals 681 500 2076 150 A primary post-natal visit is the visit of a post-natal woman who has not attended previously either ante-natally or post-natally, so that the figures for primary attendances of individuals represent the number of new cases during the year. 26 TABLE VIII. Attendances at Infants' Consultation Clinics. Centre No. on Register Attendances Sessions Average Attendance per Session *Primary Total Morden Under 1 yr. 596 226 3,023 155 28.3 1-5 years 34 1,366 Raynes Park Under 1 yr. 513 214 3,699 96 56.1 1-5 years 51 1,694 Grand Drive Under 1 yr. 938 289 4,770 150 55.9 1-5 years 36 3,615 Blakesley House Under 1 yr. 419 141 1,663 61 50.5 1-5 years 31 1,418 Merton Under 1 yr. 141 38 671 52 22.8 1-5 years 21 516 All Centres Under 1 yr. 2,607 908 13,826 505 43 6 1-5 years 173 8,609 * Excluding children known to have attended other Centres. TABLE IX. Attendances at all Centres over last 10 years. Year No. of Infants attending during year No. of Women attending Maternity Clinics ATTENDANCES Grand Total Infants Maternity Primary under 1 yr. Total 1934 1,880 233 546 17,994 590 18,584 1985 1,936 258 554 18,800 622 19,422 1986 2,010 306 561 19,957 1,106 21,063 1987 2,250 358 569 20,422 1,450 21,872 1938 2,800 469 750 25,235 2,127 27,362 1939 3,090 588 856 24,376 2,395 26,771 1940 2,614 668 705 17,255 2,364 19,619 1941 2,445 595 745 17,955 2,272 20,227 1942 2,731 774 840 21,478 1,841 22,819 1948 2,514 681 908 22,435 2,074 24,509 27 TABLE X. Number of Children under One Year and Expectant Mothers attending the Centres in relation to the Registered Births. Year Registered Births Infants under 1 year Mothers who attended either Ante-Natally or Post-Natally. Primary attendances Percentage of registered births Number attended Percentage of registered births 1926 333 124 37 1927 352 168 46 1928 392 386 98 50 12.7 1929 442 394 89 44 9.9 1930 452 446 98 49 10.8 1931 628 1,030 164 190 30.3 1932 770 1,089 141 245 31.8 1933 640 825 128 220 34.3 1934 770 545 70 233 30.2 1935 721 554 77 253 35.0 1936 789 561 71 306 39.0 1937 812 569 70 358 44.0 1938 990 750 75 469 47.3 1939 1,005 856 85 588 58.5 1940 971 705 73 668 68.8 1941 848 745 86 635 75.0 1942 1,069 840 87 774 72.0 1943 1,146 908 79 681 59.3 The Nelson Hospital Clinics. A maternity clinic is held at the Nelson Hospital every Tuesday afternoon for the antenatal and post-natal examinations of women who have booked for admission, or who have been confined at the hospital. An arrangement exists whereby Merton and Morden women attending the hospital clinic may receive dental treatment under the Council's Scheme. An infant clinic is also held on alternate Thursdays. The hospital is a voluntary organisation serving Wimbledon and Merton and Morden district. The following information kindly supplied by the Secretary indicates the work of the hospital clinics during 1943. Infant Clinic. From Merton and Morden. Total number of attendances at the infant clinic 1,288* Total number of first attendances under one year of age 74 Total number of children attending during the year:— Under one year 131 Over one year 2 28 Ante and Post Natal Clinic. Ante-natal. Post-natal. Total number of attendances during the year 1,812* 235* Total number of women who attended during the year 469* 323* * all districts. Health Visiting. The increased number of births in 1943 has necessitated a greater number of primary visits and visits to infants under one year of age. It will be observed that there were 3,025 visits to children under 1 year of age as compared with 2,731 last year; and there were 489 first visits to expectant mothers as compared with 461 last year. In consequence of the increased demand on the Health Visitors' time by the additional births and larger number of expectant mothers, the number of visits of children aged 1 to 5 has fallen, as has the number of special and total visits. The number of visits made for various purposes was as shown below:— To expectant mothers—first visits 489 total visits 750 To children under 1 year—first visits 1,218 total vists 3,025 To children 1-5 years—total visits 3,929 Visits re puerperal pyrexia, ophthalmia and miscellaneous 268 Visits to foster children re Child life protection 159 8,131 In addition to closely co-operating with our own Day Nurseries, the Health Visitors have attended at the routine medical inspections of nursery children in the schools, to afford assistance to the school Medical Officer and Head Mistresses of the schools with their more intimate knowledge of these children. Convalescent Home Treatment. Children requiring treatment are sent to Convalescent Homes through the agency of the Invalid Children's Aid Association, to whom the council makes a contribution towards the cost of the treatment. Orthopaedic Treatment. Children suffering from orthopaedic defects are referred to the Nelson Hospital under the general arrangement with that Hospital for the treatment of children attending the Welfare centres. 29 Maternity Hospital Treatment. In 1943 the Nelson Hospital admitted 248 Maternity cases from the Urban district. Complicated cases which were prior to the war accommodated at Queen Charlotte's Hospital, London, by arrangement with that hospital, can now be treated in this disrict. The opening of the Maternity Block at St. Ilelier Hospital has improved the obstetric failities in the district very considerably. The following table shows the use of the maternity accommodation in the district in the year under review. Nelson Hospital 236 Kingston County Hospital 43 St. Helier Hospital 325 Other hospitals 187 791 Emergency Maternity Unit. There was no call made on this unit during the year under review. Consultant Service. A specialist's opinion may be had in cases of obstructed labour, emergencies in pregnancy, or puerperal pyrexia. Home Helps. Domestic assistance may be provided for expectant and nursing mothers during confinement or whilst away from home undergoing treatment. The usual period for which the help is supplied during confinement is fourteen days. The number of helps provided in 1943 was 8. Arrangements were being made at the end of the year to reorganise the Home Help Scheme. Experience had shown two major difficulties, first it was becoming impossible to employ women except for the equivalent of part-time employment, second the cost, at the revised rate of l/2d. per hour, would have been excessive working according to the old arrangement. The scheme in operation at the time of writing this report is working very well. Our dental attendant has taken over the additional duties of Home Help organiser, and on the receipt of an application for a Home Help, interviews the mother and arranges the periods of duty for which a Home Help is required. The organiser then arranges for one of those on the rota to undertake the case. This personal contact between the two parties thus concerned shows signs of being a great advantage. Sterilised Maternity Outfits. Sterile outfits in sealed containers for use at confinements may be had from the Welfare Centres or from the Council's midwife. They are supplied at cost price, and in necessitous 30 cases at half price or free of cost according to means. During the year twenty-six outfits were supplied at cost price and one was supplied free. Dental Scheme. The general scope of the dental work was carried on as in previous years, but the number of attendances and the number of patients treated fell slightly from figures for previous years. Last year 325 patients made 1,021 attendances as compared this year with 288 patients making 934 attendances. The probable reason for the drop is the effect of the opportunities and demand for labour in factories and elsewhere during this fourth year of war. It will be seen from the table on page 32 that though there was a decrease in the number of extractions, there was an increase in the conservation work and fourteen more patients were fitted with dentures than in the previous year. The number of expectant mothers who attended during the year was 120. The importance of early dental care in pregnancy cannot be stressed too much. Great importance is attached to securing that these mothers shall come under observation by the Dental Surgeon at the earliest possible moment, and that immediate priority shall be given to these cases. In the absence of such a policy ante-natal dental treatment becomes a farce. The importance of such arrangements become more obvious by taking a hypothetical example. An expectant mother goes to her midwife at about 16-18 weeks to make arrangements for her confinement. The midwife arranges for her to attend the ante-natal clinic. The mother makes her first attendance perhaps at 21 or 22 weeks. She is seen by the ante-natal officer who refers her for dental treatment possibly only if her need for dental treatment is obvious to his unspecialised examination. She, therefore, if she is fortunate, may arrive for her first inspection by the Dental Surgeon at about 24 weeks. There may be a further delay where the appointment system is in operation before she really secures any treatment. She may have, therefore, been already exposed for more than two-thirds of her period of dental adversity even if she secures treatment at her first interview with the Dental Surgeon. It is clear that there are three essentials for an adequate ante-natal dental scheme—early notification, early inspection by the Dental Surgeon, and adequate facilities for early treatment. 31 TABLE XI. Attendances at Dental Clinics during 1943. Cases referred from— Number who attended during year Number of Attendances made MERTON Mothers 3 13 Children 6 10 Individuals 9 23 MORDEN Mothers 85 256 Children 29 70 Individuals 114 326 RAYNES PARK Mothers 14 67 Children 22 51 Individuals 36 118 GRAND DRIVE Mothers 39 175 Children 35 75 Individuals 74 250 BLAKESLEY HOUSE Mothers 30 153 Children 25 64 Individuals 55 217 ALL CENTRES Mothers 171 664 Children 117 270 Individuals 288 934 The dental operations performed were as follows:— TABLE XII. Dental Scheme 1943—Operations Performed. Extractions— Temporary Teeth 297 Permanent Teeth 579 Fillings— Temporary teeth 97 Permanent teeth 122 Dentures supplied— Number of cases 123 No. of local anæsthetics given 50 No. of Gases given 196 32 Midwives. One midwife is appointed by the District Council under the Surrey County Council's scheme for a salaried midwifery service. The fees fixed by the County Council are:— As maternity nurse 35/- As midwife 40/- Provision is made for a reduction in the fee in necessitous cases. The following figures indicate the work undertaken during the year by the Council's midwife:— Cases conducted: Primip. Multip. Total (a) As midwife Live 8 28 36 Still — 1 1 (b) As maternity nurse Live 8 7 15 Still — — — 16 36 52 Visits made: By midwife Ante-natal 388 During confinement 730 To midwife Ante-natal 129 Post-natal 142 1,389 Medical Aid Forms sent:—10. Reasons for sending:— Discharging Eyes 4 Rupture of Perineum 3 Laceration of Perineum 1 Prolonged second stage 1 Macerated foetus 1 Percentage of total midwife's cases which attended the Council's ante-natal clinics 100% According to notices received by the Surrey County Council there were eighteen midwives practising in the district, four of whom were salaried midwives appointed under the County Scheme, and eight members of the staff of the Nelson Hospital. In addition one member of the staff of the Wimbledon District Nursing Association practices part-time in the Merton and Morden area. Voluntary Helpers. It is the fashion, and properly so, to issue appropriate markings for length of service. The Civil Defence workers, for example wear a chevron for each year 33 of service. When this service has been rendered in London these chevrons assume added significance. Among that great number of citizens who have given their service to the Council none would be more deserving of chevrons than our voluntary helpers who have given their time and energy during arduous and exacting times, week in week out for many years. Child Life Protection. The Health Visitors are appointed Inspectors under the Child Life Protection provisions of the Public Health Act, 1936. Strict control is exercised over foster homes and particular attention is paid to the welfare of foster children. The following are the main facts relating to the administration of these provisions during the year under review. Registered homes under supervision during the year 23 Registered homes under supervision at end of year 10 New homes registered during the year 12 Children on the register at the end of the year 14 Children brought on to the register during the year 25 Children removed out of the district 16 Visits paid to nurse children 159 Children died during the year nil Legal Proceedings nil 34 SECTION C.—SANITARY CIRCUMSTANCES. Water Supply. The district is supplied by the Metropolitan Water Board and by the Sutton District Water Company. Their respective distributive areas are approximately the parishes of Merton and Morden respectively. The supply of the Metropolitan Water Board is only sampled infrequently as a routine otherwise samples are taken when circumstances indicate the necessity for local investigation. The Board supplies copies of their official minutes in which the results of their examinations are recorded. Routine examinations of the Sutton District Water Company's supply are undertaken by the Authorities in the supply area upon an agreed rota which provides for bacteriological and chemical samples each month. The Company in addition to the daily examinations undertaken by their own full-time Chemist arrange for Consulting Chemists to undertake monthly examinations. Copies of the reports of these Consulting Chemists are received by local Medical Officers of Health whilst the records of the Company's own analysis are available for inspection by the Medical Officers. The quality of the supply as shown by the sampling was satisfactory. There are two deep wells in the district, the supplies from which are used mainly for industrial purposes. They also provide the staffs of the factories at which they are situated with drinking water. Drawn from beneath the London clay, both these well waters are of a high degree of organic purity. Drainage and Sewerage. The Surrey County Council's major scheme for the improvement of the Beverley and Pyl Brooks referred to in previous reports, was completed during the year 1939. This work, in conjunction with other improvements carried out down stream, has been effectual in relieving the surcharge of this waterway. No alterations were carried out during the year under review. Closet Accommodation. All premises have water closets drained to sewers except four which are drained to cesspools. In addition there are four chemical pail closets on Sports Grounds. Public Cleansing. The collection and disposal of house refuse throughout the district is presenting much difficulty because of the shortage of staff. The salvage tonnage for the year under review was as follows:— Tons Tons Paper 472 Rags 29 Metals 167 Tins 377 Pig Food 717 Bones 24 Bottles and Glass 161 Rubber 25 35 REPORT OF THE CHIEF SANITARY INSPECTOR. Mr. Chairman, Ladies and Gentlemen, I beg to submit an abbreviated Annual Report which summarises the work carried out by your Sanitary Inspectors during the year ended December, 1943. Housing Inspections. The total number of houses inspected during the year for "sanitary defects" under the Public Health and Housing Acts was 368. Action taken in connection with defective dwelling houses is set out in the housing table on pages 42 and 43. Notices specifying the necessary work required to remedy sanitary defects were served upon owners of properties as follows:— Intimation Notices 237 Statutory Notices 26 Housing Act, 1936 2 Eradication of Bed-Bugs. Seventeen houses were found on inspection to be infested with bed-bugs, and are classified as follows in accordance with the requirements of the Ministry's Circular:— Council Houses. Other Houses. Total. 4 13 17 Of the 17 houses infested, 16 were treated by spraying with "Vermicine," and one by fumigation with sulphur-dioxide together with the use of blow-lamps. Drainage Work. At 13 houses the drainage systems were entirely reconstructed and at 62 houses extensive repairs to drains were carried out. Smoke and water tests were applied to the drains of houses in 98 instances, and obstructions were removed from drains at 134 houses. Food Supply. The total number of inspections made to premises where articles of food are prepared or exposed for sale was 1,021. At 29 premises improvements in sanitary conditions were effected. Unsound Food. The undermentioned articles of food were found, upon inspection, to be unfit for human consumption; were surrendered and either destroyed or disposed of for animal feeding or salvage:— Description. Cause. Mutton, 40 lbs. Decomposition Sausage, 60 lbs. ,, Bacon, 45 lbs. , Chopped Ham, 2 lbs. ,, Chickens, 21 ,, Fish, 81½ st. ,, Eggs, 149 ,, 36 Description. Cause. Eggs (Dried), 3 pkts. Contaminated Egg Substitute, 20 lbs. Unsound Cheese, 38½ lbs. ,, Flour, 226 lbs. Contaminated Tea, 5 lbs. ,, Biscuits, 9 lbs. ,, Margarine, 9½ lbs. Unsound Butter, 24 lbs. ,, Potatoes, 28 lbs. Contaminated Fish Cakes, 20 lbs. Decomposition Dried Peas, 10 cwt. 1 qrt. Unsound Sausage Filling, 1 cwt. Sour Confectionery, 40 lbs. Contaminated Dried Fruit, 200 lbs. Decomposition U.S.A. Meat, 6 lb., 43 tins Pierced or blown 2½ lb., 53 tins ,, ,, 12 oz., 38 tins ,, ,, Sausage Meat, l½lb., 145 tins ,, ,, Stewed Steak, 89 tins ,, ,, Minced Meat, 152 tins ,, ,, Fish (Various), 4,756 tins ,, ,, Fruit (Various), 466 tins ,, ,, Vegetables (Various), 303 tins ,, ,, Milk, 836 tins ,, ,, Soup, 339 tins ,, ,, Jam and Marmalade, 122½ lbs. Pierced, blown, or broken Pickles, 3 jars Broken Robinson's Patent Barley, 2 tins Unsound Meat Inspection. The establishment of central abattoir schemes since the war has resulted in practically all meat coming into the district from wholesale markets outside the district. Carcases Inspected. Pigs. Number killed 157 Number inspected 157 Number fit for human consumption 157 Milk Supply. At the 31st December, 1943, only one cowkeeper remained on the register, providing accommodation for about 50 cows. Practically all the milk supplied to the district is derived from the South-Eastern Counties and arrives either by rail or road. Sixty-nine inspections were made to cowsheds, dairies and milkshops during 1943. Twenty-nine samples of milk were submitted for bacteriological examination during the year. Two samples of pasteurised milk were reported unsatisfactory, the total bacteria count exceeding the prescribed standard. Eighteen licences were granted to dealers under the Milk (Special Designations) Order, 1936, and were in force at the 31st December, 1943. 37 Food and Drugs Act, 1938. The following table shows the number and nature of the samples submitted to the Public Analyst:— Article. Total Samples. Genuine. Not Genuine. Prosecutions. Anchovy- Paste 1 1 — — Arrowroot 1 1 — — Breakfast Sausage 2 2 — — Bun Flour 1 1 Retailer prosecuted. Dismissed on warranty. Brawn 1 1 — — Bacon 1 1 — — Baked Beans 1 1 — — Beef Sausage 1 1 — — Butter 2 2 — — Bismuth Dyspepsia Tablets 1 1 — — Beer 1 1 — — Bread 2 2 — — Bicarbonate of Soda 1 1 — — Black Pudding 1 1 — — Cocoa 1 1 — — California Syrup of Figs 1 1 — — Cooking Fat 1 1 — — Creamola 1 1 — — Coffee Essence (Chicory) 1 1* — Castor Oil 1 1 — — Condensed Skim Milk 1 1 — — Cod Liver Oil 1 1 — — Cheese 1 1 — — Choc-Spread 1 1 — — Custard Powder 1 1 — — Cheese Cake Mixture 1 1 — — Cake Flour 1 1 — — Dried Apple Rings 1 1 — — Egg Substitute Powder 1 1 — — English Pickles 1 1 — — Eton Soup 1 1 — — Egg Substitute 1 1 — — Fish Cake Roll 1 1 — — Flour 2 2† — Fish Paste 2 2 — — Fruit Saline 1 1 — — French Mustard 1 1 — — Golden Rising Powder 1 1 — — Grape Fruit Marmalade 1 1 — — Gelatine 1 1 Retailer prosecuted. Dismissed. Summons served too late. Grape fruit squash 1 1 — — Hard boiled sweets 1 1 — Health Salts 1 1 — — Carried forward 48 43 5 — 38 Article. Total Samples. Genuine. Not Genuine. Prosecutions. Brought forward 48 43 5 Jam 1 1 — — Lard 1 1 — —■ Liver Sausage — — Lemon Curd 1 1 — — Lobster and Tomato Paste 1 1 — — Liquid Paraffin 1 1 — — Malted Milk Tablets 1 1 — — Margarine 1 1 — — New Milk 33 33 — ■— Mixed Pickles 1 1 — i— Meat and Vegetable extract 1 1 — — Pancake Mixture 4 2 2 Retailer prosecuted. Fined £2 and £2 2s. costs. Post Luncheon Sausage 1 1 — — Orange Squash 1 1 — — Pork and Duck Stuffing 1 1 — — Pure Coffee 1 1 — — Pork Sausage 1 1 — — Pure Natural Juioe (Apple) 1 1 — — Pudding Spice 1 1 — — Raisins 1 1 — — Red Plum Jam 1 1 — — Real Egg Self-raising flour 1 1 — — Sponge Mixture 3 2 1 Retailer prosecuted. Dismissed on warranty. Sponge Cake 1 1 — Salmon and Shrimp Paste 1 1 — — Sausage Meat 2 2 — — Steamed Pudding Mixture 1 1 — — Sultanas 1 1 — — Vegetable Extract 1 1 — — White Pepper 1 1 — — Total 117 109 8 — * This brand was unobtainable for 2nd sample † Stocks withdrawn. Results of Analyses of New Milk Samples. Solids not Pat (Legal Standard is 8.5%). 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 9.0 9.1 9.2 Total — — — — 1 2 2 21 6 1 — — — 33 39 Milk Fat (Legal Standard is 3.0%). 3.2 3.3 3.4 3.5 3.6 3.7 3.8 39 4.0 4.1 4.2 Total 1 6 3 6 3 6 5 2 — — 1 33 Scheme—Gas Contaminated Foodstuffs. In accordance with the Ministry of Food's Circular MFG. 4, arrangements were made early in 1941 to recruit and train about forty part-time volunteers from the food traders. During the year 1943 the total personnel strength was increased to sixty and further practical demonstrations and routine exercises were carried out. The Deputy Chief Sanitary Inspector is designated as Food Decontamination Officer and under the general direction of the Medical Officer of Health is primarily responsible for the operation of the Service. Factories. The number of inspections made to premises registered under the Factories Act—391. Defects relating to sanitary conveniences, ventilation and other sanitary matters were dealt with at 28 premises. Water Supply. Six samples of water taken from domestic taps were taken and submitted for chemical or bacteriological examinations. The report on each sample was satisfactory. Watercourses. A number of inspections were made of the watercourses in the district for the purpose of detecting pollutions, and samples were obtained and sent for chemical analysis. In three instances pollutions were discovered, and the necessary steps were taken to remedy these conditions. Mosquitoes. A number of complaints were received from residents and paraffin spraying of ditches and stagnant ponds was carried out. Rats and Mice Destruction Act, 1919. This Act has been administered by this Conncil by delegation of powers from the Surrey County Council since the commencement of the Act, and the Officers charged with the administration can safely claim to have met with some success. During the year the Ministry of Food, viewing with alarm the destruction of foodstuffs by rats in some parts of the country, introduced what is known as the Infestation Order 1943, the provisions of which gave every Local Authority power, and in some cases ordered them, to make survey of properties and land within their area, and to take the necessary steps to secure the destruction of as many rodents as possible. 40 The Order is now jointly administered by Local Authorities and the Ministry of Food Rodent Control Dept., and your Officers are subject to directions from the Ministry whose Officers from time to time visit the area and offer advice and suggestions as to procedure. A total of 1,520 inspections were made during 1943 and infestations were dealt with at 233 premises. Shops Acts, 1912-1936. The following statement summarises the inspections made, the infringements discovered and other matters dealt with during the year:— No. of Inspections:—Day Visits 157 Evening visits — Infringements:— 1. Evening closing hours — 2. Half-day closing 2 3. Hours of employment for young persons — 4. Seats not provided for females — 5. Prescribed notices not correct or exhibited 21 6. Sanitary arrangements unsatisfactory — 7. Reasonable temperature not maintained — Summary of Sanitary Inspections. Housing—primary visits 368 Re-inspections—work in progress 1,405 Re Overcrowding 73 Miscellaneous, housing 288 Drainage work 1,215 Factories and Workshops 391 Stables and Piggeries 59 Rats and Mice Destruction 1,520 Enquiries, infectious diseases, contacts, infectious diseases 383 Visits to schools 6 Re Disinfections 346 Smoke Abatement 85 Food shops, etc. 1,021 Milk Supply 69 Rivers and Streams, pollutions 119 Complaints investigated 330 Miscellaneous 663 I am, Ladies and Gentlemen, Your obedient Servant, J. B. POINTON, Chief Sanitary Inspector. September, 1944. 41 SECTION D—HOUSING. 1. Inspection of Dwelling Houses during the year:— (1) (a) Total number of dwellinghouses inspected for housing defects (under Public Health or Housing Acts) 368 (b) Number of inspections made for the purpose 368 (2) (a) Number of dwellinghouses (included under sub-head (1) above, which were inspected and recorded under the Housing Consolidated Regulations, 1925 and 1932 — (b) Number of inspections made for the purpose — (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation — (4) Number of dwellinghouses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 237 2. Remedy of defects during the year without service of formal notice:— Number of defective dwellinghouses rendered fit in consequence of informal action by the Local Authority or their officers 197 3. Action under Statutory Powers during the year:— A.—Proceedings under Sections 9, 10 and 16 of the Housing Act, 1936. * (1) Number of dwellinghouses in respect of which notices were served requiring repairs 2 (2) Number of dwellinghouses which were rendered fit after service of formal notices:— (a) By owners — (b) By local authority in default of owners — (* Houses rendered fit by owners during 1944.) 42 B.—Proceedings under Public Health Acts:— (1) Number of dwellinghouses in respect of which notices were served requiring defects to be remedied 26 (2) Number of dwellinghouses in which defects were remedied after service of formal notices:— (a) By Owners 19 (b) By local authority in default of owners — C.—Proceedings under Sections 11 and 13 of the Housing Act, 1936:— (1) Number of dwellinghouses in respect of which Demolition Orders were made — (2) Number of dwellinghouses demolished in pursuance of Demolition Orders — D.—Proceedings under Section 12 of the Housing Act, 1936:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made — (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit — SECTION E—INSPECTION AN'D SUPERVISION OF FOOD. (See Sanitary Inspector's Report, on pages 36-39). 43 SECTION F—INFECTIOUS ILLNESS. Notification. The following diseases are notifiable in the Urban District:― Oholera. Acute Primary pneumonia. Cerebro-spinal fever. Acute influenzal pneumonia. Continued fever. Acute Poliomyelitis. Diphtheria (including mem- Acute Polioencephalitis. branous croup). Puerperal Pyrexia. Dysentery. Relapsing fever. Enteric Fever (including Scarlet fever. paratyphoid fevers). Smallpox. Erysipelas. Trench fever. Encephalitis Lethargica. Typhus fever. Food poisoning. Tuberculosis (all forms). Malaria. Whooping Cough. Ophthalmia Neonatorum. Measles. Plague. Smallpox. No cases of Smallpox were notified during the year, nor, in fact, have there been any cases in the past ten years. Enteric Fever. There was one case of Typhoid Fever notified which was discovered in St. Helier Hospital to be suffering from Para. B infection. The course of the disease was mild and there were no further cases. Dysentery. There were four cases of Dysentery notified during the year. There is evidence, however, that there were several widespread outbreaks of gastro-intestinal infection, but so mild in character that they were not reflected in the notifications of Dysentery. Three such attacks occurred in the schools; in the infants and nursery classes. In one school some 30 children were affected as well as several members of the staff. In this school B. Sonne was isolated in some of the cases. This outbreak had the appearance of being part of a general epidemic in the district, and it could not be shown to have had its origin in the school. The second outbreak involved mainly the nursery class. The disease was mild and the practice of requiring two negative rectal swabs before returning to school was put into operation. Both of these Outbreaks occurred at a time when similar gastro-intestinal infection was widespread in the general population round the schools, and though one of the staff was shown to be carrying Sonne bacilli, it seemed more probable that there was a multiplicity of sources rather than one source in the school departments. In the third school there were only 4 teachers and 6 children affected. In the second case the food was prepared in a canteen in a neighbouring district, and the information was passed on to that Public Health Department for investigation. 44 Scarlet Fever. There was an increase in the incidence of Scarlet Fever in 1943, but as in previous years the disease was of mild type. The largest number of cases occurred in the month of November, and the months of September, October and November were by far the heaviest months. There was a total of 272 cases, the highest number recorded in the past ten years. TABLE XIII. SCARLET FEVER—MONTHLY DISTRIBUTION. Wards. Total. Abbey. Bushey Mead. Central. Morden. Park. Ravensbury. Raynes Park. St. Helier. West Barnes. January — 1 1 — 7 2 1 1 — 13 February — — 1 3 1 2 — 2 2 11 March 1 — 2 4 2 1 4 1 1 16 April — 3 — 9 — — 1 2 — 15 May — 2 — 3 3 1 — 2 — 11 June 3 4 1 4 3 — 1 1 2 19 July 1 2 1 6 1 4 — 3 3 21 August 2 7 2 1 1 1 — 1 1 16 September 2 1 2 4 2 6 3 6 3 29 October 4 3 3 4 3 8 2 8 5 40 November 2 1 6 6 8 9 8 9 3 52 December 2 3 3 1 3 6 2 8 1 29 Total 17 27 22 45 34 40 22 44 21 272 Monthly mean 1.41 2.25 1.83 3.75 2.83 3.33 1.83 3.66 1.75 22.64 The incidence in the various wards was as follows:— Wards. Cases. Incidence per 1,000 population. Abbey 17 .25 Bushey Mead 27 .40 Central 22 .33 Morden 45 .68 Park 34 .51 Ravensbury 40 .60 Raynes Park 22 .33 St. Helier 44 .66 West Barnes 21 .31 45 Diphtheria. The attack rate for Diphtheria continues to below. The average for the past five years is only half that for the previous five years. The average number of cases from 1934 to 1938 inclusive being 41 and the average for the years 1939—1943 inclusive only 21. The last two years' figures are actually considerably below the average, being 16 for this year and 15 for last year. Diphtheria Immunisation. The facilities for Diphtheria Immunisation were continued as in previous years. An attempt has been made to expand the immunisation done privately by general medical practitioners by extending the existing facilities of free supply of material to payment for cases done. The number of persons immunised at the Clinics, in schools and by private practitioners is shown in Tables XIV, XV and XVI. There was one death from Diphtheria in a child aged four years. The circumstances of this case presented some interesting features. He was one of a family of ten children. Of the seven children whose ages ranged between thirteen and four months, the three youngest—aged respectively four months, two years, and four years—had not been immunised. David, the fatal case, aged four, was the eldest of these three unimmunised children. The result of swabbing showed only two positive contacts in the family, Bert aged 11 and Mary aged 9. These were immunised children and were removed to hospital. They were found, however, not to be suffering from Clinical Diphtheria, in fact had no clinical signs of any illness at all. The other children, including the unimmunised William aged two were negative. Eight days later George aged 5, who had had a negative swab developed Diphtheria. He had been immunised a year before. The family were again swabbed and all the others found to be negative, including the unimmunised William aged two. At this stage with the second exposure, it was decided to give William aged two a prophylactic dose of antitoxin. George the immunised recovered though he suffered a moderately severe attack. No other members of the family contracted the disease. At the stage where David the unimmunised succumbed and his immunised brother and sister, Bert and Mary, though showing the presence of the bacteria in the throat, presumably from the same source, escaped, it looked like a triumph for immunisation; but a week later when George, who was protected, contracted the disease and William, the 2 year old, though not protected had survived two contacts, it was clear 46 that it could not be maintained that immunisation alone was the deciding factor. It is easy to indulge in speculation as to the explanation of these events, even to underrate the value of protection given by immunisation, but two facts at any rate stand out. First, Bert and Mary provided strong evidence of having been exposed to a virulent dose of Diphtheria by the demonstration of the bacilli in their throats, and they escaped even contracting a mild form of the disease. Though William, aged two, who was not immunised, escaped, at no time was it possible to demonstrate the presence of any Diphtheria bacilli in the throat, and immediately after the second exposure he was given antitoxin. Secondly, only the unimmunised child died of the disease. If it was possible first to have forecast this interesting train of events and then to have submitted these contacts to Schick testing and done virulence tests on the organisms found, these cases would have been of greater interest and perhaps some educational value. The appended plan may serve to clarify the somewhat complicated story. 47 48  Age Immunised Case with Date Result of Swabs on 6th Case with Date Second Swab on 15th Final Result Mr.— Mrs.— Edna 19 No. — — Lily 18 No. — — Jean 17 No. — — Elsie 13 Yes — — Bert 11 Yes + Did not develop disease in throat. Mary 9 Yes + Did not develop disease in throat. George 5 Yes — 13th + Recovered. David 4 No. 5 th — — Died. William 2 No. — — Given 4,000 D.A.T. Ronald 4/12 No. TABLE XIV. Persons Immunised at Clinics during 1943 Wards. Age Groups. Total. 0—5 yrs. 5—15 yrs. 15 & Over Abbey 34 5 — 39 Bushey Mead 71 6 — 77 Central 92 9 — 101 Morden 162 15 — 177 Park 49 2 — 51 Ravensbury 54 11 — 65 Raynes Park 72 12 — 84 St. Helier 101 34 — 135 West Barnes 72 12 — 84 707 106 — 813 TABLE XV. Persons Immunised by Private Practitioners. Wards. Age Groups. Total. 0—5 yrs. 5—15 yrs. 15 & Over Abbey — — — — Bushey Mead 4 2 — 6 Central 25 1 — 26 Morden 6 — — 6 Park 14 — — 14 Ravensbury 3 3 — 6 Ravnes Park 1 — — 1 St. Helier 5 — — 5 West Barnes — — — — 58 6 — 64 TABLE XVI. Children Immunised in Schools. School Incomplete Complete St. Helier No. 1 — 17 „ „ „ 2 — 15 „ „ „ 4 13 28 Raynes Park 1 42 Merton Abbey 8 32 Aragon Road 12 34 Rutlish — 39 34 207 49 TABLE XVII. Children Immunised in Day Nurseries. Nursery Incomplete Complete Middleton Road 3 22 Manor House 3 29 6 51 The number immunised since the inauguration of the Public Clinics in 1934 is as follows:— At Clinics. By Doctors. In Schools. At Day Nurseries. Total. 1934 93 28 — — 121 1935 375 19 — — 394 1936 383 13 664 — 1,060 1937 502 27 293 — 822 1938 376 22 260 — 658 1939 277 11 303 — 591 1940 234 12 50 — 296 1941 700 6 3,198 — 3,904 1942 1,127 16 753 — 1,896 1943 813 64 211 51 1,139 TABLE XVIII. Incidence and Fatality of Diphtheria, 1920-1943. Year. Population. No. of cases. Incidence rate per 1,000 population. No. of deaths. Percentage of deaths to cases. 1920 18,200 47 2.5 3 6.3 1921 18,000 28 1.5 1 3.5 1922 18,500 62 3.3 4 6.4 1923 18,750 39 2.08 1 2.5 1924 18,710 68 3.6 6 8.9 1925 18.960 25 1.3 1 8.3 1926 19,980 24 1.2 2 8.5 1927 21,850 29 1.3 2 6.8 1928 25,780 38 1.4 — — 1929 27,430 53 1.9 1 1.8 1930 35,000 72 2.05 6 8.3 1931 41,610 80 1.9 6 7.5 1932 48,550 30 0.6 — — 1933 52,130 35 0.6 1 2.8 1934 55,550 82 1.4 8 9.7 1935 57,440 44 0.76 4 9.0 1936 61,000 28 0.45 — — 1937 65,530 22 0.33 4 18.1 1938 68,980 28 0.40 2 7.1 1939 71,220 32 0.44 2 6.2 1940 68,540 20 0.29 1 5.0 1941 64,920 24 0.36 — — 1942 66,590 15 0.22 1 6.6 1943 65,880 16 0.24 1 6.35 50 Anterior Poliomyelitis. There was one case of Acute Anterior Poliomyelitis during the year. This was in a child of ten years. The attack was moderately severe involving the right shoulder group, and the right leg. She was referred to the Nelson Hospital on leaving Wandle Valley for orthopædic treatment, and she is still having postural exercises and light treatment there. Measles. Measles was made notifiable together with Whooping Cough on the 23rd October, 1939, by the Measles and Whooping Cough Regulations, 1939. This disease shows a biennial epidemicity usually, but since the last remission year 1939 this characteristic has been lost, and the figures have maintained a pre 1939 epidemic level throughout the past four years. The presesnt figure of 433 cases shows a drop to almost 1940 level, and it will be interesting to see what the next year's figure reveals. There was only one death attributed directly to Measles. Whooping Cough. There were two hundred and fifty-two cases of Whooping Cough notified during the year. The incidence of this disease has remained high during the past five years, 1939, 1941 and the present year being greatly in excess of pre-war normal years. There was only one death directly attributable to this disease in 1943. Erysipelas. There were 11 notifications of Erysipelas during the year, and the site of infection in all except one case was the face, the exception being a case where it occurred on the forearm. There were no deaths and only one of the cases was admitted to hospital. Puerperal Pyrexia. There were 9 notifications received in respect of puerperal pyrexia, of these 7 were residents in the district giving a puerperal pyrexia rate of 6.1. Of the 9 notified 6 were in hospital, the other three were domiciliary notifications. Under present arrangements, where hospital treatment and isolation is necessary, these cases are admitted to the Wandle Valley Hospital. There were two cases treated there during the year. Ophthalmia Neonatorum. There were two cases of Ophthalmia Neonatorum notified, both were in hospital at the time of notification so that it was not necessary to arrange for their admission to White Oak, Swanley, the L.C.C. special hospital where our cases are usually admitted. Actually one of the eases was domiciled in Wimbledon, and the information 61 was passed to that borough for the necessary follow-up. The case which was resident in this district was described as mild and the infant discharged two days after the onset of the disease. Recovery was complete and vision unimpaired. Pneumonia. There were 82 cases of Pneumonia notified, of which 27 were stated to be influenzal in origin. This compared with 25 in the previous year. Food Poisoning. There were no cases notified of food poisoning during the year, but investigations were instituted as a result of complaint to the department in several minor attacks limited to the family group. Acute Stomatitis. As a matter of interest, and for purposes of record, attention is drawn to the concurrence of an infective stomatitis in the children in one of the Da y Nurseries. There was evidence that other members of the family in several cases suffered from the same complaint. Clinically it took the form of lesions on the under surface of the lower lip, the inner surface of the cheek, and sometimes on the tip of the tongue. They appeared to start as deep seated herpetiform vesicles which went on to ulceration. In one or two cases a swab result was reported " a few Vincent Spirilla present." There were seldom more than two or three cases occurring at any one time, with an interval of several weeks between the outbreaks. TUBERCULOSIS. One hundred and fifty-one new cases were added to the register of tuberculous persons, compared with 152 in 1942. These additions were:— Males. Females. Total. Pulmonary ... 69 58 127 N on-Pulmonary 14 10 24 83 68 151 Of these 151, 121 were primary notifications, 23 were transferred from other districts, and 7 came to notice in other ways. During the year, 66 persons were removed from the register for the following reasons:— Recovered ... 8 Removed from the district 29 Death ... ... ... ... ... 39 52 After allowing for the additions and deductions, the number remaining on the Register at the 31st December, 1943, was distributed as shown in the following table:— TABLE XIX. Tuberculosis Register at 31st December, 1943. Wards, Registered at 31st December, 1943, Total. Number on Register at mid-year. Pulmonary NonPulmonary. Abbey 39 10 49 46 Bushey Mead 55 12 67 64 Central 37 7 44 45 Morden 79 10 89 79 Park 79 15 94 89 Ravensbury 75 28 103 100 Raynes Park 46 6 50 52 St. Helier 112 26 138 132 West Barnes 47 14 63 57 Whole district 569 128 697 66 The Anti-Tuberculosis Scheme in this district is administered by the County Council. Institutional treatment was provided for 132 persons in 1943 from Merton and Morden, as follows:— At the County Sanatorium, Milford 17 At other Institutions 115 132 The deaths from tuberculosis number 39, of which 35 were due to pulmonary and 4 to non-pulmonary disease. The deaths are classified by age and sex in the undermentioned table:— TABLE XX. Deaths due to Tuberculosis, 1943. Ages Years Pulmonary Non-Pulmonary Totals Males Females Males Females 0— — 1 — — 1 1— — — — — — 5— 1 1 — — 2 15— 3 2 — 1 6 25— 1 2 — — 3 35— 4 3 1 — 8 45— 6 — 1 — 7 55— 5 2 1 — 8 65— 2 2 — — 4 Totals 22 13 3 1 39 53 Three deaths were in unnotified cases. The district provides a free service for the examination of sputum for tubercle bacilli. During the year 88 specimens were examined with a positive result in 6 instances. No action was taken under the Public Health (Prevention of Tuberculosis) Regulations, 1925, which gives power to prohibit the handling of milk by infectious tuberculosis persons, nor under Section 172 of the Public Health Act, 1936, which provides for the removal of an infectious person to hospital. Two Voluntary Care Committees share in the responsibility for maintaining the health of tuberculosis persons in this district. The majority of the funds which are raised by these Committees are expended in providing nourishment for patients suffering from this infection. 51 TABLE XXI. TUBERCULOSIS—New Cases, Age and Sex, Distribution and Manner of Admission to Register. Age Groups. Primary Notifications ("A"). Cases transferred from other districts. Cases brought to notice otherwise than by notification and transfer. Total new cases. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. Years. M F M F M F M F M F M F 0-1 — 1 — — — — — — — — — — 1 1-5 — — — 1 1 — — — — — — — 2 5-10 2 3 1 — — — — — — — — — 6 10-15 4 1 1 1 — 1 — — — — — — 8 15-20 5 10 3 1 — — — — — — — 1 20 20-25 4 14 3 — 1 — — — 1 — — — 23 25-35 13 7 2 — 5 6 1 1 — — — — 35 35-45 11 7 2 1 1 — — 1 1 1 — — 25 45-55 9 2 — 1 1 —- — — 1 — — — 14 55-65 4 2 — 1 2 — 1 — — 1 — — 11 65 up 3 1 — — — — — 1 — 1 — — 6 Totals 55 48 12 6 11 7 2 3 3 3 — 1 151 121 23 7 55 DAY NURSERIES. The first day nursery for the district was opened on November 9th, 1942, at Middleton Road. The building is a prefabricated hut consisting of reinforced concrete uprights to which are bolted slabs made of sawdust. The walls are lined internally with fibre board nailed direct on the slabs, and the internal partitions are of hollow tiled blocks flush pointed both sides and distempered to match the remainder of the building. The floor covering is of linoleum stuck to the oversite concrete with the exception of the ablution rooms where a patent jointless floor is laid. The roof is of corrugated asbestos cement sheets with flat asbestos cement sheet lining. Water heating is by means of a thermostatically controlled three section " Rex " gas fired boiler with a hundred gallon storage cistern. The heating of the nurseries is by means of slow combustion stoves supplied by the Ministry, but in addition 1 k.w. electric reflector fires are fixed at eaves level in the ablution rooms and corridors. They are fitted in the nurseries also, for the rapid warming of rooms in winter and for use, if needed, in the morning and evening when fires are not needed throughout the remainder of the day. Toy cupboards and other fittings are made of asbestos wood sheets ½in. thick, and the towel compartments (one for each child) are formed of asbestos cement sheeting. Each compartment is 3ft. high, 8in. wide, and 6in. deep and is provided with 3 hooks for hanging towel, face flannel and hair brush. The sizes of the nurseries are as follows:— Length Width. Stoves. Elec. Fires. Elec. Light Points. Babies 36ft. 3in. 18ft. 9½in. 2 3 3 Toddlers and Tweenies 34ft. 4½in. 18ft. 9½in. 3 6 4 The second Nursery was opened at the Manor House, Watery Lane, on April 12th, 1943. Suitable rooms were selected for ablution rooms and sanitary appliances fitted. Other rooms are furnished as nurseries, the chief adaptation work in these cases being decoration. The third Nursery at High Path was opened on September 20th, 1943. This one also is a prefabricated building, of different construction from the one at Middleton Road, but 56 similar in lay out. similar in lay out. The building is cruciform in shape and has separate Nurseries for toddlers, tweenies, and babies. Length Width. Stoves. Elec. Fires. Elec. Light Points. Babies 32ft. 6in. 19ft. 3in. 1 4 3 Toddlers 36ft, 19ft. 3in. 2 5 3 Tweenies 29ft. Gin. 19ft. 3in. 2 3 3 External paving is provided at each nursery at the rate of 25 sq. ft. per child. Air raid shelters are constructed of reinforced brickwork with a reinforced concrete roof. Two more nurseries, one in the Morden Hall Road, and the other on the Camborne Road Clinic Site were planned during the year. At the time of writing this report the one in Morden Hall Road had been completed and ready to open when it received extensive damage from H.E. blast. The other, on the Camborne Road site, was abandoned at the direction of the Ministry of Health. CLEANSING STATION. As will be seen from the appended table, 3,108 attendances were made at the Cleansing Centre. This figure compares with 2,049 in 1942. The supervision of the treatment is carried out by a trained nurse, and the attendant and his wife who were originally appointed for the slipper baths, and in addition to carry out treatment in the cleansing section, have been assisted by nursing auxiliaries from the First Aid Post. The cleansing station which was specially designed for this purpose and which contains an electric disinfector, has been of the greatest value since it was opened in September, 1941. The disinfector has been a most valuable apparatus, and in addition to its use for the disinfection of clothing of cases of Scabies undergoing treatment there, it has been extensively used for sterilising blankets and other articles from cases of infectious disease occurring among the A.R.P. Depots, Wardens' Posts and firewatchers. The Benzyl Benzoate treatment has generally been used for Scabies. In cases of children Marcussens ointment is more commonly used as it is found less irritating, and the duration of treatment is not so important. Lethane Oil continues to be used in the treatment of verminous heads. It is found to be a most effective method of rendering a verminous head non-infective, but our experience is that it does not obviate the necessity for cleaning the head as original claims for this treatment seem to suggest. Probably 57 this is a good thing as if infested heads could so easily be cleaned up this unnecessary and unpleasant condition might lose some of its horrors, and the condition cease to be confined generally to the lazy and the dirty. The following table shows the scope of treatment carried out:— Number of cases of Scabies treated 694 Cases of Scabies with concurrent verminous head 37 Cases of Scabies with Secondary Septic Skin condition 17 Number of cases of Verminous heads only 17 Total number of attendances at the Centre 3,108 Number of follow up visits to the home 58 Of the 17 children with verminous heads treated in the Cleansing Station, 8 occurred in children under five. The incidence of infestation in the Day Nurseries during the year was :— Manor House. High Path. Middleton Ed. Vermin and Nits 5 4 20 Nits only 2 2 12 The result of observations by the Health Visitors at the Clinics during the year showed only one child under five with a verminous head. 58 INDEX page Acreage 6 Ambulance Facilities 19, 20 Acute Poliomyelitis 51 Births 9-11, 25 In hospitals or maternity homes 11, 12 Rates 7 Bed Bugs—Eradication of 36 Cancer—Deaths from 41 Rate 9, 14 Cerebro-Spinal Fever 15 Child Life Protection 34 Clinics and Treatment Centres 20, 22, 28 Climatic Conditions 7 Closet Accommodation 35 Cleansing Stations 57 Deaths 7-13, 15 Causes of 13, 14, 15 Rates 7-9 Diphtheria 46 Immunisation 21,44, 50 Clinics, times and places 21 Children Immunised in Schools 49 Persons Immunised at Clinics 49 Persons Immunised by Private Practitioners 49 Incidence and fatality for 24 years 50 Swabs examined 19 Disinfestation 36 Drainage and Sewerage 35 Drainage work 36 Day Nurseries 56 Enteric Fever 44 Erysipelas 51 59 INDEX—continued. PAGE Factories 40 Food and Drugs Act, 1938 38, 39 Food Supply 36 Inspections 36, 37 Unsound Food 36 Foodstuffs—Gas Contaminated 40 Health Services 18 Heart Disease—Deaths from 13, 15 Hospitals 22, 23, 24 Housing 42 Inspections and Defects 36 Number inhabited 6 Verminous premises 36 Industry 6 Infant Mortality 7-17 Rates 9 Infectious diseases 44-52 Diseases notifiable 44 Inquests 13 Isolation Hospital 23 Laboratory Facilities 18, 19 Examination of clinical material 19 Maternal Mortality 16 Rates 9, 16 Maternity and Child Welfare 25 Ante-Natal Clinics 26, 29 Attendances at each Centre by age groups 27 Attendances at Infant Consultation Clinics 27 Attendances at Maternity Clinics 26 Attendances at all Infant Welfare Centres 27 Attendances at Centres over last ten years 27 Attendances in relation to the registered births 28 Consultant advice for maternity 30 Convalescent Home Treatment 29 60 INDEX—continued. PAGE Maternity and Child Welfare continued— Dental Scheme 30, 31 Attendances 32 Operations performed 32 Emergency Maternity Unit 30 Health Visiting 29 Home Help 30 Hospital provision for maternity 12, 24, 29 Midwives 33 Orthopaedic Treatment 29 Sessions, times and places 20 Sterilised Maternity Outfits 30 Voluntary Helpers 33 Work of the Centres 25 Meat Inspection 37 Measles 51 Milk Supply 37, 39 Neonatal Deaths 17 Nelson Hospital 12,24, 28 Notification of Births 25 Nursing in the Home 18 Ophthalmia Neonatorum 51 Population 9-11 Public Assistance 6 Public Cleansing 35 Public Health Committee 4 Puerperal Pyrexia 51 Rainfall 7 Rateable value 6 Rats and Mice Destruction 40 Respiratory diseases—deaths from 14 Representatives on:— Nelson Hospital Council 4 Wandle Valley Joint Hospital Board 4 Wandle Valley Joint Sewerage Board 4 Road Accidents (deaths from) 13 61 INDEX—continued.. PAGE Sanitary Circumstances 35 Sanitary Inspection 41 Scarlet Fever 45 Incidence in each Ward with rates 45 Monthly distribution of cases 45 Shops Acts, 1912-1936 41 Slaughterhouses 37 Smallpox 22, 44 Smoke Abatement 41 Social Conditions of the Area 6 Staff 5 Statistics 7 Comparative 10 Tuberculosis 52 Admissions to Sanatorium 24, 53 Deaths due to 53 Dispensary New cases—by age groups 55 Number on register at year end 53 Venereal Diseases 22 Water Supply 35, 40 Whooping Cough 51 Zymotic Disease—Deaths from 9 Rate 9 62