Merton and morden urban District ANNUAL REPORT OF THE Medical Officer of Health FOR THE YEAR 1945 AND REPORT OF The Sanitary Inspector Merton and Morden Urban district ANNUAL REPORT OF THE Medical Officer of Health FOR THE YEAR 1945 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 Report for the year 1945. The Registrar General has given the population for the year 1945 as 66,050 as compared with 62,760 last year. The total number of births you will see has dropped slightly from 1,157 to 1,053 this year. The comparative statistics for our population continues to be highly favourable. Our infant mortality is 34 per 1,000 live births. Our maternal mortality rate nil and our death rate 9.1 per 1,000 of the population. I am going to suggest that perusal of this Report is prefaced by examination of Table II on page 14. There in tabular form is a kaleidoscope picture of Merton and Morden from its infancy to its present maturity. The scene opens in the year 1913, the last year before our world embarked on the series of international conflicts from which even at this moment we are desperately hoping we have finally emerged. Our community in that year consisted of some 16,000 souls, and in that year 400 new births contributed to a natural increase of population, i.e., excess of births over deaths, of 13.9 per 1,000 compared with to-day a natural increase of only 6.8 per 1,000 of the population. In the next year, 1914, there were 420 births, a figure not to be again achieved until 1929— fifteen years later when the population had reached 27,000. In 1914, a population of 17,000 produced 420 babies whereas in 1930 35,000 population produced 452. Exactly double the population and still approximately the same number of babies!! Further there was a natural increase of 278 in 1914 and in 1930 it had fallen to 211. Two other facts of the greatest significance can be deduced from the Table, one that the relatively high birth rates we have experienced in the past few years were similarly experienced in the period 1920-23, and secondly that the Table is highly suggestive of a controlled birth rate, and that the fear sometimes expressed that there is a decline in racial fertility is without foundation. The Table shows that although the population slowly increased, the number of births fell and the birth rate slumped during these years when by the hideous demands of war the best of their procreative potential was being cruelly wasted in Flanders and elsewhere. With the ending of the fighting and 2 the return of the survivors to the community, the births and the birth rate take an upward curve, such a curve as we are experiencing now, but at no time does it reach pre 1914 figures and within ten years the effort is spent. What other detail can we discern in the picture? In view of the concentration of attention on the birth rate, there is perhaps some excuse for venturing some observations of a general character on this complicated question. That there is ample justification for anxiety over the population trend, in spite of the current improvement in the birth rate and the continued fall in the death rate, there is no doubt, that is of course if we accept the belief in the universal importance of the survival of the Western European races and the English and English speaking race for in many parts of the world, the reproduction rate has not fallen. The statistics for our district, although interesting to us, in addition to being too small to provide reliable hypotheses have been confused by recent immigration on a considerable scale of younger age groups of high child bearing capacity and propensity and naturally with the influx of the younger age groups diluting the population, a lower death rate, so that the increase of population in Merton and Morden, that is the excess of births over deaths, does not exactly follow the national pattern. It is this steady reduction in the natural increase of population that is giving rise to so much anxiety, and it is prophesied that it will not be long before it ceases to be an increase and becomes a decrease. While it is true that the downward trend of the birth rate was arrested in 1941 and started to rise, reaching 17.7 in 1944, the highest figure achieved since 1926, this is regarded by experts as an evanescent phenomenon and attributable to the high birth rates following the 1914-18 war which in turn are responsible for the present high marriage and birth rates. The present low death rates are attributable to the same factor, as the high birth rates of that period are held to be responsible for a high proportion of the population in the healthiest period of life, the middle years, and as the population ages the death rates will inevitably rise. In the face of such a statement which points unmistakably to population bankruptcy, the thoughts of the prudent will inevitably turn to economy and thrift as a means of salvation and they will carefully examine to see what economy is being effected and search and probe to see what further saving is possible. Public Health need have no fear of being asked to give an account of its stewardship. It has effected praiseworthy saving in infant life, it has reduced the child bearing risk; by reducing the stillbirth rate it has increased the number of survivals, and by reducing the maternal mortality it has raised the level of continuation of maternal function, both 3 fostering and reproductive. While public health may be entitled to feel complacent if such an enquiry were directed at it, no one knows better that further economy is still possible, and while the mechanism is more often than not social rather than purely medical, that does not seem to justify leaving it entirely in other hands. Apart from the reduction in the general wastage of life outlined above, there are special examples where there is a particular need for attention, e.g., the high infant mortality of illegitimacy and the loss through abortion. Abortion is a complete wastage of fertility. As a reduction of fertility itself is in some places suspected of being one cause of the decreasing birth rate some remedy must be found for this fruitless misdirection of reproduction, as a first step in any attempt to secure an increase in the births. A reduction of illegitimacy will only indirectly raise the legitimate birth rate in so far as the potential can be diverted by social measures into securer channels; more important and far reaching will be its effect on the quality of the population, but better provision for the care of the illegitimate infant wall attack the infant mortality rate at its most vulnerable point. Lest this public health prospectus encourages even the prudent to relaxation and complacency, it is a matter of regret that it is prophesied that even these measures when they are practically applied will not be sufficient to reverse the population trend without a very substantial and permanent change in the reproduction rate, and so seriously is it regarded in one Scandinavian country at least, that an active legislative policy has been adopted in an attempt to effect this correction. How far social legislation of this sort is capable of influencing population trends is a matter for speculation. Fortunately our part is much simpler, it is to secure the highest survival rate possible, with the highest possible quality of survivor. There are no very significant epidemicalogical events to record for the year. Measles with 760 cases assumed perhaps almost epidemic proportions, but as is later recorded, the disease generally was mild and there were no deaths. There were 114 cases of Scarlet Fever and 77 cases of Whooping Cough; both figures can be considered as average low annual figures. There were 139 new cases of T.B. added to the register and 45 deaths from this disease; those are also average annual figures. There are only 8 recorded cases of Dysentery but there is evidence that mild intestinal infections have been much more widespread than the number of notifications of such disturbances or Dysentery would suggest. It is fervently to be hoped that we shall speedily get back to pre-war standards of hygiene as 4 regards food handling, and indeed that we shall continue to strive to improve upon those standards; there is undoubtedly ample room for improvement. No report on the environmental conditions, as they affect the health of the public, would be complete without some reference to housing standards. Never in the history of local government was the question of housing so difficult and so serious in its effect on the public well being, but fortunately it is also true that the need for remedy was never so universally agreed and determined upon. In conclusion, I would like to express my thanks to the members of the Council and of the Public Health and Maternity and Child Welfare Committees for their support and encouragement, in the public health work of the district. To the members of the staff of the public health department I would like to pay tribute for their personal interest and devotion to the service. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, A. W. JOHNS. September, 1946. 5 URBAN DISTRICT COUNCIL of MERTON and MORDEN 1 845 NO. 3 COMMITTEE (SERVICES). Chairman : Mrs. H. Cobbett. Mr. V. H. Auger. Mrs. S. A. Lodge. Mr. W. T. Carter. Mr. C. S. Marsh. Mrs. L. A. Doel Mr. W. G. Oliver. (To September). Mr. E. R. Smale Mr. W. S. LeGros Clark (From September) Mr. S. W. Billingham (Chairman of the Council). Mr. W. H. Glasscock {Vice-chairman of the Council to September). Mrs. L. A. Doel (Vice-Chairman of the Council from. September). REPRESENTATIVES ON THE WANDLE VALLEY JOINT HOSPITAL BOARD. Mrs. H. Cobbett. Mr. S. P. Franklin. Mr. F. J. Grimme. Mr. S. W. Billingham (ex-officio). REPRESENTATIVES ON THE WANDLE VALLEY JOINT SEWERAGE BOARD. Mrs. E. M. Clifton, J.P. Mr. S. F. Franklin (To October). Mr. D. Shadbolt. Mr. C. S. Marsh (From October). Mr. W. H. Glasscock (Vice-Chairman of the Council to September). Mrs. L. A. Doel (V'ice-Chairman of the Council from September). REPRESENTATIVES ON NELSON HOSPTAL COUNCIL. Mr. A. E. Davison. Mr. W. H. Glasscock. Mr. P. Hill. 6 PUBLIC HEALTH STAFF, 1945. Medical Officer of Health: A. Wallace Johns, M.R.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. (To 5.10.45). a b F. C. Thomas, M.R.S.I, (From 6.10.45). Deputy Chief Sanitary Inspector: a b F. C. Thomas, M.R.S.I. (To 5.10.45). Sanitary Inspectors. 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 M. E. Black. Miss J. Eve (From 12.3.45) Miss A. Howard Miss E. F. Martin Miss V. M. Evans. (From 1.8.45). Senior Clerk: H. J. Herbert. Clerks: Mrs. E. Lang (To 14.9.45). Miss J. Matthews. Mrs. M. Green (From 24.9.45). A. J. Fletcher. Ante-Natal Officer: Christine Stacey, M.B., B.S., M.R.C.O.G. Consulting Obstetrician under the Puerperal Pyrexia Regulationt 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. Ancesthetist 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. 6 Sanitary Soience Certificate, University of Liverpool, c Smoke inspector's Certificate, Royal Sanitary Institute. d Meat and Food Certificate, Royal Sanitary Association of Scotland 7 SECTION A.— STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 3,238 Number of inhabited houses according to Rate Books 21,003 Rateable value at 31st December, 1945 £638,576 Sum represented by Id. rate £2,450 Industry. The number of factories registered under the Factory Act at the end of 1945 was:— Factories with mechanical power:— Employing more than 40 persons 35 Employing less than 40 persons 125 Factories without mechanical power 16 176 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. Number of persons admitted to mental hospitals 64 Total number of persons in receipt of domiciliary assistance on:— 1st January, 1945 160 1st July, 1945 206 31st December, 1945 303 Total amount of domiciliary assistance granted in Merton and Morden in the year 1945 £8,765. Climatic Conditions. Rain gauges are installed at the Joseph Hood Recreation Ground and West Barnes Pumping Station. 8 The monthly recordings are as shown below:— RAINFALL, 1945. JOSEPH HOOD RECREATION GROUND WEST BARNES PUMPING STATION Month Indies Days with O.lin. or more Days with 0.4in. or more Inches Days with O.lin.or more Days with 0.4in. or more January 1.47 23 13 1.85 22 14 February 1.23 11 9 1.51 14 9 March 1.09 11 6 .46 12 5 April 1.10 9 6 1.17 10 7 May 2.65 12 11 3.02 13 9 June 1.14 16 13 1.45 17 13 July 2.92 9 6 3.46 11 7 August 1.70 8 8 1.68 13 9 September 1.57 15 13 1.79 20 151 October 2.06 9 6 2.40 10 8 November 0.17 4 3 .31 11 3 December 2.64 16 14 2.88 17 14 TOTAL 19.74 143 108 21.98 170 113 VITAL STATISTICS. Vital Statistics for the year maintain the satisfactory standard of previous years, the figures comparing very favourably with those of the country as a whole. The birth rate was 15.5 per 1,000 population, with a total number of live births of 1,027. The death rate was 9 per 1,000 population comparing with the corresponding figure for England and Wales of 11.4. The infant mortality rate was 33.1 per 1,000 live births as compared with a figure of 46 for England and Wales. As mentioned in previous reports, the effect of what is probably a low population estimate is to raise these figures slightly, and while this gives an exaggerated picture of the birth rate, we can console ourselves with the reflection that the death rate is correspondingly raised. The total deaths from all causes was 602 and the total live births 1,027, giving, therefore, a natural increase of population of 425. 9 The appended table sets out the comparison for the past five years of the local infant mortality rate with that for England and Wales. It will be seen that the local rate is consistently very considerably below that for the whole country; in the last two years approximately half. England and Wales. Merton and Morden. 1941 59 42.5 1942 49 33.9 1943 49 23.5 1944 46 28.7 1945 46 33.1 The number of illegitimate births has increased again for the year and was 65 against 49 in the year before. It is to be hoped that this will be the last year of conditions conducive to this result and that next year we shall see a return to normal figures. As it has been pointed out before, there is a relatively high mortality rate among these infants, 95 per 1,000 births as compared with 29 per 1,000 for legitimate births. This higher mortality rate can probably also be regarded as a reasonably accurate index of the relative care bestowed on the two categories. 10 SUMMARY OF VITAL STATISTICS. (Registrar General's Figures), Population: Registrar General's Estimate 66,050 Births: M. F. Total Live (Legitimate) 463 501 964 (Illegitimate) 29 34 63 492 535 1,027 Still Births (Legitimate) 12 12 24 (Illegitimate) 1 1 2 13 13 26 Total Births 505 548 1,053 Birth Rate 15.5 per 1,000 population Still Birth Rate 24.6 per 1,000 births Deaths: M. F. Total 322 280 602 Death Rate 9.1 per 1,000 population Infant Mortality: Total deaths under 1 year 34 Infant Mortality Rate per 1,000 Live Births 33.1 Deaths of Legitimate Infants under 1 year 28 Death Rate per 1,000 Legitimate births 29 Death Rate per 1,000 Illegitimate births 95 Maternal Mortality: Deaths from Sepsis Nil Deaths from other maternal causes 1 Maternal Death Rate 0.97 Zymotic Deaths: Deaths from Measles Nil Whooping Cough Nil Diarrhoea (under 2 years) 2 7 Principal Zymotic Diseases 0.05 Deaths from Tuberculosis: All forms 45 Rate per 1,000 population 0.68 Phthisis 42 Rate per 1,000 population 0.64 Deaths from Cancer 116 Rate per 1,000 population 1.7 11 * Including Puerperal Fever. 12 TABLE I. COMPARATIVE STATISTICS, 1945. (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 Towne (Residential Populations 25,000 to 50,000 at Census). London Adminis- tive County. Merton and Morden. Rates per 1,000 Population. Births:— Live 16.1 19.1 19.2 15.7 15.5 Still 0.46 0.58 0.53 0.40 0.39 Deaths:— All causes 11.4 13.5 12.3 13.8 9.1 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 0.02 0.02 0.01 0.02 0.00 Diphtheria 0.02 0.02 0.02 0.01 0.01 Influenza 0.08 0.07 0.07 0.07 0.01 Smallpox — — — — — Measles 0.02 0.02 0.02 0.01 0.00 Notifications:— Typhoid Fever 0.01 0.01 U.U1 U.U1 U.U1 Paratyphoid fever 0.01 0.00 0.01 0.00 0.00 Cerebro-spinal fever 0.05 0.05 0.05 0.00 0.04 Scarlet fever 1.89 2.02 2.03 1.57 1.72 Whooping Cough 1.64 1.65 1.47 1.25 1.16 Diphtheria 0.46 0.52 0.56 0.31 0.22 Erysipelas ... 0.25 0.28 0.24 0.31 0.22 Smallpox 0.00 0.00 — 0.00 0.00 Measles 11.67 10.89 11.89 9.03 11.50 Pneumonia 0.87 1.03 0.72 0.78 1.07 Rates per 1,000 Live Births. Deaths under 1 year of age 46 54 43 53 33.1 Deaths from Diarrhoea and Enteritis under 2 years of age 5.6 7.8 4.5 7.6 1.9 Rates per 1,000 Total Births (Live and Still). Notifications:— Puerperal fever Puerperal pyrexia 9.3 12.65 8.81 3.60 15.87* 3.8 POPULATION. The Registrar General's estimate of the population for 1945 is 66,050. This figure is low compared with an estimate based on occupied dwellings such as is used for local computation of the ward population. The Registrar General has again provided an estimate of the population under five and between five and fifteen. This has been done primarily to secure uniformity in calculation of immunisation figures, as there is a tendency to wide variation from district to district in locally compiled estimates. The figures for the age group 0-4 inclusive is 4,720 and for the age group 5-14 inclusive is 9,480. BIRTHS. The registered live births totalled 1,027, a decrease of 124 on the previous year; and the birth rate has shown a corresponding fall from 18.3 to 15.5 per 1,000 of the population. Of the total live births 492 were males and 535 females. There were 63 illegitimate births; of these 29 were males and 34 females. There were 26 stillbirths; 13 male and 13 female. INSTITUTIONAL AND DOMICILIARY BIRTHS. The tendency of recent years towards increased Institutional confinements continued and in 1945 seventy-three per cent. of the births which occurred took place in hospitals or nursing homes, as follows:— St. Helier Hospital 341 Nelson Hospital 216 Kingston County Hospital 22 Other hospitals, institutions and nursing homes 194 773 13 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. Natural Increase 1913 10,767 400 23.5 166 9.9 234 1914 17,500 420 24 142 8.2 278 1915 17,500 402 22.9 169 10.4 233 1910 16,000 348 27.75 134 8.3 214 1917 17,000 271 15.75 145 9.0 126 1918 17,552 241 14 204 13.0 37 1919 18,100 257 14.2 210 11.8 47 1920 18,200 359 19.8 171 9.4 188 1921 18,000 322 17.8 138 7.6 184 1922 18,500 365 19.7 198 10.7 167 1923 18,750 341 18.1 153 8.1 188 1924 18,710 311 16.6 170 9.1 141 1925 18,960 307 16.2 187 9.9 120 1926 19,980 333 16.7 179 9.0 154 1927 21,850 352 16.13 200 9.2 152 1928 25,780 392 15.2 224 8.7 168 1929 27,430 442 16.1 281 10.2 161 1930 35,000 452 12.9 241 6.9 211 1931 41,610 628 15.1 333 8.0 295 1932 48,550 770 15.8 352 7.2 418 1933 52,130 644 12.3 416 7.9 228 1934 55.550 770 13.8 484 8.7 286 1935 57,440 721 12.5 433 7.5 288 1936 61,000 789 12.9 443 7.2 246 1937 65,530 812 12.3 487 7.4 325 1938 68,980 990 14.3 509 7.3 481 1939 72,150 1,005 13.9 516 7.2 489 1940 68,540 971 14.2 714 10.4 257 1941 64,920 848 13.06 557 8.58 291 1942 66,590 1,069 16.05 588 3.8 481 1943 65,880 1,146 17.4 575 8.7 571 1944 62,760 1,151 18.3 628 10 523 1945 66.050 1.053 15 5 602 9.1 451 DEATHS. The number of registered deaths after adjustment by transferable deaths, is given below :— 602 total deaths, of which 322 were males and 280 females. The seasonal mortality is indicated by the deaths for each quarter of the year, which were:— First quarter 189 Second quarter 121 Third quarter 116 Fourth quarter 176 14 Inquests. Inquests were held on 26 deaths occurring in the district, 14 of which were in respect of residents. The verdicts returned were as follows:— (1) Natural Causes 4 (2) Suicide by— Coal Gas Poisoning 5 Fall from Roof 1 Fall from Window 1 Strangulation by Hanging 1 — 8 (3) Accidental Deaths- Asphyxia from Smoke Fumes 1 Collisions with Motor Vehicles 4 Fall in Home 3 Fall from Trolley-bus 1 Knocked down by Pedal Cycle 1 Run over by Train 1 — 11 (4) Misadventure— Death by Drowning 1 Death by Electrocution 1 Fall from Roof 1 — 3 26 The total number of inquests held were six more than in the year before. Road accidents were responsible for six of the total accidental deaths, compared with two for the previous year. CAUSES OF DEATH. Heart Disease, with 142 deaths, was the commonest cause of death and next in order of frequency once more comes Cancer with 116 deaths. In considering the question of heart disease being represented statistically as the commonest cause of death, and before coming to the conclusion that heart disease is a common disease, it should be remembered that it is given a high priority on the selection list of Causes of Death, where two or more conditions are recorded on the death certificate, and as heart failure in one form of nomenclature or another appears on the majority of death certificates it inevitably achieves the highest 15 aggregate. The appended tables shows an analysis of the numbers in the various age groups allocated to Heart Disease:— Age Group No. of Deaths Age Group No. of Deaths 90 and over 5 55-60 6 86-90 5 50-55 4 80-85 10 45-50 4 75-80 17 40-46 — 70-75 14 35-40 8 66-70 7 35 and under 6 60-65 13 It will be seen that 37 were 75 and over and of all the deaths attributed to heart disease 71, or 77 per cent., occurred in persons of 60 and over. Ten of the 37 deaths over 75 were 85 or over, and 5 of them 90 or over. It is a cruel trick of fate having lived to 90 years of age to be stricken down with heart disease. Surely senility would be a truer description of the cause of these deaths; and it would have the advantage of presenting a more accurate picture of the disease. In view of the importance of increasing our knowledge of Rheumatism, an acute form of which is regarded as the commonest cause of heart disease, this question assumes even greater importance lest it be argued that heart disease, being the commonest cause of death and acute Rheumatism being the commonest cause of heart disease, acute Rheumatism is the commonest disease. Another interesting point to be seen in this analysis is that only 21 or 23 per cent, of deaths from heart disease occurred under 60 and that the two biggest groupings are 13 between 60-65 and 17 between 75-80. While deductions must be made with the greatest hesitation from such small numbers as this and locally compiled, it would seem that further study on a larger scale might well be valuable. The other causes responsible for the greater proportion of deaths are in order—Cancer, Intercranial Vascular Lesions and Tuberculosis. Reference to the Table on page 17 shows that the death rate from Cancer remains, as last year, at the highest level for ten years at 1.7 per 1,000 population. There were actually 116 deaths in 1945 as against 107 in 1944, the increase in the population figure is responsible for the unaltered rate. There were 45 deaths from Tuberculosis in 1945 as against 37 last year, the rate per 1,000 population being 0.68 as against 0.58 for the previous year. 16 CANCER DEATH RATE. No. of deaths from Cancer for past 10 years. 1936 74 1941 85 1937 93 1942 103 1938 89 1943 116 1939 91 1944 107 1940 76 1945 16 Year. Death Rate per 1,000 population. Year. Death Rate per 1,000 population. 1936 3.2 1941 1.3 1937 1.4 1942 1.5 1938 1.2 1943 1.7 1939 1.1 1944 1.7 1940 1.2 1945 1.7 TABLE III. Deaths from Respiratory Diseases, 1925-45. 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 1.2 1928 8 14 2 24 0.9 1929 11 20 4 85 1.2 1980 2 10 8 15 0.4 1931 8 24 4 86 0.8 1932 11 27 8 41 0.8 1983 12 82 6 50 0.9 1984 7 88 4 49 0.8 1985 9 22 6 87 0.6 1986 2 85 2 89 0.6 1987 14 81 6 51 0.8 1988 15 27 7 49 0.7 1989 6 20 9 84 0.4 1940 38 40 15 93 1.8 1941 30 30 6 66 0.9 1942 9 12 20 41 0.62 1948 25 86 9 70 1.05 1944 26 29 7 62 0.98 1945 86 22 12 70 1.05 17 TABLE IV. Causes of Death during the Year 1945. No. Cause of Death. Males Females Total l Typhoid and Paratyphoid Fevers — — 2 Gerebro spinal fever ] 2 3 3 Scarlet Fever — — 4 Whooping Cough — — — 5 Diphtheria 1 1 6 Tuberculosis Reepir. System 29 13 42 7 Other forms of Tuberculosis 3 — 3 8 Syphilitic diseases ... 2 — 2 9 Influenza — 1 1 10 Measles — — — 11 Ac. Polio-myel. and polioencephalitis ... ...' 12 Ac. inf. encephalitis — — 13 Canoer of hue. cav. and oesoph. (M) uterus (F) ... 7 5 12 14 Canoer of stomach and duodenum 9 9 18 15 Cancer of breast — 15 15 16 Cancer of all other sites ... 32 39 71 17 Diabetes 1 2 3 18 Intra-cranial vascular lesions '-'2 45 67 19 Heart disease ' 87 55 1+2 20 Other dis. of circ. system ... 5 7 12 21 Bronchitis 26 10 36 22 Pneumonia 9 13 22 23 Other respiratory diseases ... 7 5 12 24 TTlcer of stom. or duodenum 4 3 7 25 Diarrhoea under 2 years ... 1 1 2 26 Appendicitis — — — 27 Other digestive diseases 7 6 13 28 Nephritis 9 7 16 29 Puer. and post abort, sepsis — — — 30 Other maternal causes — 1 1 31 Premature birth 8 3 11 32 Coil. mal. birth inj. inf. dis. 9 8 17 33 Suicide 4 1 5 34 Road traffic accident 4 3 7 35 Other violent causes 4 8 12 36 All other causes 32 17 49 Total all causes 322 280 602 MATERNAL MORTALITY. One death was recorded as being dne to maternal causes during the year, giving a maternal mortality rate of 0.97 per thousand total births as against 0.84 in the previous year. The corresponding rate for England and Wales was 1.66. 18 TABLE V. Maternal Mortality, 1925-45. Year Death rate per thousand total births. Sepsis Other causes Total 1925 - 6.5 6.5 1926 — — — 1927 — 2.8 2.8 1928 — — — 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 2.94 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 1944 — 0.84 0.84 1945 — 0.97 0.97 INFANT MORTALITY. There were 34 deaths of infants under one year of age, of whom 20 were male and 14 female. The infant mortality rate for the year is 33.1 per 1,000 live births as compared with 28.7 for the previous year. The rate for England and Wales as a whole is 46 per 1,000 live births. Of the 34 deaths recorded 29 were neo-natal. This is a high proportion and conversely 5 deaths other than neo-natal out of a total of 1,027 births is a very low figure. A high proportion of neo-natal deaths are attributable to injuries at birth and is regarded as an index of obstetrics rather than of infant welfare. Deaths of infants under one year of age which are not neo-natal are of course an important index of infant welfare. Further information with regard to deaths from Prematurity will be found in the section dealing with premature babies. 19 20 Infant Deaths—With causes of death. Sex Age Cause of Death Female 9 months Broncho-Pneumonia. Male 5 days Congenital. Hypertrophic Stenosis. Male 1 day Heart Failure, Prematurity. Male 1 day Congenital Patent. Interventricular Septum of Heart. Male 18 hours Patent Foramen Ovale. Congenital Heart Disease. Male 1 month Congenital Atelectasis. Male 18 hours Prematurity. Pyelitis in Mother. Female Newly-born Accidental. Female 5 hours Prematurity. Male 5 days Oedema of Lungs and Larynx. Cardiac Failure. Large Patent Ductus Arteriosus. Female 2 weeks Septicasmia. Pemphigus Neonatorum. Female 2 weeks Meningitis. Spina Bifida. Male 2 months Meningococcal Meningitis. Male 1 hour Extreme Prematurity. Male 1 day Extreme Prematurity. Male 10 months Castro-Enteritis. Broncho-Pneumonia. Diaphragmatic Hernia. Male 4 months Gastro-Enteritis. Mastoiditis. Male 1 week Extreme Prematurity. Female 1 week Prematurity. Male 1 week Cerebral Haemorrhage. Male 4 weeks Broncho-Pneumonia. Gastro-Enteritis. Male 1 week Cardiac Failure. Prematurity. Female 1 week Pneumonitis. Male Naso-pharyngeal Infection. 1 day Extreme Prematurity. Male 2 days Atelectasis. Female 6 days Broncho-Pneumonia. Female 2 weeks Prematurity. Male 14 hours Prematurity. Maternal Toxaemia of Pregnancy. Female 3 days Prematurity. Female 1 hour Asphyxia. Prolonged Labour. Male 1 week Prematurity. PREMATURE BABIES. Since December, 1944, prematurity is required to be indicated on the birth notification card by recording the birth weight in all infants of 5|lbs. and under at birth. In 1945 in this area there were 27 of these notified births, of whom 19 were born in hospital and 8 in their own homes. Fuller details will be seen in the appended Table. The total number of premature babies notified during 1945 were as follows, born:— (a) At home 8 (b) In hospital 19 The number of those born at home:— (a) Who were nursed entirely at home 4 (b) Who died during the first 24 hours 2 (c) Who survived at the end of one month 2 The number of those born in hospital:— (a) Who died during the first 24 hours 5 (b) Who survived at the end of one month 14 In view of the high mortality among premature babies and in accordance with the recommendation of the Ministry of Health in 1944, special arrangements were made for their care, particularly of those born at home. The arrangements consist of the provision of special equipment including a specially designed cradle. In addition a children's specialist has been appointed, who is available to any practitioner for purposes of consultation. It appeared obvious from the inception of these arrangements that the very special provision for these infants should necessitate special hospital provision and St. Helier County Hospital made this provision for its adjoining areas. Provision, which in addition to a babies' ward designed and equipped for this particular purpose, included transport arrangements from the home to the hospital by an ambulance equipped with an incubator cradle. The main lines of further progress in this particular field of preventive medicine would appear to be further extension of the St. Helier type of hospital provision and a more extended use of the facilities provided. It should not be overlooked that the normal habitat of the less than 40 week fcetus is in Uterus and no pains should be spared to keep him there until the appointed time. Transport too should be effected whenever at all possible, not with 21 Sex Age Cause of Death Male 4 minutes Broncho-Pneumonia. Congenital Morbus Cordis. Female 3 weeks Broncho-Pneumonia. Female 7 months Cerebral Spinal Meningitis. the baby in the incubator in the ambulance, but with the baby in utero in the ambulance. To effect this, which must surely be the optimum arrangement, premature labour must be generally recognised to be an indication for immediate hospitalisation when parturition is inevitable. This seems to a large extent to be a matter for educational propaganda. It will be seen from the tabulated statement given above that, of 8 notified births occurring at home, only 2 lived one month or a death rate of 75 per cent., whereas of those occurring in hospital 5 out of 19 did not live one month, a death rate of 26 per cent. Premature Deaths. Of the 29 neo-natal deaths recorded it is interesting to note that 14 were attributed to Prematurity. The following table shows the place of birth, the period of survival and, where available, the birth weight of the babies. In 5 cases where the birth weight is not available the infants were born in institutions outside the district. Of the 14 deaths recorded from Prematurity 13 occurred in hospital and one at home. Of this 13 four were born at home and admitted to hospital after birth. Place of Birth Period of Survival Birth Weight Place of Birth Period of Survival Birth Weight Domiciliary 1 day 3 lbs. Hospital 3 days 3 lbs. 3½ ozs. Hospital 18 hours 4 lbs. 8 ozs. Domiciliary 1 week 4 lbs. 6 oz. Hospital 5 hours 3 lbs. 2 ozs. Hospital 1 hour Unknown Domiciliary 1 week 2 lbs. 8 ozs. Hospital 1 day Unknown Hospital 1 week 4 lbs. 8 ozs. Hospita 1 week Unknown Hospital 1 day 3 lbs. 6 ozs. Hospital 1 week Unknown Domiciliary 2 weeks 3 lbs. Domiciliary 14 hours Unknown 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 180 cases involving 1,440 visits were attended during the year and of these 15 cases were children under 5 years of age, to whom 66 visits were made. 22 (2) The St. Helier District Nursing Association employs one nurse for general nursing. No midwifery or 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 the year 144 cases were dealt with by the St. Helier District Nursing Association, 10 of these were children under 5 years of age. The total number of visits made was 3,848, of which 57 were in respect of children under 5 years. (3) The Wimbledon District Nursing Association serves Wimbledon and the western part of this district. Two nurses are employed for general nursing in Merton and Morden. The Laboratory Facilities. The routine laboratory work for district is undertaken by the Nelson Hospital. The appended Table shows the pathological work undertaken during the year:— Examinations. No. performed. Positive result. Swabs for diphtheria bacilli 212 9 Sputum for tubercle bacilli 52 2 Fasces 510 55 Swabs from Puerperal cases 1 — Urine 9 - AMBULANCE FACILITIES. Infectious Cases. Cases of infectious disease, where they are admitted to Isolation Hospital, are conveyed by ambulances of the Wandle Valley Joint Hospital Board. Non-Infectious Cases. The Council maintain one general purpose ambulance fully staffed and one ex-Army vehicle in reserve. The reciprocal arrangements previously of an informal nature were made the basis of a more formal arrangement between Sutton and Cheam, Carshalton, Mitcham and 28 figures relating to cases and visits in this district during the year are as follows:— Cases. Visits. Children under 5 years 38 285 Other cases 320 5,295 358 5,580 Merton and Morden whereby calls are transmitted by one Authority to the nearest available, when the ambulance is already out. These reciprocal arrangements to be free between the authorities concerned. The scope of the work undertaken by our ambulance is as shown below:— 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. 100 7 107 3 104 Feb. 108 7 115 9 106 March 118 11 124 n 113 April 108 9 117 8 109 May 111 4 115 13 102 June 95 6 100 7 93 July 101 19 120 11 109 Aug. 89 45 134 8 120 Sep. 121 30 151 13 138 Oct. 107 34 141 12 129 Nov. 132 64 196 23 173 Dec. 144 8 152 18 134 Total 1329 243 1572 136 1436 Time taken in executing the calls (from leaving Station to return) 1,165 hours Mileage covered 11,614 miles Average time per call 43.5 minutes Average distance per call 7.3 miles The Volunteer Car Pool established during the war by the W.V.S. has been continued under the auspices of the British Red Cross and St. John Ambulance Brigade and is now called the Hospital Car Service. The service continues to cater for ambulance patients who are required to attend out-patient departments of hospitals for treatment. Work continues on a voluntary basis and the transport is provided by public spirited persons who put themselves and their vehicles at the disposal of the organisation. A charge of 3d. per mile is made to'cover partly the actual running cost. This cost is met by the Council for residents in the district. These arrangements are a most valuable extension of the ambulance facilities provided in the district. 24 CLINICS AND TREATMENT CENTRES. 1.—Maternity and Child Welfare Clinics (provided by the Council). Centre Clinic Times of Clinics Health Centre Infant Welfare Monday 10— 12 noon. Grand Drive, ,, 2— 4 p.m. Raynes Park, Wednesday 10—12noon SW.20 Ante-Natal Wednesday at 1.80 p.m. Health Centre, Infant Welfare Wednesday 2—4 p.m. Aston Road, Friday 10—12 noon Raynes Park, S.W.20 Ante-Natal Dental Clinic Saturday at, 9.0 a.m. By appointment Friday mornings. Health Centre, Infant Welfare Tuesday 11—12 noon. Middleton Road, ,, 2— 4 p m. Morden Friday 2—4 p.m. Ante-Natal Dental Clinic Thursday 9.0 a.m. By appointment Thursday mornings. Baptist Hall, Crown Lane. Morden Infant Welfare Thursday 2—4 p.m. Hope Mission Hall Rodney Place, Merton, S.W.19 Infant Welfare Thursday 10—12 noon 2.—School Clinics (provided by the Surrey Education Committee). Aston Road, Raynes Park, General Medical Every Tuesday and Thursday 9.80—12 noon. S.W.20 Dental Every Monday. Tuesday and Thursday 9.80—12 noon 1.80—4.0 p.m. Every Friday 1.30—4.0 p.m. Eye Every 2nd and 4th Tuesday tifternoon in the month. Middleton Rd., Morden General Medical Every Monday and Wednesday 9 80—12 noon. Dental Every Tuesday, Wednesday and Friday 9.30—12 noon and 1.80—4.0 p.m. Every Monday and Saturday 9.30—12 noon. Every Thursday 1.30-4.0 p.m. Eye Every Wednesday afternoon 2.0 to 4.30 p m. 25 3.—Tuberculosis Dispensaries (provided by the Surrey County Council). St. Halier County Hospital Wrythe Lane, Carshalton, Morden Patients Monday 10 a.m. 2nd Monday in month, 6.80 p.mFriday 1.80 pm. Raynes Park Patients Monday 1.80 p.m. Wednesday 10 a.m. 1st Monday in month, 5.80 p.m. 4. 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 and at the St. Helier County Hospital. 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. This hospital is organised on a care and maintenance basis ready to be opened up at any time for the reception of cases of Small Pox. There were no such cases during the year. Infectious Disease. The Wandle Valley Hospital under a Joint Hospital Board serves this area together with three other neighbouring areas, Mitcbam, Beddington and Wallington and Coulsdon and Purley. The hospital has accommodation for 196 patients, including cubicle isolation for 38. During the year 129 patients from our district have been treated in the hospital. Reference to Table VI shows in detail the conditions for which admission was necessitated. The staffing problems referred to in the previous year's report have not eased in any way, and the standard of treatment and care maintained in the face of all these difficulties is a matter for congratulation to the hospital staff. 26 Table VI. Cases admitted to the Wandle Valley Isolation Hospital during the Year 1945. Disease. Cases Deaths Diphtheria 10 — iSearlet Fever 68 — Erysipelas 1 — TonsillitiB or Quinsy 10 — Measles 15 — Influenza 2 — Rubella 2 — Meningitis and C.S.P 3 — T.B. Meningitis 1 1 Puerperal Fever (Sepsis) 2 — Admitted with Mother 2 — Infantile Paralysis 1 — Dermatitis 3 — Enteritis and Typhoid 7 — Streptococcal Infection and Impetigo 1 — Pyelitis 1 — Total 129 1 General and Maternity. The district is well served by hospitals and the closest liaison and fullest co-operation is maintained with the hospitals serving the area. Those engaged in both services realise that something more than friendly neutrality between two sets of organisations working in the same field should be achieved and both by frequent personal contact and a belief that the best interest of the public is our obligation. The hospital contribution to public health even in our own particular field of preventive medicine is too rarely appreciated. One has only to recall the multiplicity of arrangements made with general and special hospitals by local authorities in the detection and treatment of such conditions as deformities, eye diseases, ear infections, the availability of children's specialists and in-patient accommodation for investigation of special conditions beyond the scope of the clinics, to realise that the local authority health service has had at its elbow a comprehensive ancilliary service which has supported and enhanced the work of the 27 authority's clinics. It is obviously in the best interests of both services and of the public that they shall work even closer together. 1. The Nelson Hospital for Wimbledon, Merton and district. The accommodation of this voluntary hospital, to whose funds the Council makes an annual grant, is 113 beds, 21 of which are maternity beds. 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 1,368 Number from Merton and Morden 537 Total number of new out-patients 7,619 Number from Merton and Morden 3,401 (b) Maternity Services. Number of patients admitted from all districts during the year:— (1) General Wards 299 (2) Private Wards 152 451 Number of patients admitted from Merton and Morden:— (1) General Wards 138 (2) Private Wards 72 210 2. The County and Public Assistance Hospitals. The hospital provision for the area has been greatly improved by the St. Helier Hospital which is in the Carshalton district. A considerable proportion of general and special cases from the southern parts of the area are dealt with by this hospital. In addition to 795 medical and surgical beds the hospital has a most up-to-date maternity wing of 67 beds. The maternity unit includes 25 single bed wards. There are in addition 30 ante-natal beds included in the general hospital accommodation, 4 of which are single bed wards. This makes a complement of 97 beds for maternity, of which 29 is in the form of cubicle accommodation. Reference has been made elsewhere in this report to the valuable work undertaken by the hospital in the provision for special treatment for premature births in the area. 28 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 20 persons were admitted from Merton and Morden during 1945, whilst 77 other persons received treatment in other institutions. In Surrey, as in other counties, the Sanatoria accommodation is inadequate to meet the present demands made upon it. Every effort is being made by using other accommodation and by selection of cases to mitigate the shortage which is largely contributed to by shortage of nursing staff. 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 1,013 Notified by Midwives 435 Still Births 23 Notified by doctors and parents Transferred from 27 other districts 574 1,036 1,036 The Work of the Centres. Reference to Table VIII, page 32, show that the attendances at the Welfare Centres were well up to the figures for the previous years and considerably higher than for last year, in fact, there were 3,577 infant and 3,286 child attendances more in 1945 than in 1944. A considerable increase was to be expected in view of the drop in 1944 owing to the flying bomb attacks in the summer of that year. The figures, however, compared with the immediate pre-war figures in 1938 and 1939 suggest that the peak reached in those pre-war years has been recovered. It is worthy of record that in 1944, 58 per cent, and in 1945 66 per cent, of the expectant mothers in the district received ante-natal care in our clinics. When one remembers that a proportion of our expectant mothers attend hospital 20 ante-natal clinics, The Nelson and St. Helier, apart from those under private supervision, it will be appreciated that there are not many women to-day in our area who do not receive medical supervision throughout their pregnancies. It will be seen by reference to Table VIII that the average attendance at three of our ante-natal clinics is over 20 per session. To achieve such an average means that attendances at some of these sessions are regularly very considerably in excess of 20 and it is these that must be considered to obtain a true picture; in fact, attendances have been frequently in excess of 40 per session although it appears that our responsibility for this work may soon cease, some scatter of this concentration is becoming urgent. It is greatly to the credit of our Ante-Natai Officer that this increasing volume, of perhaps the most important work in the whole field of piiblic health, has been accomplished at, a standard which justly entitles the authority to be proud of this service. It will be seen from the figures given on page 32 that at two of the infant welfare centres the average attendance during the year is over 50 and in one case over 60. It ought to be pointed out that at the Morden Clinic which shows an actual average attendance of 31.9 that one session originally set aside for Diphtheria Immunisation shows so few attendances that it practically does not count as a session and to get a proper picture of the attendance picture there, the average should be based on 100 sessions not on 150 as calculated in the report. This would give an average attendance of .47.8. As 1 have pointed out with regard to the ante-natal sessions, where an average number of attendances is 50, there will be many sessions greatly in excess of this number. This is important, as the reputation of the clinics depends on the reactions of the individuals attending and at a mother's first attendance, perhaps her only attendance—if the number is overwhelmingly large so that she is unable to secure an uninterrupted private audience with the Health Visitor for a reasonable length of time, she is deprived of a service which it is our function to provide. It is important, therefore, to keep constantly in mind that if the standard of service is to be maintained, staffing arrangements must keep pace with attendances. 30 TABLE VII. Attendances at Ante-Natal Clinics. Centre No. on Register Attendances Sessions Average per Session Primary Total Mobden Ante-Natal 284 238 1403 27.8 Post-Natal 19 2 21 62 Individuals 803 236 1424 Raynes Park (transferred duringyear from BlakeslEY Hse.) Ante-Natal 178 189 777 15.8 Post-Natal 20 — 20 52 Individuals 193 189 797 Grand Drive Ante-Natal 283 196 1031 | 20.09 Post-Natal 88 6 40 51 Individuals 266 201 1071 All Clinics Ante-Natal 690 668 8211 21.3 . Post-Natal 72 7 81 165 Individuals 762 675 8292 (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.) 31 TABLE VIII. Attendances at Infants' Consultation Clinics. Centre No. on Register Attendances Sessions Average Attendance per Session *Primary Total Morden Under 1 yr. 618 263 3,400 150 31.9 1-5 years 18 1,387 Raynes Tark Under 1 yr. 681 219 3,522 100 62.7 1-5 years 53 2,749 Baptist Hall Under 1 yr. 400 130 1,728 51 56.2 1-5 years 16 1,102 Hope Mission Under 1 yr. 158 39 697 51 27.0 1-5 years 9 680 Grand Drive Under 1 yr. 840 246 4,471 145 52. 3 1-5 years 28 3,119 All Centres Under 1 yr. 2,697 S70 13,818 497 45.9 1-5 years 124 9,037 * Excluding children known to have attended other Centres. TABLE IX. Attendances at all Centres over last 10 years. Year No. of Infants attending daring year No. of women attending Maternity Clinics ATTENDANCES Grand Total Infants Maternity Primary under 1 yr. Total 1936 2,010 806 561 19,957 1,106 21,068 1937 2,250 358 569 20,422 1,450 21,872 1938 2,800 469 750 25,235 2,127 27,862 1939 3,090 588 856 24,876 2,895 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 1,341 22,819 1943 2,514 681 908 22,485 2,074 21,509 1944 2,491 740 807 15,992 2,948 18,940 1945 2,697 762 870 22,855 3,292 26,147 32 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 1029 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 47.8 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 1944 1,151 807 70 740 64.2 1945 1,027 870 84 762 74.2 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 Ophthalmic Clinic is held every Friday and a Pediatric Clinic, which is held every Monday, was opened on 8th November. The Infant Clinic was closed on 26th July. The hospital is a voluntary organisation serving Wimbledon, Merton and Morden. The following information, kindly supplied by the Secretary, indicates the work of the hospital clinics during the year. 38 Infant Clinic. From Merton and Morden. Total number of attendances at the infant clinic 671* Total number of first attendances under one year of age 45 Total number of children attending during the year:— Under one year 42 Over one year 3 Ante and Post Natal Clinic. Ante-Natal. Post-Natal. Total number of attendances during the year *1,622 *175 Total number of women who attended during the year 135 80 * All districts. Health Visiting. While T would once again emphasise the dangers of placing absolute reliance on figures as an index of accomplishment, the records for the year 1945 do nevertheless show a very large increase in visits in all categories over the previous year. The total visits made by the Health Visitors were 9,688 last year, compared with 7,919 for the previous year. It is of interest that there were over 100 more visits to expectant mothers, compared with the previous year. One of the reasons for this increase is the large number of cases making application to St. Helier County Hospital for admission and who are referred to this department for a Health Visitor's report on the home conditions to estimate the need for hospitalisation. While this has entailed a considerable amount of extra visiting for the staff, the opportunity presented in this way for our Health Visitors to make additional contacts with our expectant mothers was welcomed. It will also be noted that there were 128 visits made to foster children. As there were 9 foster children in the area for whose supervision we are responsible this means that each child was visited on an average 14 times during the year. This brief resume of the domicilary work of the Health Visitors for the first post-war year gives sufficient indication of the response that these highly trained personnel will make to the increased demands inevitably to be made on them in the future. 34 The number of visits made for various purposes was as shown below:— To expectant mothers—first visits total visits 498 816 To children under 1 year—first, visits total visits 1,184 3,675 To children 1-5 years—total visits 4,733 Visits re puerperal pyrexia, ophthalmia neonatorum and miscellaneous 336 Visits to foster children re child life protection 128 9,688 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. Maternity Hospital Treatment. The arrangements with Queen Charlotte's Hospital, whereby complicated cases were admitted there, has fallen into disuse through the war and because facilities are now available for dealing with these locally. It will be seen in the section dealing with Hospitals that there are 21 beds in the Nelson Hospital and 67 beds in the St. Helier County Hospital. Since Chemotherapy has to a large extent supplanted surgery in the treatment of Puerperal Pyrexia, cases complicated by pyrexia are now provided for in the Wandle Valley Isolation Hospital. 35 The following table shows the use of the maternity accommodation in the district in the year under review:— Nelson Hospital 216 Kingston County Hospital 22 St. Helier County Hospital 341 Other Hospitals 194 773 Emergency Maternity Unit. There were no calls 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 Help Scheme. The extension of the Home Help arrangements to make provision for cases outside the Maternity and Child Welfare Scheme, such as aged and infirm and cases of illness, which would not be eligible under that scheme, did not bring the overwhelming demand anticipated at the inception. The Home Help staff during the year under review consisted of one full-time employee and seven employed part-time for as many hours as they were capable of giving. The work is arranged and supervised by an organiser who combines this work with duties under the Maternity and Child Welfare Dental Scheme as Dental Attendant and Clerk. In addition to the 35 maternity and child welfare cases, of whom 30 were lying-in eases, 16 cases were dealt with under the extended arrangements. Of this number 4 were in receipt of this assistance from the inception of the scheme to the end of the year. While it can be claimed that no request for such assistance when the need was urgent was left unaided, the re-arrangement of the disposition of the staff was, at times, a matter of considerable difficulty and emphasised the value and importance of the work of the Home Help Organiser. Although for the period covered by this report, recruiting of additional staff was quite impossible, since then, however, the position has been eased considerably. The number of Home Helps provided to residents of the district during the year were as follows :— Service Full Cost Partial Cost Free of Cost Total Ante and Post Natal 3 2 — 5 Maternity 13 14 3 30 Domestic 6 6 6 16 Total for year 21 22 8 61 36 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 cases, at half price or free of cost according to means. During the year 30 outfits were supplied, 29 at cost price and one free of charge. Dental Scheme. During the year a very considerable increase in the use of the dental clinics was made, when 349 mothers and children made 954 attendances as against 232 persons and 702 attendances in the year before. TABLE XI. Attendances at Dental Clinics during 1945. Cases referred from— Number who attended during year Number of Attendances made MERTON Mothers — 4 Children 3 6 Individuals 3 9 MORDEN Mothers 127 246 Children 24 28 Individuals 151 274 RAYNES PARK Mothers 22 59 Children ... 16 13 Individuals 38 72 GRAND DRIVE Mothers 77 145 Children 32 21 Individuals 109 169 BAPTIST HALL Mothers 40 74 Children 8 7 Individuals 48 81 ALL CENTRES Mothers 226 794 Children 83 160 Individuals 349 954 37 The dental operations performed were as follows :— TABLE XII. Dental Scheme 1945—Operations Performed. Extractions—Temporary Teeth 141 Permanent Teeth 591 Fillings—Temporary Teeth 42 Permanent Teeth 152 Dentures supplied—Number of cases 70 Number of local anesthetics given 48 Number of Gases given 182 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 1 26 27 Still — — — (b) As maternity nurse Live 4 4 8 Still — — — 5 30 35 Visits made: By midwife Ante-natal 371 During confinement 583 To midwife Ante-natal 118 Post-Natal 235 1,307 Medical Aid Forms sent:—9 Reasons for sending:— Convulsion, feeble infant 1 Discharging eyes 2 Oedema of hands, legs and feet 1 Perineal Tear 1 Phlebitis 1 38 Post-Partum Hæmorrhage1 Puerperal Pyrexia (Influenzal) 1 Rupture of Perineum 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 sixteen midwives practising in the district, of whom five were salaried midwives appointed under the County Scheme and eight members of the staff of the Nelson Hospital. Voluntary Helpers. A gratifying feature of our welfare services in the district is the contribution made voluntarily by a loyal and devoted band of women inspired by the motive of service and it is one of the advantages in compiling this annual record of the activities of the public health department that it affords me an opportunity of expressing my thanks to them and to draw attention to the value of their work. Child Life Protection. It will be seen that there are 8 foster-mothers and 9 foster children under the supervision of our Health Visitors who act as Child Life Protection Visitors for the purposes of the Infant Life Protection powers provided for in the Public Health Act, 1936. 115 visits were paid to these homes during the year, which is an average of 14 visits per home per year. As has been mentioned before we find it impossible to recruit fostermothers even to serve for short periods in cases of emergency where a mother is suddenly removed to hospital and a home is required to be .found for the child or children. Information from the County Public Health Department is to the effect that there are no children boarded out in our district by the Surrey County Council under public assistance or other arrangements. Further assurances have been received that information would be passed to the department if any such children were boarded out in our area. The following are the main facts relating to child life protection work ditring the year:— Registered homes under supervision during the year 16 Registered homes under supervision at end of year 8 New homes registered during the year 7 Children on register at end of year 9 Children brought on to register during year 17 Children removed out of district during year 12 Visits paid to nurse children 115 Number of children who died during year — Number of cases where-legal proceedings taken — 39 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 three deep wells in the district, the supplies from which are used mainly for industrial purposes. Drawn from beneath the London clay, 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. 40 The salvage tonnage for the year under review was as follows:— Tons Tons Paper 199 Bottles and Glass 120 Metals 23 Rags 18 Pig Food 841 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 31st December, 1945. Housing Conditions. In Merton and Morden houses occupied by, or suitable for the occupation of persons defined as " working classes " are, in my opinion generally of a high standard, but unfortunately in the older parts of the district, there are a substantial number of dwellings which, but for the outbreak of the late World War, would no doubt have been dealt with as Clearance Areas, or as individually unfit houses as provided for by the Housing Act, 1936. Owing to the cessation of maintenance repairs as a result of the war years, there has been a progressive deterioration, sometimes amounting to actual decay, of the poorer type of houses situated particularly in the north-eastern part of the district. The condition of the properties has been aggravated by damage by enemy action. Shortage of labour and of materials has made it impossible to proceed to any appreciable extent under the provisions of the Housing Act and so alleviate those insanitary conditions which are prevalent and common, not only to this Urban District but to the country as a whole. The provision of new houses must of course take first priority but one trusts that as this progresses there will soon be a sufficient supply of labour and materials available for maintaining existing houses in all respects fit for human habitation. It is hoped that the time is not far distant when it will not be possible to claim that lack of materials prevent the execution of repairs essential to the health and well-being of those who live under the present unsatisfactory conditions. Housing Inspections. The total number of houses inspected during the year for " sanitary defects" under the Public Health and Housing Acts was 457. Action taken in connection with defective dwelling houses is set out in the housing table on pages 48 and 49. Notices specifying the necessary work required to remedy sanitary defects were served upon owners of properties as follows:— Intimation notices 375 Statutory notices:— Public Health Act, 1936 42 Housing Act, 1936 9 41 Eradication of Bed Bug's. Thirty-four 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 5 29 34 Of the 34 houses infested 33 were treated by spraying with Vermicine," and one by fumigation with sulphur-dioxide together with the use of blow-lamps. In one case van-disinfestation of furniture was carried out. Drainage Work. At 15 houses the drainage systems were entirely reconstructed and at 64 houses extensive repairs to drains were carried out. Smoke and water tests were applied to the drains of houses in 75 instances, and obstructions were removed from drains at 119 houses. Food Supply. The total number of inspections made to premises where articles of food are prepared or exposed for sale was 1,142. At 17 premises improvements in sanitary conditions were elfected. 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. Beef, 179 lbs. Decomposition Pork, 2 carcases Moribund „ 10 lbs. Decomposition Bacon, 24 lbs. ,, Babbits, 72 lbs. ,, Fish, 209 stone ,, Cheese, 48 lbs. ,, Margarine, 37 lbs. Unsound Jam, 79 lbs. ,, Flour, 171 lbs. Contaminated Cocoa, 1 ewt. Weevil Sugar, 2 cwts. Contaminated Biscuits, 45 lbs. Enemy action Potato Crisps, 36 packets ,, ,, Oranges, 12 boxes Unsound Dried Fruit, 819 lbs. ,, Greens, 7 bags. ,, Dried Vegetables, 896 lbs. ,, Cereals, 838 lbs. ,, Fish Cakes, 168 Decomposition Pudding Mixtures, 1,203 pkts. Weevil 42 Description. Cause. Eggs, 131 Unsound Pickles, 8 jars Broken Tinned Meat, 218 tins Pierced or blown Vegetables, 356 tins ,, ,, ,, „ Fruit, 3 tins ,, ,, ,, „ Milk, 1,181 tins ,, ,, ,, „ Soup, 47 tins ,, ,, ,, , Fish, 558 tins ,, ,, ,, Meat Inspection. Practically the whole of the home killed meat is prepared in central abattoirs, but pig clubs established for the war period are allowed to slaughter on their premises if found suitable. Several of the pig clubs in the surrounding districts take advantage of this arrangement and use the registered slaughter-house attached to the Trafalgar Pig Club at 129 High Street, Merton. Carcases Inspected. Cattle Cows Calves Sheep Pigs Number killed — — — — 189 Number inspected — — — — 189 Number found fit for human consumption — — 187 Milk Supply. There are no producers of milk registered within the Urban District. Practically all the milk supplied to the district is derived from the South Eastern Counties and arx-ives either by rail or road. 67 inspections were made to dairies and milk shops during 1945. Twenty-three samples of milk were submitted for bacteriological examination during the year and all were reported as satisfactory. Twenty-six licences were granted to dealers under the Milk (Special Designations) Order, 1936, and were in force at 31st December, 1945. 43 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. Action taken. Arrowroot 1 1 — — Aspirin Tablets 2 2 — — Bacon 3 3 — Baking Powder 4 3 1 Manulacturer's explanation accepfccd Beans, baked 2 2 — — Beer 2 2 — — Bicarbonate of Soda 1 1 — — Bisurated Magnesia Tablets 1 1 — — Blackcurrant Pastilles 1 1 — — Black Pudding l 1 — — Brawn 1 1 — — Bread 1 1 — Bronchial Tablets l 1 — — Butter 2 2 — — Cake Mixture 1 1 — — Cheese 2 — — Chocolate Cup 1 1 — Cocoa 3 3 — Coffee Essence 1 l — Condensed Milk 1 l — Cordial, Lime flavoured 1 I — Curry Powder 1 l — — Dates 1 l — — Dried Milk 1 I — — Dried Peaches 1 l — — Egg Substitute Powder 2 — 2 Informal samples Epsom Salts 1 l — — Fish Paste 5 5 — — Flavouring Essence 1 1 — — Flour, Bun 3 3 — — Flour, self raising 2 2 — — Fruit cake 1 l — — Gelatine 1 l — — Ginger Wine 1 1 — — Glauber Salts 2 2 — — Glycerine 1 1 — — Gravy maker 1 1 — — Iodine, Tinctus of 1 1 — — Jam 3 3 — — Koray Tablets 2 2 — — Lard 1 1 — — Margarine 2 3 — — Meat Paste 3 3 Milk 25 25 — — Carried forward 95 93 — 44 Article. Total Samples. Genuine. Not Genuine. Action taken. Brought forward 95 93 3 Mincemeat 1 1 — Mustard 1 1 — Pepper. White 1 1 — — Petroleum Jelly 1 1 — — Phospherine Tablets 1 1 — — Pickling Mustard 1 1 — — Pickles 1 1 — — Pilchards, tinned 1 1 — — Raisins 1 1 — — Salinax 1 1 — — Sardines 1 1 — — Sausage Meat 2 2 — — Soup 2 1 1 Referred to Ministry of Food Sausages 1 1 — — Spice, mixed 1 1 — — Stuffing, Sage and Onions 1 1 — — Suet 1 1 — — Svrup of Figs 1 1 — — Vinegar 3 3 — — Yorkshire Pudding Mixture 1 1 — — Zinc Ointment 1 1 — — Total 120 117 4 — Results of Analyses of New Milk Samples. Solids not fat (legal standard is 8.5%). 8 5 8 6 8.7 8.8 8.9 9.0 9.1 9 2 Total — — 8 10 6 — 1 — 25 Milk fat (legal standard 3.0%). 3.1 3.2 3.3 3 4 3 5 3.6 3 7 3 8 3 9 4 0 4 1 4.2 4 4 Total 1 — — 6 4 4 7 2 — — — — 1 25 46 Factories. The number of inspections made to premises registered under the Factories Act—156. Defects relating to sanitary conveniences, ventilation and other sanitary matters were dealt with at 37 premises. Water Supply. Seven samples of water from domestic taps were taken and submitted for chemical or bacteriological examinations. The report on each sample was satisfactory. Water Courses. A number of inspections were made of the water courses in the district for the purpose of detecting pollutions and samples were obtained and sent for chemical analysis. 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—The Infestation Order, 1943. The Rats and Mice Destruction Act is administered by the Council, the Surrey County Council having delegated their powers to the Local Authority. A part-time rodent operator is employed and a free service is provided for householders. During the year under review 1,494 visits were made to premises where infestations were known or suspected and 108 premises were cleared. Shops Acts, 1912-1936. The following statement summarises the inspections made, the infringements discovered, and other matters dealt with during the yean- No. of Inspections:—Day Visits 187 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 — 46 Summary of Sanitary Inspections. Housing—primary visits 457 Re-inspections—work in progress 1,549 Re Overcrowding 78 Miscellaneous, housing 164 Drainage Work 1,791 Factories and Workplaces 156 Stables and Piggeries 93 Rats and Mice destruction 1,494 Enquiries, infectious diseases 165 Visits to schools 11 Smoke abatement 29 Food shops, etc 1,142 Milk Supply 65 Rivers and Streams, pollutions 109 Complaints investigated 271 Miscellaneous 1,265 I am, Ladies and Gentlemen, Your obedient Servant, F. C. THOMAS, Chief Sanitary Inspector August, 1946. 47 SECTION D—HOUSING. 1. Inspection of Dwelling Houses during the year:— i. (a) Total number of dwellinghouses inspected for housing defects (under Public Health or Housing Acts) 457 (b) Number of inspections made for the purpose 457 ii. (a) Number of dwellinghouses (included under sub-head (i) above, which were inspected and recorded under the Housing Consolidated Regulations, 1925 and 1932 — (b) Number of inspections made for the purpose — iii. Number of dwellinghouses found to be in a state so dangerous or injurious to health as to be unfit for human habitation — iv. 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 375 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 319 3. Action under Statutory Powers during the year A.—Proceedings under Sections 9, 10 and 16 of the Housing Act, 1936:— (i) Number of dwellinghouses in respect of which notices were served requiring repairs 9 (ii) Number of dwellinghouses which were rendered fit after service of formal notices:— (a) By owners 8 (b) By local authority in default of owners — 48 B.— Proceedings under Public Health Acts:— (i) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 42 (ii) Number of dwellinghouses in which defects were remedied after service of formal notices:— (a) By owners 34 (b) By local authority in default of owners — C.— Proceedings under Sections 11 and 13 of the Housing Act, 1936:— (i) Number of dwellinghouses in respect of which Demolition Orders were made — (ii) Number of dwellinghouses demolished in pursuance of Demolition Orders — D.— Proceedings under Section 12 of the Housing Act, 1936:— (i) Number of separate tenements or underground rooms in respect of which Closing Orders were made — (ii) 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 AND SUPERVISION OF FOOD. (See Sanitary Inspector's Report, on pages 42-45). 49 SECTION F— INFECTIOUS ILLNESS. Notification. The following diseases are notifiable in the Urban District:— Cholera Acute Primary Pneumonia Cerebro-Spinal Fever Acute Influenzal Pneumonia Continued Fever Acute Poliomyelitis Diphtheria (including Acute Polio-Encephalitis membranous 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. There were no notifications of Smallpox in our district during the year. Service and other contacts arriving from abroad necessitated a considerable amount of supervision and in some cases some anxiety, as in many of the households to which these contacts returned there were one or more unvaccinated members of the family, often adolescents. We have been fortunate in Merton and Morden in not having had an infectious case of Smallpox for some years. Enteric Fever, There have been no cases of Typhoid occurring in the district during the year. There was one case however which was diagnosed as Paratyphoid after serum tests had been done in the St. Helier County Hospital. On admission to hospital he was regarded as a case of Dysentery. No organisms were isolated from the stool and the diagnosis was made only on the agglutination reactions. No evidence of any source of infection could be discovered. Dysentery. There were 8 cases of Dysentery notified during the year as against 27 in the previous year. There were no deaths among these cases. Reference to the summary of vital statistics gives 2 deaths of children under 2 from Diarrhoea compared with four for the previous year. Scarlet Fever. There were 114 cases of Scarlet Fever notified during the year as compared with 231 for the year before. Scarlet Fever continues to be a mild disease and there were no deaths attributed to this condition during the year. 50 Diphtheria. Twelve civilian cases were finally diagnosed as Diphtheria during the year as compared with a new low record of 8 for the previous year. There was one death from this disease during the year. Measles. Measles seems almost to have changed from a biennial to an annual epidemic. There were 760 cases notified during the year. The number of cases has been almost up to epidemic scale each year for the past six years. In 1941 there were over 2,000 cases, in 1942—942, 1943—433, and in 1944 there were 252. In addition to losing its biennial character it seems also to have lost much of its severity and this year, out of 760 cases, there were no deaths. It has long been recognised that Measles took its toll mainly from the illnourished and that poverty has always played a significant part in the mortality and consequent morbidity. It is justifiable to assume that the better general standards of nutrition among these age groups, and the relatively high level of social and economic standards prevailing among this population, constitute an important contribution towards this result. Whooping Cough. According to the notifications received Whooping Cough was less prevalent than in the previous year, 77 cases being notified as against 183 in the previous year. There were no deaths from this disease. Anterior Poliomyelitis. Two cases of Infantile Paralysis were notified during the year, one of which received hospital treatment. There were no deaths, Cerebro-Spinal Fever. Three cases were notified during the year and received hospital treatment. In one ease the patient succumbed to the infection. Erysipelas. Fifteen notifications were received during the year and of this number 14 were treated at home and one received hospital treatment. Food Poisoning. No case of food poisoning was notified during the year. Ophthalmia Neonatorum. Twelve cases were notified, of which 9 were in hospital and 3 at home. In 11 cases recovery was complete and vision remained unimpaired. In one case the vision was lost. Pneumonia. There were 71 cases of Pneumonia, of which 5 were stated to be influenzal in origin. The number of cases notified in the previous year was 46. Puerperal Pyrexia. There were 4 notifications of Puerperal Pyrexia, giving a rate of 3.8 per thousand total births. Of the 51 4 cases 3 occurred in hospitals and one at home. Treatment of these cases is now undertaken by the Wandle Valley Hospital and during the year 2 of the cases were admitted for treatment. TABLE XIII Scarlet Fever—Monthly Distribution. Wards. Total. Abbey. Bushey Mead. Central. Morden. Park. Ravensbury. Ray nee Park. St. Helier. West Barnes. January - — — 2 1 1 1 2 — 7 February - — 1 — 3 1 — 1 — 6 March - — 2 2 — - — 2 — 6 April - 2 — 1 4 - — 3 — 10 May — — 1 3 — — 1 — 5 June - — 1 4 — - 2 - — 7 July 2 — — 2 2 - 1 1 — 8 August — 1 1 — — 1 — — — 3 September 1 - - - - - - 1 — 2 October 3 — 2 1 - 3 - 1 - 10 November - 1 2 4 - 8 - 12 - 27 December — 4 6 - 1 4 1 7 — 23 Total 6 8 16 19 11 18 5 31 — 114 Monthly mean 0 5 0.66 1.33 1.58 0.91 1.5 0.41 2.58 — 9 5 The incidence in the various wards was as follows:— Wards. Cases. Incidence per 1,000 population. Abbey 6 1.1 Bushey Mead 8 1.0 Central 16 1.3 Morden 19 1.6 Park 11 1.0 Ravensbury 18 2.6 Raynes Park 5 0.6 St. Helier 81 2.8 West Barnes — - 52 TABLE XIV. Persons Immunised at Clinics during-945. Wards. Age Groups. Total. 0—5 yrs. 5—15 yrs. Completed Primary. Single Boosting Injections. Completed Primary Single Boosting Infectious. Completed Primary. Single Boosting Injections. Abbey 42 - 3 - 45 - Bushey Mead 59 — 3 2 62 2 Central 106 — 13 6 119 6 Morden 174 1 17 7 191 8 Park 69 - 1 4 70 4 Ravenebury 65 — 9 3 74 3 Raynes Park 64 1 — 1 64 2 St. Helier 103 12 3 115 3 West Barnes 62 1 4 4 66 5 744 3 62 30 806 33 TABLE XV. Persons Immunised by Private Practitioners. Wards. Age Groups. Total. 0—5 yrs. 5—15 yrs. Completed Primary. Single Boosting Injections. Completed Primary. Single Boosting Injections. Completed Primary. Single Boosting Injections. Abbey 3 - - - 3 - Bushey Mead 10 — — — 10 — Central 15 — — 1 15 1 Morden 9 — 1 - 10 - Park 20 — 2 - 22 - Ravensbury 12 — - 1 12 1 Raynes Park 3 — — - 3 - St. Helier 13 — — — 13 — West Barnes 3 - - - 3 - 88 — 3 2 91 2 TABLE XVI. Children Immunised in Schools. School. Incomplete. Completed Primary. Single Boosting Injections. St. Helier No. 1 2 14 - St. Helier No. 2 2 6 2 St. Helier No. 3 2 19 — Morden Farm — 39 15 Morden County Primary — 10 5 Holy Family 5 — Hillcross — 12 6 8 105 28 58 TABLE XVII. Children Immunised in Day Nurseries. nursery Complete Middleton Road 11 Manor House 17 High Path 5 33 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 — 561 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 1944 515 54 216 28 818 1945 806 91 105 83 1.035 TABLE XVIII. Incidence and Fatality of Diphtheria, 1920-1945. 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 1920 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 1944 62,760 3 0.12 1 12.5 1945 66,050 12 0.18 1 8.3 54 Diphtheria Immunisation. Number of children 0— 5 years immunised January—June, 1945 408 „ „ „ 5—-15 years immunised January—June, 1945 110 „ „ „ 0— 5 years immunised July—December, 1945 457 „ „ „ 5—15 years immunised July—December, 1945 60 Total number of children 0— 5 years immunised during the year 1945 865 „ „ „ „ 5—15 years immunised during the year 1945 170 Number of children 0— 5 years immunised by Private Practitioners during the year 1945 88 „ „ „ 5—15 years immunised by Private Practitioners during the year 1945 3 Total number of children immunised by Private Practitioners during the year 1945 91 „ „ „ „ immunised in the Clinics during the year 1945 806 „ „ „ „ immunised in the Day Nurseries during the year 1945 33 Estimated percentage of 0— 5 years immunised during the year 1945 48.8% „ „ „ 5—15 years immunised during the year 1945 73.6% 55 Age Distribution of Immunised Children. Age at 31.12.45 i.e., born in year Under 1 1945 1 1944 2 1943 3 1942 4 1941 5 to 9 1936—1940 10 to 14 1931-1935 Total Immunised Estimated Populatien 0-5 Estimated Population 5—15 Total Population up to 15 Number Immunised 4 613 567 563 555 3,395 3,587 9,284 4.720 9,480 14.200 The foregoing tables show dearly the immunisation work done during the year. It will be seen that 865 children under 5 years were immunised during the year. Of this number 806 were immunised in the Council's clinics. This figure is an improvement on last year's figure of 515, but none the less it is hoped that the 1946 figure will show a further improvement. There were 1,150 births in 1944 and therefore some 1,150 babies arrived at the age of 1 year some time or other during 1945 and should have been immunised. Until the number of immunisations approaches more nearly to the previous year's births it cannot be regarded as satisfactory. It has been the practice to immunise about the end of the first year and at all events as soon after the first birthday as possible. It will be seen in the table showing the age distribution of immunised children that there were only four children who were immunised in the under 1 year age group. Modern opinion on immunological practice is in favour of earlier immunisation and at the time of writing this report steps are being taken to secure earlier protection against Diphtheria. In another part of this report a death from Diphtheria is recorded of a child thirteen months of age. To have secured immunity this infant would have had to receive his first injection at something like ten months of age and his second not later than eleven months of age. While the mortality in this age group is relatively small, in view of the present trend of expert opinion that immunisation can be effectively carried out before one year old, we are now endeavouring to secure earlier immunisation. 56 TUBERCULOSIS. One hundred and thirty-nine new cases were added to the register of tuberculous persons, compared with 140 in 1944. These additions were:— Males Females Total Pulmonary 54 62 116 N on-Pulmonary 15 8 23 69 70 139 Of these 139, 103 were primary notifications, 31 were transferred from other districts and 5 came to notice in other ways. During the year 95 persons were removed from the register for the following reasons:— Recovered 4 Removed from the district 42 Death 49 After allowing for the additions and deductions, the number remaining on the register at the 31st December, 1945, was distributed as shown in the following table:— TABLE XIX. Tuberculosis Register at 31st December, 1945. Wards. Registered at 81st December, 1945, Total. Number on Register at mid-year Pulmonary. NouPulmonary. Abbey 42 9 51 52 Bushey Mead 67 12 79 66 Central 51 11 62 56 Morden 90 14 104 104 Park 93 19 112 114 Ravensbury 87 26 113 112 Raynes Park 53 7 60 58 St. Helier 123 31 154 152 West Barnes 45 17 62 60 Whole district 651 146 797 773 The Anti-Tuberculosis Scheme in this district is administered by the County Council. Institutional treatment was 57 provided for 97 persons in 1945 from Merton and Morden, as follows:— At the County Sanatorium, Milford 20 At other Institutions 77 97 The deaths from Tuberculosis numbered 45, of which 42 were due to pulmonary and 3 to non-pulmonary disease. The deaths are classified by age and sex in the following table:— TABLE XX. Deaths due to Tuberculosis, 1945. Ages Yeans Pulmonary | Non-Pulmonary Totals Males Females Males Females 0— — — - - - 1— - - — — — 5— - - 1 — 1 15— 2 4 - — 6 25— 4 2 — — 6 35— 6 4 2 — 12 45— 9 . — — — 9 55— 3 2 - - 5 65— 5 1 — — 6 Totals ... 29 13 3 — 45 Four deaths were in unnotified cases. The district provides a free service for the examination of sputum for tubercle bacilli. During the year 52 specimens were examined with a positive result in 2 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 tuberculous 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 tuberculous 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. 58 TABLE XXI. TUBERCULOSIS—New Cases, Age and Sex, Distribution and Manner of Admission to Register. Age Groups. Years. Primary Notifications ("A"). Cases transferred from other districts. Cases brought to notice otherwise than by notification and transfer. Total new oases. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmooary. Pulmonary. Non-Pulmonary. M P M F M F M F M F M F 0-1 - - - - - - - - - - - - 1-5 - - 4 - - 1 - - - - - - 5 5-10 1 1 2 1 - - - - - - - - - 10-15 - 2 1 1 1 - . 1 - - - — 6 .15-20 9 12 2 - 2 - - - - - - - 26 20-25 5 11 2 1 1 4 - - - - - - 24 25-30 6 10 3 1 4 1 - - - - - 31 35-45 6 4 1 3 2 - - - 1 - - 17 45-55 5 1 - 1 - 1 - - 2 - - - 10 55-65 4 1 - - - - - - - 1 - - 6 65 up 5 1 - — 1 — 1 — 1 - — — 9 Totals 41 43 .14 6 12 15 2 1 3 2 - - 139 104 30 5 69 CLEANSING STATION. As will be seen from the appended table, 1,222 attendances were made at the Cleansing Station. This figure compares with 1,625 attendances in 1944. Number of cases of Scabies treated 445 Cases of Scabies with concurrent verminous head 7 Cases of Scabies with Secondary Septic Skin condition 42 Number of cases of Verminous heads only 54 Total number of attendances at the Centre 1,222 DAY NUKSERIES. 1945 was the first year that many of the wartime nurseries were run without the interruptions occasioned by the wailing of the sirens and the need for getting the babies under cover. While grateful for this relief, in some other ways conditions had become even more difficult, particularly with regard to staff. The teacher or warden, that pivotal member of the staff on whcse presence the activities of the 2—5'ti so largely depends, disappeared from many nurseries and there has been no possibility of filling the gap. When many of us started to run day nurseries we regarded the teacher as something of a luxury rather than a necessity. I do not suppose any of us have any doubt on this point now. Without a teacher the value of a nursery sadly deteriorates and there is a risk of it becoming a mere parking place for children. In considering the question of the continuation of day nurseries there is no doubt that many were influenced by the inevitable deterioration of the standard in the nurseries by this loss of the teachers that has occurred through normal wastage and the inability to obtain fresh recruits. It is a powerful argument for the present need of provision of accommodation for children that so many supported the continuation of the nurseries in such circumstances. If so many of our day nurseries are compelled to continue without a teacher the nursery function needs reconsideration. If one is not prepared to advocate allowances sufficient to obviate the need of certain classes of mother, such as the widow, from working, one cannot deny that nurseries must be provided for these mothers but. without a trained educationist, some modification of the claims that there ,are overpowering advantages in the nursery environment will have to be made. In the past when comparisons have been made between the 60 nusery and the home, emphasis has sometimes been laid on the educational advantage to the child in the nursery. If the quality of this aspect of nursery life is reduced it is more than ever clear that it is our duty to recognise that the nursery is, in certain circumstances, an unavoidable substitute for the home and not a superior institution to which we should encourage mothers to send their children, as providing something especially beneficial which the normal child in a normal home is unlucky enough to miss. The following table shows the daily average and the highest daily average of attendances at the Day Nurseries during the year:— 61 TABLE XXII. DAY NURSERIES—Average Daily Attendances, 1945. Nursery Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec. High Path. Daily average 32 42 89 28 47 53 50 51 51 88 35 31 Highest daily average 44 50 46 46 58 59 64 CI 56 61 40 86 Manor House. Daily average 29 82 88 31 46 48 49 55 66 56 65 28 Highest daily average 82 88 38 45 50 50 59 59 67 67 66 57 Miodlfton Road. Daily average 80 42 45 37 37 41 42 44 85 42 42 40 Highest daily average 42 49 52 54 44 49 51 52 44 51 48 48 62 INDEX PAGE Acreage 8 Ambulance Facilities 23-24 Acute Poliomyelitis 51 Births1M4, 29 In hospitals or maternity homes 13 Rates 9 Bed Bugs—Eradication of 42 Cancer—Deaths from 11, 18 Rate 11, 17 Cerebro-Spinal Fever 18, 51 Child Life Protection 39 Clinics and Treatment Centres 25-26, 33-34 Climatic Conditions8-9 Closet Accommodation 40 Cleansing Station 60 Deaths 9-12, 14 Causes of 15-18 Rates 9-12 Diphtheria 51 Immunisation 53-56 Children Immunised in Day Nurseries 54 Children Immunised in Schools 53 Persons Immunised at Clinics 53 Persons Immunised by Private Practitioners 53 Incidence and fatality for 26 years 54 Disinfestation 42 Drainage and Sewerage 40 Drainage work 42 Day Nurseries 60-62 Dysentery 50 Enteric Fever 50 Erysipelas 51 68 INDEX— continued. PAGE Factories 46 Food and Drugs Act, 1938 44-45 Food Poisoning 51 Food Supply 42 Inspections * 42 Unsound Food 42 Health Services 22-23 Heart Disease—Deaths from 15-16, 18 Hospitals 26-29 Housing 48-49 Inspections and Defects 41, 48 Number inhabited 8 Verminous premises 42 Industry 8 Infant Mortality 9, 19-21 Rates 10-11, 19 Infectious diseases 50-52 Diseases notifiable 50 Inquests 15 Isolation Hospital 26-27 Laboratory Facilities 23 Examination of clinical material 23 Maternal Mortality 18-19 Rates 11, 19 Maternity and Child "Welfare 29 Ante-Natal Clinics 31, 34 Attendances at each Centre by age groups 32 Attendances at Infant Consultation Clinics 32 Attendances at Maternity Clinics 31 Attendances at all Infant Welfare Centres 32 Attendances at Centres over last ten years 32 Attendances in relation to the registered births 33 Consultant advice for maternity 36 Convalescent Home Treatment 35 64 INDEX— continued. PAGE Maternity and Child Welfare continued— Dental Scheme 37-38 Attendances 37 Operations performed 38 Emergency Maternity Unit 36 Health Visiting 34-35 Home Helps 36 Hospital provision for maternity 27-28, 35 Midwives 38 Orthopa?dic Treatment 35 Sessions, times and places 25 Sterilised Maternity Outfits 37 Voluntary Helpers 39 Work of the Centres 29 Meat Inspection 43 Measles 51 Milk Supply 43 Mosquitoes 46 Neonatal Deaths 20 Nelson Hospital 28, 33 Notification of Births 29 Nursing in the Home 22 Ophthalmia Neonatorum 51 Population 11, 13 Pneumonia 51 Premature Babies 21-22 Public Assistance 8 Public Cleansing 40 Public Health Committee 6 Puerperal Pyrexia 51-52 Rainfall 9 Rateable value 8 Rats and Mice Destruction 46 Respiratory diseases—deaths from 17 Representatives on:— Nelson Hospital Council 6 Wandle Valley Joint Hospital Board 6 Wandle Valley Joint Sewerage Board 6 65 INDEX— continued. PAGE Road Accidents (deaths from) 15, 18 Sanitary Circumstances 40 Sanitary Inspection 47 Scarlet Fever 50 Incidence in each Ward with rates 52 Monthly distribution of cases 52 Shops Acts, 1912-1936 46 Slaughterhouses 43 Smallpox 26, 50 Smoke Abatement 47 Social Conditions of the Area 8 Staff 7 Statistics 8-11 Comparative 12 Tuberculosis 29, 57 Admissions to Sanatorium 29, 57 Deaths due to 58 Dispensary 26 New cases—by age groups 59 Number on register at year end 57 Venereal Diseases 26 Water Courses 46 Water Supply 40, 46 Whooping Cough 51 Zymotic Disease—Deaths from 11 Rate 11 66 J. B. Blackmore & Co., Ltd., Printers, Wimbledon, S.W.19.